Background
To provide optimal care, medical students should understand that the social determinants of health (SDH) impact their patients’ well-being. Those charged with teaching SDH to future ...physicians, however, face a paucity of curricular guidance.
Objective
This review’s objective is to map key characteristics from publications about teaching SDH to students in undergraduate medical education (UME).
Methods
In 2016, the authors searched PubMed, Embase, Web of Science, the Cochrane and ERIC databases, bibliographies, and MedEdPORTAL for articles published between January 2010 and November 2016. Four reviewers screened articles for eligibility then extracted and analyzed data descriptively. Scoping review methodology was used to map key concepts and curricular logistics as well as educator and student characteristics.
Results
The authors screened 3571 unique articles of which 22 were included in the final review. Many articles focused on community engagement (15). Experiential learning was a common instructional strategy (17) and typically took the form of community or clinic-based learning. Nearly half (10) of the manuscripts described school-wide curricula, of which only three spanned a full year. The majority of assessment was self-reported (20) and often related to affective change. Few studies objectively assessed learner outcomes (2).
Conclusions
The abundance of initial articles screened highlights the growing interest in SDH in medical education. The small number of selected articles with sufficient detail for abstraction demonstrates limited SDH curricular dissemination. A lack of accepted tools or practices that limit development of robust learner or program evaluation was noted. Future research should focus on identifying and evaluating effective instructional and assessment methodologies to address this gap, exploring additional innovative teaching frameworks, and examining the specific contexts and characteristics of marginalized and underserved populations and their coverage in medical education.
There is limited data on the clinical presentation and predictors of mortality in the African‐American (AA) patients hospitalized with coronavirus disease 2019 (COVID‐19) despite the ...disproportionately higher burden and mortality. The aim of this study is to report on the clinical characteristics and the predictors of mortality in hospitalized AA patients with COVID‐19 infection. In this retrospective cohort review, we included all AA patients with confirmed COVID‐19 infection admitted to an inner‐city teaching community hospital in New York city. Demographics, clinical presentation, baseline co‐morbidities, and laboratory data were compared between survivors and non‐survivors. The predictors of mortality were assessed using multivariate logistic regression analysis. Of the 408 (median age, 67 years) patients included, 276 (66.65%, median age 63 years) survived while 132 (33.35%, median age 71 years) died. The most common presenting symptoms were cough, myalgia, fever/chills, shortness of breath, and gastrointestinal symptoms (nausea, vomiting, diarrhea, and abdominal pain), with a prevalence of 62.50%, 43.87%, 53.68%, and 27.21%, respectively. Age (odds ratio OR, 1.06; confidence interval CI, 1.04‐1.08; P < .001), body mass index (OR, 1.07; CI, 1.04‐1.11; P < .001), elevated serum ferritin (OR, 1.99; CI, 1.08‐3.66; P < .02), C‐reactive protein (OR, 2.42; CI, 1.36‐4.33; P < .01), and D‐dimers (OR, 3.79; CI, 2.21‐6.50; P < .001) at the time of presentation were identified as the independent predictors of mortality. Cough, shortness of breath, fever/chills, gastrointestinal symptoms, and myalgia were the predominant presentation among AAs hospitalized with COVID‐19 infection. Advanced age, higher body mass index, elevated serum ferritin, C‐reactive protein, and D‐dimers are independent predictors of mortality among hospitalized AAs with COVID‐19 infection.
Highlights
This is the first comprehensive study to report exclusively on the clinical characteristic among African‐Americans and predictors of mortality among African‐Americans admitted and managed for COVID‐19 infection in the USA.
Cough, shortness of breath, fever/chills, gastrointestinal symptoms, and myalgia were the predominant presentation among African‐Americans hospitalized with COVID‐19 infection.
Advanced age, higher BMI, elevated ferritin, C‐reactive protein, and D‐dimers are independent predictors of mortality among hospitalized African‐Americans with COVID‐19 infection.
There is significant variation in the literature regarding the characteristics that are associated with pediatric ovarian torsion and its management. National data regarding the demographics and ...management of pediatric ovarian torsion are lacking. Our objective was to describe the epidemiology of pediatric ovarian torsion and the rate of oophorectomy by using nationally representative data. Demographic factors and hospital characteristics that are associated with rates of oophorectomy were also explored.
This was a cohort analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) 2000, 2003, and 2006. All females aged 1 to 20 years who were hospitalized with ovarian torsion in states participating in KID 2000, KID 2003, and KID 2006 representing 900, 1224, and 1232 ovarian torsion-related hospitalizations, respectively, were included. Primary outcome measures included the incidence of ovarian torsion and rate of associated oophorectomy. Multivariable regression was used to control for patient and hospital characteristics.
Among females aged 1 to 20 years, there were 1232 cases of ovarian torsion in KID 2006, an estimated incidence of 4.9 per 100000. A total of 713 (58%) were treated with oophorectomy. The rate of ovarian torsion-associated oophorectomy remained unchanged from 2000 to 2006. The adjusted odds of having an oophorectomy decreased by 0.95 for every increasing year of age. Residing in a lower quartile of household income by zip code increased the adjusted odds of oophorectomy. A diagnosis of benign neoplasm increased the adjusted odds of oophorectomy by 2.16. Fewer than 0.5% of ovarian torsion hospitalizations were associated with malignant neoplasm.
Nationally representative hospital data indicate that ovarian torsion is uncommon but occurs in all ages and is typically associated with normal ovaries or benign lesions. Improved awareness of the epidemiology may help to guide management. Ongoing analysis to identify factors that are associated with successful conservative management is warranted.
Accreditation bodies have mandated teaching social determinants of health (SDH) to medical students, but there has been limited guidance for educators on what or how to teach, and how to evaluate ...students' competence. To fill this gap, this study aimed to develop an SDH curricular consensus guide for teaching SDH to medical students.
In 2017, the authors used a modified Delphi technique to survey an expert panel of educators, researchers, students, and community advocates about knowledge, skills, and attitudes (KSA) and logistics regarding SDH teaching and assessment. They identified the panel and ranked a comprehensive list of topics based on a scoping review of SDH education studies and discussions with key informants. A total of 57 experts were invited.
Twenty-two and 12 panelists participated in Delphi rounds 1 and 2, respectively. The highest-ranked items regarding KSA were "Appreciation that the SDH are some of the root causes of health outcomes and health inequities" and "How to work effectively with community health workers." The panel achieved consensus that SDH should constitute 29% of the total curriculum and be taught continuously throughout the curriculum. Multiple-choice tests were ranked lowest as an assessment method, and patient feedback was ranked highest. Panelists noted that SDH content must be a part of standardized exams to be prioritized by faculty and students.
An expert panel endorsed essential curricular content, teaching methods, and evaluation approaches that can be used to help guide medical educators regarding SDH curriculum development.
To identify if triage hypothermia (<36.0 °C) among emergency department (ED) encounters with sepsis are independently associated with mortality.
We analyzed data from a multi-stage probability sample ...survey of visits to United States EDs between 2007 and 2015, using two inclusion approaches: an explicit definition based on diagnosis codes for sepsis and a severe sepsis definition, combining evidence of infection with organ dysfunction. We used multivariable regression to determine an association between hypothermia and in-hospital mortality.
Of 1.2 billion ED encounters (95% confidence interval CI 1.0–1.3 billion), 3.1 million (95% CI 2.7–3.5 million) met the explicit sepsis definition; 7.4% (95% CI 75.2–9.7%) had triage hypothermia. The adjusted odds ratio (aOR) for hypothermia for in-hospital mortality was 6.82 (95% CI 3.08–15.22). The severe sepsis definition identified 3.5 million (95% 3.1–4.0 million) encounters; 30.3% (95% CI 25.0–34.6%) had triage hypothermia. The aOR for hypothermia with mortality was 4.08 (95% CI 2.09–7.95). Depending on sepsis definition, 78.1–84.4% had other systemic inflammatory response syndrome vital sign abnormalities.
Up to one in three patients with sepsis have triage hypothermia, which is independently associated with mortality. 10–20% of patients with hypothermic sepsis do not have other vital sign abnormalities.
•Using an explicit definition for sepsis, 6% of patients present with hypothermia.•Hypothermia is an independent risk factor for in-hospital mortality.•10–20% of patients with hypothermic sepsis lack other triage vital sign abnormalities.
Background
A variety of approaches to defining sepsis using administrative datasets have been previously reported. We aimed to compare estimates, demographics, treatment factors, outcomes and ...longitudinal trends of patients identified with sepsis in United States emergency departments (EDs) using differing sets of sepsis criteria.
Methods
We performed a cross-sectional study using the National Healthcare Ambulatory Medical Care Survey, a complex survey of nonfederal US ED encounters between 2002 to 2018. We obtained survey-weighted population-adjusted encounters of sepsis using the following criteria: explicit sepsis, severe sepsis, and quick Sequential Organ Failure Assessment (qSOFA) score combined with the presence of infection.
Results
Age-adjusted for US adults, 18.6, 16.1 and 8.9 encounters per 10 000 population were identified when using the explicit, severe sepsis and qSOFA definitions, respectively. A higher proportion of the explicit cohort was hospitalized and had blood cultures performed, compared to cohorts ascertained using severe sepsis and qSOFA criteria, though confidence intervals overlapped. Antibiotic use was highest in encounters meeting qSOFA criteria. When inspecting unweighted encounters meeting each set of criteria, there was minimal overlap, with only 3% meeting all three. Encounters meeting the explicit and severe sepsis criteria were increasing over time.
Conclusion
The explicit, severe sepsis and qSOFA criteria generated similar annual rates of presentation when applied to US ED encounters, with some evidence of the explicit sepsis cohort being higher acuity. There was minimal overlap of cases and instability in estimates when assessed longitudinally. Our findings inform research efforts to accurately identify sepsis among ED encounters using administrative data.
Temporary transvenous cardiac pacing (TVP) is a critical intervention that emergency physicians perform infrequently in clinical practice. Prior simulation studies revealed that emergency medicine ...(EM) residents and board-certified emergency physicians perform TVP poorly during checklist-based assessments. Our objective in this report was to describe the design and implementation of a simulation-based mastery learning (SBML) curriculum and evaluate its impact on EM residents' ability to perform TVP.
An expert panel of emergency physicians and cardiologists set a minimum passing standard (MPS) for a previously developed 30-item TVP checklist using the Mastery Angoff approach. Emergency medicine residents were assessed using this checklist and a high-fidelity TVP task trainer. Residents who did not meet the MPS during baseline testing viewed a procedure video and completed a 30-minute individual deliberate practice session before retesting. Residents who did not meet the MPS during initial post-testing completed additional deliberate practice and assessment until meeting or exceeding the MPS.
The expert panel set an MPS of correctly performing 28 (93.3%) checklist items. Fifty-seven EM residents participated. Mean checklist scores improved from 13.4 (95% CI 11.8-15.0) during baseline testing to 27.5 (95% CI 26.9-28.1) during initial post-testing (P < 0.01). No residents met the MPS at baseline testing. The 21 (36.8%) residents who did not meet the MPS during initial post-testing all met or exceeded the MPS after completing one additional 30-minute deliberate practice session.
Emergency medicine residents demonstrated significantly improved TVP performance with reduced variability in checklist scores after completing a simulation-based mastery learning curriculum.
Background
Social determinants of health (SDOH) curricular content in medical schools and physician assistant programs are increasing. However, there is little understanding of current practice in ...SDOH learner assessment and program evaluation, or what the best practices are.
Objective
Our study aim was to describe the current landscape of assessment and evaluation at US medical schools and physician assistant programs as a first step in developing best practices in SDOH education.
Design
We conducted a national survey of SDOH educators from July to December 2020. The 55-item online survey covered learner assessment methods, program evaluation, faculty training, and barriers to effective assessment and evaluation. Results were analyzed using descriptive statistics.
Participants
One hundred six SDOH educators representing 26% of medical schools and 23% of PA programs in the USA completed the survey.
Key Results
Most programs reported using a variety of SDOH learner assessment methods. Faculty and self were the most common assessors of learners’ SDOH knowledge, attitudes, and skills. Common barriers to effective learner assessment were lack of agreement on “SDOH competency” and lack of faculty training in assessment. Programs reported using evaluation results to refine curricular content, identify the need for new content, and improve assessment strategies.
Conclusions
We identified a heterogeneity of SDOH assessment and evaluation practices among programs, as well as gaps and barriers in their educational practices. Specific guidance from accrediting bodies and professional organizations and agreement on SDOH competency as well as providing faculty with time, resources, and training will improve assessment and evaluation practice and ensure SDOH education is effective for students, patients, and communities.
Therapeutic antibodies against cancer Adler, Mark J; Dimitrov, Dimiter S
Hematology/oncology clinics of North America,
06/2012, Letnik:
26, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Antibody-based therapeutics against cancer are highly successful and currently enjoy unprecedented recognition of their potential; 13 monoclonal antibodies (mAbs) have been approved for clinical use ...in the European Union and in the United States. Bevacizumab, rituximab, and trastuzumab had sales in 2010 of more than $5 billion each. Hundreds of mAbs, including bispecific mAbs and multispecific fusion proteins, mAbs conjugated with small-molecule drugs, and mAbs with optimized pharmacokinetics, are in clinical trials. However, deeper understanding of mechanisms is needed to overcome major problems including resistance to therapy, access to targets, complexity of biological systems, and individual variations.
Detecting cancer at early stages significantly increases patient survival rates. Because lethal solid tumors often produce few symptoms before progressing to advanced, metastatic disease, diagnosis ...frequently occurs when surgical resection is no longer curative. One promising approach to detect early-stage, curable cancers uses biomarkers present in circulating extracellular vesicles (EVs). To explore the feasibility of this approach, we developed an EV-based blood biomarker classifier from EV protein profiles to detect stages I and II pancreatic, ovarian, and bladder cancer.
Utilizing an alternating current electrokinetics (ACE) platform to purify EVs from plasma, we use multi-marker EV-protein measurements to develop a machine learning algorithm that can discriminate cancer cases from controls. The ACE isolation method requires small sample volumes, and the streamlined process permits integration into high-throughput workflows.
In this case-control pilot study, comparison of 139 pathologically confirmed stage I and II cancer cases representing pancreatic, ovarian, or bladder patients against 184 control subjects yields an area under the curve (AUC) of 0.95 (95% CI: 0.92 to 0.97), with sensitivity of 71.2% (95% CI: 63.2 to 78.1) at 99.5% (97.0 to 99.9) specificity. Sensitivity is similar at both early stages stage I: 70.5% (60.2 to 79.0) and stage II: 72.5% (59.1 to 82.9). Detection of stage I cancer reaches 95.5% in pancreatic, 74.4% in ovarian (73.1% in Stage IA) and 43.8% in bladder cancer.
This work demonstrates that an EV-based, multi-cancer test has potential clinical value for early cancer detection and warrants future expanded studies involving prospective cohorts with multi-year follow-up.
PDF
