Addressing unprofessional behaviors in the clinical learning environment: lessons from a multi-year virtual, intergenerational, interdisciplinary workshop

INTRODUCTION

Optimizing the clinical learning environment (CLE) is a medical education priority nationwide.

MATERIALS AND METHODS

We developed a virtual, one-hour workshop engaging students, housestaff and faculty in small-group discussions of five case scenarios adapted from reported unprofessional behaviors in the CLE, plus didactics regarding mistreatment, microaggressions and bystander interventions.

RESULTS

Over two sessions (2021-2022), we engaged 340 students and 73 faculty/housestaff facilitators. Post-session surveys showed significant improvement in participants' ability to recognize and respond to challenges in the CLE.

DISCUSSION

Our innovative workshop, including scenarios derived from institutional reports of unprofessional behaviors, advanced participants' knowledge and commitment to improve the CLE.

Twelve tips for using the Understanding by Design® curriculum planning framework

BACKGROUND

Health professions faculty engaged in curriculum planning or redesign can struggle with developing courses or programs that align desired learner outcomes, such as competencies to be applied in a clinical setting, with assessment and instruction.

AIMS

Our medical school implemented the Understanding by Design (UbD) framework to achieve alignment of outcomes, assessments and teaching during the renewal of our four-year curriculum. This article shares our strategies and practices for implementing UbD with teams of faculty curriculum developers.

DESCRIPTION

The UbD framework is a 'backward' approach to curriculum development that begins by identifying learner outcomes, followed by the development of assessments that demonstrate achievement of competencies and concludes with the design of active learning experiences. UbD emphasizes the development of deep understandings that learners can transfer to novel contexts.

CONCLUSIONS

We found UbD to be a flexible, adaptable approach that aligns program and course-level outcomes with learner-centred instruction and principles of competency-based medical education and assessment.

Medical student advising during virtual residency recruitment: results of a national survey of internal medicine clerkship and sub-internship directors

INTRODUCTION

The residency application process is a critical time for medical students. The COVID-19 pandemic prompted changes to the residency recruitment procedures with the conversion of interviews to a virtual format. For medical school advisors guiding students on an all-virtual residency application process brought uncertainty to their advising practices. Thus, this study aimed to identify advising practices during the 2021 virtual application cycle.

METHODS

We administered an IRB-exempt national survey through the Clerkship Directors in Internal Medicine to 186 internal medicine core/co-/associate/assistant clerkship directors and sub-internship directors representing 140 Liaison Committee on Medical Education-accredited U.S./U.S.-territory-based medical schools in spring 2021. The 23-question survey was designed and pilot-tested by faculty-educators and leaders with expertise in undergraduate medical education. Data analysis included paired t- and z-tests and thematic analysis of open-ended questions.

RESULTS

The institutional response rate was 67% (93/140) and individual rate 55% (103/186). Half of the respondents felt prepared/very prepared (40% and 13% respectively) for their advising roles. Compared to pre-pandemic cycles, respondents advised a typical student in the middle-third of their class at their institution to apply to more residency programs (mean 24 programs vs 20, p < 0.001) and accept more interviews (mean 14 interviews vs 12, p < 0.001). Sixty-three percent (64/101) of respondents spent more time on student advising; 51% (51/101) reported more students asked them for informal advice. Fifty-nine percent (60/101) of respondents reported their advisees were able to assess a residency program 'somewhat well;' 31% (31/101) expressed that residency recruitment should remain entirely virtual in the future.

CONCLUSION

The transition to virtual residency recruitment due to COVID-19 prompted advising practices that may have contributed to application inflation and increased advising workload. Future studies should explore longitudinal outcomes of virtual interviews on student success to guide best practices in how to advise students during residency recruitment.

Effect of Broad-Spectrum Antibiotic De-escalation on Critically Ill Patient Outcomes: A Retrospective Cohort Study

PURPOSE

Antibiotic de-escalation (ADE) in critically ill patients is controversial. Previous studies mainly focused on mortality; however, data are lacking about superinfection. Therefore, we aimed to identify the impact of ADE versus continuation of therapy on superinfections rate and other outcomes in critically ill patients.

METHODS

This was a two-center retrospective cohort study of adults initiated on broad-spectrum antibiotics in the intensive care unit (ICU) for ≥ 48 h. The primary outcome was the superinfection rate. Secondary outcomes included 30-day infection recurrence, ICU and hospital length of stay, and mortality.

RESULTS

250 patients were included, 125 in each group (ADE group and continuation group). Broad spectrum antibiotic discontinuation occurred at a mean of 7.2 ± 5.2 days in the ADE arm vs. 10.3 ± 7.7 in the continuation arm (P value = 0.001). Superinfection was numerically lower in the ADE group (6.4% vs. 10.4%; P = 0.254), but the difference was not significant. Additionally, the ADE group had shorter days to infection recurrence (P = 0.045) but a longer hospital stay (26 (14-46) vs. 21 (10-36) days; P = 0.016) and a longer ICU stay (14 (6-23) vs. 8 (4-16) days; P = 0.002).

CONCLUSION

No significant differences were found in superinfection rates among ICU patients whose broad-spectrum antibiotics were de-escalated versus patients whose antibiotics were continued. Future research into the association between rapid diagnostics with antibiotic de-escalation in the setting of high resistance is warranted.

Reviewing Internal Medicine Clerkship Grading Through a Proequity Lens: Results of a National Survey

PURPOSE

Equity in assessment and grading has become imperative across medical education. Although strategies to promote equity exist, there may be variable penetrance across institutions. The objectives of this study were to identify strategies internal medicine (IM) clerkship directors (CDs) use to reduce inequities in assessment and grading and explore IM CDs' perceptions of factors that impede or facilitate the implementation of these strategies.

METHOD

From October to December 2021, the Clerkship Directors in Internal Medicine of the Alliance for Academic Internal Medicine conducted its annual survey of IM core CDs at 137 U.S. and U.S. territory-based medical schools. This study is based on 23 questions from the survey about equity in IM clerkship assessment and grading.

RESULTS

The survey response rate was 73.0% (100 of 137 medical school CDs). Use of recommended evidence-based strategies to promote equity in clerkship assessment and grading varied among IM clerkships. Only 30 respondents (30.0%) reported that their clerkships had incorporated faculty development on implicit bias for clinical supervisors of students; 31 (31.0%) provided education to faculty on how to write narrative assessments that minimize bias. Forty respondents (40.0%) provided guidance to clerkship graders on how to minimize bias when writing final IM clerkship summaries, and 41 (41.0%) used grading committees to determine IM clerkship grades. Twenty-three CDs (23.0%) received formal education by their institution on how to generate clerkship grades and summaries in a way that minimized bias.

CONCLUSIONS

This national survey found variability among medical schools in the application of evidence-based strategies to promote equity in assessment and grading within their IM clerkships. Opportunities exist to adopt and optimize proequity grading strategies, including development of programs that address bias in clerkship assessment and grading, reevaluation of the weight of standardized knowledge exam scores on grades, and implementation of grading committees.

Saudi Critical Care Society clinical practice guidelines on the prevention of venous thromboembolism in adults with trauma: reviewed for evidence-based integrity and endorsed by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

BACKGROUND

To develop evidence-based clinical practice guidelines on venous thromboembolism (VTE) prevention in adults with trauma in inpatient settings.

METHODS

The Saudi Critical Care Society (SCCS) sponsored guidelines development and included 22 multidisciplinary panel members who completed conflict-of-interest forms. The panel developed and answered structured guidelines questions. For each question, the literature was searched for relevant studies. To summarize treatment effects, meta-analyses were conducted or updated. Quality of evidence was assessed using the Grading Recommendations, Assessment, Development, and Evaluation (GRADE) approach, then the evidence-to-decision (EtD) framework was used to generate recommendations. Recommendations covered the following prioritized domains: timing of pharmacologic VTE prophylaxis initiation in non-operative blunt solid organ injuries; isolated blunt traumatic brain injury (TBI); isolated blunt spine trauma or fracture and/or spinal cord injury (SCI); type and dose of pharmacologic VTE prophylaxis; mechanical VTE prophylaxis; routine duplex ultrasonography (US) surveillance; and inferior vena cava filters (IVCFs).

RESULTS

The panel issued 12 clinical practice recommendations-one, a strong recommendation, 10 weak, and one with no recommendation due to insufficient evidence. The panel suggests starting early pharmacologic VTE prophylaxis for non-operative blunt solid organ injuries, isolated blunt TBIs, and SCIs. The panel suggests using low molecular weight heparin (LMWH) over unfractionated heparin (UFH) and suggests either intermediate-high dose LMWH or conventional dosing LMWH. For adults with trauma who are not pharmacologic candidates, the panel strongly recommends using mechanical VTE prophylaxis with intermittent pneumatic compression (IPC). The panel suggests using either combined VTE prophylaxis with mechanical and pharmacologic methods or pharmacologic VTE prophylaxis alone. Additionally, the panel suggests routine bilateral lower extremity US in adults with trauma with elevated risk of VTE who are ineligible for pharmacologic VTE prophylaxis and suggests against the routine placement of prophylactic IVCFs. Because of insufficient evidence, the panel did not issue any recommendation on the use of early pharmacologic VTE prophylaxis in adults with isolated blunt TBI requiring neurosurgical intervention.

CONCLUSION

The SCCS guidelines for VTE prevention in adults with trauma were based on the best available evidence and identified areas for further research. The framework may facilitate adaptation of recommendations by national/international guideline policymakers.

Emergence of Canonical and Noncanonical Genomic Variants following In Vitro Exposure of Clinical Mycobacterium tuberculosis Strains to Bedaquiline or Clofazimine

In Mycobacterium tuberculosis, bedaquiline and clofazimine resistance occurs primarily through Rv0678 variants, a gene encoding a repressor protein that regulates mmpS5/mmpL5 efflux pump gene expression. Despite the shared effect of both drugs on efflux, little else is known about other pathways affected. We hypothesized that in vitro generation of bedaquiline- or clofazimine-resistant mutants could provide insight into additional mechanisms of action. We performed whole-genome sequencing and determined phenotypic MICs for both drugs on progenitor and mutant progenies. Mutants were induced through serial passage on increasing concentrations of bedaquiline or clofazimine. Rv0678 variants were identified in both clofazimine- and bedaquiline-resistant mutants, with concurrent atpE SNPs occurring in the latter. Of concern was the acquisition of variants in the F420 biosynthesis pathway in clofazimine-resistant mutants obtained from either a fully susceptible (fbiD: del555GCT) or rifampicin mono-resistant (fbiA: 283delTG and T862C) progenitor. The acquisition of these variants possibly implicates a shared pathway between clofazimine and nitroimidazoles. Pathways associated with drug tolerance and persistence, F420 biosynthesis, glycerol uptake and metabolism, efflux, and NADH homeostasis appear to be affected following exposure to these drugs. Shared genes affected by both drugs include Rv0678, glpK, nuoG, and uvrD1. Genes with variants in the bedaquiline resistant mutants included atpE, fadE28, truA, mmpL5, glnH, and pks8, while clofazimine-resistant mutants displayed ppsD, fbiA, fbiD, mutT3, fadE18, Rv0988, and Rv2082 variants. These results show the importance of epistatic mechanisms as a means of responding to drug pressure and highlight the complexity of resistance acquisition in M. tuberculosis.

Near-peers effectively teach clinical documentation skills to early medical students

BACKGROUND

Composing the History of Present Illness (HPI), a key component of medical communication, requires critical thinking. Small group learning strategies have demonstrated superior effectiveness at developing critical thinking skills. Finding sufficient faculty facilitators for small groups remains a major gap in implementing these sessions. We hypothesized that "near-peer" teachers could effectively teach HPI documentation skills and fill the gap of small group facilitators. Here, we present a head-to-head comparison of near-peer and faculty teaching outcomes.

METHODS

Second-year medical students in a single institution participated in an HPI Workshop as a clinical skills course requirement. Students were randomly assigned a near-peer or faculty facilitator for the workshop. We compared mean facilitator evaluation scores and performance assessments of students assigned to either type of facilitator.

RESULTS

Three hundred sixty-five students, 29 residents (near-peers) and 16 faculty participated. On post-session evaluations (5-point Likert scale), students ranked near-peer facilitators higher than faculty facilitators on encouraging participation and achieving the goals of the session (residents 4.9, faculty 4.8), demonstrating small, statistically significant differences between groups. Mean scores on written assessments after the workshop did not differ between the groups (29.3/30 for a written H&P and 9/10 for an HPI exam question).

CONCLUSIONS

Near-peer facilitators were as effective as faculty facilitators for the HPI Workshop. Utilizing near-peers to teach HPI documentation skills provided teaching experiences for residents and increased the pool of available facilitators.

644 Improving VTE Prophylaxis in Spinal Patients – a Closed Loop Audit

Aim

Venous thromboembolism (VTE) prophylaxis is one of the key components of safe patient care and can be particularly challenging when it concerns spinal admissions to the orthopaedic trauma ward. The first cycle of our closed loop audit aimed to assess the safety of VTE prescribing in spinal admissions at a district general hospital. The current cycle aims to evaluate guideline compliance following our interventions.

Method

Quality of VTE prophylaxis prescribing was measured against NICE (NG89) recommendations as well as local guidelines. Patients were identified based on prospectively maintained admission lists. The initial audit cycle was presented locally, and the following measures were introduced in order to improve prescribing: staff teaching sessions, nomination of a VTE guardian, inclusion of VTE plans in op-notes, publication of a dedicated spinal guideline and addition of a spinal section into the trust principal VTE guideline. The current audit cycle identified 22 spinal admissions.

Results

Out of the 22 patients, only one (4%) received inadequate VTE prophylaxis which is a significant improvement compared to the initial data (8 cases - 18%). Minor prescribing concerns were noted in three cases (14%) versus 15 cases (34%) in the first cycle. Overall, the re-audit proved that following departmental interventions the majority of patients received appropriate VTE prophylaxis with no prescribing or documentation errors (82% in the current cycle vs 48% initially).

Conclusions

We have demonstrated that significant improvement in VTE prophylaxis prescribing can be achieved by the means of educating staff and introducing simple and cost-effective measures.

Becoming a Doctor During a Pandemic: Impact on Medical Student Social Identity Formation

The COVID-19 pandemic required modifications to undergraduate medical education that likely affected medical students' social identity formation (SIF). SIF is shaped by experiences throughout the medical education continuum. This commentary explores factors potentially affecting medical student SIF during the COVID-19 pandemic focusing on students' perceptions of being part of the healthcare team, their role in medicine, and their engagement during the pandemic. Based on such considerations, we propose that educators should aim to design effective learning environments to support a full educational experience that encompasses acquiring medical knowledge and building strong social identities even during a pandemic.

Innovation and Missed Opportunities in Internal Medicine Undergraduate Education During COVID-19: Results from a National Survey

BACKGROUND

COVID-19 disrupted undergraduate clinical education when medical schools removed students from clinical rotations following AAMC recommendations. Clerkship directors (CDs) had to adapt rapidly and modify clerkship curricula. However, the scope and effects of these modifications are unknown.

OBJECTIVE

To examine the effects of the initial phase of COVID-19 on the internal medicine (IM) undergraduate clinical education.

DESIGN

A nationally representative web survey.

PARTICIPANTS

IM CDs from 137 LCME-accredited US medical schools in 2020.

MAIN MEASURES

Items (80) assessed clerkship structure and curriculum, assessment in clerkships, post-clerkship IM clinical experiences, and CD roles and support. The framework of Understanding Crisis Response (Royal Society for Encouragement of Arts, Manufactures, and Commerce) was used to determine whether curricular modifications were "amplified," "restarted," "let go," or "ended."

KEY RESULTS

Response rate was 74%. In response to COVID-19, 32% (32/101) of clerkships suspended all clinical activities and 66% (67/101) only in-person. Prior to clinical disruption, students spent a median of 8.0 weeks (IQR: 2) on inpatient and 2.0 weeks (IQR: 4) on ambulatory rotations; during clinical re-entry, students were spending 5.0 (IQR: 3) and 1.0 (IQR: 2) weeks, respectively. Bedside teaching and physical exam instruction were "let go" during the early phase. Students were removed from direct patient care for a median of 85.5 days. The sub-internship curriculum remained largely unaffected. Before the pandemic, 11% of schools were using a pass/fail grading system; at clinical re-entry 47% and during the survey period 23% were using it. Due to the pandemic, 78.2% of CDs assumed new roles or had expanded responsibilities; 51% reported decreased scholarly productivity.

CONCLUSIONS

Curricular adaptations occurred in IM clerkships across US medical schools as a result of COVID-19. More research is needed to explore the long-term implications of these changes on medical student education and clinical learning environments.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Longitudinal Association between Sarcopenia and Cognitive Impairment among Older Adults in Rural Malaysia

Sarcopenia is a condition that is highly prevalent among older adults. This condition is linked to numerous adverse health outcomes, including cognitive impairment that impairs healthy ageing. While sarcopenia and cognitive impairment may share a common pathway, limited longitudinal studies exist to show the relationship between these two conditions. Therefore, this study aimed to examine the longitudinal association between sarcopenia and cognitive impairment. This is a cohort study among older adults residing in Kuala Pilah District, Negeri Sembilan, Malaysia. There were 2404 respondents at the baseline and 1946 respondents at one-year follow-up. Cognitive impairment was determined using Mini-mental State Examination scores. Sarcopenia was identified using the Asian Working Group for Sarcopenia 2019 criteria, gait speed was measured using a 4-meter gait test, handgrip strength was assessed using Jamar handheld dynamometer, and appendicular skeletal muscle mass was measured using bioelectrical impedance analysis. Generalized estimating equation (GEE) was used to determine the longitudinal association between sarcopenia and cognitive impairment, presented as relative risk (RR) and its 95% confidence interval. The prevalence of sarcopenia was 5.0% (95% CI 4.00–5.90), and severe sarcopenia was 3.60% (95% CI 2.84–4.31). Upon adjusting for covariates, older adults with sarcopenia have an 80 per cent increased risk of cognitive impairment compared to those without (RR 1.80; 95% CI 1.18–2.75). Similarly, severe sarcopenia was found to significantly increase the risk of cognitive impairment by 101 per cent in the adjusted model (RR 2.01; 95% CI 1.24–3.27). Our study showed that sarcopenia, severe sarcopenia, low physical activity, depressive symptoms, hearing impairment and chronic pain were associated with a higher risk of cognitive impairment among community-dwelling older adults. Therefore, early intervention to prevent sarcopenia, depressive symptoms, hearing impairment, chronic pain, and higher physical activity among older adults is recommended.

Antibacterial and Antifouling Properties of the Horseshoe Crab Carcinoscorpius rotundicauda

&lt;b&gt;Background and Objective:&lt;/b&gt; Horseshoe crabs are widely used in both traditional and modern pharmaceutical applications. Most of the previous studies on horseshoe crabs focused on their blood which contains hemolymph and amoebocyte lysate. This study aimed to determine the potential antibacterial and antifouling properties of different extracts from the carapace and the book gills of &lt;i&gt;Carcinoscorpius rotundicauda&lt;/i&gt;. &lt;b&gt;Materials and Methods:&lt;/b&gt; The crude extracts were subjected to the bioactivity tests using the disc-diffusion and the inhibition of biofilm-formation measurement assays, for both the antibacterial and antifouling activities respectively. &lt;b&gt;Results:&lt;/b&gt; The results obtained indicated that the carapace extracts had stronger antibacterial and antifouling effects compared to the book gills extracts. Extracts obtained from the male displayed more activity compared to the extracts from the female with a few exceptions. Methanol and acetone carapace crude extracts showed the best overall performance. A sterol compound was isolated from the carapace acetone extracts of the male of &lt;i&gt;C. rotundicauda&lt;/i&gt;. However, the compound did not display strong activity compared to the crude extract. The compound might be contributing to the observed activity with other components through a synergistic effect. &lt;b&gt;Conclusion:&lt;/b&gt; The presence of antibacterial and antifouling activities in the carapace and book gills extracts could be added to the complexity of the defence mechanisms of horseshoe crabs. The results of this study, therefore, may contribute to the knowledge of the defence mechanisms of &lt;i&gt;C. rotundicauda&lt;/i&gt;. Further research is needed to determine the bioactivities of other parts of the animal and to explore their potential applications.

Strategies From 11 U.S. Medical Schools for Integrating Basic Science Into Core Clerkships

Calls for curricular reform in medical schools and enhanced integration of basic and clinical science have resulted in a shift toward preclerkship curricula that enhance the clinical relevance of foundational science instruction and provide students with earlier immersion in the clinical environment. These reforms have resulted in shortened preclerkship curricula, yet the promise of integrated basic science education into clerkships has not been sufficiently realized because of barriers such as the nature of clinical practice, time constraints, and limited faculty knowledge. As personalized medicine requires that physicians have a more nuanced understanding of basic science, this is cause for alarm. To address this problem, several schools have developed instructional and assessment strategies to better integrate basic science into the clinical curriculum. In this article, faculty and deans from 11 U.S. medical schools discuss the strategies they implemented and the lessons they learned to provide guidance to other schools seeking to enhance basic science education during clerkships. The strategies include program-level interventions (e.g., longitudinal sessions dedicated to basic science during clerkships, weeks of lessons dedicated to basic science interspersed in clerkships), clerkship-level interventions (e.g., case-based learning with online modules, multidisciplinary clerkship dedicated to applied science), bedside-level interventions (e.g., basic science teaching scripts, self-directed learning), and changes to formative and summative assessments (e.g., spaced repetition/leveraging test-enhanced learning, developing customized examinations). The authors discovered that: interventions were more successful when buy-in from faculty and students was considered, central oversight by curricular committees collaborating with faculty was key, and some integration efforts may require schools to provide significant resources. All schools administered the United States Medical Licensing Examination Step 1 exam to students after clerkship, with positive outcomes. The authors have demonstrated that it is feasible to incorporate basic science into clinical clerkships, but certain challenges remain.

Variations in Medical Students' Educational Preferences, Attitudes and Volunteerism during the COVID-19 Global Pandemic

Public health crises require individuals, often volunteers, to help minimize disasters. The COVID-19 pandemic required such activation of individuals, but little is known about medical students' preferences of such engagement. We investigated potential variations in medical students' educational preferences, attitudes, and volunteerism during the COVID-19 pandemic based on socio-demographics to better prepare for future activation scenarios. A web-based, anonymous survey of U.S. medical students at a single institution was conducted in May 2020. Across four training year, 518 (68% response rate) students completed the survey. During the pandemic, 42.3% (n = 215) wanted to discontinue in-person clinical experiences, 32.3% (n = 164) wanted to continue, and 25.4% (n = 129) were neutral. There was no gender effect for engagement in volunteer activities or preference to engage in clinical activities during the pandemic. However, second-year (n = 59, 11.6%) and third-year students (n = 58, 11.4%) wanted to continue in-person clinical experiences at a greater proportion than expected, while a small proportion of fourth-year students (n = 17, 3.3%) wanted to continue, χ²(6) = 43.48, p < .001, φ = 0.29. Majority of respondents (n = 287, 55.5%) volunteered in clinical and non-clinical settings. A lower proportion of fourth-year (n = 12, 2.3%) and first-year students (n = 50, 9.7%) volunteered than expected. Likelihood to volunteer during a pandemic varied by gender, training year, and/or prior experience with disaster event depending on the type of volunteer-site setting. Our findings suggest socio-demographic factors may impact medical student engagement and volunteerism during a public health crisis. Educational leadership should be sensitive to such variations and can facilitate volunteer activities that allow student engagement during future pandemics.

Anti-salmonellosis agent for foodborne illness from Mangifera odorata (kuini) extracts

Salmonellosis infection caused by Salmonella bacteria is a public endemic problem in Malaysia with long-term morbidity and mortality effects. Thus, this study aimed to explore the antipathogenic activity of natural extracts from Mangifera odorata against two Salmonella species causing Salmonellosis. The extracts were derived from peel, flesh, and kernel seed of M. odorata. The inhibition performance of the extracts against both Salmonella enterica serovar Typhimurium and Salmonella enterica serovar Enteritidis bacteria were subsequently tested by using a bioassay-guided fractionation method. Results showed that the extracts derived from the kernel seed had the highest inhibition percentage of 83-90% against the Salmonellosis infection, followed by the peel with an inhibition of 61-67%, and lastly the flesh with an inhibition of 53-69%. The inhibition activities of hexane extracted flesh (FCH), methanol extracted peel (PCM), and methanol treated kernel seed (KTM) against S. enterica ser. Typhimurium bacteria were 59, 67 and 83%, respectively. Furthermore, the S. enterica ser. Enteritidis bacteria were found to be highly susceptible against the methanol extracted kernel seed (KCM), followed by the hexane extracted peel (PCH) and flesh (FTH) with the inhibition percentage of 90, 69 and 59%, respectively. The highly active anti-Salmonellosis performance of M. odorata extracts was attributed to its intrinsically high total phenolics content at 8-10 g GAE/g extract, high ferric reducing antioxidant power value (FRAP) at 18-22 g Fe2+/g extract and excellent scavenging activity with the inhibition performance ranges between 86% and 90%. This study revealed the antipathogenic activity of methanol extracts of M. odorata kernel seed inhibited the growth of both S. enterica ser. Typhimurium and S. enterica ser. Enteritidis bacteria. This study also discovered the prophylactic property of natural compounds in M. odorata kernel seed extracts and could be used as an anti-Salmonellosis agent. In the near future, M. odorata can be developed as an innovative functional food source for specific groups that are vulnerable to Salmonellosis

Implementing novel regimens for drug-resistant TB in South Africa: what can the world learn?

Worldwide uptake of new drugs in the treatment of rifampicin-resistant tuberculosis (RR-TB) has been extremely low. In June 2018, ahead of the release of the updated WHO guidelines for the management of RR-TB, South Africa announced that bedaquiline (BDQ) would be provided to virtually all RR-TB patients on shorter or longer regimens. South Africa has been the global leader in accessing BDQ for patients with RR-TB, who now represent 60% of the global BDQ cohort. The use of BDQ within a shorter modified regimen has generated the programmatic data underpinning the most recent change in WHO guidelines endorsing a shorter, injectable-free regimen. Progressive policies on access to new drugs have resulted in improved favourable outcomes and a reduction in mortality among RR-TB patients in South Africa. This supported global policy change. The strategies underpinning these bold actions include close collaboration between the South African National TB Programme and partners, introduction of new TB diagnostic tools in closely monitored conditions and the use of locally generated programmatic evidence to inform country policy changes. In this paper, we summarise a decade´s work that led to the bold decision to use a modified, short, injectable-free regimen with BDQ and linezolid under carefully monitored programmatic conditions.

Determining Grades in the Internal Medicine Clerkship: Results of a National Survey of Clerkship Directors

PURPOSE

Trust in and comparability of assessments are essential in clerkships in undergraduate medical education for many reasons, including ensuring competency in clinical skills and application of knowledge important for the transition to residency and throughout students' careers. The authors examined how assessments are used to determine internal medicine (IM) core clerkship grades across U.S. medical schools.

METHODS

A multisection web-based survey of core IM clerkship directors at 134 U.S. medical schools with membership in the Clerkship Directors in Internal Medicine was conducted in October through November 2018. The survey included a section on assessment practices to characterize current grading scales used, who determines students' final clerkship grades, the nature/type of summative assessments, and how assessments are weighted. Respondents were asked about perceptions of the influence of the National Board of Medical Examiners (NBME) Medicine Subject Examination (MSE) on students' priorities during the clerkship.

RESULTS

The response rate was 82.1% (110/134). There was considerable variability in the summative assessments and their weighting in determining final grades. The NBME MSE (91.8%), clinical performance (90.9%), professionalism (70.9%), and written notes (60.0%) were the most commonly used assessments. Clinical performance assessments and the NBME MSE accounted for the largest percentage of the total grade (on average 52.8% and 23.5%, respectively). Eighty-seven percent of respondents were concerned that students' focus on the NBME MSE performance detracted from patient care learning.

CONCLUSIONS

There was considerable variability in what IM clerkships assessed and how those assessments were translated into grades. The NBME MSE was a major contributor to the final grade despite concerns about the impact on patient care learning. These findings underscore the difficulty in comparing learners across institutions and serve to advance discussions for how to improve accuracy and comparability of grading in the clinical environment.

Gene-environment interaction in chronic kidney disease among people with type 2 diabetes from The Malaysian Cohort project: a case-control study

AIM

To examine the possible gene-environment interactions between 32 single nucleotide polymorphisms and environmental factors that could modify the probability of chronic kidney disease.

METHODS

A case-control study was conducted involving 600 people with type 2 diabetes (300 chronic kidney disease cases, 300 controls) who participated in The Malaysian Cohort project. Retrospective subanalysis was performed on the chronic kidney disease cases to assess chronic kidney disease progression from the recruitment phase. We genotyped 32 single nucleotide polymorphisms using mass spectrometry. The probability of chronic kidney disease and predicted rate of newly detected chronic kidney disease progression were estimated from the significant gene-environment interaction analyses.

RESULTS

Four single nucleotide polymorphisms (eNOS rs2070744, PPARGC1A rs8192678, KCNQ1 rs2237895 and KCNQ1 rs2283228) and five environmental factors (age, sex, smoking, waist circumference and HDL) were significantly associated with chronic kidney disease. Gene-environment interaction analyses revealed significant probabilities of chronic kidney disease for sex (PPARGC1A rs8192678), smoking (eNOS rs2070744, PPARGC1A rs8192678 and KCNQ1 rs2237895), waist circumference (eNOS rs2070744, PPARGC1A rs8192678, KCNQ1 rs2237895 and KCNQ1 rs2283228) and HDL (eNOS rs2070744 and PPARGC1A rs8192678). Subanalysis indicated that the rate of newly detected chronic kidney disease progression was 133 cases per 1000 person-years (95% CI: 115, 153), with a mean follow-up period of 4.78 (SD 0.73) years. There was a significant predicted rate of newly detected chronic kidney disease progression in gene-environment interactions between KCNQ1 rs2283228 and two environmental factors (sex and BMI).

CONCLUSIONS

Our findings suggest that the gene-environment interactions of eNOS rs2070744, PPARGC1A rs8192678, KCNQ1 rs2237895 and KCNQ1 rs2283228 with specific environmental factors could modify the probability for chronic kidney disease.

Nebulized tranexamic acid for recurring hemoptysis in critically ill patients: case series

BACKGROUND

Hemoptysis is a clinical condition encountered in the emergency department (ED) and must be managed and investigated urgently to maintain the patient's hemostasis. The management of hemoptysis depends on treating the underlying cause. Tranexamic acid (TXA) is an anti-fibrinolytic drug used to systemically control bleeding. There are a few studies available that investigate the use of nebulized tranexamic acid for hemoptysis with contradictory results. Our paper demonstrates three cases where patients presented with significant hemoptysis and had significant improvement in symptoms following the administration of nebulized tranexamic acid. The overall need for blood transfusion was reduced.

RESULTS

Three patients presented to the emergency room for evaluation of hemoptysis. All three patients had different underlying pathologies resulting in their hemoptysis and were monitored in the ICU. Initial conventional medical therapies including the correction of coagulopathy and discontinuing offending agents were utilized for treatment. After persistent symptoms, nebulized TXA at a dose of 500 mg three times a day was administered. The patients were all discharged from the hospital with improvement in their symptoms.

CONCLUSION

Tranexamic acid may be considered in the treatment of hemoptysis regardless of the underlying cause. This may be utilized pending further workup and investigation into the underlying source of the bleeding.

Teaching Laboratory Stewardship in the Medical Student Core Clerkships Pathology-Teaches

CONTEXT.—

Current health care spending is unsustainable, and there is a need to teach high-value care principles to future physicians. Pathology-Teaches is an educational intervention designed to teach laboratory stewardship early in clinical training, at the level of the medical student in their core clinical clerkships.

OBJECTIVE.—

To assess the pilot implementation of case-based educational modules in 5 required core clerkships at our institution.

DESIGN.—

The online cases were developed by using a multidisciplinary approach. In the Pathology-Teaches educational module, students make decisions regarding the ordering or interpretation of laboratory testing within the context of a clinical scenario and receive immediate feedback during the case. The intervention was assessed by using pretest and posttest. Student feedback was also collected from end-of-rotation evaluations.

RESULTS.—

A total of 203 students completed the Pathology-Teaches pilot, including 72 in Family Medicine, 72 in Emergency Medicine, 24 in Internal Medicine, 24 in Neurology, and 11 in Obstetrics-Gynecology (OB-GYN). Pathology-Teaches utility was demonstrated by significantly increased improvement between pretest and posttest scores (mean, 63.1% versus 83.5%; P < .001; Hedge g effect size = 0.93). Of the 494 students who completed the Pathology-Teaches questions on the end-of-rotation evaluation, 251 provided specific feedback, with 38.6% (97 of 251) rating the activity as "extremely valuable" or "very valuable," and 41.4% (104 of 251) as "some/moderate value." Qualitative feedback included 17 positive comments with 6 requests to scale up or include more cases, 16 constructive comments for improvement mainly regarding the technical aspects, and 5 negative comments.

CONCLUSIONS.—

Pathology-Teaches effectively teaches stewardship concepts, and most students perceived value in this educational intervention.

The developed Arabic version of the Hearing Handicap Inventory for the Elderly

Background

Hearing impairment ranks third on the list of chronic health conditions of the elderly, after arthritis and hypertension. As average lifespans increase, it is likely that the proportion of people with hearing loss will also increase. The purpose of the study was to develop, standardize, and apply an Arabic version of the Hearing Handicap Inventory for the Elderly (HHIE).

Results

The mean age of the 100 subjects included in the pretest was 64.92 ± 5.937 with age ranged from 60 to 84 years. The average score for each item (simple, clear, and relevant) for each separate question obtained more than 80% which is considered valid. One hundred percent of the participants reported that the entire inventory appeared simple, clear, and relevant, we further implied the jury opinion; the total score average of our jury for the entire inventory was calculated to determine the face validity of the questionnaire and found to be 89.81%. Responses of all participants for each question were collected and showed questions 8, 21, 6, 7, and 14 obtained the highest response results for both yes and sometimes. The HHIE showed high reliability (p value < 0.001) for all questions. The demographic data of the forty participants showed no statistically significant difference between the complaining group of hearing loss and the non-complaining group as regards age and gender. There was a highly statistically significant difference between the complaining group and the non-complaining group regarding the HHIE. The sensitivity of the HHIE was 79% for severe auditory handicapping and only 24% for mild-to-moderate auditory handicapping.

Conclusion

The developed Arabic version of the HHIE has high reliability, validity, simplicity, and clarity which found consistent with the original English questionnaire and it performed well in the detection of hearing loss in elderly Egyptians. It can be applied in a large population and for use in surveys.

Industrial enzymes-producing marine bacteria from marine resources

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Lipase is the most dominant industrial enzyme produced by cultivated marine bacteria.

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Genetic variation determines the yield of enzyme production.

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Proteobacteria (Vibrio spp.) is the main producer of industrial enzymes.

Industrial enzymes are important for various biotechnological applications. Currently, the diversity of industrial enzymes-producing marine bacteria from Malaysia remains mostly unknown. This study investigated the diversity of industrial enzyme-producing marine bacteria from culture collections at the Institute of Marine Biotechnology, Universiti Malaysia Terengganu. Out of 200 bacterial isolates revived, 163 bacteria isolate were successfully growth. Marine bacteria produced enzymes with total scoring higher than four were selected for molecular identification using 16S rDNA. About 161 bacteria isolate secreted amylase (68.7 %), lipase (88.3 %) and protease (68.7 %). The phylogenetic analysis led to the identification of three major phyla, namely Proteobacteria, Firmicutes and Bacteroidetes. These phyla were differentiated into nine genera consisted of Bacillus, Chryseomicrobium, Photobacterium, Pseudoalteromonas, Ruegeria, Shewanella, Solibacillus, Tenacibaculum and Vibrio. Genetic variation was more likely to occur within similar marine bacteria species. The microbial community was found to affect the production of industrial enzymes and the diversity of marine bacteria.

Extensively drug-resistant tuberculosis 'hotspots' and sociodemographic associations in Durban, South Africa

<sec> <title>BACKGROUND</title> In KwaZulu-Natal, South Africa, the incidence of extensively drug-resistant tuberculosis (XDR-TB) is driven by the transmission of resistant strains. As data suggest that cases may be spatially clustered, we sought to identify 'hotspots' and describe these communities. </sec> <sec> <title>METHODS</title> We enrolled XDR-TB patients diagnosed from 2011 to 2014 in eThekwini. Global positioning system (GPS) coordinates for participant homes were collected and hotspots were identified based on population-adjusted XDR-TB incidence. The sociodemographic features of hotspots were characterised using census data. For a subset of participants, we mapped non-home XDR-TB congregate locations and compared these with results including only homes. </sec> <sec> <title>RESULTS</title> Among 132 participants, 75 (57%) were female and 87 (66%) lived in urban or suburban locations. Fifteen of 197 census tracts were identified as XDR-TB hotspots with ≥95% confidence. Four spatial mapping methods identified one large hotspot in northeastern eThekwini. Hotspot communities had higher proportions of low educational attainment (12% vs. 9%) and unemployment (29.3% vs. 20.4%), and lower proportion of homes with flush toilets (36.4% vs. 68.9%). The case density shifted towards downtown Durban when congregate locations (e.g., workplaces) for 43 (33%) participants were mapped. </sec> <sec> <title>CONCLUSIONS</title> In eThekwini, XDR-TB case homes were clustered into hotspots with more poverty indicators than non-hotspots. Prevention efforts targeting hotspot communities and congregate settings may be effective in reducing community transmission. </sec>.

Chemical and antibacterial data of synthesized thioureido derivatives

This paper provided comprehensive data on spectroscopic and antibacterial activities of thioureido compounds which are relevant with research article entitled “Synthesis, Spectroscopic Studies and Antibacterial Activity of New Lauroyl Thiourea Amino Acid Derivatives” [1]. Based on the reported study, four new thioureido derivatives, namely 3-(3-dodecanoyl-thioureido)propionic acid (R1), 2-(3-dodecanoyl-thioureido)-3-methyl butyric acid (R2), (3-dodecanoyl-thioureido)acetic acid (R3) and 2-(3-dodecanoyl-thioureido)-3-phenyl propionic acid (R4) were characterized by elemental analysis, Fourier Transform Infrared (FTIR), ¹H Nuclear Magnetic Resonance (¹H NMR) and ¹³C Nuclear Magnetic Resonance (¹³C NMR), and Ultraviolet Visible spectroscopy (UV-Vis). The preliminary results from antibacterial assay which were tested against Gram-positive bacteria such as Bacillus subtilis, Staphylococcus epidermidis, Staphylococcus aureus and Gram-negative bacteria such as Escherichia coli, Salmonella typhimurium are also described.

Impact of austerity on prison health in England: a qualitative study involving national policymakers

Prisons offer states access to a population that is at high risk of morbidity. The UK austerity policy adopted in 2010 led to a 22% reduction (-£2.71bn) in prison spending by 2017. Whilst the number of prison officers dropped by 30%, the long-term impact of austerity on prison health in England has not been systematically contextualised. This research seeks to articulate the impact of austerity on prison health in England from the perspective of national policymakers.

Semi-structured interviews (X: 66 min) were conducted with 30 key prison policymakers. Constructivist grounded theory was used to assess the impact of austerity on prisoner health in England. Transcripts of 195,680 narrative texts were analysed using NVivo 11 until data saturation was achieved.

As a stealthy political ideology, austerity has caused societal disruption, which disproportionately affects prisons. The lack of access to services offered by the welfare state, including health-related provisions, precipitates societal unrest, increases prisoner numbers, and encourages harsher and longer sentences.

The prolonged constrained funding and the burgeoning population widen health inequalities in prisons. Healthcare provisions become increasingly limited, which unduly affects older and female prisoners who require more complex support. The degrading living conditions and lack of purposeful activities contribute to the increasing violence, self-harm and suicides in prisons, and reorient the healthcare provision from planned services to health emergencies. The excessive focus on Brexit and the perpetual changing political direction imposed on prisons reinforce the system’s instability.

Despite having the fifth largest economy in the world, England’s poorest population continues to bear the brunt of austerity. Initiating a more informed economic recovery policy and considering alternatives to imprisonment would help to ensure that England lives up to its view of itself as a progressive society.

Prevalence and characteristics of e-cigarette users among Malaysian current and ex-smokers

INTRODUCTION

Electronic cigarettes (ECs) are new devices that have been accepted widely by both smokers and non-smokers. However, the evidence on EC used in Malaysia is scarce. The objective of this study was to determine the prevalence of EC use and the socio-demographic and smoking characteristics associated with current EC use among Malaysian current and ex-smokers.

METHODS

This was a sub-analysis of data from a cross-sectional, national-population- based EC study conducted from May to June in 2016 in Malaysia. A detailed description of the sampling methods can be found in the National E-cigarette Survey (NECS) 2016 report. Briefly, data were obtained from 1396 individuals who had ever been smokers, i.e., 957 (68.6%) current smokers and 439 (31.4%) ex-smokers.

RESULTS

Current EC use was found predominantly among current smokers (8.0%) as compared with ex-smokers (4.3%). Among current smokers, the main reasons given for smoking ECs were wanting to try it (44.7%), followed by intention to quit tobacco smoking (15.8%) and to reduce tobacco smoking (10.5%). Using multiple logistic regression analysis, we found that among current smokers, current EC users were more likely to be younger, i.e., 18-44 years (aOR= 4.83, 95% CI= 1.97-11.86, p=0.001), urban residents (aOR= 1.89, 95% CI= 1.15-3.11, p=0.012), single/ divorced/ widowed (aOR= 2.11, 95% CI= 1.24-3.61, p=0.006) and students (aOR= 2.25, 95% CI= 1.01-5.01, p=0.048). Among exsmokers, only younger respondents (18-44 years old) was reported as being more likely to be current EC users (aOR= 3.81, 95% CI= 1.14-12.76, p=0.030).

CONCLUSION

This study showed that currently using and ever having used ECs were more prevalent among current smokers. The reasons given for initiating EC use among current smokers were mainly wanting to try it, followed by intention to quit and to reduce tobacco smoking. Current EC use appears to be common among current smokers who are younger, urban residents, single/divorced/widowed and students. Therefore, EC cessation intervention strategies and policies should target these high-prevalence groups.

Development and validation of TaqMan real-time PCR for the detection of Burkholderia pseudomallei isolates from Malaysia

Rapid detection of Burkholderia pseudomallei, the etiologic agent of melioidosis, allows for timely initiation of appropriate treatment and better clinical outcomes. In the current gold standard, the culture method is time consuming and suffers from low sensitivity. Meanwhile, previously reported molecular assays are fast and sensitive, but their performance on isolates from Malaysia, an endemic region of melioidosis is under reported. This study designed oligonucleotides targeting orf2 of Type III secretion system (TTSS) genes cluster for the detection of Malaysian B. pseudomallei isolates and evaluated the assay on 95 local B. pseudomallei strains, 58 other microorganisms and 71 clinical specimens from patients. The developed assay exclusively detected all tested B. pseudomallei isolates with a detection limit of 20 fg per reaction (equivalent to ~2.5 copies). Subsequent testing on clinical samples showed that the assay detected all confirmed specimens with the growth of B. pseudomallei (n = 10/10). None of the negative specimens had a detectable signal of our TTSS-orf2 assay (n = 0/61). In conclusion, the present study provides crucial preliminary data for a subsequent study and should be considered as a potential alternative to current time-consuming culture method for the detection of B. pseudomallei.