Early identification and remediation of professionalism concerns in medical students remains a critical challenge in medical education, particularly when professionalism lapses occur alongside clinical skill deficits. This article describes a structured approach to remediating combined clinical and professionalism deficiencies in a first-year medical student through independent expert preceptorship, workplace-based assessments, and guided reflective practice. Drawing from established remediation frameworks and our program experience, the remediation model includes components of clear professionalism criteria, structured reflection with attention to self-assessment capacity, and serial evaluation to identify patterns of behavior over time. The framework also highlights key implementation considerations, including preceptor preparation, faculty development needs, and the use of practical tools such as reflection prompts and behavior-pattern classifications to support consistent remediation decisions. This approach emphasizes early intervention, transparent expectations, targeted feedback, and longitudinal assessment to support learner growth while maintaining educational standards and professional accountability.
The application of artificial intelligence (AI) in simulating detailed patient-doctor interactions for objective structured clinical examinations (OSCEs) remains emerging. This study aimed to evaluate an AI virtual patient (AIVP) innovation designed to support medical education through interactive patient simulations and feedback. This prospective mixed-methods pilot recruited final-year medical students during their critical care term. Two cohorts were examined: a volunteer AIVP group (n = 43) and an educational-support medical education enhancement training (MEET) group (n = 8). Participants completed pre- and postintervention OSCEs scored across communication, history and examination, management, and overall outcome domains. Students accessed nine emergency medicine scenarios featuring AI-driven dialogue, speech recognition, avatar interaction, and immediate feedback. Quantitative outcomes were analyzed using the Wilcoxon signed-rank test. Postintervention surveys (Likert scale) and focus groups provided qualitative data, which were analyzed thematically. In the AIVP cohort, descriptive improvements were observed across domains; however, Wilcoxon testing identified no statistically significant changes. MEET students demonstrated significant improvement in overall OSCE outcomes (median 37 [IQR: 30-67] vs 67 [IQR: 47-75]; P = 0.03), with positive trends in all domains. Survey responses (n = 25) showed high agreement that AIVP enhanced confidence in history-taking (83%), differential diagnosis (78%), and management planning (78%). Thematic analysis from 10 students demonstrated that AIVP was experienced as a structured, exam-focused, and confidence-building learning tool that addresses gaps in workplace-based learning. AIVP was feasible and well received, providing practice aligned with university OSCE standards. While the volunteer cohort showed modest gains, the MEET group demonstrated significant improvement, suggesting benefit for students needing structured support. Tailored feedback and alignment with OSCE standards highlight AIVP as a promising adjunct for training.
We hypothesized that receiving cervical length screening (CLS) would be associated with a lower incidence of preterm birth (PTB) among patients with a history of PTB. Patients who delivered live and stillborn infants at Baylor Scott & White Medical Center - Temple from January 1, 2023, to December 31, 2023 and had a medical history of PTB were included in the analysis. We performed a bivariate analysis between patients who did and did not have PTB. We then performed a multivariate logistic regression to determine which variables were independently associated with PTB. There were 2756 births during the study period, and 185 patients met inclusion criteria. Tricare versus commercial insurance (adjusted odds ratio [aOR] 3.39; 95% confidence interval [CI] 1.17-9.80; P = 0.02) and receiving CLS (aOR 2.82; 95% CI 1.37-5.81; P = 0.005) were independently associated with PTB. The c-statistic of this multivariate model was 0.68. Tricare versus commercial insurance and receiving CLS were associated with a 239% and 182% increase, respectively, in the chance of PTB. It is possible that unmeasured variables among patients who had CLS were associated with PTB.
We present the case of a 20-year-old man with a non-necrotic, shallow, well-circumscribed ulcer on the shoulder. The patient had no significant medical history, although he noted that he was joining the military and received a smallpox vaccine injection at the same site several weeks earlier. While the differential diagnosis also included pyoderma gangrenosum, brown recluse bite, and Buruli ulcer, the patient's presentation is characteristic of a typical postvaccination progression, which is self-limited. It is important for dermatologists for be aware of this postvaccination response to avoid misdiagnosis and unnecessary workup, given that the smallpox vaccine is still administered in healthcare workers and military recruits. A typical smallpox postvaccination response may appear as a papule at the inoculation site (days 3–4), progressing to a vesicle with surrounding erythema and ulceration (days 5–6). Scabs may form by days 7 to 8.Isolated ulceration at a prior inoculation site should prompt consideration of smallpox vaccination response, particularly in military or healthcare personnel, as this history alone may establish the diagnosis.Systemic symptoms, nonhealing ulcers, and generalized cutaneous involvement are key features that distinguish rare vaccine-related complications from the expected localized reaction.Prompt recognition of characteristic postvaccination progression can reduce misdiagnosis and unnecessary workup.
Peripheral arterial disease (PAD) is a progressive vascular disorder among older adults that is associated with significant disability and elevated cardiovascular mortality. However, national mortality trends and disparities among US adults aged ≥65 years with PAD listed on death certificates have not been fully characterized. This study evaluated national mortality trends and demographic disparities among US adults aged ≥65 years with PAD or selected peripheral vascular/arterial conditions. Using the CDC WONDER Multiple Cause of Death database (1999-2020), we conducted a retrospective population-based analysis. ICD-10 codes for peripheral vascular and arterial diseases were used to identify deaths in which PAD or associated peripheral arterial/vascular conditions were listed as an underlying or contributing cause of death. Age-adjusted mortality rates (AAMR) per 100,000 population were calculated using the 2000 US standard population. We used joinpoint regression to estimate annual percent change (APC) and average annual percent change (AAPC), with P values < 0.05 considered statistically significant. A total of 1,738,432 PAD-related deaths occurred among adults aged ≥65 years. The overall AAMR declined from 245.14 in 1999 to 145.82 in 2020. Mortality was higher among males than females (282.70 vs 215.26 in 1999; 173.84 vs 117.10 in 2020). Non-Hispanic Black individuals had the highest mortality burden (319.28; 179.12), whereas non-Hispanic Asian or Pacific Islander individuals had the lowest (116.56; 77.52). Adults aged ≥85 years exhibited the highest mortality (836.30; 473.61). Nonmetropolitan areas demonstrated higher mortality than metropolitan areas (268.35 vs 239.55 in 1999; 160.15 vs 142.88 in 2020). Regionally, the Midwest had the highest AAMR (265.61; 148.99), while the Northeast had the lowest (203.99; 127.07). State-level variation ranged from 281.89 in Ohio to 114.82 in Hawaii. Most deaths occurred in medical facilities (39.1%). Mortality among older adults with PAD or selected peripheral vascular/arterial conditions listed on death certificates declined overall. However, demographic and geographic disparities persisted, with recent increases observed after 2018. Targeted prevention, early detection, and modification of risk factors are needed for high-risk older populations.
Septic arthritis (SA) is a medical emergency associated with substantial morbidity and mortality. Although the knee is the most commonly affected joint in adults, contemporary national data describing characteristics, mortality, and healthcare utilization in knee-specific native SA are limited. We conducted a retrospective study of adult hospitalizations for nongonococcal native knee SA in the United States using the National Inpatient Sample database from 2016 to 2022. Hospitalizations were identified using ICD-10 diagnostic codes, excluding gonococcal and prosthetic joint infections. Thus, the analytic cohort was restricted to native joint disease and did not include prosthetic joint infection. Weighted analyses were performed to generate national estimates. Multivariable logistic regression was used to identify factors independently associated with in-hospital mortality. Among approximately 205 million adult hospitalizations, 92,290 (0.045%) had native SA of the knee. In-hospital mortality was 2.5%. Patients who died were older, had longer lengths of stay, and incurred more than double the median hospital charges compared with survivors. In multivariable analysis, factors independently associated with higher odds of in-hospital death included respiratory failure (odds ratio [OR] 8.54), sepsis (OR 3.57), liver disease (OR 3.45), cerebrovascular disease (OR 2.27), acute kidney injury (OR 2.05), chronic kidney disease (OR 1.66), myocardial infarction (OR 1.60), heart failure (OR 1.55), and increasing age. Survivors demonstrated substantial postacute care needs, with 36% discharged to skilled nursing or intermediate care facilities. In this nationally representative cohort, nongonococcal native septic knee arthritis showed substantial in-hospital mortality, morbidity, and healthcare utilization. Mortality was driven primarily by multiorgan dysfunction rather than demographic or socioeconomic factors. Early identification and aggressive management of high-risk patients may improve outcomes.
Characterizing the incidence and determinants of corneal abrasions in burn patients and evaluating the roles of burn severity, comorbidities, and social determinants of health (SDOH) in shaping risk can inform screening and care. We conducted a retrospective cohort study of patients admitted to a regional burn center between January 1, 2019, and January 1, 2024. Eligible patients had documented burns and a complete ophthalmologic examination at admission. Demographics, burn severity, comorbidities, SDOH indices (Social Vulnerability Index [SVI], Area Deprivation Index [ADI]), geographic access, and outcomes were abstracted from the medical record. Group comparisons were performed using standard statistical tests. Among 2023 patients, 90 (4.4%) had corneal abrasions. They had greater total body surface area burned (17.5% vs 6.2%, P < 0.001) and longer hospitalizations, intensive care unit stays, and ventilation durations (all P < 0.001). Abrasions were associated with inhalation injury (58% vs 19%, P < 0.001) and in-hospital mortality (18.9% vs 4.9%, P < 0.001). Patients with abrasions traveled farther (151 vs 121 miles, P = 0.02) and were more often from out of state (8.2% vs 3.6%). No significant differences were found in SVI, ADI, or most comorbidities, though diabetes was less common (7.8% vs 16.4%, P = 0.04). Corneal abrasions occur in about 1 in 20 burn admissions and are strongly associated with burn severity and critical illness. Geographic distance and incomplete race documentation were additional risk factors, while SDOH indices and diabetes were not. These findings identify corneal abrasions as markers of systemic severity and health system disparities, supporting standardized eye-care protocols for high-risk burn patients.
Dermatology is one of the most interdisciplinary specialties in medicine, yet the pathways through which physicians may enter dermatologic practice are not always clearly defined for trainees. Although dermatology residency remains the primary route to board certification, alternative pathways allow physicians from other specialties to participate in dermatologic care. These include fellowships and training opportunities in dermatopathology, pediatric dermatology, cosmetic dermatologic surgery, micrographic surgery and dermatologic oncology, and community-based dermatology fellowships for physicians trained in family medicine or internal medicine. This review outlines the major residency and fellowship routes that lead to dermatologic practice in the United States and highlights the evolving interdisciplinary structure of the dermatology workforce. The growing role of primary care providers in dermatologic care is also highlighted alongside emerging training opportunities to expand access while maintaining quality. While alternative pathways offer opportunities to expand access to dermatologic care and foster collaboration across specialties, they also present limitations related to variability in training exposure, procedural experience, and standardization of curriculum. Understanding these pathways is important for medical students, residents, and educators seeking to navigate career planning within dermatology and related specialties. A comprehensive overview of these routes may improve transparency in dermatology training and support a more collaborative, multidisciplinary approach to skin health.
Transcatheter aortic valve replacement (TAVR) is now the standard of care for severe symptomatic aortic stenosis; however, rare procedural complications such as valve embolization can result in life-threatening consequences. We describe a case of intraprocedural embolization of a self-expanding Medtronic Evolut FX valve into the ascending aorta during deployment. The embolized prosthesis was stabilized with a snare and parked distal to the sinotubular junction. Because a second self-expanding valve could not be advanced across the displaced frame, a 23 mm balloon-expandable Edwards SAPIEN 3 Ultra RESILIA valve was successfully delivered through the embolized prosthesis and deployed in the native annulus. This cross-platform valve-through-valve bailout restored durable valve function without surgery and underscores the importance of procedural adaptability in managing complex TAVR complications. Valve embolization during TAVR occurs in approximately 0.5% to 1% of cases and can lead to catastrophic hemodynamic compromise.Snare-assisted stabilization can prevent further migration and facilitate implantation of a second valve, potentially avoiding emergent surgery.A second transcatheter valve can be successfully delivered through an embolized self-expanding frame as a rescue strategy.Valve-through-valve bailout is a feasible alternative to surgical intervention in selected hemodynamically stable patients.
Early 2021 data showed significant disparities in intravascular lithotripsy (IVL) access, with women, Black patients, and Medicaid beneficiaries less likely to receive treatment. We evaluated whether disparities persisted during rapid national expansion and whether they were associated with differential clinical outcomes. Using 2021-2023 National Inpatient Sample data, we examined access disparities among 267,598 percutaneous coronary intervention patients and clinical outcomes among 9824 IVL recipients. Multivariable logistic regression predicted IVL use and mortality, adjusting for demographics, comorbidities, and hospital characteristics. Due to Healthcare Cost and Utilization Project restrictions, race/regional analyses were limited to 2021-2022; sex and insurance analyses included all years. IVL utilization increased from 0.55% in 2021 to 6.40% in 2023 (11.6-fold, P < 0.001). Females had 12% lower odds of receiving IVL (adjusted odds ratio [aOR] 0.88, 95% confidence interval [CI] 0.84-0.93), improved from the 35% gap in 2021. Race-based disparities were not statistically significant (Black aOR 0.93, 95% CI 0.80-1.08). Insurance disparities persisted with smaller effect sizes than earlier reports. Among IVL recipients, in-hospital mortality (4.2%) did not differ by sex, race, or insurance. Black patients experienced longer hospitalizations (8.2 vs 5.5 days; adjusted +2.2 days, P = 0.003). Sex-based differences in IVL utilization narrowed substantially during the 11.6-fold expansion from 2021 to 2023, while race-based differences were no longer detectable within the study period. Insurance-related disparities persisted, although to a lesser extent. Comparable in-hospital mortality across demographic groups suggests that the remaining differences in access are more likely attributable to systemic barriers. The longer hospital length of stay observed among Black patients warrants further investigation into social determinants of health.
When thyroid tissue is found within a cervical lymph node, clinicians must distinguish between a benign ectopic inclusion (thyroidosis) and metastatic thyroid carcinoma-a distinction with major management implications. This narrative review synthesizes the available literature on benign thyroid tissue incidentally identified in cervical lymph nodes. A focused literature search was conducted using the PubMed/MEDLINE database with an end date of April 15, 2026. Publications were included if they reported cases of benign thyroid tissue identified in cervical lymph nodes with histological or molecular confirmation, encompassing case reports, case series, or original studies. Fifteen publications were identified, covering approximately 35 to 45 cases. Patients ranged in age from 13 to 72 years (mean 46), with a marked female predominance (∼75%). Lateral cervical nodes (levels II-IV) were involved in ∼80% of cases. Histologically, benign inclusions were characterized by well-formed follicles with colloid, capsular or subcapsular positioning, and no malignant cytology. Immunohistochemical markers (e.g., HBME-1, CK19) and molecular testing (BRAF/RAS mutation analysis) were reported to be helpful in differentiating benign from malignant thyroid tissue. Associated conditions included autoimmune thyroiditis, head and neck malignancies, and postablative states. Over follow-up periods of 6 months to 10 years, no malignant transformation was observed. Rigorous histological evaluation, supported by ancillary testing, enables confident diagnosis. Conservative surveillance-rather than thyroidectomy-is appropriate when malignancy has been excluded.
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a systemic inflammatory disorder that affects small blood vessels. However, the association between AAV and lung cancer risk remains uncertain. We performed a systematic review and meta-analysis to evaluate the relationship between AAV and the risk of lung cancer. We systematically searched PubMed, Embase, Scopus, and Web of Science from inception through March 2025. Studies reporting relative risks (RRs), odds ratios (ORs), hazard ratios (HRs), or standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) were included. SIRs were used to estimate relative risk versus the general population. Pooled RR and 95% CI were calculated using a random-effects model (DerSimonian and Laird). Heterogeneity and publication bias were assessed. Thirteen studies (11 cohort, 2 case-control) including 8004 participants were analyzed. The mean age at diagnosis was 58.83 ± 16.99 years, with 49.68% male. Follow-up ranged from 2 to 26 years. The pooled RR for lung cancer was 2.08 (95% CI, 1.52-2.83), indicating increased risk. Moderate heterogeneity was observed (I2 = 48.38%). There is an increased risk of lung cancer in patients with AAV. Further studies are warranted to better elucidate the underlying mechanisms and guide appropriate screening strategies.
Diffuse pulmonary meningotheliomatosis (DPM) is an exceedingly rare benign condition characterized by innumerable minute pulmonary meningothelial-like nodules diffusely involving both lungs. We report a 44-year-old woman with Hashimoto's thyroiditis and chronic sinusitis requiring biologic therapy, who presented with incidentally discovered innumerable centrilobular ground-glass nodules. Extensive workup excluded infectious, malignant, and vasculitic etiologies. Surgical lung biopsy was consistent with DPM. This case is notable for younger age, absence of malignancy, preserved pulmonary function despite extensive radiographic disease, and a prominent systemic inflammatory phenotype. Diffuse pulmonary meningotheliomatosis (DPM) is a rare benign condition that can closely mimic metastatic or inflammatory lung disease on imaging, often necessitating tissue diagnosis for confirmation.A key distinguishing feature of DPM is the discordance between extensive radiographic disease and minimal or absent clinical symptoms with preserved pulmonary function, as seen in this case.Although no established association with autoimmune disease exists, DPM should be considered in the differential diagnosis of diffuse pulmonary micronodules, when extensive radiographic abnormalities occur despite minimal symptoms and preserved pulmonary function.
暂无摘要（点击查看详情）
As the public increasingly interacts with artificial intelligence (AI) chatbots, we compared the answers from five AI chatbots to standardized questions that patients might ask about ovarian and cervical cancer. ChatGPT 3.5, Google Gemini 2.0, Reddit Answers, Bootcamp, and DeepSeek were queried with 15 frequently asked questions (FAQs) on cervical cancer and 11 on ovarian cancer. In a blinded, randomized survey, each deidentified response was independently assessed by three gynecologic oncologists using a 4-point scale (1, accurate and comprehensive; 2, accurate but inadequate; 3, accurate but outdated or inaccurate; 4, completely inaccurate). Readability (Flesch-Kincaid grade level) and word count were recorded. For cervical cancer FAQs, ChatGPT 3.5, Google Gemini 2.0, Reddit Answers, Bootcamp, and DeepSeek received scores of 1.4, 1.6, 2.7, 1.5, and 1.5, respectively. For ovarian cancer FAQs, average scores were 1.3, 1.4, 2.5, 1.2, and 1.4, respectively. All AI chatbot responses were written at a reading level above 11th grade, making them generally difficult for the average American to read. Although generally rated as accurate and adequate, the answers were frequently off-topic and not generalizable. Healthcare providers should be aware of unintentionally generated misinformation to better counsel patients.
Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome caused by uncontrolled immune activation and cytokine storm. Secondary HLH is frequently triggered by infections, malignancies, or autoimmune conditions; tuberculosis is an uncommon but increasingly recognized cause, particularly in endemic regions. We report a 33-year-old South Asian woman who presented with severe respiratory failure, pancytopenia, and systemic hyperinflammation. Microbiological and histopathological evaluation confirmed disseminated tuberculosis complicated by secondary HLH. Early initiation of antitubercular therapy combined with corticosteroids resulted in clinical improvement. This case underscores the importance of maintaining a high index of suspicion for HLH in patients with disseminated tuberculosis presenting with cytopenias and hyperinflammation, where prompt diagnosis and treatment are critical to reducing mortality.
Sentinel lymph node biopsy (SLNB) is crucial for staging melanoma and determining metastasis. Indocyanine green (ICG) has emerged as a promising near-infrared fluorescence mapping technique. Recent advancements in near-infrared fluorescence imaging systems, with color-segmented fluorescence (termed "red capping"), may enhance the detection of positive sentinel lymph nodes. This study retrospectively compared node positivity rates between a control group using standard ICG alone and a study group utilizing the newer ICG combined with red capping technology in melanoma patients undergoing SLNB. A total of 70 patients met the study criteria, with 47 in the ICG-alone control group and 23 in the ICG with red capping study group. Both groups achieved a 100% sentinel lymph node detection rate, confirmed by radiotracer. The red capping group demonstrated a node positivity rate of 26.1% compared to 19.1% in the ICG-alone group. While this represents a higher proportion of positive nodes, it is important to note that the red capping group also contained a higher percentage of aggressive tumor features, including a 30.4% rate of ulceration (vs 21.3%) and a higher proportion of tumors with >7 mitoses/mm2 (21.7% vs 6.4%). The observed node positivity likely reflects these underlying biological differences between the cohorts rather than the imaging modality itself. Both imaging modes achieved a 100% detection rate when verified by radiotracer, indicating that red capping is an effective and highly visual alternative for intraoperative nodal mapping. Red capping provides an effective visualization tool for intraoperative lymphatic mapping and demonstrates comparable sentinel node identification to standard ICG fluorescence.
Infant botulism is a rare, life-threatening neuroparalytic illness. Its rapid progression necessitates early clinical detection and prompt treatment to prevent respiratory failure. Its rising national and regional incidence trends were evaluated and analyzed with a focus on epidemiology within the public health regions (PHR) in Texas and recent outbreaks affecting the state. A retrospective analysis of Centers for Disease Control and Prevention National Botulism Surveillance System (2000-2021) and Texas Department of State Health Services reports (2006-2023) was performed. Incidence rates, incidence rate ratios (IRR), and confidence intervals (CI) were calculated using Poisson-based statistical methods. The overall incidence of IB in the US has been on the rise from 2000 to 2021 (annual IRR 1.042; 95% CI 1.035-1.048; P < 0.001). Texas showed a similar rise from 2006 to 2023 (annual IRR 1.063; 95% CI 1.028-1.100; P < 0.001). Regional analysis showed a heterogeneous distribution in Texas, with the highest incidence rate in certain regions with significant rural makeup (PHRs 4, 9, and 10) during the years 2006 to 2018. The rising incidence and recent industrial outbreak highlight the need for increased clinical suspicion, particularly in PHRs 4, 9, and 10, as well as stricter regulatory oversight of infant formula supply chains.