Graduate Medical Education Works

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    The Sin of Exclusion: Applicability of Trials Encouraging Omission of Radiation Therapy to Nonwhite Patients With Breast Cancer
    (ASCO, 2018-11) McClelland, Shearwood, III; Xanthopoulos, Eric P.; Mitin, Timur; Graduate Medical Education, School of Medicine
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    PET and SPECT Imaging of the Brain: History, Technical Considerations, Applications, and Radiotracers
    (Elsevier, 2020-12) Davis, Korbin M.; Ryan, Joshua L.; Aaron, Vasantha D.; Sims, Justin B.; Graduate Medical Education, School of Medicine
    Advances in nuclear medicine have revolutionized our ability to accurately diagnose patients with a wide array of neurologic pathologies and provide appropriate therapy. The development of new radiopharmaceuticals has made possible the identification of regional differences in brain tissue composition and metabolism. In addition, the evolution of 3-dimensional molecular imaging followed by fusion with computed tomography and magnetic resonance imaging have allowed for more precise localization of pathologies. This review will introduce single photon emission computed tomography and positron emission tomographic imaging of the brain, including the history of their development, technical considerations, and a brief overview of pertinent radiopharmaceuticals and their applications.
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    Hypothermia is Associated With Poor Prognosis in Hospitalized Patients With Severe COVID-19 Symptoms
    (2021) Maait, Yousef; El Khoury, Marc; McKinley, Lee; El Khoury, Anthony; Graduate Medical Education, Office of Educational Affairs, IU School of Medicine
    Rationale Hypothermia forms a part of the diagnostic criteria for Systemic Inflammatory Response Syndrome (SIRS), National Early Warning Score (NEWS) and has repeatedly been shown to be associated with worse outcomes when compared to normothermic and hyperthermic patients with sepsis. We evaluate whether this is the case in COVID-19 patients. Objective To determine whether there is an association between hypothermia and worse prognosis in COVID-19 patients in the intensive care unit. Methods Retrospective study of a cohort of patients (n = 57) admitted to the intensive care unit of a community hospital with a positive test for COVID-19. Measurements Data relating to mortality, comorbidities and length of stay was recorded from electronic medical records for each patient. Hypothermia was defined as ≥2 recorded body temperatures of less than 96.5℉ (35.83℃) at the time of admission. Main results Of the 57 patients enrolled in the study, 21 developed hypothermia during their stay and 36 did not. Our results show that patients who have hypothermia at the time of admission spend a longer time intubated (p < 0.01) and go through longer ICU stays (p < 0.01). These patients are also 2.18 times more likely to suffer a fatal outcome compared to patients that did not develop hypothermia while in the intensive care unit (Chi-squared = 8.6209, p < 0.01, RR = 2.18). Conclusions Hypothermia in patients with severe COVID-19 at the time of admission to the ICU is associated with poorer outcomes for patients. This manifests as a longer period of intubation, longer ICU stay, and increased risk of mortality.
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    Mutations in CRBN and other cereblon pathway genes are infrequently associated with acquired resistance to immunomodulatory drugs
    (Springer Nature, 2021) Jones, J. R.; Barber, A.; Le Bihan, Y-V; Weinhold, N.; Ashby, C.; Walker, B. A.; Wardell, C. P.; Wang, H.; Kaiser, M. F.; Jackson, G. H.; Davies, F. E.; Chopra, R.; Morgan, G. J.; Pawlyn, C.; Graduate Medical Education, School of Medicine
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    Performance of crisis standards of care guidelines in a cohort of critically ill COVID-19 patients in the United States
    (Elsevier, 2021) Jezmir, Julia L.; Bharadwaj, Maheetha; Chaitoff, Alexander; Diephuis, Bradford; Crowley, Conor P.; Kishore, Sandeep P.; Goralnick, Eric; Merriam, Louis T.; Milliken, Aimee; Rhee, Chanu; Sadovnikoff, Nicholas; Shah, Sejal B.; Gupta, Shruti; Leaf, David E.; Feldman, William B.; Kim, Edy Y.; STOP-COVID Investigators; Graduate Medical Education, School of Medicine
    Many US states published crisis standards of care (CSC) guidelines for allocating scarce critical care resources during the COVID-19 pandemic. However, the performance of these guidelines in maximizing their population benefit has not been well tested. In 2,272 adults with COVID-19 requiring mechanical ventilation drawn from the Study of the Treatment and Outcomes in Critically Ill Patients with COVID-19 (STOP-COVID) multicenter cohort, we test the following three approaches to CSC algorithms: Sequential Organ Failure Assessment (SOFA) scores grouped into ranges, SOFA score ranges plus comorbidities, and a hypothetical approach using raw SOFA scores not grouped into ranges. We find that area under receiver operating characteristic (AUROC) curves for all three algorithms demonstrate only modest discrimination for 28-day mortality. Adding comorbidity scoring modestly improves algorithm performance over SOFA scores alone. The algorithm incorporating comorbidities has modestly worse predictive performance for Black compared to white patients. CSC algorithms should be empirically examined to refine approaches to the allocation of scarce resources during pandemics and to avoid potential exacerbation of racial inequities.
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    Use of External Tissue Expanders to Assist in Reverse Sural Flap Donor Site Closure
    (Wolters Kluwer, 2021) Cox, Cameron; Gaschen, Paul D.; Foley, David; MacKay, Brendan; Graduate Medical Education, School of Medicine
    Background: Complex lower extremity injuries can cause large soft tissue defects that require reconstruction. In the distal third of the lower leg, the reverse sural artery fasciocutaneous flap is a viable coverage option due to its versatility, vascular supply, and ability to cover larger defects than other local pedicled flaps. Although advances in techniques have improved reliability of reverse sural flaps, complications such as donor site morbidity remain a challenge for surgeons. Donor wounds may be difficult to close, and delayed closure can increase the risk for infection and other postoperative complications. In these cases, donor site skin grafting can cause additional morbidity and/or mobility restrictions. Methods: In this case series, 16 patients underwent reconstruction with large reverse sural artery fasciocutaneous flaps and a continuous external tissue expander to assist in donor site closure. Results: One patient was lost to follow-up. All donor sites healed without complication with an average time to healing of 9.2 weeks (n = 15, range: 3–18). At the most recent follow-up, all flaps survived without complication. Conclusions: Given our success in 100% of patients, we purport that this system of enhanced closure may be a valuable adjunctive therapy in closing reverse sural artery fasciocutaneous flaps. We believe that this method may be useful in closing other difficult donor wounds.
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    Student-Led Curricular Approaches in Medical Education: The Value-Added Effects of a Virtual Fundamentals of COVID-19 Course
    (Research Square, 2021-05-10) Chiu, Megan Z.; Baker, Joseph M.; Gomez, Maritza; Brown, Cameron M.; Brenner, Abigail M.; Huang, Christina C.; Graduate Medical Education, School of Medicine
    Background As the eld of education was adapting to virtual learning during the COVID-19 pandemic, a need quickly emerged for a course to prepare medical students for future clinical practice. This call to action was answered by creating an innovative Fundamentals of COVID-19 course at the Indiana University School of Medicine (IUSM). As a group of medical student leaders at IUSM, we developed this online course in order to support our fellow students and the community. The course was implemented in May 2020 and enrolled a total of 724 third- and fourth-year medical students. Subsequently, we carried out a research study about this student-led curricular approach and its implications for medical education. Methods The study examined the value-added educational effects of completing the Fundamentals of COVID-19 course. In order to examine these effects, the study asked enrolled students to complete both a pre- and post-course self-assessment survey. Students were asked an identical set of questions on each survey about their knowledge (7), skills (5), and abilities (5) (KSA) regarding COVID-19. Composite scores were created for each KSA learning domain. Responses were provided using a ve-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. Results Out of the 724 students enrolled, 645 students completed both the pre- and post-course assessment surveys. Findings show that there were both meaningful and statistically signi cant differences in students’ responses to the pre- and post-course surveys. Results show 1.) a signi cant mean increase in the knowledge composite score of 1.01, 95% CI [0.95, 1.06], t(644) = 36.4 , p <.001, d = 1.43; 2.) a signi cant mean increase in the skills composite score of .55, 95% CI [0.50, 0.60], t(644) = 20.70, p <.001, d = 0.81. and 3.) a signi cant mean increase of the abilities composite score of 1.02, 95% CI [.97, 1.07], t(644) = 36.56, p <.001, d = 1.44. Conclusions These ndings demonstrate that the student-developed, online Fundamentals of COVID-19 course resulted in value-added educational effects. Overall, this study provides evidence to support virtually delivered, student-led curricular approaches in medical education.
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    Eating disorder symptomatology in transgender patients: Differences across gender identity and gender affirmation
    (Wiley, 2021-08) Nowaskie, Dustin Z.; Filipowicz, Andrew T.; Choi, Yena; Fogel, Janine M.; Graduate Medical Education, Office of Educational Affairs, IU School of Medicine
    OBJECTIVE: Past studies have reported high rates of eating disorder (ED) symptomatology among transgender people, yet without consideration of gender affirmation. The primary objective of this study was to evaluate the relationship between gender identity, gender affirming interventions such as gender affirming hormones (GAH) and gender affirming surgeries (GAS), and ED symptomatology. METHOD: Transgender patients at a primary care outpatient gender health program in the United States completed a survey consisting of demographics, medical history, and clinical variables, including the Eating Disorder Examination Questionnaire (EDE-Q). Multivariate analyses of covariance were conducted to compare EDE-Q scores across gender identity and gender affirmation. RESULTS: Compared to transgender men (n = 79), transgender women (n = 87) reported higher EDE-Q scores and significantly higher Eating Concern. Compared to hormone/surgery-naïve and hormone-experienced/surgery-naïve patients, hormone/surgery-experienced patients had lower EDE-Q scores. Hormone/surgery-experienced patients reported significantly lower Shape Concern and marginally lower Global Score and Weight Concern than hormone-experienced/surgery-naïve patients. There were no differences in EDE-Q scores between hormone/surgery-naïve and hormone-experienced/surgery-naïve patients. DISCUSSION: Transgender patients report high levels of ED symptomatology. There are subtle, yet important, differences in ED between gender identities and gender affirmations. High ED prevalence may result from the dual pathways of sociocultural pressures as well as gender dysphoria. Both GAH and GAS may be effective interventions to support gender affirmation and thereby alleviate ED symptomatology. While the potential positive benefits of GAS on ED are more apparent, the effects of GAH are less clear.
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    Acute psychosis and serotonin syndrome in the setting of "Triple-C" overdose: a case report
    (BMC, 2021-11) Bachar, Roudi; Majewski, John Robert; Shrack, Christopher; El-Khoury, Anthony; Graduate Medical Education, School of Medicine
    BACKGROUND: Over-the-counter medication overdose is a difficult diagnostic challenge for many physicians as common drug screening assays cannot detect these substances. We present a case of acute psychosis, serotonin syndrome, and anticholinergic overdose-like properties in the setting of Coricidin HBP Cough & Cold tablets, known by their street name Triple-C. This is the first case report we are aware of involving a patient presenting with these symptoms and requiring critical-care-level support. CASE PRESENTATION: A 31-year-old African American female with a past medical history of anxiety, childhood asthma, previous methamphetamine abuse, and coronavirus disease 2019 infection in August 2020 was brought to the emergency department by the local police department with altered mental status. Initial blood work, including extended drug screens, were unremarkable for a definitive diagnosis. This patient required critical-care-level support and high sedation because of her symptoms. Collateral history revealed the patient regularly consumed Triple-C daily for the 6 weeks prior to admission. A trial off sedation was attempted after 24 hours with no complications. The patient admitted to regular Triple-C consumption and auditory hallucinations since adolescence. She was discharged safely after 48 hours back into the community. She was lost to follow-up with psychiatry and internal medicine; however, she was evaluated in the emergency room 1 month later with a similar psychiatric presentation. CONCLUSION: Overdose of Triple-C should be kept in the differential diagnosis of patients presenting with a triad of psychosis, serotonin syndrome, and anticholinergic overdose, in the setting of unknown substance ingestion.
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    Vascular Biomarkers from Optical Coherence Tomography Angiography and Glaucoma: Where do we stand in 2021?
    (Wiley, 2022) Shin, Joshua D.; Wolf, Amber T.; Harris, Alon; Verticchio Vercellin, Alice; Siesky, Brent; Rowe, Lucas W.; Packles, Michelle; Oddone, Francesco; Graduate Medical Education, School of Medicine
    Biomarkers of ocular blood flow originating from a wide variety of imaging modalities have been associated with glaucoma onset and progression for many decades. Advancements in imaging platforms including optical coherence tomography angiography (OCTA) have provided the ability to quantify vascular changes in glaucoma patients, alongside traditional measures such as retinal nerve fiber layer thickness (RNFL) and optic nerve head (ONH) structure. Current literature on vascular biomarkers, as measured by OCTA, indicates significant relationships between glaucoma and blood flow and capillary density in the retina and ONH. The data currently available, however, is highly diverse and lacks robust longitudinal data on OCTA vascular outcomes and glaucoma progression. Herein we discuss and summarize the relevant current literature on OCTA vascular biomarkers and glaucoma reviewed from December 14, 2020 through March 1, 2021. Associations between OCTA vascular biomarkers and clinical structural and functional glaucoma outcomes as well as differences between glaucoma patients and healthy controls are reviewed and summarized. The available data identifies significantly decreased flow density, flow index, and vessel density in the ONH, peripapillary vascular layer, and macula of glaucoma patients compared to controls. Whole image vessel density is also significantly decreased in glaucoma patients compared to controls and this outcome has been found to correspond to severity of visual field loss. OCTA vascular biomarkers alongside clinical structural outcomes may aid in assessing overall risk for glaucoma in patients.