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PurposeThere were 2 related goals for this study. The first purpose was to describe the structure (type, staffing, and number of educational sessions provided), process (preferred learning approaches), and outcome measures commonly used to provide patient education. The second purpose was to identify the influences, resources, and constraints that affect and alter the attitudes and practices of diabetes educators.MethodsA 30-item questionnaire that addressed 4 areas--demographics, practice characteristics, education program structure, and educational processes--was mailed to a sample of American Association of Diabetes Educators members. Three hundred sixty-one registered nurse and registered dietician certified diabetes educators completed the questionnaire and were included in the final analysis.ResultsThis survey indicated that this group of certified diabetes educators has incorporated new research findings and innovative teaching methods into their practices. They experience few barriers and tend to make changes in their attitudes and practices based on scientific and experiential evidence. The 3 most highly rated influences on these changes were related to patient responses to their teaching, followed by continuing education conferences and new research findings.ConclusionsBased on these findings, providing continuing education that first and foremost incorporates experience-based examples of effective strategies supported by research published in professional journals appears to have the most influence on the practice of educators. [ABSTRACT FROM AUTHOR]

This study examines the impact of an interdisciplinary training program on knowledge and attitudes of learners from four health care programs: medicine, pharmacy, social work, and nursing. Sixty-two learners participated in a 4-day educational program (one day each week for 4 weeks) focusing on interdisciplinary geriatric care. After completing the program, learner scores improved on a knowledge test and two attitudinal subscales, and they reported a positive training experience. A short-term interdisciplinary educational intervention can have an impact on learners' knowledge of and attitudes toward older adults, and improve their understanding and confidence in participating in an interdisciplinary collaborative care team. [ABSTRACT FROM AUTHOR]

PURPOSE: The purpose of this study was to determine if participation in screening clinics to detect and treat diabetes-related eye disease also led to informal patient learning that had an impact on self-management behavior and blood glucose control. METHODS: To evaluate the evidence for patient learning over time, the data of patients who returned as advised for 2 subsequent annual diabetes disease screenings were analyzed. Evaluation measures included medication use, self-management behavior, and hemoglobin A1c (A1C). RESULTS: During the 2-year study period, the use of insulin increased by 37% at the first exam, 43% at the second exam, and 42% at the third exam (P = .02). No significant changes were found in the use of oral medication. Glucose self-monitoring also increased by 61% at the first exam, 71% at the second exam, and 76% at the third exam (P < .01). Mean A1C values for returning participants declined by 9.2% at the first exam, 8.9% at the second exam, and 8.6% at the third exam (P = .03). CONCLUSIONS: The screening clinics had an educational impact associated with behavior change (improved self-management and glucose control) even though the clinics were not intended to produce such change. Therefore, caregivers should consider that patient learning can and should be part of every diabetes care encounter. [ABSTRACT FROM AUTHOR]

PURPOSE: This pilot study explored health professionals' and patients' perceptions of diabetes through the development of the Diabetes Semantic Differential Scales (DSDS). These scales evaluate the meaning of diabetes-related concepts. METHODS: Health professionals (n = 39) attending a CME course completed the health professional version of the DSDS. Patients (n = 70) completed the patient version of the DSDS. RESULTS: The reliability of the DSDS was supported. The scale scores of health professionals, African American patients, and Caucasian patients, examined initially by one-way analyses of variance, showed significant differences among the groups for 4 of the 18 diabetes concepts. Effect sizes were also examined among these groups. For 7 concepts, there was a significant practical difference between the perceptions of the health professionals and the African American patients. For the Caucasian patients, differences were noted for 6 concepts. CONCLUSIONS: There are 3 primary inferences from this pilot study. First, health professionals and patients are likely to hold different perceptions of key diabetes concepts. Second, the concepts on which professionals and patients differ are not always what one would expect. Third, health professionals should clarify patients' understanding of diabetes to minimize the potential for miscommunication. [ABSTRACT FROM AUTHOR]

Background: Adults and children in the United States get two to six colds per year. Evidence that zinc is effective therapy for colds is inconsistent.Objective: To test the efficacy of zinc acetate lozenges in reducing the duration of symptoms of the common cold.Design: Randomized, double-blind, placebo-controlled trial.Setting: Detroit Medical Center, Detroit, Michigan.Patients: 50 ambulatory volunteers recruited within 24 hours of developing symptoms of the common cold.Intervention: Participants took one lozenge containing 12.8 mg of zinc acetate or placebo every 2 to 3 hours while awake as long as they had cold symptoms.Measurements: Subjective symptom scores for sore throat, nasal discharge, nasal congestion, sneezing, cough, scratchy throat, hoarseness, muscle ache, fever, and headache were recorded daily for 12 days. Plasma zinc and proinflammatory cytokine levels were measured on day 1 and after participants were well.Results: Forty-eight participants completed the study (25 in the zinc group and 23 in the placebo group). Compared with the placebo group, the zinc group had shorter mean overall duration of cold symptoms (4.5 vs. 8.1 days), cough (3.1 [95% CI, 2.1 to 4.1] vs. 6.3 [CI, 4.9 to 7.7] days), and nasal discharge (4.1 [CI, 3.3 to 4.9] vs. 5.8 [CI, 4.3 to 7.3] days) and decreased total severity scores for all symptoms (P < 0.002, test for treatment x time interaction). Mean changes in soluble interleukin-1 receptor antagonist level differed nonsignificantly between the zinc group and the placebo group (difference between changes, -89.4 pg/mL [CI, -243.6 to -64.8 pg/mL]).Conclusion: Administration of zinc lozenges was associated with reduced duration and severity of cold symptoms, especially cough. Improvement in clinical symptoms with zinc treatment may be related to a decrease in proinflammatory cytokine levels; however, in this study, the observed differences between changes in cytokine levels in zinc and placebo recipients were not significant. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to assess the validity, reliability, and utility of the Diabetes Empowerment Scale (DES), which is a measure of diabetes-related psychosocial self-efficacy.Research Design and Methods: In this study (n = 375), the psychometric properties of the DES were calculated. To establish validity, DES subscales were compared with 2 previously validated subscales of the Diabetes Care Profile (DCP). Factor and item analyses were conducted to develop subscales that were coherent, meaningful, and had an acceptable coefficient alpha.Results: The psychometric analyses resulted in a 28-item DES (alpha = 0.96) with 3 subscales: Managing the Psychosocial Aspects of Diabetes (alpha = 0.93), Assessing Dissatisfaction and Readiness To Change (alpha = 0.81), and Setting and Achieving Diabetes Goals (alpha = 0.91). Consistent correlations in the expected direction between DES subscales and DCP subscales provided evidence of concurrent validity.Conclusions: This study provides preliminary evidence that the DES is a valid and reliable measure of diabetes-related psychosocial self-efficacy. The DES should be a useful outcome measure for various educational and psychosocial interventions related to diabetes. [ABSTRACT FROM AUTHOR]

PURPOSE: This study was conducted to assess the cultural relevance of an education program for urban African Americans with diabetes. METHODS: A set of 12 videotape vignettes were developed for use in diabetes education for urban African Americans with diabetes. Focus groups and questionnaires were used to determine if patients and diabetes educators would find the materials stimulating, culturally appropriate, and useful. RESULTS: The videotape and discussion guide were perceived as valuable by both healthcare professionals and patients. CONCLUSIONS: This education program could be a valuable resource for diabetes educators who want to provide culturally sensitive and relevant diabetes education for urban African Americans with diabetes. [ABSTRACT FROM AUTHOR]

The Diabetes Care Profile (DCP) is an instrument used to assess social and psychological factors related to diabetes and its treatment. The reliability of the DCP was established in populations consisting primarily of Caucasians with type 2 diabetes. This study tests whether the DCP is a reliable instrument for African Americans with type 2 diabetes. Both African American (n = 511) and Caucasian (n = 235) patients with type 2 diabetes were recruited at six sites located in the metropolitan Detroit area. Scale reliability was calculated by Cronbach's coefficient alpha. The scale reliabilities ranged from .70 to .97 for African Americans. These reliabilities were similar to those of Caucasians, whose scale reliabilities ranged from .68 to .96. The Feldt test was used to determine differences between the reliabilities of the two patient populations. No significant differences were found. The DCP is a reliable survey instrument for African American and Caucasian patients with type 2 diabetes. [ABSTRACT FROM AUTHOR]

African-American and Caucasian patients with non-insulin-dependent diabetes mellitus were surveyed to determine differences in self-reported dietary adherence. The relationship between dietary adherence and other psychosocial factors also was explored. The Diabetes Care Profile, an instrument designed to assess psychosocial factors related to diabetes, was completed by 178 patients. Correlation and regression analyses were used to examine the relationship between dietary adherence and 15 other scales in this instrument. Regression analyses revealed that selected scales were better at predicting dietary adherence for African Americans than for Caucasians. Self-care adherence was the most significant predictor of dietary adherence for African Americans while support was the most significant predictor for Caucasians. These findings suggest that cultural and social functions of food and diet should be examined and incorporated in the development of appropriate meal plans and educational interventions. [ABSTRACT FROM AUTHOR]

This study focused on three questions: Is there a difference in men's and women's diabetes attitudes? Do health professionals give different recommendations to men and women? Is there a difference between men and women in care adherence? A total of 1201 patients with diabetes were surveyed; 65% of these patients were women. Differences in diabetes attitudes (three of seven attitudes) were most evident between men and women with insulin-dependent diabetes mellitus (IDDM). No differences were found in the attitudes of men and women with non-insulin-dependent diabetes mellitus (NIDDM) using insulin, and only one attitude was different for patients with NIDDM not using insulin. Few differences were observed in the recommendations given by health professionals to men and women. Gender differences in adherence to the components of self-care also were minimal. These findings may indicate that there are many similarities in the reactions of men and women who have been diagnosed with diabetes. [ABSTRACT FROM AUTHOR]

The purpose of this study was to describe the diabetes education and nutritional counseling received by patients under the active care of community physicians. The study population consisted of 440 patients with diabetes from the practices of 68 primary care physicians in eight Michigan communities. Fifty-eight percent of the sample reported having received diabetes education, and the mean number of years since the most recent education was 4.15 years. Sixty-six percent reported having seen a dietitian. Patients who had received diabetes education scored higher on a basic diabetes knowledge test (70% correct vs 60%) than patients who had not received diabetes education. From 1981 to 1991, a decline was observed in the percentage of patients who reported having received diabetes education (70% to 58%). Although patient education is an integral part of comprehensive diabetes care, too few patients are receiving it. Furthermore, diabetes education often results in less-than-optimal levels of knowledge. The situation has deteriorated over the past 10 years, and patients who are not on insulin typically are the least well served. [ABSTRACT FROM AUTHOR]

This study involved 1202 patients who were placed into low adherence or high adherence groups based on their answers to questionnaires. The attitudes of each group were compared for a variety of adherence behaviors. Patients who reported high levels of adherence tended to have attitudes more in accord with diabetes experts. Members of the high adherence group strongly supported the need for special training for health care professionals who treat diabetes, favored team care, accepted the importance of patient compliance, acknowledged the seriousness of non-insulin-dependent diabetes mellitus (NIDDM), and recognized the relationship between glucose control and complications. Differences in attitudes between high- and low adherence groups were more prevalent for difficult adherence areas, eg, diet and exercise, than for easy adherence areas, eg, carrying sweets or diabetic identification. An understanding of patients' attitudes can help diabetes educators and patients develop realistic and relevant self-care plans. [ABSTRACT FROM AUTHOR]

This study evaluated a monthly, activated patient newsletter sent to over 7000 patients in Michigan with diabetes. The newsletter provided concise and action-oriented information about diabetes care. Patients who had signed up to receive the newsletter during the first 4 months of the project (1963) were surveyed to determine how many patients found the newsletter helpful; 80% (1498) of the patients replied. Patients who found the newsletter most helpful were older, had lower incomes, and reported more complications, less understanding of diabetes, and being in poorer overall health. They also were more likely to have non-insulin-dependent diabetes mellitus (NIDDM) than insulin-dependent diabetes mellitus (IDDM). We concluded that the activated patient newsletter is a useful public health/patient education intervention for persons with diabetes. Such a newsletter should be part of a coordinated system of ongoing patient care, education, screening, and social and psychological support. [ABSTRACT FROM AUTHOR]

Background: Mistreatment from patients is prevalent and has far-reaching negative consequences., Aim: To develop a practice-based curriculum on patient-initiated mistreatment and examine participant perceptions before and after the curriculum., Setting: Single medical school in the United States., Participants: 306 senior medical students from classes 2022 and 2023., Program Description: A single patient-initiated mistreatment session delivered during specialty-specific residency preparation courses (RPCs) featuring a literature discussion, a response framework, and patient-actor skills practice., Program Evaluation: Between February 2022 and October 2023, 22 sessions occurred. Electronic surveys were delivered before, following, and approximately eight months after each session. A total of 257 (84.0%) and 174 (56.9%) participants completed pre- and post-session surveys, respectively. Significant increases in mean scores were noted for confidence in recognizing mistreatment (pre-session 4.25, post-session 4.68; p < 0.001) and comfort in addressing mistreatment personally (pre-session 2.86, post-session 4.30; p < 0.001) and as a bystander (pre-session 2.98, post-session 4.27; p < 0.001). In the follow-up survey, participants noted that the session was useful in preparing them for residency., Discussion: A novel patient-initiated mistreatment curriculum empowered students, resulting in enhanced confidence in responding and sustained skill usage. Medical schools may consider including this training for all graduating students., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: As part of the residency application process in the United States, many medical specialties now offer applicants the opportunity to send program signals that indicate high interest to a limited number of residency programs. To determine which residency programs to apply to, and which programs to send signals to, applicants need accurate information to determine which programs align with their future training goals. Most applicants use a program's website to review program characteristics and criteria, so describing the current state of residency program websites can inform programs of best practices., Objective: This study aims to characterize information available on obstetrics and gynecology residency program websites and to determine whether there are differences in information available between different types of residency programs., Methods: This was a cross-sectional observational study of all US obstetrics and gynecology residency program website content. The authorship group identified factors that would be useful for residency applicants around program demographics and learner trajectories; application criteria including standardized testing metrics, residency statistics, and benefits; and diversity, equity, and inclusion mission statements and values. Two authors examined all available websites from November 2011 through March 2022. Data analysis consisted of descriptive statistics and one-way ANOVA, with P<.05 considered significant., Results: Among 290 programs, 283 (97.6%) had websites; 238 (82.1%) listed medical schools of current residents; 158 (54.5%) described residency alumni trajectories; 107 (36.9%) included guidance related to the preferred United States Medical Licensing Examination Step 1 scores; 53 (18.3%) included guidance related to the Comprehensive Osteopathic Medical Licensing Examination Level 1 scores; 185 (63.8%) included international applicant guidance; 132 (45.5%) included a program-specific mission statement; 84 (29%) included a diversity, equity, and inclusion statement; and 167 (57.6%) included program-specific media or links to program social media on their websites. University-based programs were more likely to include a variety of information compared to community-based university-affiliated and community-based programs, including medical schools of current residents (113/123, 91.9%, university-based; 85/111, 76.6%, community-based university-affiliated; 40/56, 71.4%, community-based; P<.001); alumni trajectories (90/123, 73.2%, university-based; 51/111, 45.9%, community-based university-affiliated; 17/56, 30.4%, community-based; P<.001); the United States Medical Licensing Examination Step 1 score guidance (58/123, 47.2%, university-based; 36/111, 32.4%, community-based university-affiliated; 13/56, 23.2%, community-based; P=.004); and diversity, equity, and inclusion statements (57/123, 46.3%, university-based; 19/111, 17.1%, community-based university-affiliated; 8/56, 14.3%, community-based; P<.001)., Conclusions: There are opportunities to improve the quantity and quality of data on residency websites. From this work, we propose best practices for what information should be included on residency websites that will enable applicants to make informed decisions., (© Paulina M Devlin, Oluwabukola Akingbola, Jody Stonehocker, James T Fitzgerald, Abigail Ford Winkel, Maya M Hammoud, Helen K Morgan. Originally published in JMIR Medical Education (https://mededu.jmir.org).)

Background: As the gender demographics of medical students have evolved over the past decades, it is important to understand potential stressors and challenges that may affect clinical learning experiences. This study investigated the prevalence of prior sexual assault (SA) and interpersonal violence (IPV) in medical students and how these affect their clinical clerkship experiences., Methods: A survey was distributed to third- and fourth-year medical students at a single institution in August 2022 querying respondents on demographics and prior experiences with SA/IPV at any point in their lives. Respondents who indicated they had previously experienced SA/IPV were directed to questions about how these experiences affected clerkships., Findings: Of 419 students, 125 responded to the survey (30.8% response rate). Forty (31.1%) reported a history of SA/IPV-32 (80.0%) women, five (12.5%) men, and three (7.5%) who did not report gender or identified as non-binary. Of the 40 respondents with a history of SA/IPV, 20 (50.0%) reported that their prior history affected their overall clinical experience, and nine (22.5%) felt that it affected their performance. Only seven (17.5%) reported using any resources, such as counselling, during their clerkships. Narrative responses discussed significant effects on performing physical exams, taking a history, interacting with team members, and engaging during clerkships., Discussion: This work demonstrates the high number of students affected by SA/IPV and how these prior experiences affected core components of their clerkship experiences., Conclusions: Institutions must be proactive to create better supports for learners with histories of trauma, including SA/IPV., (© 2024 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Interprofessional experiences during medical school are often delivered during pre-clinical years, but less is known about the value of clinical students. Our institution implemented a specialty-specific interprofessiona curriculum during Residency Preparation Courses (RPCs) for senior students including didactics, clinical experiences, and a simulated paging curriculum. Our aim was to determine whether this intervention improved perceptions of interprofesiona roles. We distributed anonymous surveys before (pre-survey) and after (post-survey, collected within 2 weeks of course completion) the RPC to 90 students with questions related to interprofessional roles using a 5-point scale (1 =  strongly disagree , 5 =  strongly agree ). Three months after the start of residency, we sent follow-up surveys inquiring about the usefulness of RPC components (1 =  not at all useful , 5 =  extremely useful ). Response rates were 84.4% pre-survey, 63.3% post-survey, and 41.1% follow-up survey. Post-surveys indicated improvement in self-reported ability in all domains: understanding one's contributions to interprofessional teams (3.9 to 4.4, p < .0001), understanding other team members' contributions (3.9 to 4.4, p < .0001), learning from interprofessional team members (4.2 to 4.6, p = .0002), accounting for interprofessional perspectives (4.2 to 4.6, p < .0001), and co-developing effective care plans (3.9 to 4.4, p < .0001). Follow-up surveys rated clinical experiences as slightly-to-moderately useful (2.3 ± 1.0) and paging curriculum very-to-extremely useful (4.3 ± 1.0). This study demonstrates the value of interprofessional education for advanced students.

Introduction: Residents have the important task of updating family members of hospitalized patients, often by telephone. There are limited curricula dedicated to preparing medical students for this task, which will become their responsibility as residents., Methods: We created a virtual workshop, including four patient cases, to facilitate teaching senior medical students enrolled in an internal medicine residency preparation course. Students alternated role-playing either physician or family member. We assessed performance using a self-assessment rubric before (preworkshop) and after (postworkshop) a didactic session. We compared pre- and postworkshop scores using t tests. We also used a retrospective pre-post survey with a 5-point Likert scale to assess each participant's comfort level, knowledge, and perceived ability., Results: Thirty-nine students completed the pre- and postworkshop evaluation (response rate: 70%). The mean score on the preworkshop self-assessment was 83% ( SD = 9%) and on the postworkshop self-assessment was 94% ( SD = 8%; p < .01), with a large effect size of 1.22. Among the 31 students (62%) who completed the survey, there was improvement in comfort level (2.9 vs. 3.7, p < .001), knowledge (2.7 vs. 3.8, p < .001), and perceived ability (2.9 vs. 3.7, p < .001)., Discussion: Our workshop was effective in teaching medical students a structured format for providing telephone updates and was well received. The workshop was also effective when delivered virtually (with videos off) to mimic the non-face-to-face communication that occurs when delivering family updates by telephone. The curriculum could be expanded to other learner groups., (© 2022 Edwards et al.)

Introduction: Postgraduate trainees address outpatient telephone calls (OTCs) with little prior training. This study determines the skills necessary for OTCs and examines whether a video intervention improves medical students' performance on simulated OTCs., Materials and Methods: We utilized a Delphi technique to determine skills needed for OTCs and created a 9-min video teaching these skills. Senior medical students were randomized to Intervention (viewed video) and Control (did not view video) groups. Students were assessed pre-/post-intervention on simulated OTCs. The primary outcome was the between-group difference in improvement., Results: The Delphi yielded 34 important skills with the highest focus on communication ( n  = 13) and triage ( n  = 6). Seventy-two students completed assessments (Control, n  = 41; Intervention, n  = 31). The score (mean ± SD) improved 4.3% in the Control group (62.3 ± 14.3% to 66.6 ± 25.0%) and 12.2% in the Intervention group (60.7 ± 15.2% to 72.9 ± 20.4%, p  = 0.15). The effect size measured by Cohen's d was 0.55, considered effective (> 0.33) for an educational intervention., Conclusions: This project fills a gap in OTC training. The use of the Delphi technique, intervention development based on the results, and evaluation of efficacy is a process that could be reproduced for other educational gaps., Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-021-01331-w., Competing Interests: Conflict of InterestThe authors declare no competing interests., (© International Association of Medical Science Educators 2021.)

Background: Educational handovers can provide competency information about graduating medical students to residency program directors post-residency placement. Little is known about students' comfort with this novel communication., Objective: To examine graduated medical students' perceptions of educational handovers., Methods: The authors created and distributed an anonymous survey to 166 medical students at a single institution following graduation in the spring of 2018. Within this cohort, 40 students had an educational handover sent to their future program director. The survey explored comfort level with handovers (1=very uncomfortable; 5=very comfortable) and ideal content (e.g., student strengths, areas for improvement, goals, grades received after residency application). Respondents self-reported their performance in medical school and whether a handover was sent. Correlation analyses examined relationships between performance and other variables. T-tests examined differences between students who did and did not have a handover letter sent., Results: The survey response rate was 40.4% (67/166) - 47.8% of students felt comfortable with handovers, 19.4% were neutral, and 32.8% were uncomfortable. There was no correlation between self-reported medical school performance and comfort level. Respondents felt most strongly that strengths should be included, followed by goals. Those who had a handover letter sent expressed significantly higher comfort level (3.8 ± 1.0 vs. 2.6 ±1.3, p=0.003) with this communication., Conclusion: Medical students reported varying levels of comfort with educational handovers; however, those who had handovers sent had more positive perceptions. In order to improve the education continuum, it is essential to engage students in the development of this handover communication., (© 2021 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

This study aimed to (1) examine what patient-centeredness means for older adults and family caregivers, and (2) assess circumstances underlying their preference for geriatric care. We conducted separate focus groups with older adults and family caregivers of older adults about health care experiences and expectations and conducted a vignette-based experiment to assess preference for geriatric care. Participants expressed a need for greater skill and empathy and integration of caregivers. They preferred geriatric care to usual primary care with increasing social, health, and healthcare complexity. Distinct needs of older adults should be considered in referral practices to geriatric medicine., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Purpose: To explore internal medicine residents' and geriatrics fellows' perceptions of how personal, social, and institutional characteristics contribute to their professional identity and subspecialty decisions related to geriatric medicine., Method: The authors conducted 23 in-depth, semistructured interviews with internal medicine residents, with and without an interest in geriatrics, and geriatrics fellows across 3 academic medical centers in the United States from October 2018 through June 2019. They then used a qualitative narrative approach to analyze the interview data., Results: Trainees related personal experiences, such as exposure to physicians and experiences with grandparents, to their interest in medicine. Trainees with an interest in geriatrics at 2 institutions did not feel supported, or understood, by peers and mentors in their respective institutions but maintained their interest in the field. The following variations between institutions that are supportive and those that are not were noted: the number of geriatricians, the proximity of the institution to geriatrics clinics, and the ways in which institutional leaders portrayed the prestige of geriatric medicine. Institutional characteristics influenced trainees' understanding of what it meant to be a doctor, what meaning they garnered from work as a physician, and their comfort with different types of complexity, such as those presented when providing care to older adults., Conclusions: Institutional characteristics may be particularly important in shaping trainee interest in geriatric medicine. Institutions should encourage leadership training and opportunities for geriatricians so they can serve as role models and as hands-on mentors for trainees beginning in medical school. Increasing the number of geriatricians requires institutions to increase the value they place on geriatrics to generate a positive interest in this field among trainees. Institutions facilitating formation of professional identity and sense of purpose in work may consider engaging geriatricians in leadership and mentoring roles as well as curriculum development., (Copyright © 2020 by the Association of American Medical Colleges.)

Introduction: The majority of older adults with advanced dementia (AD) develop difficulties with eating and swallowing, often prompting concerns about nutrition and quality of life. Employing a palliative approach requires providers to attain skills in addressing symptoms and communicating with family caregivers about the trajectory of AD and associated dysphagia, as well as to elicit goals of care. Research suggests internal medicine (IM) residents often perceive minimal education during training addressing skills needed to care for patients with AD., Methods: We developed and piloted a small-group interactive seminar utilizing a trigger video depicting a family meeting addressing eating problems in a patient with AD. Case-based learning, small-group discussion, and learner reflection were employed. We assessed the impact on 82 of the 106 IM, medicine-pediatrics, and neurology residents who participated in the seminar., Results: Participant evaluation indicated residents showed high satisfaction and perceived the educational content of the seminar to be robust and clinically relevant. We found statistically significant ( p < .001) improvements in self-reported confidence in dementia-specific skills postseminar. Effect size was large to very large (Cohen's d = 1.3-1.7)., Discussion: An interactive, case-based seminar utilizing a video depicting a realistic family meeting improved residents' self-efficacy in skills needed to address nutritional issues, engage in goals-of-care discussions, and reflect on concerns among caregivers of patients with AD. The seminar teaches important geriatric and palliative concepts meant to improve residents' ability to care for older adults with AD in their future careers., (© 2020 Manu et al.)

Effective physician-nurse communication is critical to patient safety, yet internal medicine trainees are rarely given feedback on this skill. In order to address this gap, we developed a 4-week simulated paging curriculum for senior medical students. Standardized Registered Nurses administered five acute inpatient paging cases to students via telephone and scored communication on a 10-point global scale (1 =  highly ineffective to 10 =  highly effective ) and seven communication domains using a 5-point Likert-type scale. The domains included precision/clarity, instructive, directing, assertive, ability to solicit information, engaged, and structured communication. Students received verbal and written feedback from the nurses on communication skills and clinical decision-making. Our primary goal was to determine if student-nurse communication improved throughout the curriculum. Data were analyzed using multivariate ANOVAs with repeated measures. Twenty-seven students participated. Global communication scores increased significantly from case 1 to case 5 (7.1 to 8.7, p < .01). The following communication domains increased significantly: precision (3.8 to 4.4, p < .01), instructive (3.6 to 4.7, p < .01), directing (4.0 to 4.6, p = .02), assertiveness (4.0 to 4.7, p = .04), engaged (4.1 to 4.7, p < .01). In conclusion, this curriculum can be an innovative approach to improve physician-nurse communication using standardized registered nurses to deliver structured feedback to medical trainees.

Objectives: To examine the current state of cross-cover education in undergraduate medical education and intern perceived readiness to provide cross-cover., Methods: An electronic survey was distributed to 126 incoming interns in surgery, internal medicine, family medicine and paediatrics residencies at a single academic centre. Information regarding prior cross-cover training, experience, confidence, and responses to a sample cross-cover case were obtained., Results: The survey response rate was 69.8% (88 of 126), which included both partial and complete responses. Fifty-seven interns out of 85 (67.1%) had no formal training and 51 (60.0%) had no experience performing cross-cover. They reported feeling unprepared to provide cross-cover, with an average score of 1.8 on a 5-point Likert scale (1, not at all confident; 5, extremely confident). Interns had more confidence in performing cross-cover tasks if they had prior direct cross-cover experience (p = 0.001), and were the least confident in performing the initial evaluation and management of urgent issues (Likert score = 1.6). Scores on the sample case were correlated with the amount of prior experience with patients (p = 0.06). Only 77.7% of interns indicated that they would notify their senior resident in two urgent scenarios. Those who reported higher confidence in knowing when to ask for help were more likely to appropriately notify their senior colleague (p = 0.005). We identified gaps in cross-cover training and in the preparedness of incoming interns CONCLUSIONS: We identified gaps in cross-cover training and in the preparedness of incoming interns. This has important implications for the first day of residency, when interns are often asked to perform cross-coverage, yet feel unprepared to do so and express the greatest concern in urgent cross-cover scenarios. Addressing this curricular gap is crucial in assuring safe cross-cover care., (© 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Background: Residents regularly care for hospitalized patients for whom they are not the primary provider (cross-cover), often without guidance., Objective: We identified and defined components of safe cross-cover care., Methods: Sixty medical and surgical faculty physicians and chief residents from the Midwest were invited to participate in a Delphi study analyzing the appropriateness of cross-covering residents evaluating patients at bedside, deferring issues to the primary team, documenting a note, contacting the attending, and communicating with nurses. The first survey was free text, and responses were categorized. In the second survey, physicians rated categorized responses based on appropriateness using a 5-point Likert scale. High consensus was defined as ≥ 80% agreement, approaching consensus as 51% to 79% agreement, and nonconsensus as ≤ 50% agreement. Results were analyzed by specialty and cross-cover experience in the past year using Pearson χ 2 test or Fisher exact test., Results: Forty respondents (67%) completed the first survey and 30 (50%) completed the second. Responses led to 46 categories. Twenty-eight items (60%) achieved high consensus, 8 (17%) approached consensus, and 10 (22%) did not achieve consensus, with no difference based on specialty or experience. Responses with 100% consensus included: residents should evaluate a patient at bedside whenever asked by the nurse; documentation should occur for change in level of care, death, code, or rapid response team activation; and physician-nurse communication should be respectful and closed loop., Conclusions: This regional physician panel reached consensus on 28 elements important in cross-cover care, which can be used for training and future studies., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Purpose: The fourth year of medical school (M4) should prepare students for residency yet remains generally unstructured, with ill-defined goals. The primary aim of this study was to determine whether there were performance changes in evidence-based medicine (EBM) and urgent clinical scenarios (UCS) assessments before and after M4 year., Method: University of Michigan Medical School graduates who matched into internship at Michigan Medicine completed identical assessments on EBM and UCS at the beginning of M4 year and 13 months later during postgraduate year 1 (PGY1) orientation. Individual scores on these assessments were compared using paired t test analysis. The associations of academic performance, residency specialty classification, and initial performance on knowledge changes were analyzed., Results: During academic years 2014 and 2015, 76 students matched into a Michigan Medicine internship; 52 completed identical EBM stations and 53 completed UCS stations. Learners' performance on the EBM assessment decreased from M4 to PGY1 (mean 93% [SD = 7%] vs. mean 80% [SD = 13%], P < .01), while performance on UCS remained stable (mean 80% [SD = 9%] vs. mean 82% [SD = 8%], P = .22). High M4 performers experienced a greater rate of decline in knowledge level compared with low M4 performers for EBM (-20% vs. -4%, P = .01). Residency specialty and academic performance did not affect performance., Conclusions: This study demonstrated degradation of performance in EBM during the fourth year and adds to the growing literature that highlights the need for curricular reform during this year.

Background: Despite their placement in Veterans Health Administration centers nationwide, residents' training and assessment in veteran-centered care is variable and often insufficient., Objective: We assessed residents' ability to recognize and address mental health issues that affect US military veterans., Methods: Two unannounced standardized patient (SP) cases were used to assess internal medicine residents' veteran-centered care skills from September 2014 to March 2016. Residents were assessed on 7 domains: military history taking, communication skills, assessment skills, mental health screening, triage, and professionalism, using a 36-item checklist. After each encounter, residents completed a questionnaire to assess their ability to recognize knowledge deficits. Residents' mean scores were compared across training levels, between the 2 cases, and by SP gender. We conducted analysis of variance (ANOVA) tests to analyze mean performance differences across training levels and descriptive statistics to analyze self-assessment questionnaire results., Results: Ninety-eight residents from 2 internal medicine programs completed the encounter and 53 completed the self-assessment questionnaire. Residents performed best on professionalism (0.92 ± 0.20, percentage of the maximal score) and triage (0.87 ± 0.17), and they scored lowest on posttraumatic stress disorder (0.52 ± 0.30) and military sexual trauma (0.33 ± 0.39). Few residents reported that they sought out training to enhance their knowledge and skills in the provision of services and support to military and veteran groups beyond their core curriculum., Conclusions: This study suggests that additional education and assessment in veteran-centered care may be needed, particularly in the areas of posttraumatic stress disorder and military sexual trauma., Competing Interests: Conflict of interest: The authors declare they have no competing interests. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

International research suggests that a proportion of youth facing legal charges are at risk of being unfit (or incompetent) to stand trial. In New Zealand, only a fraction of youth coming before Youth Court are referred for fitness to stand trial evaluations. Amid debate surrounding notions that youth offending could be deterred by providing harsher penalties, it is important to consider fitness to stand trial in youth facing criminal proceedings. This study sought to capture a cross-sectional view of how fitness (competency) to stand trial is addressed in the Youth Court, and how evaluator opinions relate to ultimate court findings. A retrospective review of reports for fitness to stand trial in 79 youth consecutively referred to the Regional Youth Forensic Service from 2010 to 2015 was conducted. Data were combined with Youth Court outcomes obtained from the Ministry of Justice. The mean age is 15.6 years. Intellectual disability is associated with unfit opinions and legal findings ( p = .002 and p = .03, respectively), and cases disposed through the Intellectual Disability (Compulsory Care and Rehabilitation) Act 2003. Immaturity itself does not appear to have a significant effect on evaluator opinions or court findings of fitness to stand trial. The majority of the referred youth were both opined and found fit., Competing Interests: No potential conflict of interest was reported by the authors., (© 2017 The Australian and New Zealand Association of Psychiatry, Psychology and Law.)

Background: A previous meta-analysis of 3 zinc acetate lozenge trials estimated that colds were on average 40% shorter for the zinc groups. However, the duration of colds is a time outcome, and survival analysis may be a more informative approach. The objective of this individual patient data (IPD) meta-analysis was to estimate the effect of zinc acetate lozenges on the rate of recovery from colds., Methods: We analyzed IPD for 3 randomized placebo-controlled trials in which 80-92 mg/day of elemental zinc were administered as zinc acetate lozenges to 199 common cold patients. We used mixed-effects Cox regression to estimate the effect of zinc., Results: Patients administered zinc lozenges recovered faster by rate ratio 3.1 (95% confidence interval, 2.1-4.7). The effect was not modified by age, sex, race, allergy, smoking, or baseline common cold severity. On the 5th day, 70% of the zinc patients had recovered compared with 27% of the placebo patients. Accordingly, 2.6 times more patients were cured in the zinc group. The difference also corresponds to the number needed to treat of 2.3 on the 5th day. None of the studies observed serious adverse effects of zinc., Conclusions: The 3-fold increase in the rate of recovery from the common cold is a clinically important effect. The optimal formulation of zinc lozenges and an ideal frequency of their administration should be examined. Given the evidence of efficacy, common cold patients may be instructed to try zinc acetate lozenges within 24 hours of onset of symptoms., (© The Author 2017. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Aims: The aim of this study was to determine whether the allergy status and other characteristics of common cold patients modify the effects of zinc acetate lozenges., Methods: We had available individual patient data for three randomized placebo-controlled trials in which zinc acetate lozenges were administered to common cold patients. We used both one stage and two stage meta-analysis to estimate the effects of zinc lozenges., Results: The total number of common cold patients was 199, the majority being females. Eighty percent of them fell into the age range 20-50 years. One third of the patients had allergies. The one stage meta-analysis gave an overall estimate of 2.73 days (95% CI 1.8, 3.3 days) shorter colds by zinc acetate lozenge usage. The two stage meta-analysis gave an estimate of 2.94 days (95% CI 2.1, 3.8 days) reduction in common cold duration. These estimates are to be compared with the 7 day average duration of colds in the three trials. The effect of zinc lozenges was not modified by allergy status, smoking, baseline severity of the common cold, age, gender or ethnic group., Conclusion: Since the effects of zinc acetate lozenges were consistent between the compared subgroups, the overall estimates for effect seemed applicable over a wide range of common cold patients. While the optimal composition of zinc lozenges and the best frequency of their administration should be further investigated, given the current evidence of efficacy, common cold patients may be encouraged to try zinc lozenges for treating their colds., (© 2016 The British Pharmacological Society.)

Purpose: Many genome-wide association studies have identified common single nucleotide polymorphisms (SNPs) at the 9p21 glaucoma locus (CDKN2B/CDKN2B-AS1) to be significantly associated with primary open-angle glaucoma (POAG), with association being stronger in normal tension glaucoma (NTG) and advanced glaucoma. We aimed to determine whether any observed differences in genetic association at the 9p21 locus are influenced by sex., Methods: Sex was assessed as a risk factor for POAG for 2241 glaucoma participants from the Australian and New Zealand Registry of Advanced Glaucoma, the Glaucoma Inheritance Study in Tasmania, and the Flinders Medical Centre. A total of 3176 controls were drawn from the Blue Mountains Eye Study and South Australia: 1523 advanced POAG and 718 nonadvanced POAG cases were genotyped along with 3176 controls. We selected 13 SNPs at the 9p21 locus, and association results were subanalyszd by sex for high-tension glaucoma (HTG) and NTG. Odds ratios (ORs) between sexes were compared., Results: A sex bias was present within advanced NTG cases (57.1% female versus 42.9% male, P = 0.0026). In all POAG cases, the strongest associated SNP at 9p21 was rs1063192 (OR, 1.43; P = 4 × 10-18). This association was stronger in females (OR, 1.5; P = 5 × 10-13) than in males (OR, 1.35; P = 7 × 10-7), with a statistically significant difference in female to male OR comparison (P = 1.0 × 10-2). An NTG to HTG subanalysis yielded statistically significant results only in females (OR, 1.63; P = 1.5 × 10-4) but not in males (OR, 1.15; P = 2.8 × 10-1), with a statistically significant difference in female to male OR comparison (P = 1.4 × 10-4)., Conclusions: This study demonstrated that female sex is a risk factor for developing advanced NTG. The stronger genetic signals at the 9p21 locus among females may contribute at least in part to the observed sex bias for NTG.

Context: Competency-based education (CBE) has been widely cited as an educational framework for medical students and residents, and provides a framework for designing educational programmes that reflect four critical features: a focus on outcomes, an emphasis on abilities, a reduction of emphasis on time-based training, and promotion of learner centredness. Each of these features has implications and potential challenges for implementing CBE., Methods: As an experiment in CBE programme design and implementation, the University of Michigan Master of Health Professions Education (UM-MHPE) degree programme was examined for lessons to be learned when putting CBE into practice. The UM-MHPE identifies 12 educational competencies and 20 educational entrustable professional activities (EPAs) that serve as the vehicle for both learning and assessment. The programme also defines distinct roles of faculty members as assessors, mentors and subject-matter experts focused on highly individualised learning plans adapted to each learner., Conclusions: Early experience with implementing the UM-MHPE indicates that EPAs and competencies can provide a viable alternative to traditional courses and a vehicle for rigorous assessment. A high level of individualisation is feasible but carries with it significant costs and makes intentional community building essential. Most significantly, abandoning a time-based framework is a difficult innovation to implement in a university structure that is predicated on time-based education., (© 2016 John Wiley & Sons Ltd.)

There is a growing demand for health sciences faculty with formal training in education. Addressing this need, the University of Michigan Medical School created a Master in Health Professions Education (UM-MHPE). The UM-MHPE is a competency-based education (CBE) program targeting professionals. The program is individualized and adaptive to the learner's situation using personal mentoring. Critical to CBE is an assessment process that accurately and reliably determines a learner's competence in educational domains. The program's assessment method has two principal components: an independent assessment committee and a learner repository. Learners submit evidence of competence that is evaluated by three independent assessors. The assessments are presented to an Assessment Committee who determines whether the submission provides evidence of competence. The learner receives feedback on the submission and, if needed, the actions needed to reach competency. During the program's first year, six learners presented 10 submissions for review. Assessing learners in a competency-based program has created challenges; setting standards that are not readily quantifiable is difficult. However, we argue it is a more genuine form of assessment and that this process could be adapted for use within most competency-based formats. While our approach is demanding, we document practical learning outcomes that assess competence.

Purpose: The purpose of this study is to examine the reliability and validity of the revised Diabetes Knowledge Test (DKT2). The original test was updated to reflect current diabetes care and education guidelines. The test has 2 components: a 14-item general test and a 9-item insulin use subscale., Methods: Two samples were used to evaluate the DKT2. The first came from an online survey company (Qualtrics, LCC) (n = 101) and the second from University of Michigan's (UofM) Diabetes Registry (n = 89). Cronbach's coefficient alpha was used to calculate reliability. To examine validity, comparisons by type of diabetes, insulin use and oral medication use, and educational level were completed. Correlations between diabetes duration and both the general test and insulin subscale were calculated for the UofM sample., Results: The two samples differed demographically. While the reliabilities between the samples were disparate, when combined, the coefficient alphas demonstrated reliability for both the general test (.77) and the insulin use subscale (.84). The validation comparisons proved to be similar; different results occurred between samples but when combined demonstrated validity., Conclusions: The reliability and validity tests were inconsistent by sample. The different results can, in part, be attributed to the demographic differences between the 2 samples. With the exception of age, the samples differed in every other measured variable. However, when the samples were combined, the analyses supported the reliability and validity of the Diabetes Knowledge Test 2. The DKT2 is a quick and low-cost method of assessing general knowledge of diabetes and diabetes self-care., (© 2016 The Author(s).)

Importance: Indwelling devices (eg, urinary catheters and feeding tubes) are often used in nursing homes (NHs). Inadequate care of residents with these devices contributes to high rates of multidrug-resistant organisms (MDROs) and device-related infections in NHs., Objective: To test whether a multimodal targeted infection program (TIP) reduces the prevalence of MDROs and incident device-related infections., Design, Setting, and Participants: Randomized clinical trial at 12 community-based NHs from May 2010 to April 2013. Participants were high-risk NH residents with urinary catheters, feeding tubes, or both., Interventions: Multimodal, including preemptive barrier precautions, active surveillance for MDROs and infections, and NH staff education., Main Outcomes and Measures: The primary outcome was the prevalence density rate of MDROs, defined as the total number of MDROs isolated per visit averaged over the duration of a resident's participation. Secondary outcomes included new MDRO acquisitions and new clinically defined device-associated infections. Data were analyzed using a mixed-effects multilevel Poisson regression model (primary outcome) and a Cox proportional hazards model (secondary outcome), adjusting for facility-level clustering and resident-level variables., Results: In total, 418 NH residents with indwelling devices were enrolled, with 34,174 device-days and 6557 anatomic sites sampled. Intervention NHs had a decrease in the overall MDRO prevalence density (rate ratio, 0.77; 95% CI, 0.62-0.94). The rate of new methicillin-resistant Staphylococcus aureus acquisitions was lower in the intervention group than in the control group (rate ratio, 0.78; 95% CI, 0.64-0.96). Hazard ratios for the first and all (including recurrent) clinically defined catheter-associated urinary tract infections were 0.54 (95% CI, 0.30-0.97) and 0.69 (95% CI, 0.49-0.99), respectively, in the intervention group and the control group. There were no reductions in new vancomycin-resistant enterococci or resistant gram-negative bacilli acquisitions or in new feeding tube-associated pneumonias or skin and soft-tissue infections., Conclusions and Relevance: Our multimodal TIP intervention reduced the overall MDRO prevalence density, new methicillin-resistant S aureus acquisitions, and clinically defined catheter-associated urinary tract infection rates in high-risk NH residents with indwelling devices. Further studies are needed to evaluate the cost-effectiveness of this approach as well as its effects on the reduction of MDRO transmission to other residents, on the environment, and on referring hospitals., Trial Registration: clinicaltrials.gov Identifier: NCT01062841.

Background: Increase in intraocular pressure is a recognized complication of corticosteroid treatment via intravitreal or periocular injections for treatment of a range of conditions including macular oedema and retinal neovascularization., Design: This surveillance study was designed to determine the incidence and nature of severe intraocular pressure elevation as a complication of intravitreal or periocular corticosteroid injections in Australia and New Zealand., Participants: Seventeen cases meeting the defined criteria of severe intraocular pressure elevation, above 35 mmHg, following an intravitreal or periocular corticosteroid injection were included in the study., Methods: Over an 18-month period, ophthalmologists were invited to report cases to the Australian and New Zealand Ophthalmic Surveillance Unit. After reporting, further demographic and clinical information was sought via a follow-up questionnaire., Main Outcome Measures: Intraocular pressure elevation above 35 mmHg., Results: Follow-up questionnaires were received for 20 cases of 34 initially reported to the unit. Seventeen met the defined criteria. Triamcinolone acetonide was used in all 17 cases, with 16 delivered as a 4-mg intravitreal injection. There was an absence of identified underlying risk factors in the majority of cases with personal history of glaucoma in 2 of 17 cases. No cases reported a positive family history of glaucoma. Trabeculectomy was performed in 8 of 17 patients (47%) for intraocular pressure management., Conclusions: Severe intraocular pressure elevation following intravitreal or periocular corticosteroid injection can occur in the absence of risk factors such as personal and family history of glaucoma. The severe intraocular pressure elevation may ultimately require trabeculectomy., (© 2014 Royal Australian and New Zealand College of Ophthalmologists.)

Objectives: Determine postgraduate first-year (PGY-1) trainees ability to perform patient care handoffs and associated medical school training., Methods: About 173 incoming PGY-1 trainees completed an OSCE handoff station and a survey eliciting their training and confidence in conducting handoffs. Independent t-tests compared OSCE performance of trainees who reported receiving handoff training to those who had not. Analysis of variance examined differences in performance based on prior handoff instruction and across levels of self-assessed abilities, with significance set at p<0.05., Results: About 35% of trainees reported receiving instruction and 51% reported receiving feedback about their handoff performance in medical school. Mean handoff performance score was 69.5%. Trainees who received instruction or feedback during medical school had higher total and component handoff performance scores (p<0.05); they were also more confident in their handoff abilities (p<0.001). Trainees with higher self-assessed skills and preparedness performed better on the OSCE (p<0.05)., Conclusions: This study provides evidence that incoming trainees are not well prepared to perform handoffs. However, those who received instruction during medical school perform better and are more confident on standardized performance assessments. Given communication failures lead to uncertainty in patient care and increases in medical errors, medical schools should incorporate handoff training as required instruction.

Primary open-angle glaucoma (POAG) is a major cause of irreversible blindness worldwide. We performed a genome-wide association study in an Australian discovery cohort comprising 1,155 cases with advanced POAG and 1,992 controls. We investigated the association of the top SNPs from the discovery stage in two Australian replication cohorts (932 cases and 6,862 controls total) and two US replication cohorts (2,616 cases and 2,634 controls total). Meta-analysis of all cohorts identified three loci newly associated with development of POAG. These loci are located upstream of ABCA1 (rs2472493[G], odds ratio (OR) = 1.31, P = 2.1 × 10(-19)), within AFAP1 (rs4619890[G], OR = 1.20, P = 7.0 × 10(-10)) and within GMDS (rs11969985[G], OR = 1.31, P = 7.7 × 10(-10)). Using RT-PCR and immunolabeling, we show that these genes are expressed within human retina, optic nerve and trabecular meshwork and that ABCA1 and AFAP1 are also expressed in retinal ganglion cells.

Objectives: To determine the proportion of all Myocilin coding mutations responsible for advanced primary open-angle glaucoma (POAG) in early-age-at-onset individuals and to investigate the prevalence of exon 3 Myocilin mutations in advanced POAG at any age at onset in a large Australasian cohort., Design: Cross-sectional study using a national disease registry., Participants: One thousand sixty individuals with advanced POAG (103 with age at onset of 40 years or younger) and 320 with nonadvanced POAG all recruited by the Australian and New Zealand Registry of Advanced Glaucoma., Methods: Participants were examined and referred by their eye practitioner, and Myocilin genetic testing was performed by direct sequencing. Cascade genetic testing was made available for relatives of participants found to carry a Myocilin mutation., Main Outcome Measures: Advanced glaucoma diagnosis based on strict visual field entry criteria. Prevalence and spectrum of Myocilin mutations in individuals with advanced and nonadvanced POAG., Results: This is the first study to report Myocilin mutations in an advanced POAG cohort. No pathogenic Myocilin mutations were identified in exons 1 and 2 in early-age-at-onset advanced POAG cases. Exon 3 Myocilin mutations were identified in 45 advanced POAG patients (4.2%), which is significantly higher (P = 0.02) compared with nonadvanced POAG patients (1.6%). A novel mutation (Trp373X) and a new variant of uncertain pathogenicity (Ala447Thr) also were reported. The prevalence of Myocilin mutations rose from 16% to 40% in selected advanced POAG subgroups based on different thresholds of maximum recorded intraocular pressure, age at diagnosis, and the presence and strength of positive family history. Twenty-six individuals with Myocilin mutations were identified through cascade genetic testing of first-degree relatives of affected mutation carriers., Conclusions: The prevalence of Myocilin mutations in glaucoma cases with severe visual field loss is significantly greater than in nonadvanced glaucoma patients. Myocilin screening in phenotypically selected cases can have a much higher yield than in previous unselected series. Identifying individuals who have Myocilin mutations provides an opportunity to screen at-risk clinically unaffected relatives and to reduce glaucoma blindness through early management and intervention., Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article., (Copyright © 2013 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

A-74528 is a C30 polyketide natural product that functions as an inhibitor of 2',5'-oligoadenylate phosphodiesterase (2'-PDE), a key regulatory enzyme of the interferon pathway. Modulation of 2'-PDE represents a unique therapeutic approach for regulating viral infections. The gene cluster responsible for biosynthesis of A-74528 yields minute amounts of this natural product together with considerably larger quantities of a structurally dissimilar C30 cytotoxic agent, fredericamycin. Through construction and analysis of a series of knockout mutants, we identified the genes necessary for A-74528 biosynthesis. Remarkably, the formation of six stereocenters and the regiospecific formation of six rings in A-74528 appear to be catalyzed by only two tailoring enzymes, a cyclase and an oxygenase, in addition to the core polyketide synthase. The inferred pathway was genetically refactored in a heterologous host, Streptomyces coelicolor CH999, to produce 3 mg/L A-74528 in the absence of fredericamycin.

Background: A defined diagnostic panel differentiated patients who had been diagnosed with chronic fatigue syndrome (CFS), based upon Fukuda/Carruthers criteria. This diagnostic panel identified an Epstein-Barr virus (EBV) subset of patients (6), excluding for the first time other similar "clinical" conditions such as cytomegalovirus (CMV), human herpesvirus 6 (HHV6), babesiosis, ehrlichiosis, borreliosis, Mycoplasma pneumoniae, Chlamydia pneumoniae, and adult rheumatic fever, which may be mistakenly called CFS. CFS patients were treated with valacyclovir (14.3 mg/kg q6h) for ≥ 12 months. Each patient improved, based upon the Functional Activity Appraisal: Energy Index Score Healthcare Worker Assessment (EIPS), which is a validated (FSS-9), item scale with high degree of internal consistency measured by Cronbach's alpha., Methods: Antibody to EBV viral capsid antigen (VCA) IgM, EBV Diffuse Early Antigen EA(D), and neutralizing antibodies against EBV-encoded DNA polymerase and EBV-encoded dUTPase were assayed serially approximately every three months for 13-16 months from sera obtained from patients with CFS (6) and from sera obtained from twenty patients who had no history of CFS., Results: Antibodies to EBV EA(D) and neutralizing antibodies against the encoded-proteins EBV DNA polymerase and deoxyuridine triphosphate nucleotidohydrolase (dUTPase) were present in the EBV subset CFS patients. Of the sera samples obtained from patients with CFS 93.9% were positive for EA(D), while 31.6% of the control patients were positive for EBV EA(D). Serum samples were positive for neutralizing antibodies against the EBV-encoded dUTPase (23/52; 44.2%) and DNA polymerase (41/52; 78.8%) in EBV subset CFS patients, but negative in sera of controls., Conclusions: There is prolonged elevated antibody level against the encoded proteins EBV dUTPase and EBV DNA polymerase in a subset of CFS patients, suggesting that this antibody panel could be used to identify these patients, if these preliminary findings are corroborated by studies with a larger number of EBV subset CFS patients.