Implementing a telemedicine curriculum for internal medicine residents during a pandemic: the Cleveland Clinic experience

Telemedicine training was not a substantial element of most residency programmes prior to the COVID-19 pandemic. Social distancing measures changed this. The Cleveland Clinic Internal Medicine Residency Programme (IMRP) is one of the largest programmes in the USA, which made the task of implementing a telemedicine curriculum more complex. Here we describe our experience implementing an effective, expedited telemedicine curriculum for our ambulatory resident clinics. This study was started in April 2020 when we implemented a resident-led curriculum and training programme for providing ambulatory telemedicine care. The curriculum was finalised in less than 5 weeks. It entailed introducing a formal training programme for residents, creating a resource guide for different video communication tools and training preceptors to safely supervise care in this new paradigm. Residents were surveyed before the curriculum to assess prior experience with telemedicine, and then afterward to assess the curriculum's effectiveness. We also created a mini-CEX assessment for residents to solicit feedback on their performance during virtual appointments. Over 2000 virtual visits were performed by residents in a span of 10 weeks. Of 148 residents, 38% responded to the pre-participation survey. A majority had no prior telemedicine experience and expressed only slight comfort with the modality. Through collaboration with experienced residents and faculty, we expeditiously deployed an enhancement to our ambulatory care curriculum to teach residents how to provide virtual care and help faculty with supervision. We share our insights on this experience for other residency programmes to use.

Teaching residents how to break bad news: piloting a resident-led curriculum and feedback task force as a proof-of-concept study

Background

Breaking bad news (BBN) is a critically important skill set for residents. Limited formal supervision and unpredictable timing of bad news delivery serve as barriers to the exchange of meaningful feedback.

Purpose of study

The goal of this educational innovation was to improve internal medicine residents’ communication skills during challenging BBN encounters. A formal BBN training programme and innovative on-demand task force were part of this two-phase project.

Study design

Internal medicine residents at a large academic medical centre participated in an interactive workshop focused on BBN. Workshop survey results served as a needs assessment for the development of a novel resident-led BBN task force. The task force was created to provide observations at the bedside and feedback after BBN encounters. Training of task force members incorporated video triggers and a feedback checklist. Inter-rater reliability was analysed prior to field testing, which provided data on real-world implementation challenges.

Results

148 residents were trained during the 2-hour communications skills workshop. Based on survey results, 73% (108 of 148) of the residents indicated enhanced confidence in BBN after participation. Field testing of the task force on a hospital ward revealed potential workflow barriers for residents requesting observations and prompted troubleshooting. Solutions were implemented based on field testing results.

Conclusions

A trainee-led BBN task force and communication skills workshop is offered as an innovative model for improving residents’ interpersonal and communication skills in BBN. We believe the model is both sustainable and reproducible. Lessons learnt are offered to aid in implementation in other settings.

The COVID-19 pandemic as a catalyst for medical education innovation: A learner's perspective

The COVID‐19 pandemic has been transformative for healthcare and medical education. Physician trainees and the education system that serves them adapted quickly so that trainees could finish the academic year on time and advance to the next phase of training without compromising clinical competency or public safety. Systemic changes have had the most significant impact on telemedicine training, virtual learning, secure testing, and the interview process for residency and fellowship training positions. Trainees are now getting regular, supervised practice experience with telemedicine. Some secure testing is being done remotely, without jeopardizing examination test items or trainee assessment. Attending physicians are experimenting with novel ways to engage learners with video for virtual rounds to keep the rounding team safe. Finally, the interview process for medical school, residency, and fellowship programs, which has traditionally been an expensive and travel‐laden process, has been made completely virtual for the first time ever. These changes have disadvantages, including a lack of social connection, potential distraction when learning remotely, and limited contact with a potential training program when interviewing by video. This perspective paper, written by a senior internal medicine resident, details his firsthand experience with these changes during the pandemic. It also looks forward to how the current changes will likely change medical education permanently and for the better.

Students as catalysts for curricular innovation: A change management framework

Introduction: The role of medical students in catalyzing and leading curricular change in US medical schools is not well described. Here, American Medical Association student and physician leaders in the Accelerating Change in Medical Education initiative use qualitative methods to better define student leadership in curricular change.Methods: The authors developed case studies describing student leadership in curricular change efforts. Case studies were presented at a national medical education workshop; participants provided worksheet reflections and were surveyed, and responses were transcribed. Kotter's change management framework was used to categorize reported student roles in curricular change. Thematic analysis was used to identify barriers to student engagement and activators to overcome these barriers.Results: Student roles spanned all eight steps of Kotter's change management framework. Barriers to student engagement were related to faculty (e.g. view student roles narrowly), students (e.g. fear change or expect faculty-led curricula), or both (e.g. lack leadership training). Activators were: (1) recruiting collaborative faculty, staff, and students; (2) broadening student leadership roles; (3) empowering student leaders; and (4) recognizing student successes.Conclusions: By applying these activators, medical schools can build robust student-faculty partnerships that maximize collaboration, moving students beyond passive educational consumption to change agency and curricular co-creation.

The impact of interdisciplinary shared medical appointments in newly diagnosed early-stage melanoma patients: The Cleveland Clinic experience

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Background: Shared Medical Appointments (SMA) serve as a unique means of improving outcomes and patient satisfaction while reducing clinic wait times and healthcare costs. Early-stage melanoma survivors may benefit from a targeted SMA. This cohort exhibits high rates of psychosocial distress, with up to 30% warranting clinical intervention (Kasparian, 2013). Additionally,numerically more melanoma deaths are related to thin ( < 1mm) melanomas than those with thick ( > 4mm) on presentation (Whitehall et al, 2015). We hypothesized that an SMA targeting early-stage melanoma patients may reducepsychologic fear and stress, as well as improve patients’ melanoma-related knowledge and adherence to their individualized care plans. Methods: The Cleveland Clinic’s Early Stage Melanoma Survivorship SMA interdisciplinary care team focused on crucial survivorship and prevention techniques, in addition to targeting modifiable behaviors for patients to collaboratively explore (format introduced ASCO Quality 2018, abst 69). A retrospective chart review assessed for demographics, participation rates, changes in depression scores, follow-up show-rates, and post-SMA survey results. Results: Of 477 early stage melanoma patients seen during the time of SMA implementation (6/2018-4/2019), only 91 (19.1%) attended oncology follow-up appointments, and 34 (7.1%) participated in an SMA. Participants expressed high rates of satisfaction and improvement in melanoma-related knowledge, whileexhibiting a > 92% show rate in subsequent oncologic and dermatologic medical appointments compared to 74% and 73%, respectively, in the non-SMA group. No significant improvement in depression and anxiety scoring was noted in SMA vs. non-SMA groups. SMA attendance was notably higher in younger (mean age 56 vs 61) and female (56% vs 30%) patient cohorts without appreciable differences in social history, marital status, or socioeconomic region. Conclusions: Survivorship SMAs for early stage melanoma patients appear to exhibit high rates of patient satisfaction, improvement in clinical knowledge, and adherence to routine dermatology and oncology follow-up appointments.

Low UBE4B expression increases sensitivity of chemoresistant neuroblastoma cells to EGFR and STAT5 inhibition

Neuroblastoma is the most common malignancy in infants. Overexpression of the epidermal growth factor receptor (EGFR) in neuroblastoma tumors underlies resistance to chemotherapeutics. UBE4B, an E3/E4 ubiquitin ligase involved in EGFR degradation, is located on chromosome 1p36, a region in which loss of heterozygosity is observed in approximately one-third of neuroblastoma tumors and is correlated with poor prognosis. In chemoresistant neuroblastoma cells, depletion of UBE4B yielded significantly reduced cell proliferation and migration, and enhanced apoptosis in response to EGFR inhibitor, Cetuximab. We have previously shown that UBE4B levels are inversely correlated with EGFR levels in neuroblastoma tumors. We searched for additional targets of UBE4B that mediate cellular alterations associated with tumorogenesis in chemoresistant neuroblastoma cells depleted of UBE4B using reverse phase protein arrays. The expression of STAT5a, an effector protein downstream of EGFR, doubled in the absence of UBE4B, and verified by quantitative immunoblotting. Chemoresistant neuroblastoma cells were treated with SH-4-54, a STAT5 inhibitor, and observed insignificant effects on cell proliferation, migration, and apoptosis. However, SH-4-54 significantly enhanced the anti-proliferative and anti-migratory effects of Cetuximab in naïve SK-N-AS neuroblastoma cells. Interestingly, in UBE4B depleted SK-N-AS cells, SH-4-54 significantly potentiated the effect of Cetuximab rendering cells increasingly sensitive an otherwise minimally effective Cetuximab concentration. Thus, neuroblastoma cells with low UBE4B levels were significantly more sensitive to combined EGFR and STAT5 inhibition than parental cells. These findings may have potential therapeutic implications for patients with 1p36 chromosome LOH and low tumor UBE4B expression.

Author Correction: A recellularized human colon model identifies cancer driver genes

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

A recellularized human colon model identifies cancer driver genes

Refined cancer models are needed to bridge the gaps between cell line, animal and clinical research. Here we describe the engineering of an organotypic colon cancer model by recellularization of a native human matrix that contains cell-populated mucosa and an intact muscularis mucosa layer. This ex vivo system recapitulates the pathophysiological progression from APC-mutant neoplasia to submucosal invasive tumor. We used it to perform a Sleeping Beauty transposon mutagenesis screen to identify genes that cooperate with mutant APC in driving invasive neoplasia. We identified 38 candidate invasion-driver genes, 17 of which, including TCF7L2, TWIST2, MSH2, DCC, EPHB1 and EPHB2 have been previously implicated in colorectal cancer progression. Six invasion-driver genes that have not, to our knowledge, been previously described were validated in vitro using cell proliferation, migration and invasion assays and ex vivo using recellularized human colon. These results demonstrate the utility of our organoid model for studying cancer biology.

A New Imaging Platform for Visualizing Biological Effects of Non-Invasive Radiofrequency Electric-Field Cancer Hyperthermia

Herein, we present a novel imaging platform to study the biological effects of non-invasive radiofrequency (RF) electric field cancer hyperthermia. This system allows for real-time in vivo intravital microscopy (IVM) imaging of radiofrequency-induced biological alterations such as changes in vessel structure and drug perfusion. Our results indicate that the IVM system is able to handle exposure to high-power electric-fields without inducing significant hardware damage or imaging artifacts. Furthermore, short durations of low-power (< 200 W) radiofrequency exposure increased transport and perfusion of fluorescent tracers into the tumors at temperatures below 41°C. Vessel deformations and blood coagulation were seen for tumor temperatures around 44°C. These results highlight the use of our integrated IVM-RF imaging platform as a powerful new tool to visualize the dynamics and interplay between radiofrequency energy and biological tissues, organs, and tumors.

Abstract 2594: Adjuvant cationic nanoliposomes induce anti-cancer immunity in a murine model of breast cancer

Nanoparticles, such as liposomes, provide opportunities to simultaneously present antigens and immune modulators. Using a 4T1 murine model of breast cancer, a cationic nanoliposomal formulation containing monophosphoryl lipid A and the cationic lipid 1,2-dioleoyl-3-trimethylammonium-propane induced anti-tumor activity following intratumoral administration. Addition of recombinant interleukin-12 (IL-12) further suppressed tumor growth and augmented T helper-1 cell (Th-1) polarization, with enhanced tumor infiltration by cytotoxic T cells, dendritic cells, and M1 macrophages, and amplification of interferon gamma secretion. Mice bearing dual tumors displayed arrest of tumor growth in treated tumors as well as distal, untreated tumors following combination therapy with adjuvant nanoliposomes and IL-12. In summary, adjuvant MPL-liposomes combined with localized IL-12 therapy block tumor growth, stimulate a Th-1 bias of the tumor microenvironment, and induce cancer-specific immune responses.

Citation Format: Ismail M. Meraz, David J. Savage, Jianhua Gu, Jessica Rhudy, Rita E. Serda. Adjuvant cationic nanoliposomes induce anti-cancer immunity in a murine model of breast cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2594. doi:10.1158/1538-7445.AM2014-2594

Adjuvant cationic liposomes presenting MPL and IL-12 induce cell death, suppress tumor growth, and alter the cellular phenotype of tumors in a murine model of breast cancer

Dendritic cells (DC) process and present antigens to T lymphocytes, inducing potent immune responses when encountered in association with activating signals, such as pathogen-associated molecular patterns. Using the 4T1 murine model of breast cancer, cationic liposomes containing monophosphoryl lipid A (MPL) and interleukin (IL)-12 were administered by intratumoral injection. Combination multivalent presentation of the Toll-like receptor-4 ligand MPL and cytotoxic 1,2-dioleoyl-3-trmethylammonium-propane lipids induced cell death, decreased cellular proliferation, and increased serum levels of IL-1β and tumor necrosis factor (TNF)-α. The addition of recombinant IL-12 further suppressed tumor growth and increased expression of IL-1β, TNF-α, and interferon-γ. IL-12 also increased the percentage of cytolytic T cells, DC, and F4/80(+) macrophages in the tumor. While single agent therapy elevated levels of nitric oxide synthase 3-fold above basal levels in the tumor, combination therapy with MPL cationic liposomes and IL-12 stimulated a 7-fold increase, supporting the observed cell cycle arrest (loss of Ki-67 expression) and apoptosis (TUNEL positive). In mice bearing dual tumors, the growth of distal, untreated tumors mirrored that of liposome-treated tumors, supporting the presence of a systemic immune response.

Porous silicon advances in drug delivery and immunotherapy

Biomedical applications of porous silicon include drug delivery, imaging, diagnostics and immunotherapy. This review summarizes new silicon particle fabrication techniques, dynamics of cellular transport, advances in the multistage vector approach to drug delivery, and the use of porous silicon as immune adjuvants. Recent findings support superior therapeutic efficacy of the multistage vector approach over single particle drug delivery systems in mouse models of ovarian and breast cancer. With respect to vaccine development, multivalent presentation of pathogen-associated molecular patterns on the particle surface creates powerful platforms for immunotherapy, with the porous matrix able to carry both antigens and immune modulators.

Plaque antibacterial levels following controlled food intake and use of a toothpaste containing 2% zinc citrate and 0.3% Triclosan

OBJECTIVES

To measure the levels of zinc and Triclosan present in plaque 12 hours post-brushing and following two weeks home use of a toothpaste formulation containing 2% zinc citrate and 0.3% Triclosan. To measure the levels of zinc and Triclosan in plaque following two weeks home use of the test toothpaste formulation together with a further morning's brushing and a day of controlled food intake.

METHODS

A total of 104 subjects completed the study. Plaque samples were taken before use of the test toothpaste and again after a specified regime of product use and food intake. The samples were analysed for zinc or Triclosan.

RESULTS

Levels of zinc and Triclosan in plaque 12 hours after last brushing and following a 2-week home usage of product, were 149.1 microg/g and 8.6 microg/g respectively. Following a morning brushing and a day of controlled food intake zinc and Triclosan levels were 94.7 microg/g and 4.1 microg/g respectively. These levels of agents were found to reduce pH drop in vitro.

CONCLUSIONS

Regular use of a toothpaste containing 2% zinc citrate and 0.3% Triclosan can lead to a build-up of antibacterial agents in plaque that continue to work even after controlled food intake.

The effect of a 2% zinc citrate, 0.3% Triclosan dentifrice on plaque acid production following consumption of a snackfood

OBJECTIVES

A) To assess plaque lactate production following consumption of three foods (cake, chocolate/caramel bar, sweetened coffee), and B) To measure the effect of a fluoride dentifrice containing 2% zinc citrate and 0.3% Triclosan on plaque lactate and pH drop following consumption of cake.

METHODS

A) 10 subjects completed the first study. Plaque samples taken before and at 8,15 and 30 minutes after eating. Samples were analysed for lactate via Capillary Electrophoresis. B) 30 subjects completed the second study. Plaque samples were taken before and after cake and use of test dentifrice or no treatment control. Plaque pH and lactate content were assessed.

RESULTS

A) Plaque lactate levels increased after all three foods; peak lactate levels occurred 8 minutes after eating. B) Plaque lactate concentrations after eating cake were 39.2mM for the control treatment and a significantly lower value, 23.6mM, for the test 2% zinc citrate, 0.3% Triclosan dentifrice. After food challenge, pH values were 5.53 for the no treatment group and a significantly higher value of 5.79 for the test dentifrice group.

CONCLUSIONS

A toothpaste containing 2% zinc citrate, 0.3% Triclosan can significantly reduce plaque lactate generation and pH drop induced by cake, compared to no treatment control.

Abiotrophia species as a cause of endophthalmitis following cataract extraction

Microorganisms of the genus Abiotrophia, members of the oral flora, are known as important causes of bacterial endocarditis. In this study, we report two individual cases of acute vitreous infection caused by Abiotrophia adiacens and Abiotrophia defectiva approximately a week after cataract extraction. Abiotrophia isolates were recovered by cultivation of vitreous humor on chocolate agar and identified via conventional and API 20 Strep identification systems. An 83-year-old male patient (A) and an 80-year-old female patient (B) demonstrated almost identical symptoms of infectious endophthalmitis manifested as hypopyon and opaque media. The vision of both patients was reduced to detection of hand motion in the left and the right eyes, respectively. An emergency pars plana core vitrectomy was performed, and intraocular antibiotics were administered to each patient, who presented 8 months apart in two different institutions. Patients A and B were treated with an intravitreal injection of vancomycin-amikacin and vancomycin-ceftazidime, respectively, which resulted in complete recovery.

[Scoliosis studies with low-dose X-rays]

A modification of the Oxford technique for the radiological examination of scoliotic curvatures in school-children has been devised. Satisfactory image quality is achieved in this way and the radiation dose to patients, despite examinations every 3 months, is only a fraction of the maximum permissible level for radiation workers. The method is simple. Conventional X-ray equipment can be employed.

Amyloidosis of the vitreous. Fluorescein angiographic findings and association with neovascularization

A case of primary systemic amyloidosis with bilateral asymmetric involvement of the vitreous was followed up throughout a 45-month span, during which two vitrectomy procedures were done on one eye. The progressive nature of this disease was documented by serial fluorescein angiograms and fundus photography. The amyloid seemed to be derived from the retina, at small multifocal areas over arterioles and venules that were otherwise clinically and angiographically normal in appearance. Follow-up studies suggested that these focal deposits were actually preretinal, since they disappeared after posterior vitrectomy. Peripheral neovascularization was visible in this case, which has not previously been reported. Amyloidosis of the vitreous can mimic numerous other diseases. Vitrectomy can be effective in restoring visual acuity, although recurrence may be rapid. The diagnosis is readily made by pathologic examination of the vitreous aspirate.

Ionizing radiation causing a risk of cancer in man: a short review and a discussion

An attempt has been made to present, in short review, the most important carcinogens that have been implicated in the development of cancer in the various organ sites of the human body and to demonstrate the relatively minor role played by ionizing radiation, especially radiotherapy, in causing a risk of cancer in man.

Situations related to drinking alcohol. A factor analysis of questionnaire responses

Problem and nonproblem drinkers indicated on a questionnaire the degree to which they used alcohol in certain situations. The responses were factor analyzed and seven factor scales were developed. It is suggested that the questionnaire could be used as an initial diagnostic step leading to specific treatment alternatives.