Listen Before You Auscultate: An Active-Learning Approach to Bedside Cardiac Assessment.

Introduction: Bedside cardiac assessment (BCA) is deficient across a spectrum of noncardiology trainees. Learners not taught BCA well may become instructors who do not teach well, creating a self-perpetuating problem. To improve BCA teaching and learning, we developed a high-quality, patient-centered curriculum for medicine clerkship students that could be flexibly implemented and accessible to other health professions learners. Methods: With a constructivist perspective, we aligned learning goals, activities, and assessments. The curriculum used a "listen before you auscultate" framework, capturing patient history as context for a six-step, systematic approach. In the flipped classroom, short videos and practice questions preceded two 1-hour class activities that integrated diagnostic reasoning, pathophysiology, physical diagnosis, and reflection. Activities included case discussions, jugular venous pressure evaluation, heart sound competitions, and simulated conversations with patients. Two hundred sixty-eight students at four US and international medical schools participated. We incorporated feedback, performed thematic analysis, and assessed learners' confidence and knowledge. Results: Low posttest data capture limited quantitative results. Students reported increased confidence in BCA ability. Knowledge increased in both BCA and control groups. Thematic analysis suggested instructional design strategies were effective and peer encounters, skills practice, and encounters with educators were meaningful. Discussion: The curriculum supported active learning of day-to-day clinical competencies and promoted professional identity formation alongside BCA ability. Feedback and increased confidence on the late-clerkship posttest suggested durable learning. We recommend approaches to confirm this and other elements of knowledge, skill acquisition, or behaviors and are surveying impacts on professional identity formation-related constructs.

Derivation and Validation of a Clinical Risk Assessment Model for Cancer-Associated Thrombosis in Two Unique US Health Care Systems.

PURPOSE: Venous thromboembolism (VTE), especially pulmonary embolism (PE) and lower extremity deep vein thrombosis (LE-DVT), is a serious and potentially preventable complication for patients with cancer undergoing systemic therapy. METHODS: Using retrospective data from patients diagnosed with incident cancer from 2011-2020, we derived a parsimonious risk assessment model (RAM) using least absolute shrinkage and selection operator regression from the Harris Health System (HHS, n = 9,769) and externally validated it using the Veterans Affairs (VA) health care system (n = 79,517). Bootstrapped c statistics and calibration curves were used to assess external model discrimination and fit. Dichotomized risk strata using integer scores were created and compared against the Khorana score (KS). RESULTS: Incident VTE and PE/LE-DVT at 6 months occurred in 590 (6.2%) and 437 (4.6%) patients in HHS and 4,027 (5.1%) and 3,331 (4.2%) patients in the VA health care system. Assessed at the time of systemic therapy initiation, the new RAM included components of the KS with the modified cancer subtype, cancer staging, systemic therapy class, history of VTE, history of paralysis/immobility, recent hospitalization, and Asian/Pacific Islander race. The c statistic was 0.71 in HHS and 0.68 in the VA health care system (compared with 0.65 and 0.60, respectively, for KS). Furthermore, the new RAM appropriately reclassified 28% of patients and increased the proportion of VTEs in the high-risk group from 37% to 68% in the validation data set. CONCLUSION: The novel RAM stratified patients with cancer into a high-risk group with 8%-10% cumulative incidence of VTE and 7% PE/LE-DVT at 6 months (v 3% and 2%, respectively, in the low-risk group). The model had improved performance over the original KS and doubled the number of VTE events in the high-risk stratum. We encourage additional external validation from prospective studies.[Media: see text].

Sistemas vinculares vitimizado e cidadão: uma proposta socionômica / Victimized and citizen bond systems: a socionomic proposal / Sistemas vinculares victimizado y ciudadano: una propuesta socionómica

RESUMO Neste relato de experiência como terapeuta em programa governamental na periferia da cidade de São Paulo, o objetivo foi compreender, com enfoque na metodologia socionômica, como técnicos e usuários de um serviço assistencial lidaram com seus desafios do dia a dia no contexto comunitário. Foram identificadas duas sociodinâmicas dos papéis observados: o denominado Sistema Vincular Vitimizado (SVV), que atribui grande parte da responsabilidade dos acontecimentos a terceiros, envolvendo expectativa, culpa, busca de bodes expiatórios e consequente exclusão social; e o denominado Sistema Vincular Cidadão (SVC), que atribui corresponsabilidade, envolvendo diálogo e negociação na procura de soluções viáveis e gerando inclusão social. O SVV se mostrou menos eficiente na superação de desafios e a intervenção socionômica facilitou uma transição do SVV para o SVC.

ABSTRACT In this experience report as a therapist in a governmental program on the outskirts of the city of São Paulo, the goal was to understand, focusing on the socionomic methodology, how technicians and users of assistance service managed their day-to-day challenges in the community context. Two socio-dynamics were identified in the observed roles: the first one, named Victimized Bond System (VBS), assumes that most of the responsibility of the events belongs to third parties, involving expectation, guilt, scapegoating and consequent social exclusion; and the so-called Citizen Bond System (CBS), which attributes co-responsibility, involving dialogue and negotiation in search of viable solutions and generating social inclusion. VBS was proved less efficient in overcoming challenges and the socionomic intervention facilitated a transition from VBS to CBS.

RESUMEN En este informe de experiencia como terapeuta en programa gubernamental en las afueras de la ciudad de São Paulo, el objetivo fue comprender, enfocándose em la metodologia socionómica, cómo técnicos y usuarios del servicio de asistencia afrontaban sus desafíos cotidianos em el contexto comunitario. Se identificaron dos sociodinámicas de los roles observados: el llamado Sistema de Enlace Victimizado (SEV), que atribuye gran parte de la responsabilidad de los eventos a terceros, lo que implica expectativas, culpa, chivos expiatorios y la consiguiente exclusión social; y el llamado Sistema de Enlace Ciudadano (SEC), que atribuye la corresponsabilidad, lo que implica el diálogo y la negociación em la búsqueda de soluciones viables y generando inclusión social. El SVV fue menos eficiente para superar los desafíos y la intervención socionómica facilitó la transición del SEV al SEC.

A Mixed Methods Study on Engagement and Satisfaction with a Digitally-Enhanced Pilot Intervention Among African American and Hispanic Women.

African American and Hispanic women report less physical activity (PA) than non-Hispanic White women. As such, a digitally-enhanced 16-week social support pilot intervention was conducted to promote PA among African American and Hispanic women dyads. This study quantitatively and qualitatively examined the engagement and satisfaction of participants (N = 30; 15 dyads) assigned to the intervention. Intervention participants received telephone counseling calls based on motivational interviewing and a Jawbone UP activity monitor. Intervention engagement and satisfaction data were collected from the Jawbone UP, call logs, self-report questionnaires conducted at the 16-week follow-up, and two post-intervention focus groups. Nonparametric tests assessed group differences across engagement and satisfaction measures, and a manually-driven coding scheme was used to evaluate emerging themes from qualitative text. Participants demonstrated high engagement in the telephone counseling sessions and moderate engagement with the Jawbone UP. Friend/co-worker dyads and participants who were 45 years and older were more likely to use the device. Qualitative results emphasized participants' appreciation for the counseling calls, the Jawbone UP, and the overall dyadic framework of the study to collectively nurture social support and accountability for PA. Overall, the intervention group reacted positively to study components. Additional research is needed to understand the role of technology in facilitating long-lasting PA change via social support in minority populations.

An open comparative study of nail drilling as adjunctive treatment for toenail onychomycosis (.).

Introduction Novel treatment regimens are being developed to improve drug penetration through the nail plate. This study investigated the efficacy of nail drilling regimens for the treatment of onychomycosis. Methods Participants were assigned to holes with combination (oral plus topical terbinafine) therapy (Group 1), holes with topical terbinafine (Group 2) or topical terbinafine only (Group 3). Measurement of clear nail and mycology was performed at baseline and at weeks 4, 10, 16, 22 and 28. Mixed linear models were used to compare mean percent clear nail. Mycological cure rates were also tabulated for each group. Tolerability and adverse events were documented. Results Ninety-eight participants were enrolled (106 nails). Both groups with holes had significantly higher percentage of clear nail compared with topical terbinafine alone. Although no significant difference between the two groups where holes were drilled in the nail plate, Group 1 demonstrated improvement over Group 3 earlier than Group 2 (visit 2 versus visit 4). Group 1 also had the highest mycological cure rates. Conclusion Treatment with holes plus topical terbinafine produces significantly greater improvement in toenails' appearance and higher mycological cure rates compared to treating the dorsal aspect of the nail plate with topical terbinafine alone.

Severe obesity prior to diagnosis limits survival in colorectal cancer patients evaluated at a large cancer centre.

BACKGROUND: In contrast to the consistent evidence for obesity and colorectal cancer (CRC) risk, the impact of obesity in CRC patients is less clear. In a well-characterised cohort of CRC patients, we prospectively evaluated class I and class II obesity with survival outcomes. METHODS: The CRC patients (N=634) were followed from the date of diagnosis until disease progression/first recurrence (progression-free survival (PFS)) or death (overall survival (OS)). Body mass index (BMI) was calculated from reported usual weight prior to diagnosis. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated in models adjusted for clinicopathologic, treatment, and lifestyle factors. RESULTS: Over a median follow-up of 4 years, 208 (33%) patients died and 235 (37%) recurred or progressed. Class II obesity, as compared with either overweight or normal weight, was associated with an increased risk of death (HR and 95% CI: 1.55 (0.97-2.48) and 1.65 (1.02-2.68), respectively), but no clear association was observed with PFS. In analyses restricted to patients who presented as stages I-III, who reported stable weight, or who were aged <50 years, obesity was associated with a significant two- to five-fold increased risk of death. CONCLUSIONS: In CRC patients evaluated at a large cancer centre, severely obese patients experienced worse survival outcomes independent of many other factors.

Dietary intake of nitrate and nitrite and risk of renal cell carcinoma in the NIH-AARP Diet and Health Study.

BACKGROUND: Nitrate and nitrite are present in many foods and are precursors of N-nitroso compounds, known animal carcinogens and potential human carcinogens. We prospectively investigated the association between nitrate and nitrite intake from dietary sources and risk of renal cell carcinoma (RCC) overall and clear cell and papillary histological subtypes in the NIH-AARP Diet and Health Study. METHODS: Nitrate and nitrite intakes were estimated from a 124-item food frequency questionnaire. Over a mean follow-up of 9 years, we identified 1816 RCC cases (n=498, clear cell; n=115, papillary cell) among 491 841 participants. Cox proportional hazard regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS: Individuals in the highest quintile of nitrite intake from animal sources compared with those in the lowest quintile, had an increased risk of total RCC and clear cell subtype (HR=1.28, 95% CI, 1.10-1.49 and HR=1.68, 95% CI, 1.25-2.27, respectively). Nitrite from processed meats and other animal sources were associated with increased clear cell adenocarcinoma risk (HR=1.33, 95% CI, 1.01-1.76 and HR=1.78, 95% CI, 1.34-2.36, respectively). We found no association for nitrite intake from plant sources or nitrate intake overall. CONCLUSION: Our findings suggest that nitrite from animal sources may increase the risk of RCC, particularly clear cell adenocarcinomas.

Considerações sobre o processo de orientação de monografia em Psicodrama / Reflections on the mentoring process of preparing psycodrama dissertations

A literatura científica é escassa no que se refere aos aspectos subjetivos que influenciam as relações de orientador, orientando e parecerista, no processo de elaboração da produção teórica nos cursos de pós-graduação lato sensu. Considerando essas relações como determinantes para que o sujeito complete ou não sua pós-graduação, o intuito do texto é trazer à luz a alguns aspectos identificados a partir da literatura disponível, além de efetuar uma leitura socionômica do fenômeno referido. Com isso, pretendemos instrumentalizar os atores em questão para que logrem cuidar deste processo, a partir de uma perspectiva relacional, a fim de diminuir a ocorrência de desistências de entrega de monografias, e, dessa maneira, incrementar ainda mais o conhecimento científico e socionômico.(AU)

There is very little academic literature available regarding the subjective aspects that influence how mentors, in their relationship with students, advise and review them while writing their theoretical dissertations for post-gradual courses in general. As this relationship is crucial in determining whether students will complete their post-graduate training, the aim of this study is to shed light on some aspects of this relationship through reflecting on the available academic literature, as well as to explore this phenomenon from a socionomic perspective. By this, we intend to provide tools for those involved, in order to be able and better manage this process using a relational perspective, to reduce the number of abandoned dissertations, and to thus further enhance scientific and socionomic knowledge.(AU)

Considerações sobre o processo de orientação de monografia em Psicodrama / Reflections on the mentoring process of preparing psycodrama dissertations

A literatura científica é escassa no que se refere aos aspectos subjetivos que influenciam as relações de orientador, orientando e parecerista, no processo de elaboração da produção teórica nos cursos de pós-graduação lato sensu. Considerando essas relações como determinantes para que o sujeito complete ou não sua pós-graduação, o intuito do texto é trazer à luz a alguns aspectos identificados a partir da literatura disponível, além de efetuar uma leitura socionômica do fenômeno referido. Com isso, pretendemos instrumentalizar os atores em questão para que logrem cuidar deste processo, a partir de uma perspectiva relacional, a fim de diminuir a ocorrência de desistências de entrega de monografias, e, dessa maneira, incrementar ainda mais o conhecimento científico e socionômico...

There is very little academic literature available regarding the subjective aspects that influence how mentors, in their relationship with students, advise and review them while writing their theoretical dissertations for post-gradual courses in general. As this relationship is crucial in determining whether students will complete their post-graduate training, the aim of this study is to shed light on some aspects of this relationship through reflecting on the available academic literature, as well as to explore this phenomenon from a socionomic perspective. By this, we intend to provide tools for those involved, in order to be able and better manage this process using a relational perspective, to reduce the number of abandoned dissertations, and to thus further enhance scientific and socionomic knowledge...

Characterizing changes in student empathy throughout medical school.

BACKGROUND: Empathy is important in the physician-patient relationship. Prior studies suggest that medical student empathy declines with clinical training. AIMS: We examined the trend of empathy longitudinally; determined differences in empathy according to gender and medical specialty preferences; and determined empathy and career preference differences among students admitted through different medical school admission pathways. METHOD: The data for this study were collected using a longitudinal cohort design and included 2652 observations nested within 1162 individuals. Participants were medical students at a university-based medical school surveyed yearly from 2007 through 2010. Empathy was measured by the Jefferson Scale of Physician Empathy-Student Version (JSPE-S), a validated, 20-item self-administered questionnaire. Predictors of JSPE-S scores included gender, age, anticipated financial debt upon graduation and future career interest. RESULTS: Empathy scores of students in preclinical years were higher than in clinical years. Gender was a significant predictor of empathy, with women having higher empathy scores than men. Students preferring technology-oriented specialties had lower empathy scores. When career preference was controlled, higher levels of debt were significantly associated with greater empathy. Students with high baseline empathy decreased less than students with low baseline empathy during medical school. Students in traditional four-year medical school programs had higher baseline empathy than those in early pathway programs. CONCLUSIONS: Self-reported empathy for patients, a possibly critical factor in high-quality patient-centered care, wanes as students advance in clinical training, particularly among those entering technology-oriented specialties. In the era of new health care policy and primary care shortages, our research may have implications for the medical education system and admission policy.

Meat-cooking mutagens and risk of renal cell carcinoma.

BACKGROUND: High-temperature cooked meat contains two families of carcinogens, heterocyclic amines (HCAs) and polycyclic aromatic hydrocarbons (PAHs). Given the kidneys' role in metabolism and urinary excretion of these compounds, we investigated meat-derived mutagens, as well as meat intake and cooking methods, in a population-based case-control study conducted in metropolitan Detroit and Chicago. METHODS: Newly diagnosed, histologically confirmed adenocarcinoma of the renal parenchyma (renal cell carcinoma (RCC)) cases (n=1192) were frequency matched on age, sex, and race to controls (n=1175). The interviewer-administered Diet History Questionnaire (DHQ) included queries for meat-cooking methods and doneness with photographic aids. Levels of meat mutagens were estimated using the DHQ in conjunction with the CHARRED database. RESULTS: The risk of RCC increased with intake of barbecued meat (P(trend)=0.04) and the PAH, benzo(a)pyrene (BaP) (multivariable-adjusted odds ratio and 95% confidence interval, highest vs lowest quartile: 1.50 (1.14, 1.95), P(trend)=0.001). With increasing BaP intake, the risk of RCC was more than twofold in African Americans and current smokers (P(interaction)<0.05). We found no association for HCAs or overall meat intake. CONCLUSION: BaP intake, a PAH in barbecued meat, was positively associated with RCC. These biologically plausible findings advocate further epidemiological investigation into dietary intake of BaP and risk of RCC.

Tire-me desta, mas daqui não me deixe sair Hospitalismo: reflexões sobre o drama da (co) depedência em instituição psiquiátrica / 'Get me out of here, but don't let me get out of here.' Being institutionalised: Reflections on the drama of (co)dependence in a psychiatric institution

Este artigo visa desenvolver uma compreensão do fenômeno do hospitalismo pela perspectiva da socionomia - sua definição, fatores sociodinâmicos que facilitam sua ocorrência e recursos sociátricos como forma de tratamento. O hospitalismo, como condição social, grupal e individual que se manifesta em cenário institucional, caracteriza-se pela ênfase numa relação entre quem tem dificuldades (dependente, inadaptado, impotente) e quem sabe como administrar as dificuldades (codependente, onipotente). Na condição de sistema fechado em ambiente hospitalar, papéis são vividos de forma enrijecida por pacientes - no caso psiquiátricos -, familiares e técnicos. Sociodrama institucional, grupo temático de desligamento e acompanhamento terapêutico são apresentados como recursos para a superação do fenômeno, com ganhos para a equipe técnica, pacientes, familiares e comunidade.(AU)

This article aims to develop a comprehension of the phenomenon of hospitalism from a socionomic perspective - it´s definition, sociodynamic factors that facilitate its occurrence and sociatry as a possible treatment resource. The hospitalism, as a social, group and individual condition which manifests itself in the institutional setting, features a relationship among those who have difficulties (dependent, inadequate, impotent) and those who know how to manage the difficulties (codependent, omnipotent). As a closed system in the hospital setting, roles are experienced in a nonflexible way by psychiatric patients, family, and the staff. Institutional sociodrama, thematic group of detachment and therapeutic attendance are presented as resources to overcome the phenomenon, with gains for the staff, patients, families and the community.(AU)

Comparing a self-administered measure of empathy with observed behavior among medical students.

PURPOSE: Studies show that measures of physician and medical students' empathy decline with clinical training. Presently, there are limited data relating self-reported measures to observed behavior. This study explores a self-reported measure and observed empathy in medical students. METHOD: Students in the Class of 2009, at a university-based medical school, were surveyed at the end of their 2nd and 3rd year. Students completed the Jefferson Scale of Physician Empathy-Student Version (JSPE-S), a self-administered scale, and were evaluated for demonstrated empathic behavior during Objective Structured Clinical Examinations (OSCEs). RESULTS: 97.6% and 98.1% of eligible students participated in their 2nd and 3rd year, respectively. The overall correlation between the JSPE-S and OSCE empathy scores was 0.22, p < 0.0001. Students had higher self-reported JSPE-S scores in their 2nd year compared to their 3rd year (118.63 vs. 116.08, p < 0.0001), but had lower observed empathy scores (3.96 vs. 4.15, p < 0.0001). CONCLUSIONS: Empathy measured by a self-administered scale decreased, whereas observed empathy increased among medical students with more medical training.

Phase I trial of the anti-Lewis Y drug immunoconjugate BR96-doxorubicin in patients with lewis Y-expressing epithelial tumors.

PURPOSE: We conducted a phase I clinical trial of BR96-Doxorubicin (BR96-Dox), a chimeric anti-Lewis Y (Le(Y)) monoclonal antibody conjugated to doxorubicin, in patients whose tumors expressed the Le(Y) antigen. The study aimed to determine the toxicity, maximum-tolerated dose, pharmacokinetics, and immunogenicity of BR96-Dox. PATIENTS AND METHODS: This was a phase I dose escalation study. BR96-Dox was initially administered alone as a 2-hour infusion every 3 weeks. The occurrence of gastrointestinal (GI) toxicity necessitated the administration of BR96-Dox as a continuous infusion over 24 hours and use of antiemetics and antigastritis premedication. Patients experiencing severe GI toxicity underwent GI endoscopy. All patients underwent restaging after two cycles. RESULTS: A total of 66 patients predominantly with metastatic colon and breast cancer were enrolled onto the study. The most common side effects were GI toxicity, fever, and elevation of pancreatic lipase. At higher doses, BR96-Dox was associated with nausea, vomiting, and endoscopically documented exudative gastritis of the upper GI tract, which was dose-limiting at a maximum dose of 875 mg/m(2) (doxorubicin equivalent, 25 mg/m(2)) administered every 3 weeks. Toxicity was reversible and generally of short duration. Premedication with the antiemetic Kytril (granisetron hydrochloride; SmithKline Beecham, Philadelphia, PA), the antacid omeprazole, and dexamethasone was most effective in ameliorating GI toxicity. A dose of 700 mg/m(2) BR96-Dox (doxorubicin equivalent, 19 mg/m(2)) every 3 weeks was determined to be the optimal phase II dose when administered with antiemetic and antigastritis prophylaxis. BR96-Dox deposition on tumor tissue was documented immunohistochemically and by confocal microscopy. At the 550-mg/m(2) dose, the half-life (mean +/- SD) of BR96 and doxorubicin was 300 +/- 95 hours and 43 +/- 4 hours, respectively. BR96-Dox elicited a weak immune response in 37% of patients. Objective clinical responses were seen in two patients. CONCLUSION: BR96-Dox provides a unique strategy to deliver doxorubicin to Le(Y)-expressing tumor and was well tolerated at doses of 700 mg/m(2) every 3 weeks. BR96-Dox was not associated with the typical side-effect profile of native doxorubicin and can potentially deliver high doses of doxorubicin to antigen-expressing tumors. A phase II study in doxorubicin-sensitive tumors is warranted.

Safety of itraconazole pulse therapy for onychomycosis. An update.

After experience with more than 34 million patients over 10 years, the safety of itraconazole and its potential drug-drug interactions are well known. In clinical trials, the average incidence of adverse events with a 1-week pulse regimen was 18% in pooled safety data (n = 2,867); only 2.2% of patients dropped out. In direct comparative trials, the incidence of mild and reversible adverse effects was comparable for itraconazole and terbinafine (31% and 28%, respectively) during treatment. The rate of permanent withdrawal because of adverse events was 3.6% for itraconazole and 7.5% for terbinafine (P < .05). Itraconazole was significantly better tolerated as evaluated by the investigator and patients. The analysis of the elderly subpopulation showed that patients 65 and older tolerated itraconazole pulse well, with only 20% experiencing mild and reversible side effects (total group). In direct comparative trials, itraconazole also produced fewer adverse effects than terbinafine (13% vs 32%, respectively). As newer oral antifungal agents gain widespread use, clinicians need to be aware of their potential drug-drug interactions and their possibly serious adverse events. However, pooled data from the 1-week itraconazole pulse regimen indicated a favorable safety profile, and a dose increase to 400 mg had no impact on safety.

Factors that may affect the response of onychomycosis to oral antifungal therapy.

With the advent of the newer oral antifungals available to treat onychomycosis, the majority of patients respond to therapy. However, there may be subsets of patients who exhibit poor response or failure. Possible explanations for this may be grouped into categories, including: (i) patient characteristics; (ii) organisms causing or associated with the nail infection; (iii) nail characteristics; and (iv) local diseases involving the nail.