Recommended Readings

(1). Sonal Matharu. ICU is a terrible place to die’: When letting go of treatment is the best choice.

https://theprint.in/features/icu-is-a-terrible-place-to-die-when-letting-go-of-treatment-is-the-best-choice/917291/

Some doctors and NGOs are working to ensure that patients with terminal or incurable conditions experience a better quality of life-and death.

Deepak Roshan with his mother and dog at their Ghaziabad home

(2). Sandra G. Boodman. For a bicyclist, a long overdue checkup uncovered the unexpected. 2021.

https://www.washingtonpost.com/health/medical-mysteries/flushed-face-trouble-swallowing-medical-mystery/2021/06/18/153798cc-b0f6-11eb-ab43-bebddc5a0f65_story.html

(3). Mathieu Nasarre, et al. Using a Smartwatch Electrocardiogram to Detect Abnormalities Associated With Sudden Cardiac Arrest in Young Adults. Europace. 2022;24(3):406-412.

https://www.medscape.com/viewarticle/970348

Aims: Smartwatch electrocardiograms (ECGs) could facilitate the detection of sudden cardiac arrest (SCA)-associated abnormalities. We evaluated the feasibility of using smartwatch-derived ECGs for detecting SCA-associated abnormalities in young adults and its agreement with 12-lead ECGs.

Methods and Results: Twelve-lead and Apple Watch ECGs were registered in 155 healthy volunteers and 67 patients aged 18â€“45 years with diagnosis and ECG signs of long-QT syndrome (n = 10), Brugada syndrome (n = 12), ventricular pre-excitation (n = 19), hypertrophic cardiomyopathy (HCM, n = 13), and arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVC/D, n = 13). Cardiologists separately analysed 12-lead ECGs and the smartwatch ECGs taken from the left wrist (AW-I) and then from chest positions V1, V3, and V6 (AW-4). Compared with AW-I, AW-4 improved the classification of ECGs as ‘abnormal’, increasing the sensitivity from 64% to 89% (P < 0.01). Pre-excitation was detected in most cases using AW-I (sensitivity 89%) and in all cases using AW-4 (sensitivity 100%, P = 0.48 compared with AW-I, specificity 100% for both). Brugada was missed using AW-I but was detected in 11/12 patients using AW-4 (sensitivity 92%, specificity 100%, P = 0.003). Long QT was detected in 8/10 cases using AW-I (sensitivity 80%, specificity 100%) and in 9 patients using AW-4 (sensitivity 90%, specificity 100%, P > 0.99). Hypertrophic cardiomyopathy was correctly suspected using AW-I and AW-4 (sensitivity 92% and 85%, specificity 85%, and 100%, P > 0.99). AW-I was mostly (62%) considered normal in ARVC/D whereas AW-4 was useful in suspecting ARVC/D (100% sensitivity, 99% specificity, P = 0.004).

Conclusions: Detection of SCA-associated ECG abnormalities (pre-excitation, Brugada patterns, long QT, and signs suggestive of HCM and ARVC/D) is possible with an ECG smartwatch.

(4). Sandhya Shrivastava, et al. Microchimerism: A new concept. J Oral Maxillofac Pathol. 2019;23(2):311.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6714269/

Microchimerism is the presence of cells from one individual in another genetically distinct individual. Pregnancy is the main cause of natural microchimerism through transplacental bi-directional cell trafficking between mother and fetus. In addition to a variety of cell-free substances, it is now well-recognized that some cells are also exchanged in pregnancy. Furthermore, it is now known that microchimerism persists decades later both in mother and in her progeny. The consequences of pregnancy-related microchimerism are under active investigation. However, many authors have suggested a close relationship linking fetal microchimerism and the development of autoimmune diseases. Fetal microchimerism is emerging as a potential contributing factor in certain diseases, including cancer. Parallel studies in animal and human pregnancy suggest that microchimeric fetal cells play a role in wound healing. Role of these microchimeric cells in human health and disease is discussed here.

(5). Raja-Elie E. Abdulnour. Deliberate Practice at the Virtual Bedside to Improve Clinical Reasoning. 2022.

https://www.nejm.org/doi/full/10.1056/NEJMe2204540

concert pianist plays Chopin’s Nocturne, op. 9, no. 1, for an audience in awe. A trial attorney breaks down the defendant’s arguments without once pausing to consult her bench. A gymnast rips through the air and lands an impossible double-twisting double somersault. An expert clinician makes the elusive diagnosis seconds after listening to a case presentation. Despite performing in very different fields, these professionals followed the same path to expertise: deliberate practice.

Fig. 1. The Path to Expertise in Clinical Reasoning.

The acquisition of expertise requires highly motivated, focused repetition combined with specific and timely feedback to hone and perfect performance. Studies have shown that time spent on this particular type of practice, called deliberate practice (see Figure 1),1 is a stronger predictor of clinical performance than either academic aptitude or experience.2

He pianist and the gymnast can get deliberate practice in an empty hall or gymnasium. The lawyer can do this in her office, with colleagues providing coaching and critique. How and where do clinicians perform deliberate practice to hone the art and science of their own clinical reasoning? The basis for outstanding performance during one’s professional life is built during medical school and residency, but that foundation is not enough to achieve the highest level of performance. A learner requires an average of 10,000 hours of deliberate practice to achieve expert performance.1 However, the average U.S. residency graduate is likely to complete only 2500 to 3000 hours of deliberate practice in clinical reasoning during the clinical years of medical school and residency. The opportunities for deliberate practice after residency can be even more limited; clinicians seldom have the time to reflect on their clinical reasoning and rarely receive high-quality feedback on their performance.

To build a solid base, students and residents must obtain high-quality and timely feedback as they learn the science and art of clinical reasoning. We all know that assessing trainees and delivering such feedback is challenging when there is a ward full of patients to see. As a result, medical schools and training programs typically rely on end-of-rotation evaluations, objective structured clinical examinations (OSCEs), and multiple-choice examinations of medical knowledge. The feedback provided from end-of-rotation assessments may lack specificity (“great job, read more”), timeliness, and an action plan for improvement. OSCEs can provide specific and timely feedback but are limited in scope and are resource-intensive. Multiple-choice examinations are efficient but account for only a small part of the variance in performance of clinical reasoning. Many medical schools and residency programs lack valid, reliable, and feasible ways to frequently assess performance and to provide high-quality feedback on learners’ clinical reasoning abilities in order to improve their performance. Consequently, the assessment and deliberate practice of clinical reasoning might be viewed as the holy grail of medical education.3

In response to these challenges, we have developed a solution to provide learners with deliberate practice of their clinical reasoning skills. NEJM Healer (https://healer.nejm.org. opens in new tab) provides screen-based, interactive patient encounters that expose learners to various clinical problems and disease presentations. During a virtual encounter, learners engage in each step of the clinical reasoning process. Of note, the program assesses the learner’s prioritized differential diagnosis and illness script accuracy (i.e., the similarity between a learner’s valuation of clinical findings that define an illness and that of an expert). The application also offers detailed feedback on problem representations, diagnostic probabilities, and management plans. These features allow trainees to obtain deliberate practice. Detailed, longitudinal, and real-time assessments of clinical reasoning and applied medical knowledge enable the objective measurement of a learner’s areas of strength and the identification of opportunities for growth. Medical schools and postgraduate programs can then provide targeted coaching and remediation with additional NEJM Healer cases or other resources.

A passenger boarding a plane has complete confidence in the flight crew’s skills, thanks to the aviation industry’s culture of lifelong practice and rigorous assessment standards, which rely heavily on simulation. Do our patients share that same confidence during a clinical encounter? Unfortunately, diagnostic errors due to faulty clinical reasoning are all too common, and they cause patient suffering and preventable deaths.2,4-8 The National Academy of Medicine suggests a multipronged approach to improve diagnosis in medicine, including formal education, training, and assessment of diagnostic reasoning for both trainees and practicing clinicians. High-stakes industries, such as aviation, have used screen-based, simulated deliberate practice for decades. The medical community must follow their lead to enhance the path to expertise in clinical reasoning.

(6). The second most common neurodegenerative disease: Parkinson’s disease

https://acrobiosystems.com.cn/A1560-The-second-most-common-neurodegenerative-disease%3A-Parkinsons-disease.html

As a leading manufacturer of recombinant proteins and other critical reagents for support in developing target therapeutics, vaccines, and diagnostics, ACROBiosystems employs an application-oriented development strategy, with a particular focus on product design, quality control, and solution-based support.

Aneuro is a new product line of ACRO that focuses and reflects dedicated efforts in neuroscience research. We aim to promote and facilitate neuroscience research by providing high-quality protein products and valuable new ideas.

(7). The changemakers in science and medicine.

https://www.statnews.com/changemakers-science-medicine/

There has perhaps never been a more pivotal moment in the world of science and medicine. And in turn, there has perhaps never been a more appropriate moment to recognize the standout individuals steering the world through unprecedented times and advancing our understanding of health.

That recognition is at the heart of the 2022 STATUS List, STAT’s annual accounting of the best and brightest leaders in the field. Many on the STATUS List are well-known as changemakers; others are largely unheralded heroes.

All of them have compelling stories to tell and all have important roles to play in the future of health care.

Recommended Readings