Hypertension update, JNC8 and beyond.

Hypertension is the most preventable major risk factor for cardiovascular morbidity and mortality. The etiology of elevated blood pressure is a complex process involving the interaction of genetics, demographics, comorbid disorders, and environmental influences. Effective hypertensive therapy has been shown to reduce cardiovascular morbidity and mortality. JNC reports have served as a valuable source of guidelines, and JNC 8 is the most recently updated guideline for the prevention, diagnosis, and treatment of hypertension. It includes modification of JNC 7 regarding the threshold for therapy, therapeutic goals, and medications or combinations of medications that differ in benefits for certain patient populations. However, JNC 8 generated a significant degree of controversy. This review will evaluate JNC 7 versus JNC 8 guidelines and discuss the most controversial aspects of JNC 8 through a therapeutic perspective. This review will also discuss the most recently available evidence that has an impact on the JNC 8 recommendations. Despite the nuance of clinical guidelines, blood pressure control rates remains suboptimal. We will explore potential reasons and solutions for this dilemma including pharmacogenomics, novel risk-stratification strategies, lifestyle interventions, and integrative care.

Radiation-induced breast cancer: the question of early breast cancer screening in Hodgkin's lymphoma survivors.

Chest irradiation is associated with numerous early and late complications that arise from ionizing radiation-induced damage to cellular structures within the field of therapy. In patients exposed to chest irradiation at an early age as part of the treatment of childhood cancer, specifically Hodgkin's lymphoma, the increased risk of breast cancer in the long run should be considered. A case of a 35-year-old woman who exposed to chest irradiation as part of the treatment of Hodgkin's lymphoma at the age of 20 years is presented here and serves as a reminder of this somewhat overlooked complication. The article presents the evidence available for and against breast cancer screening in this particular patient population.

Teaching Medical Students to Help Patients Quit Smoking: Outcomes of a 10-School Randomized Controlled Trial.

BACKGROUND: Early in medical education, physicians must develop competencies needed for tobacco dependence treatment. OBJECTIVE: To assess the effect of a multi-modal tobacco dependence treatment curriculum on medical students' counseling skills. DESIGN: A group-randomized controlled trial (2010-2014) included ten U.S. medical schools that were randomized to receive either multi-modal tobacco treatment education (MME) or traditional tobacco treatment education (TE). SETTING/PARTICIPANTS: Students from the classes of 2012 and 2014 at ten medical schools participated. Students from the class of 2012 (N = 1345) completed objective structured clinical examinations (OSCEs), and 50 % (N = 660) were randomly selected for pre-intervention evaluation. A total of 72.9 % of eligible students (N = 1096) from the class of 2014 completed an OSCE and 69.7 % (N = 1047) completed pre and post surveys. INTERVENTIONS: The MME included a Web-based course, a role-play classroom demonstration, and a clerkship booster session. Clerkship preceptors in MME schools participated in an academic detailing module and were encouraged to be role models for third-year students. MEASUREMENTS: The primary outcome was student tobacco treatment skills using the 5As measured by an objective structured clinical examination (OSCE) scored on a 33-item behavior checklist. Secondary outcomes were student self-reported skills for performing 5As and pharmacotherapy counseling. RESULTS: Although the difference was not statistically significant, MME students completed more tobacco counseling behaviors on the OSCE checklist (mean 8.7 [SE 0.6] vs. mean 8.0 [SE 0.6], p = 0.52) than TE students. Several of the individual Assist and Arrange items were significantly more likely to have been completed by MME students, including suggesting behavioral strategies (11.8 % vs. 4.5 %, p < 0.001) and providing information regarding quitline (21.0 % vs. 3.8 %, p < 0.001). MME students reported higher self-efficacy for Assist, Arrange, and Pharmacotherapy counseling items (ps ≤0.05). LIMITATIONS: Inclusion of only ten schools limits generalizability. CONCLUSIONS: Subsequent interventions should incorporate lessons learned from this first randomized controlled trial of a multi-modal longitudinal tobacco treatment curriculum in multiple U.S. medical schools. NIH Trial Registry Number: NCT01905618.

Student involvement on teaching rounds.

BACKGROUND: Inpatient internal medicine education occurs in a fragile learning environment. The authors hypothesized that when medical students are involved in teaching rounds, residents may perceive a decrease in value of attending teaching. METHOD: During two summer periods, trained research assistants shadowed teaching rounds, tracking patient census and team call status, recording basic content of rounds, and delivering a survey instrument to the learners, asking them to rate the quality of the attending's teaching that day. RESULTS: One hundred sixty-six rounds were analyzed. Attending teaching ratings peaked when students were highly involved. In fact, high student involvement was an independent predictor of higher resident evaluation of teaching rounds (P < .0001). CONCLUSIONS: The best teaching occurred when involvement of medical students was greatest and their involvement was not necessarily a zero-sum game. The authors conclude that attending investment in medical student education during teaching rounds benefits all members of the inpatient team.

Lessons from industry: one school's transformation toward "lean" curricular governance.

As medical education grapples with organizational calls for centralized curricular oversight, programs may be compelled to respond by establishing highly vertical, stacked governance structures. Although these models offer discrete advantages over the horizontal, compartmentalized structures they are designed to replace, they pose new challenges to ensuring curricular quality and the educational innovations that drive the curricula. The authors describe a hybrid quality-assurance (QA) governance structure introduced in 2003 at the University of Kentucky College of Medicine (UKCOM) that ensures centralized curricular oversight of the educational product while allowing individualized creative control over the educational process. Based on a Lean production model, this approach draws on industry experiences that strategically separate institutional accountability (management) for a quality curriculum from the decision-making processes required to ensure it (production). In so doing, the authors acknowledge general similarities and key differences between overseeing the manufacture of a complex product versus the education of a physician-emphasizing the structured, sequential, and measurable nature of each process. Further, the authors briefly trace the emergence of quality approaches in manufacturing and discuss the philosophical changes that accompany transition to an institutional governance system that relies on vigorous, robust performance measures to offer continuous feedback on curricular quality.

The Kentucky medical curriculum: continuing innovations in educating physicians.

The University of Kentucky College of Medicine (UKCOM) retains a long history of educational commitment, quality, and innovation. Since undergoing a major curricular revision in the early 1990s, the evolving UKCOM curriculum has continued to incorporate advances in biomedical knowledge and pedagogy while meeting changing societal needs and expectations for physicians in practice. Building upon its established record of excellence in medical education, a curricular quality assurance (QA) program has been initiated to more efficiently guide improvement and innovation by providing faculty with key resources to identify and disseminate local best practices in teaching, learning, and evaluation. Through such efforts, the University of Kentucky College of Medicine is committed to providing a rich educational experience that will meet the needs of students, physicians, and patients well into the 21st century.

Urticaria, exanthems, and other benign dermatologic reactions to smallpox vaccination in adults.

A phase 1 smallpox vaccine trial involving 350 adult volunteers was conducted. Of these subjects, 250 were naive to vaccinia virus vaccine (i.e., "vaccinia naive"). Volunteers received a new cell-cultured smallpox vaccine or a live vaccinia virus vaccine. Nine self-limiting rashes (3.6%) were observed in the vaccinia-naive group. None of the vaccinia-experienced patients had a rash. Rashes appeared 6-19 days after vaccination and had 5 different clinical presentations. Five volunteers had urticarial rashes that resolved within 4-15 days, 1 had an exanthem that lasted 20 days, and 1 each presented with folliculitis, contact dermatitis, and erythematous papules found only on the hands and fingers. Volunteers reported pruritus, tingling, and occasional headaches. Relief was obtained with antihistamine and acetaminophen therapy. No volunteer experienced fever or significant discomfort.