Inquiry for the win: Fostering curiosity through a BINGO exercise in a longitudinally integrated clerkship.

EDUCATIONAL CHALLENGE: As technological advancements challenge the current roles healthcare workers fill, curiosity and lifelong learning are becoming increasingly important. However, descriptions of specific curricular interventions that successfully develop these attitudes and skills remain limited. PROPOSED SOLUTION: We aimed to promote curiosity and advance practical application of evidenced-based medicine through a longitudinal, gamified learning activity within a longitudinal integrated clerkship (LIC). Thirty-seven students across two inquiry-themed LICs based at a university hospital and a community-based integrated healthcare delivery system used BINGO cards containing various assignments designed to develop the skill of asking and answering clinical questions. Assignments included: engaging experts, using evidence-based medical resources, attending education events, utilizing medical library resources, and Phone-a-Scientist. Students shared their experiences in a group setting and wrote a reflection for each assignment that was qualitatively analyzed to determine the perceived educational outcomes according to the Kirkpatrick Evaluation Model. LESSONS LEARNED: Results suggest that Inquiry BINGO fosters curiosity and builds skill in applied evidenced-based medicine early in clinical training. Most assignments prompted students to engage in opportunities they might not have otherwise explored. All but three students reported a change in behavior as a result of the assignment and 57% reported positive clinical or research results. NEXT STEPS: Future iterations of this activity should be evaluated by obtaining patient and/or preceptor feedback as well as longitudinal evaluations of student behavior to ensure higher level educational outcomes are being met.

Mycobacterium abscessus Meningitis Associated with Stem Cell Treatment During Medical Tourism.

Mycobacterium abscessus infections have been reported as adverse events related to medical tourism. We report M. abscessus meningitis in a patient who traveled from Colorado, USA, to Mexico to receive intrathecal stem cell injections as treatment for multiple sclerosis. We also review the management of this challenging central nervous system infection.

Household Transmission Dynamics of Seasonal Human Coronaviruses.

BACKGROUND: Household transmission studies inform how viruses spread among close contacts, but few characterize household transmission of endemic coronaviruses. METHODS: We used data collected from 223 households with school-age children participating in weekly disease surveillance over 2 respiratory virus seasons (December 2015 to May 2017), to describe clinical characteristics of endemic human coronaviruses (HCoV-229E, HcoV-HKU1, HcoV-NL63, HcoV-OC43) infections, and community and household transmission probabilities using a chain-binomial model correcting for missing data from untested households. RESULTS: Among 947 participants in 223 households, we observed 121 infections during the study, most commonly subtype HCoV-OC43. Higher proportions of infected children (<19 years) displayed influenza-like illness symptoms than infected adults (relative risk, 3.0; 95% credible interval [CrI], 1.5-6.9). The estimated weekly household transmission probability was 9% (95% CrI, 6-13) and weekly community acquisition probability was 7% (95% CrI, 5-10). We found no evidence for differences in community or household transmission probabilities by age or symptom status. Simulations suggest that our study was underpowered to detect such differences. CONCLUSIONS: Our study highlights the need for large household studies to inform household transmission, the challenges in estimating household transmission probabilities from asymptomatic individuals, and implications for controlling endemic CoVs.

The Predictive Potential of Elevated Serum Inflammatory Markers in Determining the Need for Intubation in CoVID-19 Patients.

Introduction: The predictive potential of demographics, clinical characteristics, and inflammatory markers at admission to determine future intubation needs of hospitalised CoVID-19 patients is unknown. The study aimed to determine the predictive potential of elevated serum inflammatory markers in determining the need for intubation in CoVID-19 Patients. Methods: In a retrospective cohort study of hospitalised SARS-CoV2 positive patients, single and multivariable regression analyses were used to determine covariate effects on intubation odds, and a minimax concave penalty regularised logistic regression was used to build a predictive model. A second prospective independent cohort tested the model. Results: Systemic inflammatory markers obtained at admission were higher in patients that required subsequent intubation, and adjusted odds of intubation increased for every standard deviation above the mean for c-reactive protein (CRP) OR:2.8 (95% CI 1.8-4.5, p<0.001) and lactate dehydrogenase OR:2.1 (95% CI 1.33.3, p=0.002). A predictive model incorporating C-reactive protein, lactate dehydrogenase, and diabetes status at the time of admission predicted intubation status with an area under the curve (AUC) of 0.78 with corresponding sensitivity of 86%, specificity of 63%. This predictive model achieved an AUC of 0.83, 91% sensitivity, and 41% specificity on the validation cohort. Conclusion: In patients hospitalised with CoVID-19, elevated serum inflammatory markers measured within the first twenty-four hours of admission are associated with an increased need for intubation. Additionally, a model of C-reactive protein, lactate dehydrogenase, and the presence of diabetes may play a predictive role in determining the future need for intubation.

Factors Associated with Retention and Adherence in a Comprehensive, Diverse HIV Pre-Exposure Prophylaxis Clinic.

Retention in HIV pre-exposure prophylaxis (PrEP) care and adherence to PrEP have been suboptimal in some populations, despite evidence that high adherence dramatically enhances PrEP efficacy. A comprehensive PrEP Clinic with a retention specialist and clinical pharmacist could impact patient's retention and adherence in PrEP care. A retrospective electronic medical record review of patients attending an academic PrEP Clinic was conducted between June 2018 and June 2019 (at least one visit attended for PrEP was required). Retention was defined as a medical or laboratory visit every 3 months ±30 days, as recommended by CDC guidelines, but was analyzed using the number of visits and time between visits via multivariate regression analyses. PrEP adherence was calculated using a Medication-Possession Ratio (MPR) and compared between patient characteristics using Kruskal-Wallis tests. One hundred twenty-two patients were identified by chart review, 96 had sufficient data for follow-up and were included in at least one analysis. The population was primarily cisgender men who have sex with men and over half were African American or Hispanic. Overall, patient retention was 43%. The retention analysis demonstrated that individuals who self-identified as gay were more likely to be retained than those who identified as heterosexual (53% vs. 18%, hazard ratio = 1.75, 95% confidence interval = [1.01-3.03], p = .045). Although not statistically significant, African Americans and cisgender women were less likely to be retained in care. The adherence analysis identified higher median MPRs among patients not reporting previous incarceration (80% vs. 35%, p < .01). Although not statistically significant, there was lower adherence among youth 18-24 (11% vs. 54% MPR >80, p = .058). Despite comprehensive PrEP clinical care, heterosexual individuals were less likely to be retained in PrEP care than those who self-identified as gay and previously incarcerated individuals were less likely to be adherent to PrEP.

Implementation of holistic review into emergency medicine residency application screening to improve recruitment of underrepresented in medicine applicants.

INTRODUCTION: Increasing the diversity of the emergency medicine (EM) workforce is imperative, with more diverse teams showing improved patient care and increased innovation. Holistic review, adapted from the Association of American Medical Colleges (AAMC), focuses on screening applicants with a balanced method, valuing their experiences, attributes, and academic metrics equally. A core tenet to holistic review is that diversity is essential to excellence. OBJECTIVE: Implementation of holistic review into the residency application screening process is effective at improving exposure to underrepresented in medicine (URiM) applicants. METHODS: After adjustment of our residency application screening rubric, improving our balance across the experience, attributes, and metrics domains, we conducted a retrospective cohort study comparing the representation of URiM applicants invited to interview, interviewed, and ranked by composite score compared to our previous primarily metric-based process. RESULTS: A total of 8,343 applicants were included in the study. Following implementation of holistic review, we saw an increase in the absolute percent of URiM applicants invited to interview (+11%, 95% confidence interview [CI] = 6.9% to 15.4%, p < 0.01), interviewed (+7.9%, 95% CI = 3.6% to 12.2%, p < 0.01), and represented in the top 75 through top 200 cutpoints based on composite score rank. The mean composite score for URiM applicants increased significantly compared to non-URiM applicants (+9.7, 95% CI = 8.2 to 11.2, p < 0.01 vs. +4.7, 95% CI = 3.5 to 5.9, p < 0.01). CONCLUSION: Holistic review can be used as a systematic and equitable tool to increase the exposure and recruitment of URiM applicants in EM training programs.

Predicting virologically confirmed influenza using school absences in Allegheny County, Pennsylvania, USA during the 2007-2015 influenza seasons.

BACKGROUND: Children are important in community-level influenza transmission. School-based monitoring may inform influenza surveillance. METHODS: We used reported weekly confirmed influenza in Allegheny County during the 2007 and 2010-2015 influenza seasons using Pennsylvania's Allegheny County Health Department all-age influenza cases from health facilities, and all-cause and influenza-like illness (ILI)-specific absences from nine county school districts. Negative binomial regression predicted influenza cases using all-cause and illness-specific absence rates, calendar week, average weekly temperature, and relative humidity, using four cross-validations. RESULTS: School districts reported 2 184 220 all-cause absences (2010-2015). Three one-season studies reported 19 577 all-cause and 3012 ILI-related absences (2007, 2012, 2015). Over seven seasons, 11 946 confirmed influenza cases were reported. Absences improved seasonal model fits and predictions. Multivariate models using elementary school absences outperformed middle and high school models (relative mean absolute error (relMAE) = 0.94, 0.98, 0.99). K-5 grade-specific absence models had lowest mean absolute errors (MAE) in cross-validations. ILI-specific absences performed marginally better than all-cause absences in two years, adjusting for other covariates, but markedly worse one year. CONCLUSIONS: Our findings suggest seasonal models including K-5th grade absences predict all-age-confirmed influenza and may serve as a useful surveillance tool.

Influenza and other respiratory viral infections associated with absence from school among schoolchildren in Pittsburgh, Pennsylvania, USA: a cohort study.

BACKGROUND: Information on the etiology and age-specific burden of respiratory viral infections among school-aged children remains limited. Though school aged children are often recognized as driving the transmission of influenza as well as other respiratory viruses, little detailed information is available on the distribution of respiratory infections among children of different ages within this group. Factors other than age including gender and time spent in school may also be important in determining risk of infection but have been little studied in this age group. METHODS: We conducted a cohort study to determine the etiology of influenza like illness (ILI) among 2519 K-12 students during the 2012-13 influenza season. We obtained nasal swabs from students with ILI-related absences. Generalized linear mixed-effect regressions determined associations of outcomes, including ILI and laboratory-confirmed respiratory virus infection, with school grade and other covariates. RESULTS: Overall, 459 swabs were obtained from 552 ILI-related absences. Respiratory viruses were found in 292 (63.6%) samples. Influenza was found in 189 (41.2%) samples. With influenza B found in 134 (70.9%). Rates of influenza B were significantly higher in grades 1 (10.1, 95% CI 6.8-14.4%), 2 (9.7, 6.6-13.6%), 3 (9.3, 6.3-13.2%), and 4 (9.9, 6.8-13.8%) than in kindergarteners (3.2, 1.5-6.0%). After accounting for grade, sex and self-reported vaccination status, influenza B infection risk was lower among kindergarteners in half-day programs compared to kindergarteners in full-day programs (OR = 0.19; 95% CI 0.08-0.45). CONCLUSIONS: ILI and influenza infection is concentrated in younger schoolchildren. Reduced infection by respiratory viruses is associated with a truncated school day for kindergarteners but this finding requires further investigation in other grades and populations.

Age-specific social mixing of school-aged children in a US setting using proximity detecting sensors and contact surveys.

Comparisons of the utility and accuracy of methods for measuring social interactions relevant to disease transmission are rare. To increase the evidence base supporting specific methods to measure social interaction, we compared data from self-reported contact surveys and wearable proximity sensors from a cohort of schoolchildren in the Pittsburgh metropolitan area. Although the number and type of contacts recorded by each participant differed between the two methods, we found good correspondence between the two methods in aggregate measures of age-specific interactions. Fewer, but longer, contacts were reported in surveys, relative to the generally short proximal interactions captured by wearable sensors. When adjusted for expectations of proportionate mixing, though, the two methods produced highly similar, assortative age-mixing matrices. These aggregate mixing matrices, when used in simulation, resulted in similar estimates of risk of infection by age. While proximity sensors and survey methods may not be interchangeable for capturing individual contacts, they can generate highly correlated data on age-specific mixing patterns relevant to the dynamics of respiratory virus transmission.

Risk Factors of SARS-CoV-2 Antibodies in Arapahoe County First Responders-The COVID-19 Arapahoe SErosurveillance Study (CASES) Project.

OBJECTIVES: Define the seroprevalence and risk factors for SARS-CoV-2 antibodies in Arapahoe County, Colorado first responders (eg, law enforcement, human services, fire departments). METHODS: Two hundred sixty four first responders were enrolled June to July 2020. SARS-CoV-2 seropositivity was defined as detection of immunoglobulin G (IgG) antibodies to both spike receptor binding domain and nucleocapsid in venous blood by validated enzyme-linked immunosorbent assay. We compared risk factors for being seropositive versus seronegative. RESULTS: 4% (11/264) were SARS-CoV-2 seropositive. Seropositive participants were significantly more likely to have lung disease (% seropositive, % seronegative; P-value) (36%, 8%; P = 0.01), prior SARS-CoV-2/COVID-19 testing (36%, 8%; P ≤ 0.01), a prior positive result (18%, less than 1%), and to believe they previously had COVID-19 (64%, 15%; P < 0.01). Only 15% of those believing they had COVID-19 had anti-SARS-CoV-2 antibodies. CONCLUSIONS: Human services employees and individuals with lung disease are at SARS-CoV-2 exposure risk. Few individuals believed they had COVID-19 had prior exposure.

Remembering and Enhancing the Impact of Women in Infectious Diseases.

Following the establishment of the Infectious Diseases Society of America (IDSA), women played a minor role as IDSA leaders, awards recipients, and presenters at the national meeting. Since the formation of the IDSA Women's Committee in 1992, women have played an increasing role in all of these domains of the Society. Two subsequent IDSA task forces have emphasized the importance of women, and other unrepresented minorities, to the success of the core missions of the Society. Ongoing efforts to maintain the presence of women and their unique talents, experiences, and understandings in the Society will sustain the strengths of IDSA.

Age-specific social mixing of school-aged children in a US setting using proximity detecting sensors and contact surveys.

Comparisons of the utility and accuracy of methods for measuring social interactions relevant to disease transmission are rare. To increase the evidence base supporting specific methods to measure social interaction, we compared data from self-reported contact surveys and wearable proximity sensors from a cohort of schoolchildren in the Pittsburgh metropolitan area. Although the number and type of contacts recorded by each participant differed between the two methods, we found good correspondence between the two methods in aggregate measures of age-specific interactions. Fewer, but longer, contacts were reported in surveys, relative to the generally short proximal interactions captured by wearable sensors. When adjusted for expectations of proportionate mixing, though, the two methods produced highly similar, assortative age-mixing matrices. These aggregate mixing matrices, when used in simulation, resulted in similar estimates of risk of infection by age. While proximity sensors and survey methods may not be interchangeable for capturing individual contacts, they can generate highly correlated data on age-specific mixing patterns relevant to the dynamics of respiratory virus transmission.

Structural Vulnerability in the U.S. Revealed in Three Waves of COVID-19.

The novel coronavirus disease (COVID-19) pandemic has unveiled underlying health inequities throughout the United States. The pandemic has spread across U.S. states, affecting different vulnerable populations, including both inner-city and rural populations, and those living in congregate settings such as nursing homes and assisted-living facilities. In addition, since early April, there has been an increasing number of outbreaks of COVID-19 in jails and prisons. We describe three overlapping epidemiologic waves of spread of COVID-19 linked to three different kinds of structural vulnerabilities.

A Program to Support Scholarship During Internal Medicine Residency Training: Impact on Academic Productivity and Resident Experiences.

Problem: Although scholarship during residency training is an important requirement from the Accreditation Council for Graduate Medical Education, efforts to support resident scholarship have demonstrated inconsistent effects and have not comprehensively evaluated resident experiences. Intervention: We developed the Leadership and Discovery Program (LEAD) to facilitate scholarship among all non-research-track categorical internal medicine (IM) residents. This multifaceted program set expectations for all residents to participate in a scholarly project, supported faculty to manage the program, facilitated access to faculty mentors, established a local resident research day to highlight scholarship, and developed a didactic lecture series. Context: We implemented LEAD at a large university training program. We assessed resident scholarship before and after LEAD implementation using objective metrics of academic productivity (i.e., scientific presentations, peer-reviewed publications, and both presentations and publications). We compared these metrics in LEAD participants and a similar historical group of pre-LEAD controls. We also assessed these outcomes over the same two periods in research track residents who participated in research training independent from and predating LEAD (research track controls and pre-LEAD research track controls). We conducted focus groups to qualitatively assess resident experiences with LEAD. Outcome: Compared to 63 pre-LEAD controls, greater proportions of 52 LEAD participants completed scientific presentations (48.1% vs. 28.6%, p = .03) and scientific presentations and peer-reviewed publications (23.1% vs. 9.5%, p = .05). No significant differences existed for any academic productivity metrics among research track controls and pre-LEAD research track controls (p > .23, all comparisons). Perceived facilitators of participation in LEAD included residents' desire for research experiences and opportunities to publish prior to fellowship training; the main barrier to participation was feeling overwhelmed due to the time constraints imposed by clinical training. Suggestions for improvement included establishing clearer programmatic expectations and providing lists of potential mentors and projects. Lessons Learned: Implementation of a multifaceted program to support scholarship during residency was associated with significant increases in academic productivity among IM residents. Residents perceived that programs to support scholarship during residency training should outline clear expectations and identify available mentors and projects for residents who are challenged by the time constraints of clinical training.

A Mixed Methods Evaluation of an Inclusive Sexual History Taking and HIV Prevention Curriculum for Trainees.

BACKGROUND: Health disparities exist in HIV risk in the USA among the lesbian-gay-bisexual-transgender-queer (LGBTQ) community. There is also scarce literature on curricula for HIV prevention and pre-exposure prophylaxis (PrEP) for trainees. AIM: To create a curriculum to train residents to perform inclusive sexual history taking and HIV prevention care. The curriculum covers sexual history, LGBTQ health, sexually transmitted infections, and HIV risk assessment and risk reduction counseling including use of PrEP. SETTING: A dedicated PrEP Clinic was created within an Academic Medical Center Outpatient HIV Clinic. Patients were primarily LGBTQ identified, but also included HIV sero-discordant couples, cisgender individuals, heterosexual invididuals, and those with experience of homelessness, sex work, and substance abuse. PARTICIPANTS: Thirty-four internal medicine residents completed the course between November 2017 and May 2018. PROGRAM DESCRIPTION: The curriculum was delivered as Just in Time Teaching (JiTT) via online virtual patient cases followed by directly observed clinical care at a large urban PrEP clinic. PROGRAM EVALUATION AND RESULTS: The effectiveness of the curriculum was assessed through paired pre/post-self-assessment surveys (n = 19), additional post-surveys on the online modules (n = 22), and interviews (n = 9). Many respondents reported no prior training or inadequate prior training in the course content. As a result of the course, participants reported statistically significant increased confidence and comfort in all seven HIV prevention topic areas, with the greatest gains in safe sex counseling for LGBTQ patients and in discussing PrEP (mean changes of 1.21, 1.58 on 5-point Likert scale, respectively, p < 0.0001). Six of nine interviewees post-course had applied what they learned to patient care; five indicated their learning would benefit patients. DISCUSSION: An HIV prevention curriculum focused on cultural humility in care can improve trainee's skills in HIV risk reduction counseling, including PrEP, among all patients including those identifying as LGBTQ.

Gender differences in career development awards in United States' anesthesiology and surgery departments, 2006-2016.

BACKGROUND: Although the status of women in anesthesiology has advanced by many measures, obtaining career development funding remains challenging. Here, we sought to compare the characteristics of funded career development awards from the National Institutes of Health (NIH) between the specialties of anesthesiology and surgery. We hypothesized that the two groups differ in percentage of faculty with awards, gender distribution among principal investigators, as well as the number of awards promoting diversity. METHODS: The NIH grant-funding database RePORT was queried for career development awards for the years 2006-2016 using the filters "Anesthesiology" and "Surgery." Grants were characterized based on the gender of the principal investigator and whether the funding opportunity announcement indicated promotion of underrepresented minorities (URM). The 2016 Association of American Medical Colleges (AAMC) report on "Distribution of U.S. Medical School Faculty by Sex and Rank" was used to adjust comparisons according to baseline gender distributions in anesthesiology and surgery departments. Cohorts were characterized using descriptive methods and compared using Chi-square or Fisher's exact test. RESULTS: Based on our AAMC data query, in 2016, the number of women faculty members at the instructor or assistant professor level in U.S. medical schools was 2314 (41%) for anesthesiology and 2281 (30%) for surgery. Between 2006 and 2016, there were 88 career development grants awarded to investigators in anesthesiology departments compared to 261 in surgery departments. Of the grantees in each specialty, 29 (33%) were women in anesthesiology and 72 (28%) in surgery (P = 0.344). Awards to promote URM were identified for two grants (2%) in anesthesiology and nine grants (3%) in surgery (P = 0.737). Faculty members in surgery were more likely to receive an award than in anesthesiology (P < 0.0001), and women were less likely to receive an award than men (P = 0.026). CONCLUSIONS: The major difference between US anesthesiology and surgery departments is that the number of faculty career development awards is significantly higher in surgery departments. Future efforts should aim to identify the reasons for such differences in order to inform strategies that can improve the likelihood for junior faculty members to receive career development funding.

Identification of facilitators and barriers to residents' use of a clinical reasoning tool.

BACKGROUND: While there is some experimental evidence to support the use of cognitive forcing strategies to reduce diagnostic error in residents, the potential usability of such strategies in the clinical setting has not been explored. We sought to test the effect of a clinical reasoning tool on diagnostic accuracy and to obtain feedback on its usability and acceptability. METHODS: We conducted a randomized behavioral experiment testing the effect of this tool on diagnostic accuracy on written cases among post-graduate 3 (PGY-3) residents at a single internal medical residency program in 2014. Residents completed written clinical cases in a proctored setting with and without prompts to use the tool. The tool encouraged reflection on concordant and discordant aspects of each case. We used random effects regression to assess the effect of the tool on diagnostic accuracy of the independent case sets, controlling for case complexity. We then conducted audiotaped structured focus group debriefing sessions and reviewed the tapes for facilitators and barriers to use of the tool. RESULTS: Of 51 eligible PGY-3 residents, 34 (67%) participated in the study. The average diagnostic accuracy increased from 52% to 60% with the tool, a difference that just met the test for statistical significance in adjusted analyses (p=0.05). Residents reported that the tool was generally acceptable and understandable but did not recognize its utility for use with simple cases, suggesting the presence of overconfidence bias. CONCLUSIONS: A clinical reasoning tool improved residents' diagnostic accuracy on written cases. Overconfidence bias is a potential barrier to its use in the clinical setting.

The 50/50 Block Schedule: Impact on Residents' and Preceptors' Perceptions, Patient Outcomes, and Continuity of Care.

PROBLEM: Traditionally, internal medicine continuity clinic consists of a half day per week, regardless of rotation, which may create conflict with ongoing inpatient responsibilities. A 50/50 block schedule, which alternates inpatient and outpatient rotations and concentrates continuity clinic during outpatient rotations, minimizes conflicting responsibilities. However, its impact on patient care has not been widely studied. Continuity is a concern, and intervisit continuity in particular has not been evaluated. INTERVENTION: We implemented a 50/50 block model with "clinic buddy" system to optimize continuity and assessed outcomes pre- and postintervention. Residents alternated inpatient and elective blocks, with clinic 1 full day per week on elective blocks only. Resident and preceptor perceptions were measured using 5-point Likert surveys to evaluate impact on clinic experience and workload. The authors calculated visit and intervisit continuity using a Usual Provider of Care index and measured blood pressure and hemoglobin A1c as quality markers to evaluate the impact on continuity and quality of care. CONTEXT: Participants were 208 medicine residents and 39 core faculty members at 3 University of Pittsburgh Medical Center clinics. The intervention was implemented in June 2014. OUTCOME: In the 50/50 system, inpatient distractions decreased (3.59 vs. 1.71, p < .001). Residents more strongly agreed that there was adequate time for conferences (3.33 vs. 4.05), they worked well within the system to achieve best patient care (3.13 vs. 3.61), and multidisciplinary teams worked well together (3.51 vs. 4.08) (all p < .001). Intervisit continuity was unchanged (73%, both models, p = .79). Visit continuity decreased (67.2% vs. 63.7%, p < .001). Blood pressure and hemoglobin A1c were unchanged. LESSONS LEARNED: This 50/50 model minimized inpatient distractions in clinic and increased perceived time for learning. Residents reported improved sense of patient ownership, relations within the multidisciplinary team, and integration into the clinic system. Intervisit continuity was preserved, visit continuity was slightly decreased, and patient outcomes were not impacted in this model.