BACKGROUND:To understand the experiences of parents of children with cerebral palsy (CP) participating in an online parenting course grounded in acceptance and commitment therapy (PACT) from an implementation perspective. METHOD:Fifty-five parents from 50 families of children with CP (GMFCS I = 21, II = 15, III = 8, IV = 8, V = 3) participated in this mixed methods study. Families were drawn from 67 families participating in an RCT of PACT. Parents participated in a qualitative interview and gave additional feedback on 10-point Likert scales and open-ended questions via the course platform. The implementation analysis consisted of a thematic analysis as well as descriptive statistics, t-tests and ANOVAs to examine the impact of child age and motor functioning as potential barriers. RESULTS:Parents reported that they liked both the ACT content and the online format, and the modules were rated highly in the course feedback (7-9 on 10-point Likert scales). Parents reported positive changes for both them and their child. Parents of younger (2-5 years) children rated the videos from Module One Living a Meaningful Life more highly than parents of older (6-10 years) children. There were no other effects of child age or motor functioning. CONCLUSION:Overall, parental response to PACT was positive, and child age and motor functioning level were not barriers. The online format of the programme and ACT content were well suited to the needs of this population. In particular, the ACT components of values and mindfulness were found to be particularly relevant. Implementation should focus on understanding that ACT can be psychologically challenging, ensuring that parents who need individualised support for intervention adaptation receive it, providing good support to address technological difficulties and building effective reminders into the intervention protocol. TRIAL REGISTRATION:Australian New Zealand Clinical Trials Registry: ACTRN12616000351415.

Aim: To test an online course Parenting Acceptance and Commitment Therapy (PACT) in an RCT with families of children with cerebral palsy (CP), predicting improvements in emotional availability and parent and child adjustment.Method: 67 families of children (2-10 years) with CP participated. Families were randomly assigned to waitlist control or PACT. Assessments at baseline, post-intervention and at six-month follow up (durability of intervention effects) focussed on emotional availability, adjustment and quality of life. Analysis consisted of repeated measure linear regression models.Results: At postintervention (T2), an intervention effect was demonstrated for two aspects of observed emotional availability: parental non-intrusiveness MD = 0.68 (-0.56 to 1.92), p = 0.050 and child involvement, MD = 0.91 (-0.36 to 2.18), p = 0.011. An intervention effect was also found for the parent-reported emotional availability in terms of child involvement. Further intervention effects were found in parent-report measures of child quality of life (social wellbeing and acceptance, participation and physical health), parental mindfulness, parental acceptance, support, social connection, and meaning. No effects were found on parent or child adjustment. Analyses focussed on durability of intervention effect, collapsed across groups, indicated that effects persisted at 6 month follow up (T4).Interpretation: PACT demonstrated an intervention effect for two aspects of emotional availability-parental nonintrusiveness and child involvement-as well as parental mindfulness and child quality of life. Parents reported increased comfort with the CP diagnosis, higher likelihood to seek support, higher likelihood to stay connected to others and greater meaningful living. PACT is an effective online/telehealth parenting support intervention for parents of children with CP.

Dementia is a common disease worldwide and is largely underdiagnosed. A timely diagnosis of dementia is beneficial for both the patient and family for many reasons, and exclusion and treatment of other mimics of dementia are crucial to avoid long-term consequences. Making a diagnosis of dementia requires attention to subtle cues from both patients and other informants, as often patients and family members will not notice early signs and symptoms. Although universal screening is not recommended by the USPSTF, screening in high-risk populations is recommended by many organizations. Screening with the Mini-Cog and AD8 combined is a highly sensitive way to identify patients with dementia, and confirmation testing can be performed with the MoCA or MMSE. Specific subtypes of dementia, including Alzheimer's disease, vascular dementia, Lewy body dementia, frontotemporal dementia, and others, sometimes can be differentiated by unique physical examination findings. Timely referral to dementia specialists is useful in the management of this group of diseases. However, as the aging population grows and access to specialists is often limited, it is important for all physicians to understand how to make a diagnosis of dementia.

Direct oral anticoagulants (DOAC) are increasingly utilized for the prevention of thrombotic events. Unlike warfarin they do not require drug‐level monitoring making dedicated DOAC monitoring uncommon. The purpose of this study is to describe the interventions made by a DOAC monitoring service over 3 years.

This study explored the impact response of two bio-inspired composite laminates with linear and non-linear helicoidal fibre architectures. The helicoidal laminates, together with quasi-isotropic and cross-ply control samples, were fabricated using heterocyclic aramid fibres and tested against a spherical projectile under high impact velocities. The results revealed that helicoidal lay-ups with small rotation angles led to inferior perforation resistance and energy absorption capacity when compared to the quasi-isotropic and cross-ply counterparts. The cross-ply configuration was confirmed as the optimal fibre architecture for impact perforation. Post-impact inspections highlighted that the failure mechanisms of laminates were significantly affected by their lay-ups. The number of fractured fibres was found to reduce with the decrease of inter-ply angle. This was due to the small rotation angles promoted a wedge-in mechanism. Moreover, a smaller angle mismatch resulted in diminished overall delamination area in a laminate. Due to these two effects, therefore, helicoidal lay-up configurations with small inter-ply angles are not recommended for impact-resistant laminates reinforced by tough fibres.

Pharmacogenetic testing (PGT) is increasingly being used as a tool to guide clinical decisions. This article describes the development of an outpatient, pharmacist-led, pharmacogenetics consult clinic within internal medicine, its workflow, and early results, along with successes and challenges. A pharmacogenetics-trained pharmacist encouraged primary care physicians (PCPs) to refer patients who were experiencing side effects/ineffectiveness from certain antidepressants, opioids, and/or proton pump inhibitors. In clinic, the pharmacist confirmed the need for and ordered CYP2C19 and/or CYP2D6 testing, provided evidence-based pharmacogenetic recommendations to PCPs, and educated PCPs and patients on the results. Operational and clinical metrics were analyzed. In two years, 91 referred patients were seen in clinic (mean age 57, 67% women, 91% European-American). Of patients who received PGT, 77% had at least one CYP2C19 and/or CYP2D6 phenotype that would make conventional prescribing unfavorable. Recommendations suggested that physicians change a medication/dose for 59% of patients; excluding two patients lost to follow-up, 87% of recommendations were accepted. Challenges included PGT reimbursement and referral maintenance. High frequency of actionable results suggests physician education on who to refer was successful and illustrates the potential to reduce trial-and-error prescribing. High recommendation acceptance rate demonstrates the pharmacist’s effectiveness in providing genotype-guided recommendations, emphasizing a successful pharmacist–physician collaboration.

Purpose Peer-assisted learning (PAL) promotes the development of communication, facilitates improvements in clinical skills, and is a way to provide feedback to learners. We utilized PAL as a conceptual framework to explore the feasibility of peer-assisted feedback (PAF) to improve note-writing skills without requiring faculty time. The aim was to assess whether PAL was a successful method to provide feedback on the United States Medical Licensing Exams (USMLE)-style clinical skills exam notes by using student feedback on a survey in the United States. Methods The University of Florida College of Medicine administers clinical skills examination (CSEs) that include USMLE-like note-writing. PAL, in which students support the learning of their peers, was utilized as an alternative to faculty feedback. Second-year (MS2) and third-year (MS3) medical students taking CSEs participated in faculty-run note-grading sessions immediately after testing, which included explanations of grading rubrics and the feedback process. Students graded an anonymized peer’s notes. The graded material was then forwarded anonymously to its student author to review. Students were surveyed on their perceived ability to provide feedback and the benefits derived from PAF using a Likert scale (1–6) and open-ended comments during the 2017–2018 academic year. Results Students felt generally positively about the activity, with mean scores for items related to educational value of 4.49 for MS2s and 5.11 for MS3s (out of 6). MS3s perceived peer feedback as constructive, felt that evaluating each other’s notes was beneficial, and felt that the exercise would improve their future notes. While still positive, MS2 students gave lower scores than the MS3 students. Conclusion PAF was a successful method of providing feedback on student CSE notes, especially for MS3s. MS2s commented that although they learned during the process, they might be more invested in improving their note-writing as they approach their own USMLE exam.

PURPOSE:Incorporating a patient's genotype into the clinical decision-making process is one approach to precision medicine. The University of Florida (UF) Health Precision Medicine Program is a pharmacist-led multidisciplinary effort that has led the clinical implementation of six gene-drug(s) pairs to date. This study focuses on the challenges encountered and lessons learned with implementing pharmacogenetic testing for three of these: CYP2D6-opioids, CYP2D6/CYP2C19-selective serotonin reuptake inhibitors, and CYP2C19-proton pump inhibitors within six pragmatic clinical trials at UF Health and partners. METHODS:We compared common measures collected within each of the pharmacogenetic implementations as well as solicited feedback from stakeholders to identify challenges, successes, and lessons learned. RESULTS:We identified several challenges related to trial design and implementation, and learned valuable lessons. Most notably, case discussions are effective for prescriber education, prescribers need clear concise guidance on genotype-based actions, having genotype results available at the time of the patient-prescriber encounter helps optimize the ability to act on them, children prefer noninvasive sample collection, and study participants are willing to answer patient-reported outcomes questionnaires if they are not overly burdensome, among others. CONCLUSION:The lessons learned from implementing three gene-drug pairs in ambulatory care settings will help shape future pharmacogenetic clinical trials and clinical implementations.

Perspectives Viewpoints•Women and minority physicians are hesitant to negotiate elements of their contract, including wage, benefits, research, and personal time.•The ‘Imposter Syndrome’ is one of the reasons for not negotiating.•Negotiation skills are usually not taught during residency training, leaving residents in the lurch when they negotiate their first contract out of training.•Developing a curricular blueprint of essential negotiation and business skills residents will require on graduation is essential.A senior resident in her last months of training interviews for a job that she likes and is in an ideal location for her. She is offered the position and she immediately accepts the offer and signs a contract. Later that week, the resident learns that a male colleague also interviewed for the job and signed a contract that was $16,500 more than the salary she had accepted. She is very surprised and disappointed; she had no idea that she could have negotiated. •Women and minority physicians are hesitant to negotiate elements of their contract, including wage, benefits, research, and personal time.•The ‘Imposter Syndrome’ is one of the reasons for not negotiating.•Negotiation skills are usually not taught during residency training, leaving residents in the lurch when they negotiate their first contract out of training.•Developing a curricular blueprint of essential negotiation and business skills residents will require on graduation is essential. The United Nations has a new campaign to stop women from being “robbed” of equal pay: #stoptherobbery.1Farber M. The United Nations has a new campaign to stop women from being ‘robbed’ of equal pay. Available at: http://fortune.com/2017/03/15/un-women-campaign-gender-pay-gap/. Accessed May 21, 2018.Google Scholar In this article, we make a case for residency program directors to step forward to contribute to #stoptherobbery in medicine. Women are increasingly a large percentage of the medical workforce every year. In 1966, only 6.9% of medical school graduates were women; this number increased to 50.7% by 2017.2Association of American Medical Colleges (AAMC). U.S. medical school applications and matriculants by school, state of legal residence, and sex, 2017-2018. Available at: https://www.aamc.org/download/321442/data/factstablea1.pdf. Accessed May 21, 2018.Google Scholar In 2007, the Committee on Maximizing the Potential of Women in Academic Science and Engineering found that “female faculty members are paid less, promoted more slowly, and hold fewer leadership positions than men,” despite the fact that women are an increasingly large percentage of the medical workforce.3Arora VM It is time for equal pay for equal work for Physicians-paging Dr Ledbetter.JAMA Intern Med. 2016; 176: 1305-1306Crossref PubMed Scopus (7) Google Scholar One reason previously thought to explain the pay gap was the relatively high number of women in lower-paying primary care fields.4Phillips SP Austin EB The feminization of medicine and population health.JAMA. 2009; 301: 863-864Crossref PubMed Scopus (61) Google Scholar However, even with a decreasing percentage of women choosing to enter primary care, the pay gap has not closed.5Lambert EM Holmboe ES The relationship between specialty choice and gender of US medical students, 1990–2003.Acad Med. 2005; 80: 797-802Crossref PubMed Scopus (166) Google Scholar Another reason thought to explain the compensation and promotion discrepancy was a perceived lower productivity by female physicians.6Kaplan SH Sullivan LM Dukes KA Phillips CF Kelch RP Schaller JG Sex differences in academic advancement—results of a national study of pediatricians.N Engl J Med. 1996; 335: 1282-1290Crossref PubMed Scopus (210) Google Scholar After adjustment for confounding influences on productivity, no sex-based difference in numbers of publications or grants can be found between women and men faculty.7Carr PL Friedman RH Moskowitz MA Kazis LE Comparing the status of women and men in academic medicine.Ann Intern Med. 1993; 119: 908-913Crossref PubMed Scopus (113) Google Scholar,8Wright AL Schwindt LA Bassford TL et al.Gender differences in academic advancement: Patterns, causes, and potential solutions in one US college of medicine.Acad Med. 2003; 78: 500-508Crossref PubMed Scopus (193) Google Scholar There are isolated examples of institutional intervention to reduce the salary disparities.9Wright AL Ryan K Germain PS Schwindt L Sager R Reed KL Compensation in academic medicine: Progress toward gender equity.J Gen Intern Med. 2007; 22: 1398-1402Crossref PubMed Scopus (23) Google Scholar In the absence of such interventions, it is important to highlight this disparity and provide women with the tools to negotiate their fair share. A common misconception, that the inability to negotiate is a baby-boomer problem, has been negated with research showing that failure to negotiate is pervasive among younger generations as well.10Babcock L Laschever S Dunbrooke S Women Don't Ask. Princeton University Press, Princeton, NJ2014Google Scholar Women continue to underestimate their skills while men will generally overestimate their abilities.11Kay K Shipman C The confidence gap.Atlantic. 2014; 14: 1-18Google Scholar Women will not attempt promotions or negotiate salary increases until they feel they are “perfect,” whereas men will attempt these advances with fewer qualifications.11Kay K Shipman C The confidence gap.Atlantic. 2014; 14: 1-18Google Scholar This disparity can lead to lack of advancement; in Women Don't Ask, Babcock et al10Babcock L Laschever S Dunbrooke S Women Don't Ask. Princeton University Press, Princeton, NJ2014Google Scholar describe many situations in which hard-working women with great achievements were not rewarded by raises due to lack of self-promotion. Negotiation skills are not commonly part of the medical school or residency curriculum. However, women physicians often find themselves negotiating for salary and other benefits prior to residency completion. If the starting salary is not negotiated, women physicians will likely never catch up to the salary of men who negotiated their salary initially.10Babcock L Laschever S Dunbrooke S Women Don't Ask. Princeton University Press, Princeton, NJ2014Google Scholar Women often start out with a lower salary expectation than their male counterparts.12Stevens CK Bavetta AG Gist ME Gender differences in the acquisition of salary negotiation skills: The role of goals, self-efficacy, and perceived control.J Appl Psychol. 1993; 78: 723-735Crossref PubMed Scopus (159) Google Scholar Male sex is associated with a higher salary for physician researchers (about $13,000 more) even after adjustment for specialty, academic rank, leadership positions, and research time.13Jagsi R Griffith KA Stewart A Sambuco D DeCastro R Ubel PA Gender differences in the salaries of physician researchers.JAMA. 2012; 307: 2410-2417Crossref PubMed Scopus (283) Google Scholar Overall, women faculty earn $20,520 less than men and make 90 cents for every dollar earned by male faculty.14Freund KM Raj A Kaplan SE et al.Inequities in academic compensation by gender: A follow-up to the national faculty survey cohort study.Acad Med. 2016; 91: 1068-1073Crossref PubMed Scopus (127) Google Scholar When interviewed, women faculty view negotiation as less important to an academic career than their male colleagues.15Sarfaty S Kolb D Barnett R et al.Negotiation in academic medicine: a necessary career skill.J Womens Health (Larchmt). 2007; 16: 235-244Crossref PubMed Scopus (39) Google Scholar The authors of the paper note: “The naiveté of faculty in our survey regarding the use of negotiation in faculty careers suggests that academic medical institutions and their leadership have not fully understood the importance or the benefits that can result from skilled negotiation.” Teaching negotiation skills during residency could help eliminate the gaps in both salary and promotion that occur in academic medicine. There is very little in medical education literature about negotiation training. Providing training in negotiation skills would help to equalize the playing field for women and lead to equitable compensation. Creating awareness about the pay gap is step one. While it is imperative for programs to ensure that women physicians are aware of the pay gap, creating awareness is equally important for male physicians, as some may gain leadership positions in the future and can help support equal pay. Training sessions are step 2: highlighting the best time window to negotiate, emphasizing the importance ofcompleting due diligence about the job, careful self-reflection of competencies, and acknowledging financial and nonfinancial priorities would help women physicians negotiate their first jobs.16Morahan PS Katz JK We like you and want to hire you!.Acad Physician Sci. 2006; : 4-6Google Scholar Additionally, providing opportunities to rehearse negotiating strategy would help create awareness of their own limits while understanding the importance of searching for mutual benefit between themselves and the employer. Similar to the business world training sessions, this rehearsal should create awareness of how things can go wrong while negotiating, or the “four traps of negotiation”—including leaving money on the table (not getting as much money as you should), settling for too little (the winner's curse), walking away when you should not, and settling for terms that are worse than your current situation.17Thompson LL The Mind and Heart of the Negotiator. Pearson, Boston2015Google Scholar It is imperative for residency program directors to consider adding interactive sessions, workshops, or seminars on negotiating skills for trainees who are about to graduate. Because residency curriculum is usually structured, these sessions should be added to the current conference schedule (can be an educational lecture) or be offered as an optional activity (evening presentation or retreat hosted by experts in the field). There have been a few programs that have delivered this curriculum in different manners, and overall, residents have found the information to be very helpful.18Salib S Moreno A Good-bye and good luck: teaching residents the business of medicine after residency.J Grad Med Educ. 2015; 7: 338-340Crossref PubMed Scopus (5) Google Scholar Residency program directors often have little (or no) room to add curriculum, and program directors may struggle to find time to add new activities; however, Salib et al18Salib S Moreno A Good-bye and good luck: teaching residents the business of medicine after residency.J Grad Med Educ. 2015; 7: 338-340Crossref PubMed Scopus (5) Google Scholar demonstrate the benefit of single training sessions for internal medicine residents. It is important to note that these activities should not be considered separate from residency training curricula. In fact, Gunderman and Tawadros19Gunderman RB Tawadros AM Business education for radiology residents the value of full-time business educators.Acad Radiol. 2011; 18: 645-649Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar link such training sessions to the Accreditation Council for Graduate Medical Education competencies. The Table18Salib S Moreno A Good-bye and good luck: teaching residents the business of medicine after residency.J Grad Med Educ. 2015; 7: 338-340Crossref PubMed Scopus (5) Google Scholar, 19Gunderman RB Tawadros AM Business education for radiology residents the value of full-time business educators.Acad Radiol. 2011; 18: 645-649Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 20Williams LL Teaching residents practice-management knowledge and skills: an in vivo experience.Acad Psychiatry. 2009; 33: 135-138Crossref PubMed Scopus (8) Google Scholar, 21Holak EJ Kaslow O Pagel PS Facilitating the transition to practice: a weekend retreat curriculum for business-ofmedicine education of United States anesthesiology residents.J Anesth. 2010; 24: 807-810Crossref PubMed Scopus (17) Google Scholar describes programs that have implemented training sessions and how they were incorporated into residency curriculum. We recommend that residency program directors consider the following points to help them design curricula to address specifically negotiation skills and, more broadly, other business skills residents will require on graduation:1.Develop a blueprint (linked to Accreditation Council for Graduate Medical Education competencies) of essential negotiation and business skills residents will require on graduation. The blueprint should describe the “what, why, how, when, and where” questions related to designing curricular activities.2.Collaborate with faculty from business/finance schools to design interactive sessions on the identified topics.3.Design program evaluation of the curriculum, gathering data on the effectiveness of the program as well as areas for further improvement.TableExamples of Negotiation Skills Training During ResidencyProgramDescription of Previous CurriculaUniversity of Texas at Austin Internal Medicine Residency18Salib S Moreno A Good-bye and good luck: teaching residents the business of medicine after residency.J Grad Med Educ. 2015; 7: 338-340Crossref PubMed Scopus (5) Google Scholar“Life After Residency Curriculum”:18Salib S Moreno A Good-bye and good luck: teaching residents the business of medicine after residency.J Grad Med Educ. 2015; 7: 338-340Crossref PubMed Scopus (5) Google Scholar one mandatory afternoon conference consisting of lecture format, expert faculty discussion, small group sessions, and ending with question and answer panel. Highlighted topics such as the job search (preparing curriculum vitae and interviews), contract management (malpractice, clauses, and compensation), and negotiation skills basics.Baylor University Psychiatry Residency Program20Williams LL Teaching residents practice-management knowledge and skills: an in vivo experience.Acad Psychiatry. 2009; 33: 135-138Crossref PubMed Scopus (8) Google Scholar“Independent Practice Clinic Experience”:20Williams LL Teaching residents practice-management knowledge and skills: an in vivo experience.Acad Psychiatry. 2009; 33: 135-138Crossref PubMed Scopus (8) Google Scholar psychiatry residents spent one half-day clinic per week with a faculty member learning the business aspect of clinic. During this clinic session, they were able to address issues such as employment contracts and negotiation skills.The Medical College of Wisconsin Department of Anesthesiology21Holak EJ Kaslow O Pagel PS Facilitating the transition to practice: a weekend retreat curriculum for business-ofmedicine education of United States anesthesiology residents.J Anesth. 2010; 24: 807-810Crossref PubMed Scopus (17) Google Scholar“Mandatory Weekend Retreat”—discussing business-of-medicine education.21Holak EJ Kaslow O Pagel PS Facilitating the transition to practice: a weekend retreat curriculum for business-ofmedicine education of United States anesthesiology residents.J Anesth. 2010; 24: 807-810Crossref PubMed Scopus (17) Google Scholar Retreat hosted by experts in the field that discussed interview skills, contract law, negotiation skills, physician reimbursement, malpractice, and financial planning. Presentations were mostly discussion format to facilitate conversation.Department of Radiology, Indiana University School of Medicine19Gunderman RB Tawadros AM Business education for radiology residents the value of full-time business educators.Acad Radiol. 2011; 18: 645-649Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar“Business Course Elective”:19Gunderman RB Tawadros AM Business education for radiology residents the value of full-time business educators.Acad Radiol. 2011; 18: 645-649Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar elective incorporated into residency program. Consisted of educational course during the afternoon (twice per week) during which time residents were excused from clinical duties. Courses taught by expert faculty members from the university and discussed leadership, finances, and contract negotiation/management. Open table in a new tab We conclude by noting the gap in literature regarding description of negotiation skills sessions in medical education, particularly in residency programs. Training material with interactive scenarios would be a contribution to the literature along with description of the impact of such sessions. It is indeed sobering to note that residents in general are not trained to negotiate salary and women residents in particular are consequently less likely to negotiate research time and personal time, all factors contributing to the leaky pipeline. We provide an example of what our initial scenario should ideally look like—Residency program directors: There is a need to step in and contribute to #Stoptherobbery!A senior resident in her last months of training interviews for a job that she likes and is in an ideal location for her. During her residency training, she has attended a series of interactive sessions on “life after residency.” She recalls the emphasis placed during the sessions on researching work environment and salaries prior to signing a contract. She proactively contacts a friend who is also working with the group for information and searches online for salaries offered in the region. The following week she is offered the position but at a lower salary than expected. She uses her negotiation training skills to effectively obtain an offer for a salary at par to other physicians working in the group.

PURPOSE:CYP2D6 bioactivates codeine and tramadol, with intermediate and poor metabolizers (IMs and PMs) expected to have impaired analgesia. This pragmatic proof-of-concept trial tested the effects of CYP2D6-guided opioid prescribing on pain control. METHODS:Participants with chronic pain (94% on an opioid) from seven clinics were enrolled into CYP2D6-guided (n = 235) or usual care (n = 135) arms using a cluster design. CYP2D6 phenotypes were assigned based on genotype and CYP2D6 inhibitor use, with recommendations for opioid prescribing made in the CYP2D6-guided arm. Pain was assessed at baseline and 3 months using PROMIS® measures. RESULTS:On stepwise multiple linear regression, the primary outcome of composite pain intensity (composite of current pain and worst and average pain in the past week) among IM/PMs initially prescribed tramadol/codeine (n = 45) had greater improvement in the CYP2D6-guided versus usual care arm (-1.01 ± 1.59 vs. -0.40 ± 1.20; adj P = 0.016); 24% of CYP2D6-guided versus 0% of usual care participants reported ≥30% (clinically meaningful) reduction in the composite outcome. In contrast, among normal metabolizers prescribed tramadol or codeine at baseline, there was no difference in the change in composite pain intensity at 3 months between CYP2D6-guided (-0.61 ± 1.39) and usual care (-0.54 ± 1.69) groups (adj P = 0.540). CONCLUSION:These data support the potential benefits of CYP2D6-guided pain management.

An 86-year-old woman presented with marked blistering of her left index fingertip and ulceration of the left middle fingertip, with a 2-year history of recurrent blistering and ulceration of her fingers bilaterally. She denied any preceding finger trauma, although she reported frequent gardening. She denied systemic symptoms. Her medical history was significant for a 2-year history of atrial fibrillation on carvedilol, amiodarone and apixaban, and she was a lifetime non-smoker. On admission, she had elevated inflammatory markers but unremarkable autoantibodies. Radiograph of the hand revealed diffuse soft tissue fullness and subtle irregularities at the tuft of the index finger, but all other investigations were unremarkable. The lesion was incised and drained, revealing blood-tinged purulent fluid. Wound biopsy revealed spongiosis with neutrophils, consistent with a diagnosis of blistering distal dactylitis.

The first semester of anatomy at the University of Florida College of Medicine is based upon teaching relevant anatomy as it relates to the physical exam and the utilization of prosections in the anatomy laboratory to see and learn the assigned anatomy. With a class size of ~140 students and with 4 hours allotted to an anatomy laboratory experience per week, students are divided into 10 teams; each team of students are further divided into an orange group and a blue group. Students of 2 groups of the 20 groups decide which of 14 lab sessions they will serve as peer teachers. To prepare for their peer‐teaching experience, they meet a week prior to the selected laboratory session with the teaching faculty to learn the assigned prosected anatomy. Students are expected to practice teaching the assigned anatomy and present one or more 15 minute teaching sessions to the faculty. On the day of an anatomy lab, there were 4 stations of student teachers. Members of the first‐year class rotate to different stations every 15 minutes. The students' perspective of the value of the peer‐teaching has been very positive. An online survey taken this past academic year by students in the first 3 years of training identified that the student peer‐teaching: 1) was beneficial to their learning of assigned laboratory anatomy (84% strongly agreed or agreed) and 2) facilitated their learning of the assigned anatomy by rotating to different stations with different peer teachers (84% strongly agreed or agreed). Quantitative data of the survey and course debriefings further support the view that student peer‐teaching positively augments student learning of anatomy. While some students stated they would be more comfortable with a member of the faculty to teach them, a greater number of students thoroughly enjoyed being taught by their peers; they believed it was the best part of anatomy. In fact, student peer‐teaching is used as a recruitment feature by first and second years when they interact with perspective candidates.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Objective: Unusual clinical course Background: Serotonin syndrome is a common yet potentially life-threatening condition caused by increased serotonergic activity, usually from serotonergic pharmaceutical agents. Primary features of serotonin syndrome include mental status changes, autonomic hyperactivity, and neuromuscular abnormalities. However, the presentation of serotonin syndrome is often quite variable, leading to its under-diagnosis. Case Report: A 50-year-old female with chronic kidney disease on peritoneal dialysis presented to the Emergency Department with severe, diffuse body pain. Over the course of her hospital stay, she developed severe nausea, vomiting, and diarrhea followed by hyperreflexia and inducible clonus. Laboratory studies were remarkable for elevated liver transaminases. Review of her medications revealed several serotonergic agents, including duloxetine, tramadol, and ondansetron. Given her symptoms and the multiple serotonergic agents she was taking, she was diagnosed with serotonin syndrome. Discontinuation of the serotonergic agents led to resolution of her symptoms over the course of 4 days. Conclusions: Our patient's initial presentation of diffuse body pain highlights the variable presentation of serotonin syndrome. Our case also demonstrates the importance of recognizing serotonin syndrome, as the supportive ondansetron we gave to alleviate her nausea and vomiting likely exacerbated her serotonin syndrome.

Anatomy retention and recall (R & R) boot camps were created to further strengthen student's learning of clinically‐relevant gross anatomy. Three boot camps were given generally during a 2 week period prior to an anatomy practical. Importantly, the boot camps were spaced so students could self‐assess their level of anatomical knowledge and have time to review areas that they might be need more time to learn. The anatomy R & R boot camps replaced the traditional practice practical that usually was held the day before the anatomy practical, thereby, lessening the possibility that student could significantly increase their level of knowledge a day before a given practical. Each boot camp session was scheduled for 1 hour; students were asked to identify tagged structures at 25 stations during the first 30 minutes; students then had ~ 30 minutes to immediately review and gain feedback on what clues were used to identify a given structure. Students' perspective of the value of the anatomy R & R boot camps have been overwhelmingly positive. An online survey taken this past academic year by students in the first 3 years of training identified that the boot camps: 1) enhanced their recall and improved their retention (99% strongly agreed); 2) increased their confidence in their ability to identify structures and functions (81% strongly agreed); 3) facilitated their learning of anatomy (99% strongly agreed); and 4) provided feedback on their level of knowledge (88% strongly agreed). Qualitative data further confirmed the positive impact students placed on the boot camps. Although setting up individual boot camps was time‐intensive, the teaching faculty viewed the boot camps experiences as a means to further enrich students' knowledge base of anatomy. This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal .

Anticoagulation is the mainstay of treatment for pulmonary embolism. However, if bleeding unfortunately occurs, the risks and benefits of anticoagulation present a challenge. Management of one hemorrhagic complication, retroperitoneal hematoma, is rare, difficult, and controversial.

Many medical schools have undergone curricula revisions and attempted to integrate basic and clinical sciences.In 2012, our program at the University of Florida College of Medicine underwent significant curricular reform, transitioning from the standard medical curriculum to a systems-based approach.The teaching of anatomy, clinical skills, radiology, ethics, population health, human behavior, and evidence-based medicine was integrated into one class, "Introduction to Clinical Medicine", which spans 68 weeks in the pre-clerkship curriculum.As a result, there was a reduction of anatomy teaching from 166 to 120 hours.Our curriculum integration demonstrates opportunities for enhanced teaching including increasing peer learning, incorporating multidisciplinary case presentations, and allowing for a deliberate overlap and layering of anatomy education across two years of medical school.This paper describes our reflection on the effect of the curriculum change on student learning.Five years after implementation of these changes shows that our efforts also illustrate the challenges inherent to curricular integration including scheduling constraints, unclear sources of financial support, apprehension about the effect on future National Board of Medical Examiners (NBME) scores, and difficulty assessing which areas a student needs to remediate within a failed integrated course.Overall, the integration of anatomy with other classes into a revised course at our College of Medicine has been well received and successful.

Introduction Over the past decade, portfolios have gained popularity in medical education as tools to evaluate and provide feedback about learning and completion of professionally authentic tasks. Though faculty development has been noted to be key for successful portfolios, there are few available resources. As part of an interinstitutional collaborative project, we have developed online faculty development modules that provide pedagogical information about portfolios, practical advice, and resources from the available literature. Methods The materials associated with this publication include downloadable modules, which take approximately 45 minutes to complete and can be paused at any time, and sample questions to facilitate small-group discussion with faculty either in the planning stage of portfolios or as part of program evaluation of an institution's portfolios. Results A survey taken by faculty from four medical schools after completion of the modules showed that they were well received, with 41% of participants stating that they were very knowledgeable after undertaking the modules compared to 11% before undertaking the modules. Faculty reported increased interest in the topic and increased confidence in their ability to undertake planning for development of portfolios at their institution and considered using the modules as a mandatory curriculum for portfolio coaches at their institutions. Discussion We suggest that these modules be used for individual self-development, as part of faculty development sessions for portfolio coaches and mentors, or to provide faculty with background information about portfolios during the planning phase of portfolios at an institution.

Aim: We sought to investigate the number of US medical schools utilizing portfolios, the format of portfolios, information technology (IT) innovations, purpose of portfolios and their ability to engage faculty and students.Methods: A 21-question survey regarding portfolios was sent to the 141 LCME-accredited, US medical schools. The response rate was 50% (71/141); 47% of respondents (33/71) reported that their medical school used portfolios in some form. Of those, 7% reported the use of paper-based portfolios and 76% use electronic portfolios. Forty-five percent reported portfolio use for formative evaluation only; 48% for both formative and summative evaluation, and 3% for summative evaluation alone.Results: Seventy-two percent developed a longitudinal, competency-based portfolio. The most common feature of portfolios was reflective writing (79%). Seventy-three percent allow access to the portfolio off-campus, 58% allow usage of tablets and mobile devices, and 9% involve social media within the portfolio. Eighty percent and 69% agreed that the portfolio engaged students and faculty, respectively. Ninety-seven percent reported that the portfolios used at their institution have room for improvement.Conclusion: While there is significant variation in the purpose and structure of portfolios in the medical schools surveyed, most schools using portfolios reported a high level of engagement with students and faculty.