Southern Medical Journal最新文献

[This corrects the article DOI: 10.14423/SMJ.0000000000001576.].

Objectives: Much of the literature on value-added student roles focuses on medical student participation in health systems science-related learning experiences. Our study sought to understand how students perceive that they improve patient care in the clinical setting.

Methods: We reviewed qualitative data from the 2020-2021 academic year collected from all third-year medical students (N = 119) at the end of each of their clerkships in response to the prompt "How were you able to improve the quality of patient care?" Data were analyzed using a thematic approach of the responses from all clerkships (Family Medicine, Internal Medicine, Surgery, Neurology, Obstetrics and Gynecology, Psychiatry, Pediatrics). Three independent coders reviewed all of the responses, created a preliminary coding framework and corresponding themes, and then reconciled and revised codes and themes to construct a final code book.

Results: We identified seven themes regarding student perceptions of their impact on the quality of patient care. Five themes were patient facing: spending more time with patients, providing patient-centered care, completing care tasks, using evidence-based medicine, and participating in the healthcare team. Two student-facing themes also were identified, and several students reported no value-added role.

Conclusions: Most of the students perceived that they improved care quality via numerous value-added roles during their core clerkships. Many of these roles could be mapped to the Entrustable Professional Activities framework, with notable additions, including care related to social determinants of health, patient-centered communication, and patient education. These findings have implications for clinical teaching and assessment of students, clinical faculty development, and the future of Entrustable Professional Activities iterations.

Objective: The objective of our study was to determine the effect of a pamphlet in increasing awareness of eye disease among patient populations to boost early utilization of eye care and screening.

Methods: This was a pre-post study using a survey to measure changes in self-evaluated knowledge regarding eye disease and comfort in identifying symptoms before and after exposure to a pamphlet. The study was conducted in Orlando, Florida and took place from July 2023 through October 2023, with a total of 33 participants.

Results: The mean preknowledge and comfort were 5.36 and 5.27, respectively, and the mean postknowledge and comfort were 6.97 and 6.91, respectively. This change was significant on a paired samples t test using an alpha of 0.05. The mean clarity rating was 9.06 with a standard deviation of 1.44, with 1 being the lowest rating and 10 being the highest.

Conclusions: Statistically significant changes in self-evaluated knowledge and comfort were seen, with P < 0.001 for an alpha of 0.05. The main limitations of this study were sample size and study recruitment.

Objectives: Remdesivir is a nucleotide analog used to treat coronavirus disease 2019 (COVID-19). We determined whether reduced kidney function is associated with the completion of a full course of remdesivir in hospitalized patients with COVID-19.

Methods: This was a retrospective study of 1103 adults hospitalized with COVID-19. The primary outcome was completion of a full course of remdesivir therapy. Secondary outcomes were in-hospital mortality, length of hospital stay, and liver function tests five times greater than the upper limit of normal. The main predictor variable was glomerular filtration rate (GFR; mL/min), which was categorized as >59, 30 to 59, 15 to 29, and < 15.

Results: The GFR groups of 15 to 29 (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.35-0.996, P = 0.048) and < 15 (OR 0.34, 95% CI 0.16-0.71, P = 0.01) were each significantly associated with decreased odds for the completion of a full course of remdesivir therapy. The GFR groups of 30 to 59 (OR 2.29, 95% CI 1.60-3.27, P < 0.001), 15-29 (OR 4.77, 95% CI 2.77-8.21, P < 0.001), and < 15 (OR 2.41, 95% CI 1.06-5.47, P = 0.04) were each significantly associated with increased odds for mortality. The GFR 15 to 29 group was significantly associated (β = -0.14, standard error = 0.05, P = 0.002) with decreased length of hospital stay. No significant association occurred for GFR and liver function tests.

Conclusions: Individuals with lower GFR had lower odds to receive at least 5 days of remdesivir when compared with those with a GFR >59. We recommend that clinicians be aware that patients with kidney disease may not be able to complete a full course of therapy.

Objectives: Despite the critical oversight role that the graduate medical education committee (GMEC) plays in Graduate Medical Education (GME), there has been little examination and assessment of the most effective way to conduct GMEC meetings to establish best practices and optimize efficacy. Using the modified nominal group technique (mNGT), an innovative methodology for evaluating medical education activities, we studied perceived strengths and weaknesses of GMEC meetings and developed an action plan based on our assessment.

Methods: We conducted an mNGT at an annual GME leadership retreat involving leaders from 16 residency and fellowship programs. Participants ranked strengths and weaknesses in accordance with standard mNGT methodology. Results were tabulated, and an action plan was developed following a discussion period.

Results: Study participants ranked provision of informational updates and fostering collaboration among training programs as the most useful aspects of the GMEC, and areas for improvement included reviewing agenda content, ensuring all committee members are heard, and optimizing meeting logistics. These results were reviewed with the entire GMEC membership, and several changes were implemented, including adjusting meeting format and developing a process for program leadership to provide input regarding agenda items.

Conclusions: This study demonstrates that the mNGT is an efficient and effective means to evaluate the strengths and weakness of GMEC meetings so that changes can be made when necessary to optimize the oversight of this critically important committee.

Objectives: Patients with a history of massive weight loss (MWL) frequently undergo body-contouring surgery such as abdominoplasty, and the safety profile of this procedure is well accepted. The deep inferior epigastric artery perforator (DIEP) flap is a procedure where excess abdominal tissue is used to reconstruct the breast. The abdominal muscles are preserved by isolating the flap on vascular perforators to the abdominal skin and adipose tissue, whereas in abdominoplasty, the same tissue is removed and discarded. In this study, the abdominal-contouring outcomes of patients who underwent DIEP breast reconstruction following MWL were compared with the abdominal contouring outcomes of those who received abdominoplasty following MWL.

Methods: A propensity-matched retrospective cohort study was performed comparing MWL patients who underwent either DIEP flap breast reconstruction after breast cancer treatments with mastectomy or abdominoplasty. Patients were matched for multiple preoperative variables. Statistical analysis included an independent-samples t test and the Fisher exact test for univariate analysis and multivariate analysis for predictive variables of postoperative complications.

Results: Eighteen patients with a history of MWL who underwent DIEP flaps were matched to 18 patients who underwent abdominoplasty. Patient data for the DIEP cohort were obtained from a database of 314 patients and a total of 484 flaps performed at our institution. Patient data for the abdominoplasty cohort were obtained from a database of 155 patients who underwent abdominoplasty at our institution. Groups differed on body mass index and total body weight loss (P = 0.008 and P = 0.002, respectively), but they did not differ in excess body weight loss (P = 0.094). All abdominoplasty patients and 50% of the DIEP patients had undergone bariatric surgery. Complication rates at the abdominal site were similar between the two groups (DIEP 33% vs body-contouring surgery 39%, P = 0.73).

Conclusions: Patients with DIEP procedures were found to have abdominal complication rates similar to those who received standard abdominoplasty. This information can be used by plastic surgeons to counsel MWL patients considering DIEP that their chance of a postoperative abdominal complication is similar to abdominal body-contouring procedures.

Objectives: The RxPONDER trial showed premenopausal patients with pT1-2 N1 hormone receptor-positive (HR⁺)/HER2^- breast cancer benefit from chemotherapy regardless of 21-gene recurrence score (RS), but it did not analyze whether the number of positive lymph nodes (+LNs) was correlative of outcomes. Our study sought to evaluate whether the number of +LNs predicted chemotherapy benefit in pN1 premenopausal women with a low RS.

Methods: Using the National Cancer Database, we identified females younger than 50 years with HR⁺/HER2^- invasive breast cancer, stratified by RS (<25 and > 25) and number of +LNs. We analyzed clinicopathologic features, adjuvant therapies received, and overall survival (OS).

Results: Within the cohort of 12,017 patients, 86% had a RS ≤25, whereas 77% had 1 +LN, 18% had 2 +LNs, and only 5% had three +LNs. Of patients with RS ≤25, 57% had endocrine therapy alone and 38% had combination chemoendocrine therapy. Chemotherapy omission was associated with worse unadjusted OS in the overall cohort and in the subgroup with only 1 +LN (both P < 0.001). Factors associated with worse adjusted OS were Black race (hazard ratio 1.91), intermediate/high tumor grade (hazard ratios 1.93 and 3.75), T2 tumors (hazard ratio 1.59), having 2 or 3 +LNs (hazard ratios 1.53 and 2.17), the use of endocrine therapy alone (hazard ratio 1.64), and increasing RS (hazard ratio 1.08; all P < 0.05).

Conclusions: Chemotherapy was omitted in more than half of the patients younger than 50 years with RS ≤25 during the study period, and omission was associated with worse OS in every LN category. These findings confirm the benefit of chemotherapy even in patients with limited nodal disease.