HMS Theses and Dissertations

Acute ischemic stroke is a serious medical emergency caused by the blockage of blood flow to the brain. With an estimated 15 million new cases each year, it is a leading cause of morbidity and mortality worldwide. The evaluation of the clinical stroke treatment and care is, therefore, crucial to mitigate the burden of this severe disease. In this thesis, we conducted two observational studies which made two reflections on clinical stroke care by analyzing the Comprehensive stroke center database at Massachusetts General Hospital (MGH) from 2012-2022, which contained 8943 patients with acute stroke admitted to MGH.

 Over the past few decades, thrombolytic and endovascular therapies have become became the mainstay of acute ischemic stroke treatment. However, the routine imaging of 24h non-contrast head computed tomography (CT) for patients post thrombolysis and thrombectomy can be costly and time-consuming. In the first paper, we aimed to evaluate the utility of 24-hour per-protocol CT scan for patients who have undergone thrombolysis or mechanical thrombectomy. We aimed to identify the risk factors for clinically meaningful CT scans and predict changes in management. This could help reduce unnecessary imaging and optimize patient care.

 Metformin is a widely used oral antidiabetic medication that has been shown to have neuroprotective effects in animal models of stroke. Previous studies have also shown that patients with stroke and diabetes on treatment with metformin post intravenous thrombolysis had less severe strokes on admission. In the second paper, we hypothesized that pretreatment with metformin for patients with type 2 diabetes had less severe strokes on admission, less mortality during hospitalization, and better functional outcomes at discharge. This research could lead to a better understanding of the neuroprotective effects of metformin and inform stroke treatment strategies for patients with diabetes. 

   By analyzing the Comprehensive Stroke Center database and investigating the use of 24-hour per-protocol CT scans and the effects of metformin treatment, this thesis aims to improve our understanding of acute ischemic stroke treatment and care.

Abstract Purpose: To determine if an association exists between 5-α Reductase Inhibitor (5-ARI) use and the risk of overall bladder cancer or lethal bladder cancer. Materials and Methods: This prospective cohort study included 39,427 men in the United States who were part of the Harvard School of Public Health’s Health Professionals Follow-up Study. We identified men who did not carry a diagnosis of cancer (other than non-melanoma skin cancer) in 1996 and prospectively followed them for 5-ARI use, cancer incidence, metastases, and mortality until 2012 using biannual questionnaires and, beginning in 2000, an annual bladder cancer specific cancer survey for men carrying that diagnosis. The primary exposure variable was 5-ARI use Results: Over the course of 16 years (595,377 person-years) of follow-up, there were 943 diagnosed cases of bladder cancer, of which 159 were cases of lethal bladder cancer. Ever use of 5-ARIs was reported by 4105 men (10.4%) between 1996 and 2012. No association with 5-ARI ever use and bladder cancer was detected in either our age-adjusted model (HR 1.24, 95% CI 0.98-1.56) or in our multivariate analysis (HR 1.15, 95% CI 0.91-1.46, p=.25). Similarly, no significantly changed risk was of bladder cancer was detected when an analysis was conducted examining duration of 5-ARI exposure. Conclusions: There was no statistically significant relationship between 5-ARI usage, ever vs. never or duration of use, and the development of overall or lethal bladder cancer in either age adjusted or fully adjusted models.

Benign prostatic hyperplasia (BPH) is one of the most commonly diagnosed chronic diseases in older men associated with a gradual deterioration of lower urinary tract symptoms (LUTS). 5-α reductase inhibitors (5ARIs) are among the most commonly used pharmacological treatments for BPH(1, 2). They act by inhibiting the enzyme 5α-reductase, promoting prostatic apoptosis and prostate size reduction in order to improve urinary symptoms. Although multiple clinical trials showed 5ARIs could reduce the risk of AUR or need for surgery(3-7), In practice, poor adherence to 5ARIs treatment remains to be a problem, which could lead to a reduced efficacy. The relationship between levels of adherence and long-term clinical outcomes has not been determined. Despite the fact that 5ARIs are widely used for benign prostatic hyperplasia, several preclinical studies have demonstrated that treatment with an anti-androgen such as 5ARIs could potentially decrease the incidence of bladder cancer(8, 9). Limited results from observational studies failed to reach a consensus on whether there was a difference in the incidence of bladder cancer between men who received 5ARIs and those who did not(10, 11). In our study we utilized big data generated from medical claims by the Partners Center for Population Health Evaluation and Research Unit to investigate the effect of 5ARIs therapy on men diagnosed with BPH. In the first part of the study, we focused on evaluation of drug adherence and long-term clinical outcomes. In the second part, we investigated if 5ARIs therapy affect on bladder cancer incidence.

TITLE: A Behavioral Study of Digital Technology for Improving Post-Operative Incentive Spirometer Adherence Laura Banashek, BA, John Pearson, MD, Charles Safran, MD Purpose: This study seeks to determine whether incentive spirometer (IS) data gathered via a smartphone platform can be utilized to determine baseline adherence to prescribed IS exercises, as well as improve patient adherence in the post-operative period. A customized smartphone-based device will be the primary intervention and will record as well as encourage use of prescribed spirometer exercises through a connected spirometer device (Smart Peak FlowTM) and smartphone-based app. By establishing a dose-response relationship between IS and post-operative pulmonary complications (PPCs), we can make a more informed decision regarding the use of IS in the post-operative period. Methods: This study is a prospective, randomized, participant blinded, single center, clinical trial. Based on our planned analysis, we expect to enroll 50 patients (25 in each arm). The control group will be given the BIDMC standard VoldyneTM IS with an attached Smart Peak FlowTM device to passively record usage. The study group will be given the Smart Peak FlowTM device connected to an android smartphone to record usage. Patients in the study group will also utilize a smartphone application to view their usage and receive encouragement to continue using their device. Results: Due to delays in device development, outcomes data are not currently available for analysis. However, we plan to begin recruiting participants over the next two to three months. The primary endpoint is patient adherence to prescribed IS exercises in the perioperative period. Secondary outcomes are largely clinical and included PPCs as measured by atelectasis, respiratory failure, tracheobronchial infection, or pneumonia. Other secondary measures include total mortality from respiratory causes, all other post-op complications, length of in hospital stay, all-cause mortality, and cost analysis. Conclusions: Incentive spirometry has been a mainstay of affordable PPC prevention for decades, but a lack of adherence data (whether due to imperfect use or imperfect data capture) has led many to question the true clinical effectiveness of this intervention. Our study utilizes a custom IS and Smart Peak FlowTM meter to measure and record baseline adherence data on a smartphone platform. Once we have a more reliable measure of baseline adherence, we can analyze the dose-response relationship between IS exercises and the incidence of PPCs. This will provide more conclusive evidence to support either the continued use of post-operative IS or its discontinuation.

Early breast cancer diagnosis is challenging due to the high false-positive rate and a lack of molecular classification of the current, imaging-based mammography. An estimated 50% of women screened annually in the U.S. experience a false-positive result, and of these women, 7%- 17% will receive unnecessary biopsies. Since tumors, even at early stages, secrete molecules into the bloodstream, a liquid biopsy has the potential to provide an alternative classification method for early detection. Concurrently, liquid biopsies could provide molecular information which would facilitate subtyping and help guide treatment. Although biomarkers can be overexpressed in breast cancer tissues, many clinically-relevant proteins are present at sub pg/mL concentrations in the blood and are therefore difficult to measure. To overcome this challenge, the Walt lab has previously developed a Single Molecule Array (Simoa) platform to achieve protein concentrations detection at a 10-19 M level compared to the conventional ELISA’s ability of 10-12 M detection. By labeling and isolating each immunocomplex into femtoliter-sized wells, we can digitally count the number of molecules in a sample. This assay format has been automated to reduce human error and increase accuracy. Additionally, due to the high sensitivity, only a low sample volume of 25 microliter or less is required. We collected 120 blood samples from healthy controls and 102 blood samples from untreated breast cancer patients. Testing a panel of 10 biomarkers on these blood samples, we achieve an AUC of 93% for breast cancer detection, which significantly outperforms mammograms. Whether Simoa confers robust prediction for subtypes and stages remains to be validated.

Purpose: Obstructive sleep apnea (OSA) is a sleep disorder characterized by complete or partial airway closure during sleep. The treatment for OSA is positive airway pressure (PAP), but 34% of patients who are receiving this treatment are non-adherent. One proven method of increasing adherence is through remote patient monitoring (RPM), or in other words, staying connected to patients through real-time monitoring of their physiologic data. Medicare, as well as other insurance companies, have become aware of the benefits of RPM, and have recently introduced new billing codes to incentivize clinicians to incorporate RPM in their clinical practice. However, the current systems for RPM are described by clinicians as being unfriendly and time-intensive, resulting in little to no monitoring of patient data. Thus, I developed a business plan for an RPM platform that keeps sleep medicine physicians updated on their patients’ response to therapy, with the goal of improving adherence and overall patient outcomes.
Methods: To better understand the pain points in RPM, I developed a survey which I sent to board-certified physicians of sleep medicine who treat patients with OSA. The survey was sent to physicians in both private practice and academia (primarily within the Harvard hospital system including Brigham and Women’s Hospital, Massachusetts General Hospital, and Beth Israel Deaconess Medical Center). The survey was completed by eleven clinicians (see Appendix for sample survey). Additionally, I interviewed four of the clinicians individually to better understand how they integrate RPM in their practice. The combination of survey responses and interviews provided me with a better understanding of the pain points in RPM, which I then used to design a startup responding to the clinicians’ needs. Results: Of the eleven clinicians who responded to the survey, nine (81%) were in academia and two (19%) were in private practice. Seven (64%) of them used RPM in their practice to track their patients on PAP therapy. Three (27%) reported that they did not know that RPM was billable by Medicare or other insurers. When asked about pain points, seven (64%) reported that time was a constraint and eight (73%) reported that software issues were another constraint in their ability to engage in RPM. Overall, there were five major pain points commonly reported by clinicians: 1) RPM is not worth the effort, 2) I do not have the time to monitor all of my patients, 3) It is difficult to know who is doing well and who is not, 4) I cannot keep track of patients I monitored or contacted, and 5) I did not know you could bill for RPM. Conclusions: Using the feedback I obtained from physicians, I developed a business plan for “MonitAir” – a startup that aims to improve RPM for the treatment of OSA. MonitAir consists of two parts: 1) a software that allows physicians to keep track of their patients’ sleep data, and 2) an outsourced monitoring service. Outsourced monitoring refers to contracting medical staff (i.e., nurses and medical assistants) who can keep track of patient data remotely, make interventions as needed, assist in billing, and provide updates to physicians. This two-part design solves the problems of time and software constraints, providing clinicians with a solution that is directly targeted at improving adherence to therapy and overall patient outcomes. Other RPM startups have emerged in this area and are focused on tackling other diseases like hypertension and diabetes, but MonitAir is the first startup focused on OSA. The vision for MonitAir is to eventually dominate the untapped respiratory care segment, beginning with OSA and expanding into the more prevalent COPD and Asthma populations once the current business model is proven.

Abstract Strong leadership is associated with better performance of individuals, teams, and organizations. This project aimed to determine whether a flipped-classroom and mastery-learning curriculum is associated with measurable changes in leadership knowledge and skills in healthcare leadership learners. The study measured leadership knowledge (based on a course-specific test) and skill (based on the validated Multifactor Leadership Questionnaire 5x Short (MLQ 5x Short), given to both students and their classmates) in all 15 learners enrolled in the Core Executive Leadership course within the HMS Masters in Clinical Service Operations program. Measurements were collected both before and after the course. The results showed significant improvement in leadership skills: 1. Building Trust (Idealized attributes: Cohen’s d = 0.53, p = 0.029) and Acts with Integrity (Idealized Behaviors: Cohen’s d = 0.47, p = 0.044). Findings also show significant improvement in Transactional Leadership: Rewards Achievement (Contingent Reward: Cohen’s d = 0.52, p = 0.032). These course outcomes demonstrate meaningful, moderate effect sizes following the educational innovation: namely, the combined mastery learning and flipped classroom approach described previously. Results from the Rater Survey, a companion survey which utilizes the same 45 questions as the MLQ 5x Short but in the perspective of an observer, and Post-course survey demonstrated significance in one skill: Transactional Leadership Contingent Reward (t (15) = -0.57, p= 0.03), indicating learners’ most accurate self assessment may be related to this skill in particular. Utilizing a combined mastery learning and flipped classroom approach, this study has demonstrated meaningful change in 2 attributes related to Transformational Leadership: Idealized Attributes and Idealized Behaviors, as well as in Transactional Leadership: Contingent Rewards. However, the Rater survey correlated more closely with the Pre-Course Survey than the Post-course survey, indicating an increase in confidence but not in practice.

Background: Maternal mortality remains the greatest global health disparity with postpartum hemorrhage (PPH) the most common cause. Uterine balloon tamponade (UBT) devices offer a highly effective, point of care intervention that does not require complex equipment. However, there are many UBT devices on the market and few studies have compared them in clinical practice. Additionally, no studies have examined differences in user experience between devices. In cases of PPH, it is essential to have simple, easy to use equipment that can be deployed in minutes. Understanding how ease of use compares between devices is critical to informing PPH guidelines and practice. Methods: User experience was assessed with five UBT devices by simulating emergency PPH clinical scenarios with a SynDaver pelvic model. The five devices tested encompassed a range of commercial, low-cost, and improvised devices, including: Ellavi balloon, Bakri balloon, Ebb balloon, Every Second Matters-UBT (ESM-UBT), and an improvised condom balloon. Participants placed and inflated each device in the SynDaver uterus during PPH simulations. Data collected included user subjective experiences reported via surveys and the time and number of attempts required for participants to achieve successful placement. Results: Four key findings were drawn from this study. Firstly, Ellavi balloon was rated to be the simplest, easiest, and fastest device to use overall. Secondly, both Ellavi and the ESM-UBT, lowcost alternatives to expensive commercial devices, were found to be non-inferior with regard to ease of use and may be superior to Bakri balloon. Thirdly, the ESM-UBT was rated higher than the improvised balloon and was faster to assemble and inflate even without simulating one of the greatest differences between the devices, which is that the components for the improvised are often not readily available. Fourthly, the Ebb was fast to use but also more confusing for users with a higher rate of error. Finally, Bakri balloon was not as highly rated as expected given that it is the gold standard. It ranked fourth overall, just above the improvised device. Conclusion: This study provides evidence that devices vary substantially in their user-friendliness and speed at which they can be assembled, placed, and inflated. Given the high cost of commercial devices like Bakri balloon, which is approximately 100x the cost of Ellavi and ESM-UBT, and a climate of rising healthcare costs, these results suggest it may be time to consider adopting less expensive, easier to use devices that have recently come to market.

Purpose: Surgery is increasingly accepted as a necessary part of a functioning health system. In 2015, the Lancet Commission on Global Surgery (LCoGS) recommended that every country report its surgical volume and post-operative mortality rate (POMR) as part of six indicators on the strength of a surgical system. The LCoGS did not make recommendations on the best method to collect these data. This study aimed to collect these metrics at a regional referral hospital in Uganda, and to compare observational prospective data collection with retrospective review of patient charts and ward logbooks. We hypothesized that logbooks would be an efficient method, whereas prospective data collection and patient charts would be too time-consuming for large-scale data collection. Methods: For one month, basic information was taken about every patient who had an operation at a regional referral hospital in Western Uganda. These patients were followed up through daily ward observation and their outcomes were followed until discharge or death. Prospective data were compared with data obtained from logbooks and patient charts to determine the validity of using retrospective methods for collecting these metrics. Results: Surgical volume at this regional hospital in Uganda was projected to be 8,515 operations/year. The POMR at this hospital is 2.4%. Finding patient files in the medical records department was time consuming and yielded only 62% of the files. Furthermore, a comparison of missing versus found charts revealed that the missing charts are significantly different from the found charts. Logbooks, on the other hand, captured 99% of the operations and 94% of the deaths. Conclusion:  This regional referral hospital has a large volume of surgery, with a POMR that is equivalent to that reported from similar settings. Logbooks, which are ubiquitous in low-resource settings, represent a good source of data for measuring simple metrics such as POMR and surgical volume.

Introduction: The patient-centered medical home (PCMH) is a team-based model of care that seeks to improve quality of care and control costs. The Oklahoma Health Care Authority (OHCA) directs Oklahoma’s Medicaid program and contracts with 861 medical home practices across the state in one of three tiers of operational capacity: Tier 1 (Basic), Tier 2 (Advanced) and Tier 3 (Optimal). Only 13.5% (n=116) homes are at the optimal level; the majority (59%, n=508) at the basic level. In this study, we sought to determine the barriers that prevented Tier 1 homes from advancing to Tier 3 level and the incentives that would motivate providers to advance from Tier 1 to 3. Our hypotheses were that Tier 1 medical homes were located in smaller practices with limited resources and the providers are not convinced that the expense of advancing from Tier 1 status to Tier 3 status was worth the added value. Methods: We analyzed OHCA records to compare the 508 Tier 1 (entry-level) with 116 Tier 3 (optimal) medical homes for demographic differences with regards to location: urban or rural, duration as medical home, percentage of contracts that were group contracts, number of providers per group contract, panel age range, panel size, and member-provider ratio. We surveyed all 508 Tier 1 homes with a mail–in survey, and with focused follow up visits to identify the barriers to, and incentives for, upgrading from Tier 1 to Tier 2 or 3. Results: We found that Tier 1 homes were more likely to be in rural areas, run by solo practitioners, serve exclusively adult panels, have smaller panel sizes, and have higher member- to-provider ratios in comparison with Tier 3 homes. Our survey had a 35% response rate. Results showed that the most difficult changes for Tier 1 homes to implement were providing 4 hours of after-hours care and a dedicated program for mental illness and substance abuse. The results also showed that the most compelling incentives for encouraging Tier 1 homes to upgrade their tier status were less “red tape” with prior authorizations, higher pay, and help with panel member follow-up. Discussion: Multiple interventions may help medical homes in Oklahoma advance from the basic to the optimal level such as sharing of resources among adjoining practices, expansion of OHCA online resources to help with pre-authorizations and patient follow up, and the generation and transmission of data on the benefits of medical homes.

The blended learning method can potentially increase the quality of newly established medical schools in rural Indonesia. Blended learning faces significant challenges when it comes to engaging diverse students across digital divides and with varying socioeconomic disparities. There are 14 variables explored on this study through statistical analysis, including regressions. The variable group A consists of 7 variables associated with digital divides and socioeconomic disparities are measured through a survey. The variable group B consists of 5 variables relating to online learning engagement and are measured through platform analytics. The two academic performance variables are measured by two similar tests: Readiness Assessment Test (RAT) and Delayed Post-test (DPT). This study is designed to compare the variable group A to the variable group B in terms of each variable group’s effect on the academic performances of students. The sample includes 46 medical students in their clinical year who are involved in a designed blended learning curriculum. The RAT has bivariate associations with the first login and duration of access. Also, the RAT has a multivariate association with the first login and duration of access. The DPT has bivariate associations with the first login and the comfortability level in technology usage. We do not find any association among any of the other variables in the variable group A or in the variable group B with regard to academic performance. There is also a significant difference of differences between a group that previously had lower scores and a group that previously had higher scores, before and after the face-to- face session. To conclude, a student’s engagement in online learning has a more direct association with their academic performance than to other variables related to the digital divide and socioeconomic disparities. The students who procrastinate in starting to access online lesson is more likely to have a weaker overall performance. The face-to-face component of blended learning is just as important as the online learning component.

Background: The extent of variation in analgesic prescribing following musculoskeletal injury between countries is poorly understood. Understanding how analgesic prescribing varies between countries and cultural contexts can inform both domestic prescribing and future policy. Our survey study aimed to evaluate how opioid and non-opioid prescribing by orthopedic residents varies by geographic context. Methods: Orthopedic residents in 3 countries in which residents are the primary prescribers of postoperative analgesia at academic medical centers (Haiti, the Netherlands, and the U.S.) responded to surveys utilizing vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for post-discharge analgesia. We standardized opioid prescriptions by conversion to Morphine Milligram Equivalents (MMEs), and we quantified the likelihood and dose of acetaminophen or a non-steroidal anti-inflammatory drug (NSAID) prescription. We constructed multivariable regressions with generalized estimation equations to describe differences in opioid and non-opioid prescription between countries based on prescriber and test case characteristics. Results: Compared to residents from the Netherlands and Haiti, U.S. residents prescribed more total MMEs per case overall (in MMEs, U.S.:383 [CI:331-435]; Netherlands:229 [CI:160-297]; Haiti:101 [CI:52-150], p<0.0001) as well as when analyses were stratified by anatomical site of injury. Similar results were obtained when examining MMEs prescribed per day, opioid prescription duration, and likelihood of opioid prescription. Residents from Haiti were more likely to prescribe non-opioids (OR 3.22 [CI:1.94-5.34], p<0.0001) compared to U.S. residents, and residents from the Netherlands nearly always prescribed non-opioids. When prescribing opioids, providers co-prescribed a non-opioid (acetaminophen or NSAID) in 345/603 (57.2%) of U.S., 152/152 (100%) of Dutch, and 69/97 (71.1%) of Haitian cases (Fisher's exact test p-value <0.0001). Finally, providers prescribed only non-opioids for pain control in 3/348 (0.86%) of U.S., 32/184 (17.4%) of Dutch, and 107/176 (60.8%) of Haitian cases (Fisher's exact test p<0.0001). Conclusions: Our results demonstrate greater post-operative discharge opioid prescribing in the U.S. compared to at least 2 other countries, one low-income and one high-income. Additionally, U.S. prescribers prescribed non-opioid analgesics less frequently, either in isolation or in conjunction with opioids. Our findings highlight the high domestic reliance on opioid prescribing for post-operative pain in orthopedic trauma.

Background: Diabetes affects 3.85 million in the Kingdom of Saudi Arabia (KSA). Physicians providing care for diabetes patient in the primary care setting (PCPs) are at the forefront of the battle against diabetes at the Ministry of Health (MOH) of KSA, but their knowledge, attitudes, and beliefs towards their knowledge of diabetes and access to supportive educational and expert guidance have not been adequately studied. Objectives: Assess PCPs’ 1) knowledge of the various diabetes domains from diagnosis to management of complications; 2) self-efficacy; 3) sense of burden and anxiety when caring for patients with diabetes; 4) professional satisfaction; 5) professional isolation; 6) satisfaction with access to continuing medical education (CME) and expert opinion; 7) transfer of knowledge; and 8) perceived patient and clinic benefit/ referral to endocrine /diabetes clinics from current participation in CME.
Design: An online self-administered open book case-based validated and timed multiple-choice exam and survey of PCPs. Participants: 249 PCPs currently employed and caring for diabetes patients at the MOH of KSA sampled from 19 primary locations and 11 diabetes units across KSA. Main measures: Descriptive analyses of exam results, survey questions on self-efficacy, sense of burden/anxiety when caring for diabetes patients, professional isolation, professional satisfaction, satisfaction with access to CME/expert opinion, transfer of knowledge, and perceived benefit to patients and reduction of referral to endocrine or diabetes clinics. Various tests of statistical association between the survey domains and knowledge scores were performed. Key results: Participants scored an average of 55% on the knowledge score exam and only 12% achieved a passing score of at least 70%. Around 50% reported a self-efficacy of competent, very competent, or expert in diabetes. More than 30% of participants reported moderate to severe levels of burden/stress when caring for patients with diabetes in all clinical domains of diabetes and more than 50% reported the same levels of burden in diabetes emergencies or inpatient diabetes care. Conclusions: These findings suggest that alignment between quality improvement initiatives and targeted CME activities is warranted. Furthermore, a wider needs assessment is required to explore the high levels of stress burden in this group.

Over the last decade, thousands of United States service members have sustained limb injuries from blast exposure, largely attributed to the rising use of improvised explosive devices (IEDs) by terrorist and insurgent groups. These blasts destroy large amounts of tissue causing peripheral nerve injuries and amputations in many cases. The objective of this research was to develop a device to improve functional recovery among these patients by providing in vivo monitoring of neuromuscular regeneration, maintenance of acetylcholine receptors for reinnervation and prevention of muscle atrophy. An implantable, flexible microelectrode array (MEA) was engineered that provides stimulation and recording during acute denervation of muscle distal to nerve injuries and muscle grafts for creation of regenerative peripheral nerve interfaces (RPNIs). One issue that has prevented the development of muscle surface electrodes is the immune-mediated foreign body response resulting in fibrotic capsule formation around the device. To inhibit fibrosis, the electrode was embedded with crystal formulations of a drug called GW2580, a Colony Stimulating Factor 1 (CSF1R) inhibitor allowing for long-term release of the drug from the surface of the MEA. The MEA uses a flexible polyimide elastomer and an array of gold-based microelectrodes featuring Peano curve motifs, which together maintain electrode flexibility. A new surgical technique was developed utilizing a biceps femoris muscle flap along the dorsal surface of the electrode to prevent wound breakdown during implantation. The devices were implanted along the denervated gastrocnemius muscles of rats. These rats underwent therapeutic stimulation using the MEA daily beginning on post-operative day 2. Tissues were harvested on post-operative day 14 and evaluated for quantification acetylcholine receptors and muscle fiber area using immunofluorescence and histological staining. Additionally, the MEAs were implanted along the dorsal surface of free flap grafts to serve as a RPNI for 6 weeks in rats. Using electrophysiological and histological assessments, we compare with unstimulated control grafts. The Young’s modulus was 1.67 GPa, which is comparable to native tendon and muscle. The devices successfully recorded electromyogram data when implanted in rats. When compared to untreated denervated muscles, MEA therapy attenuated atrophy by maintaining larger muscle fiber cross-sectional areas. Furthermore, the acetylcholine receptor areas were markedly larger with MEA treatment. The postoperative course of one animal without the biceps femoris flap (control) was complicated by complete wound dehiscence requiring euthanasia of the animal on postoperative day 4; the remaining control animals showed evidence of ulceration at the implant. The animals that did have the biceps femoris flap did not have ulcerative lesions on postoperative day 7. Expression of specific markers for acute inflammation (TNF-alpha), innate immune cell macrophages (CD68) and fibrosis (alphaSMactin) were also decreased in the flap group by qPCR analysis. Drug-loading with crystalized formulations of GW2580 successfully prevented fibrotic capsule formation and improved therapeutic efficacy of the SMEA. When the MEAs were implanted along the surface of muscle grafts for RPNIs, we found significantly delayed reinnervation and abnormal electromyographic (EMG) signals, with significantly more polyphasia, lower compound muscle action potentials and higher fatigability in stimulated animals. These metrics are suggestive of myopathy in the free flap grafts stimulated with the electrode. Active inflammatory processes and partial necrosis were observed in grafts stimulated with the MEA. This work demonstrates the ability to combine conformability, tensile strength-enhancing metal micropatterning and drug loading for long-term release into a functional implant for both epimysial stimulation and recording during acute denervation injury. However, under the same treatment protocol, implanted epimysial electrodes and electrical stimulation to deinnervated and devascularized flaps during the early recovery phase may be detrimental to regeneration.

A Gallery Based Approach to Learning Radiology in Medical School Purpose: To create an organized online teaching resource for learning radiology that organizes radiological images by teaching points into extensive image galleries. Methods: Images were collected from the electronic medical record/teaching files from collaborating radiologists. These images were then processed (with the help of a Python program created for this project), annotated, and then uploaded by topic into online teaching points to the website www.stepwards.com. Results: Many different teaching modules were created and published online throughout the course of this project (outlined more below) that covered important topic such as normal/unremarkable radiological studies, radiological anatomy, and the radiological appearance of pathological conditions. Conclusions: The efforts of this project were successful in creating the teaching modules to the originally desired specifications. The modules were so effective that they are currently being utilized by the Mount Auburn diagnostic radiology program to aid in teaching residents/trainees about key concepts in radiology. With this in mind, there is still much more work to be done, and many more teaching points in radiology that would benefit from additional teaching modules. One day it would be most effective to try and collaborate with others who share the goal behind this project in order to generate conent more quickly and efficiently.

Background: Global Health is an emerging field in medicine that has been introduced in many medical colleges across the world but still does not exist in Saudi Arabia’s undergraduate medical education curricula. Objective: To carry out a needs assessment that evaluates students’ and faculty’s perceptions about introducing a Global Health Curriculum at King Saud Medical College in Riyadh, Saudi Arabia. Methods: This paper is a cross-sectional mixed methods study that took place at King Saud University and involved a student survey (n=600) and 10 faculty interviews. A 17 item survey was emailed to 4th and 5th year medical students. Faculty interviews, consisting of 4 open-ended questions, were conducted electronically. Faculty members belonged to the Medical Education and Community Medicine departments. The survey results were used to make a connection with the qualitative data. Results: 253/600 students completed the survey (42% response rate). 83% (210) of the students endorsed the introduction of a Global Health course while 17% (43) said they didn’t.
Half of the students 51% (129) endorsed the course as an elective, and 32% (81) as a compulsory course. The faculty encouraged the introduction of a global health curriculum; acknowledging its benefits and stating the barriers that need to be overcome. Conclusion: Students at King Saud Medical College are interested in a Global Health curriculum. By learning from other universities who have preceded us in this field, faculty noted the benefits of such a curriculum a expressed interest in introducing it.

Purpose: Asthma disproportionately affects poor and minority children. Limited parental knowledge and confidence in asthma management, as well as stress from chronic illness may contribute to poor outcomes. Novel approaches for providing care are essential for this vulnerable population. As part of a quality improvement initiative, we developed and implemented a pilot asthma group visit to: 1) evaluate the feasibility of the group visit format for high risk children with asthma, 2) assess parents’ experiences with the group visit, and 3) assess the impact of participation on parents’ confidence in asthma management. Methods: Our primary care practice provides care for over 2,600 children with asthma. Many have public insurance. Children classified as high-risk (≥1 asthma-related emergency department visit/hospitalization in the preceding two years) were eligible to participate. During the group visit, children received brief physical exams, medication reviews, and updated Asthma Action Plans (AAPs). Separate educational sessions were held for children and parents. Pre- and post-group visit surveys were used to assess parents’ experience and changes in confidence in asthma management. Results: Twenty children and their parents participated. Mean parent confidence scores (five-point Likert scale, 5 indicating greatest confidence) improved in: managing their child’s asthma symptoms (3.60, 4.40 p≤ 0.005), managing their child’s asthma medications (3.85, 4.30 p ≤0.005), using their child’s AAP (3.79, 4.45 p≤ 0.02), communicating with the school about their child’s food allergies (4.32, 4.72 p≤0.03), and helping their child relax to reduce emotional triggers of asthma (3.25, 4.47, p≤0.01). All families reported that they would return to a group visit. Conclusion: Group visits are feasible for providing care, education, and peer support to a vulnerable population. Parents expressed satisfaction and improved confidence in aspects of asthma management. Group visits have the potential to engage high-risk families and improve asthma health outcomes.

Within our hospitals, we have the privilege each day to meet individuals from all walks of life who seek care. Our patients, as does make up the United States, are a mix of varying cultural identities, different socioeconomic status, and speak different languages. The most frequently spoken non-English language within the United States is Spanish, and although we are tasked with caring for the health of these patients in our clinics, within medicine there is a shortage of Spanish speaking physicians. Language discordance between doctor and patient is associated with poorer quality care and thus poorer health outcomes. The aim of this scholarly work was to develop fluency in Spanish and to then reflect on my experiences through that journey through reflective writing, written entirely in my newly learned second language.
During my fourth year at Harvard Medical School, I embarked on this process through an intensive medical Spanish course and rounded out the journey through working clinically abroad for eight weeks in a Spanish-speaking country. I met a number of patients that both inspired me to carry out this goal but who also contributed to my learning along the way, and it is these patients I reflected on in my creative arts piece. Although I recognize that each individuals’ journey in medicine must be their own, and that my path to learning a second language is not universal a roadmap, I hope my story may inspire others to strive to learn a second language for their patients. The opportunity has helped me grow into not only a Spanish-speaking future provider, but one who will only be better for their patients as a result.

Purpose: To assess the association between Medicare Advantage Star Ratings and enrollment decisions of new Medicare Advantage enrollees. Methods: We studied the enrollment decisions of new Medicare Advantage beneficiaries from 2012-2017 using a conditional logistic regression, controlling for plan- and beneficiary-level characteristics. We modeled those who were not previously enrolled in Medicare and those who switched from fee-for-service (FFS) Medicare separately. Results: In the main study cohort, a 1-star increase in Star Rating was associated with a OR 1.88 (95% CI, 1.86-1.89) increase in the likelihood of enrollment among first-time Medicare enrollees and a OR 1.64 (95% CI, 1.55-1.7) increase among those switching from FFS Medicare. The association persisted across all years, though the association was weaker among black, Asian, and older enrollees. Conclusions: Our results indicate that higher Star Ratings is positively associated with likelihood of enrollment for new Medicare Advantage enrollees between 2012-2017.

Purpose: To evaluate the impact of three gastroenterology-focused podcast episodes on clerkship student learning during the internal medicine rotation. Methods: We produced a pilot series of three medical education podcast episodes to teach medical students about gastrointestinal (GI) bleeding: Non-Variceal Upper GI Bleed; Variceal Upper GI Bleed; and Lower GI Bleed. We chose these topics because they are likely to be encountered on an internal medicine service. Episodes ranged from 15 to 18 minutes and featured an interview with an attending gastroenterologist. The discussion focused on the presentation, workup, diagnosis, and management of GI bleeds. We conducted a study to analyze the potential impact of this pilot series. Episodes were distributed to six second-year students starting their internal medicine rotation in October 2019. To elicit feedback, we administered a 9- item survey that included Likert scale questions and two free-form questions about the content, efficacy, and duration of the episodes. Responses were collected using Qualtrics, a web-based survey tool. Results: Survey response rate was 100% (6/6). All respondents listened to at least two of the three episodes and were satisfied with the quality of the podcast as a learning resource. All students strongly agreed or agreed that the podcasts helped build a foundational approach and increased confidence during their rotation. Most students thought the episodes were appropriate for their level of knowledge (83% marked “strongly agree” or “agree”) and 100% of students would recommend the podcast to other students. The majority of students (83%) thought the episode duration was appropriate. Free-form feedback included comments praising the podcast’s clinical relevance and focus on frameworks. (Frameworks in this context refer to a pedagogical tool that broadly conceptualizes a problem and offers a stepwise approach to finding solutions.) Respondents identified potential areas of improvement including sound quality and the addition of associated diagrams or outlines. Conclusions: Medical students found this pilot series of GI podcast episodes to be a helpful resource. Educational podcasts can serve as an easily accessible resource with high-yield teaching for medical students as they transition from the classroom to the hospital setting. Podcasts may help create a foundation of knowledge and build clinical confidence. Next steps include incorporating feedback and expanding the clinical content covered.