Wilderness Medicine Curricula in United States EMS Fellowship, Emergency Medicine Residency, and Wilderness Medicine Programs.

OBJECTIVE: Wilderness Medicine (WM) focuses on care delivered in austere or resource-scarce environments. The Accreditation Council for Graduate Medical Education (ACGME) requirements and core content for Emergency Medicine (EM) residency and Emergency Medical Services (EMS) fellowship in the United States (US) include some WM topics that are covered to varying degrees in these programs. Furthermore, there are no ACGME-approved WM fellowships or specific curricula. Different training programs may develop WM content and curricula that differ significantly, leading to variations in WM competencies and training. In 2009, the American College of Emergency Physicians (ACEP) Wilderness Medicine Section created a Fellowship Subcommittee and Taskforce to develop a standardized curriculum and core content for EM-based WM fellowships. However, to date, EMS fellowship and EM residency WM curricula in the US content have not been analyzed for consistency with the ACEP WM fellowship curriculum. METHODS: In this study, the WM curricula components of EM residency and EMS fellowship were evaluated using the ACEP WM fellowship curriculum as a control. Potential curriculum gaps for each program type were identified. RESULTS: Of the 19 WM competencies developed by the ACEP Wilderness Medicine Section Fellowship Subcommittee and Taskforce, EMS fellowship covers more WM topics (16 topics, or 84%) than EM residency (12 topics, or 63%), and combined, they cover 89% of these topics. CONCLUSIONS: By expanding to cover two additional WM topics, all WM curricula topics recommended by the ACEP WM fellowship curriculum could potentially be covered in EM residency + EMS fellowship; however, the depth of education in each topic may vary. It may be beneficial for Graduate Medical Education (GME)-level learners for programs to implement hands-on educational experiences in WM topics.

The Impact of an Unconventional Elective in Narrative Medicine and Pediatric Psycho-oncology on Humanism in Medical Students.

Over the course of medical school, students' optimism and hopefulness often devolve into a cynical view of medicine that continues throughout clinical rotations and beyond (Neumann et al., Acad Med 86(8):996-1009, 2011). Here, we present a qualitative evaluation of a novel immersive elective in pediatric psycho-oncology coupled with narrative medicine and its impact on students. Participants were third- and fourth-year medical students who were relieved of traditional clinical duties. Alternatively, they shadowed pediatric cancer patients, keeping narrative journals of their observations and insights. A trained team of pre-clinical medical students and faculty conducted a retrospective analysis of 120 journals written between 2008 and 2019. They compared recurring concepts to assess how blending experiential learning and reflective writing influenced the attitudes and behaviors of students. Consistent themes emerged related to developing a rich understanding of patient experiences, a humanistic appreciation of the context of illness, the ability to meaningfully reflect on insights to critically ill children, and an appreciation for the unique learning opportunity. Additionally, families expressed gratitude for the students' attentiveness to their emotional needs. By the conclusion of the elective, most students discovered that they had reignited their intrinsic empathic behaviors and were provided with beneficial insights that they believed would continue into future rotations. Experiential teaching methods paired with narrative reflection may be a valuable and therapeutic tool to learn the intricacies of the patient perspective, with the potential to enhance humanism in students during a critical time in their medical training when empathy tends to drift. Longitudinal and quantitative studies are warranted to better understand the degree and duration of specific benefits.

Evaluación de la grelina plasmática tras aplicación de neuroestimulación percutánea del dermatoma T6 en el tratamiento de la obesidad / Plasma ghrelin levels after percutaneous electrical nerve stimulation of dermatome T6 for the treatment of obesity

Introducción: Los pacientes con obesidad, con frecuencia, tienen dificultad para adherirse a una dieta baja en calorías durante largos períodos de tiempo. Una de las causas del fracaso dietético es la sensación continua de hambre. La grelina es un péptido orexígeno, secretado por células enterocromafines del fundus gástrico. El objetivo de este estudio fue analizar las variaciones de los valores plasmáticos de grelina tras PENS del dermatoma T6 asociado a dieta hipocalórica, así como la modificación del apetito y la pérdida de peso, comparándolo con un grupo control en el que solo se pautó una dieta hipocalórica. Material y métodos: Realizamos un estudio prospectivo no aleatorizado, incluyendo 20 pacientes sometidos a PENS del dermatoma T6, asociado a dieta hipocalórica, como tratamiento previo a ser sometidos a una técnica de cirugía bariátrica y con el fin de reducir peso (grupo 1), y 20 pacientes a los que se les pautó exclusivamente dieta hipocalórica previa a la intervención quirúrgica (grupo 2). En el grupo 1 se analizaron los niveles de grelina plasmática en 5 momentos diferentes del procedimiento: antes de realizar la primera sesión de PENS (muestra 1a), al finalizar la primera sesión de PENS (muestra 1b), antes de realizar la última sesión de PENS (muestra 2a), al finalizar la última sesión de PENS (muestra 2b) y un mes después de haber finalizado el tratamiento (muestra 3). En el grupo 2 se obtuvieron solo 2 muestras, antes de comenzar la dieta (muestra 1) y tras 12 semanas de dieta (muestra 2). Resultados: Tras 12 semanas de tratamiento se observó una pérdida de IMC del 8,42 ± 2,6% en el grupo 1 y del 1,32 ± 0,98% en el grupo 2 (p = 0,007). En el grupo 1 se apreció un descenso significativo de los valores de grelina entre las muestras 1a y 2a, y entre las muestras 1a y 3. En el grupo 2 se observó un aumento no significativo de los niveles de grelina entre las muestras 1 y 2. Conclusión: El PENS del dermatoma T6 se asoció con una disminución en los valores de grelina plasmática. Esta terapia, asociada a una dieta hipocalórica, consigue una pérdida de IMC superior al 8% en 12 semanas de tratamiento

Introduction: Obese patients often find it difficult to adhere to long-term low-calorie diets. One of the reasons for dietary failure is the permanent feeling of hunger. Ghrelin is an orexigenic hormone, secreted by enterochromaffin cells in the gastric fundus. The aim of this study was to analyze changes in plasma ghrelin levels after PENS of dermatome T6 associated to a low-calorie diet, as well as changes in appetite and weight loss, as compared to a control group on a low-calorie alone. Material and methods: A prospective, non-randomized study was conducted including 20 patients who underwent PENS of dermatome T6 associated to a low-calorie diet before undergoing bariatric surgery to lose weight (Group 1), and 20 patients who were only prescribed a low-calorie diet before surgery (Group 2). In Group 1, plasma ghrelin levels were measured at 5 timepoints: before the first PENS session (Sample 1a); after the first PENS session (Sample 1b); before the last PENS session (Sample 2a); after the last PENS session (Sample 2b); and one month after treatment completion (Sample 3). In Group 2, only two samples were collected: before the start of the diet (Sample 1) and after 12 weeks of diet (Sample 2). Results: After 12 weeks of treatment, BMI decreases of 8.42% ± 2.6% and 1.32% ± 0.98% were seen in Group 1 and Group 2 respectively (p = 0.007). A significant decrease was seen in ghrelin levels between samples 1a and 2a, and between samples 1a and 3. In Group 2, a non-significant increase was seen in ghrelin levels. Conclusion: PENS of dermatome T6 was associated to decreased plasma ghrelin levels. This therapy, associated to a low-calorie diet, achieves a BMI reduction greater than 8% after 12 weeks of treatment

Plasma ghrelin levels after percutaneous electrical nerve stimulation of dermatome T6 for the treatment of obesity. / Evaluación de la grelina plasmática tras aplicación de neuroestimulación percutánea del dermatoma T6 en el tratamiento de la obesidad.

INTRODUCTION: Obese patients often find it difficult to adhere to long-term low-calorie diets. One of the reasons for dietary failure is the permanent feeling of hunger. Ghrelin is an orexigenic hormone, secreted by enterochromaffin cells in the gastric fundus. The aim of this study was to analyze changes in plasma ghrelin levels after PENS of dermatome T6 associated to a low-calorie diet, as well as changes in appetite and weight loss, as compared to a control group on a low-calorie alone. MATERIAL AND METHODS: A prospective, non-randomized study was conducted including 20 patients who underwent PENS of dermatome T6 associated to a low-calorie diet before undergoing bariatric surgery to lose weight (Group 1), and 20 patients who were only prescribed a low-calorie diet before surgery (Group 2). In Group 1, plasma ghrelin levels were measured at 5 timepoints: before the first PENS session (Sample 1a); after the first PENS session (Sample 1b); before the last PENS session (Sample 2a); after the last PENS session (Sample 2b); and one month after treatment completion (Sample 3). In Group 2, only two samples were collected: before the start of the diet (Sample 1) and after 12 weeks of diet (Sample 2). RESULTS: After 12 weeks of treatment, BMI decreases of 8.42%±2.6% and 1.32%±0.98% were seen in Group 1 and Group 2 respectively (p=0.007). A significant decrease was seen in ghrelin levels between samples 1a and 2a, and between samples 1a and 3. In Group 2, a non-significant increase was seen in ghrelin levels. CONCLUSION: PENS of dermatome T6 was associated to decreased plasma ghrelin levels. This therapy, associated to a low-calorie diet, achieves a BMI reduction greater than 8% after 12 weeks of treatment.

Tumor-infiltrating Foxp3-CD4+CD25+ T cells predict poor survival in renal cell carcinoma.

PURPOSE: Regulatory T cells (Tregs) have been implicated as inhibitors of antitumoral immunity, and evidence suggests that elimination of Tregs may augment natural and pharmacologic immunity. We tested for the presence of putative Tregs within renal cell carcinoma (RCC) tumors. EXPERIMENTAL DESIGN: We identified 170 patients who underwent radical or partial nephrectomy for clear cell RCC between 2000 and 2002. Specimens were stained with anti-CD4, anti-CD25, and anti-Foxp3 antibodies and examined using confocal microscopy. Associations of CD4(+)CD25(+)Foxp3(-) and CD4(+)CD25(+)Foxp3(+) T cells with death from RCC were evaluated using Cox proportional hazards regression models. RESULTS: At last follow-up, 46 of 170 patients had died; of these, 37 died from RCC at a median of 1.4 years following nephrectomy (range, 0-4.4). Among the 124 remaining patients, median follow-up was 3.7 years (range, 0-5.7). Forty-three (25.3%) tumors harbored CD4(+)CD25(+)Foxp3(+) T cells. The presence of Foxp3(+) T cells was not significantly associated with RCC death univariately. One hundred forty-three (84.1%) tumors harbored CD4(+)CD25(+)Foxp3(-) T cells. The indicator for >or=10% CD4(+)CD25(+)Foxp3(-) T cells was significantly associated with RCC death univariately [risk ratio (RR), 2.60; 95% confidence interval (95% CI), 1.35-4.98; P = 0.004], after adjusting for tumor B7-H1 expression (RR, 2.53; 95% CI, 1.32-4.85; P = 0.005) and lymphocytic infiltration (RR, 2.53; 95% CI, 1.32-4.87; P = 0.005). CONCLUSIONS: Increased presence of CD4(+)CD25(+)Foxp3(+) T cells was not significantly associated with RCC death. In contrast, CD4(+)CD25(+)Foxp3(-) T cells, which may represent a unique set of Tregs or activated helper T cells, was significantly associated with outcome.

Early effects of pharmacological androgen deprivation in human prostate cancer.

OBJECTIVES: To assess the early histological effects of pharmacological androgen deprivation (AD), which have been assessed only over longer periods, as surgical castration leads rapidly to diminished cell proliferation and enhanced cell death within the prostate. PATIENTS AND METHODS: With Institutional Review Board approval, 35 patients were randomly assigned (seven in each group) to receive 0, 7, 14, 21 and 28 days of AD (flutamide, 250 mg orally three times/day, and one injection with leuprolide acetate 7.5 mg) before radical prostatectomy. The surgical specimens were assessed by conventional histology and immunohistochemistry, while macroarray analysis and quantitative real-time polymerase chain reaction (QRT-PCR) were used to examine gene expression. RESULTS: There were morphological changes within the prostatic tissues as early as 7 days after initiating AD, similar to the response to castration. There was tumour cell vacuolization indicating cellular injury, glandular atrophy and mononuclear cell infiltration as prominent and progressive effects but, by contrast with castration studies, there were no changes in epithelial proliferation or apoptosis. Macroarray analysis, validated by QRT-PCR and immunohistochemistry, showed up-regulation of numerous and potentially counter-effective genes involved in the cell cycle and apoptosis. CONCLUSIONS: Pharmacological AD induces significant involution within prostatic tissues over 7-28 days, but allows the persistence of some viable tumour cells capable of proliferation.

Augmentation of T cell levels and responses induced by androgen deprivation.

Androgen has been implicated as a negative regulator of host immune function and a factor contributing to the gender dimorphism of autoimmunity. Conversely, androgen deprivation has been suggested to potentiate male host immunity. Studies have shown that removal of androgen in postpubertal male mice produces an increase in size and cellularity of primary and peripheral lymphoid organs, and enhances a variety of immune responses. Yet, few details are known about the effect of androgen removal on T cell-mediated immunity. In this study, we demonstrate two pronounced and independent alterations in T cell immunity that occur in response to androgen deprivation, provided by castration, in postpubertal male mice. First, we show that levels of T cells in peripheral lymphoid tissues of mice are increased by androgen deprivation. Second, T cells from these mice transiently proliferate more vigorously to TCR- and CD28-mediated costimulation as well as to Ag-specific activation. In addition, androgen deprivation accelerates normalization of host T and B cell levels following chemotherapy-induced lymphocyte depletion. Such alterations induced by androgen deprivation may have implications for enhancing immune responses to immunotherapy and for accelerating the recovery of the immune system following chemotherapy.