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Educational Challenge: Frequent transitions between core clinical rotations in medical school increase anxiety and cognitive load. Few formalized programs exist to ease these transitions. Our institutional needs-assessment found that approximately 85% of students believed that additional rotation-specific information prior to starting a new rotation would reduce anxiety and increase success., Proposed Solution and Implementation of Solution: We developed a novel web-based peer-to-peer handoff tool available to all clerkship students at a single, large academic institution. The tool contains the names and contact information of students who most recently completed rotations on each service for all clerkships. A handoff checklist was also created with suggested discussion points for handoffs. Students were encouraged to schedule a handoff 1-2 weeks before starting a new rotation., Lessons Learned: Overall, 83 students (66%) utilized the handoff tool, with use and efficacy decreasing with time during the clinical year. Of tool users, 65% expressed that having access to the tool prior to starting a new rotation helped to reduce anxiety, and 74% felt that the information gained helped to ease transitions. Our peer-to-peer handoff tool may help students feel more prepared to start a new rotation, decrease anxiety during clerkship year, and ease transitions., Next Steps: This low-resource intervention may be implemented at other institutions to provide students with equal opportunities to receive valuable information prior to starting new rotations, regardless of pre-existing peer connections. An automated update system, which we are implementing at our institution, could greatly decrease the time required to maintain a handoff tool and improve sustainability.

Context: A growth mindset and mastery approach have gained attention as useful learning orientations in medical education, however few studies of interventions to foster these orientations exist., Objectives: We sought to discover whether a communication skills session on delivering serious news could foster a communication growth mindset and/or a mastery approach in medical students., Methods: This was an interventional survey study of third-year medical students before and after a session on delivering serious news. Students were administered a communication mindset survey before and after the session; achievement goal and learning environment surveys were administered after the session. Chi-square tests were used to assess the difference in pre and post mindsets. Logistic regression was used to determine the odds of achieving a mastery approach with pre- and post-communication growth mindset as the independent variables., Results: Students' communication growth mindset increased from 79% (n = 186) before the intervention to 92% (n = 142) after the intervention. Achievement goal analysis demonstrated that 64% (n = 91) of students had a mastery approach, 14% (n = 20) had a performance approach and 22% (n = 32) had an avoidant approach. Ninety-nine percent (n = 151) felt the session provided a safe learning environment. The odds of having a mastery approach correlated with both pre and post-intervention growth mindset, with post-session growth mindset having the strongest correlation., Conclusions: A novel communication skills session on delivering serious news fostered a communication growth mindset in third year medical students. Most students exhibited a mastery approach to learning; this approach was more likely when they had a growth mindset., Competing Interests: Disclosures and Acknowledgments The CARE-7 curriculum is generously funded by Barbara M. Jordan, a Penn Medicine Board member and spouse of the late Henry A. Jordan, MD, a Penn alumnus (M’62 from the School of Medicine). The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2024 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Palliative care (PC) longitudinal curricula are increasingly being recognized as important in Undergraduate Medical Education (UME). They are however, not yet commonplace, and where they do exist may be implemented without a systematic, prospective approach to curriculum evaluation. This paper describes an implementation of a new longitudinal curriculum at the Perelman School of Medicine (PSOM) at the University of Pennsylvania. We used the Context Input Process Product (CIPP) model, a holistic evaluation model, to assess the local environment, design the curriculum, guide the improvement process, and evaluate outcomes. Comprehensive models such as CIPP provide a more robust approach to curriculum evaluation than outcomes-only models and may be of use to other programs who are implementing new curricula or improving upon existing programs., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This study explored measures of subjective and objective sleep health and the association with fall occurrence and falls risk for older adults. A longitudinal observational study was conducted with participants in residential aged care (n = 36) and community dwelling (n = 35) settings. At baseline, objective sleep data involved wearing wrist worn accelerometers and measuring falls risk by walking using the Quantitative timed up and go (QTUG) of a simple, cognitive, and motor task. Subjective sleep data was collected by completing sleep diaries using the Karolinska Sleepiness Scale and sleep quality scale, respectively. Longitudinal falls data were collected at baseline, 3, 6, and 9 months. Falls risk was calculated via QTUG. Responses to a fall questionnaire were used to quantify fall occurrence. Independent samples t -test examined differences in objective and subjective sleep variables between settings. Logistic regression explored whether objective or subjective sleep variables could predict an overall fall occurrence. Linear regression determined if a particular sleep variable could predict an overall falls risk. Multiple regression determined if sleep variables could predict falls risk. No significant differences were found between residential and community-dwelling adults in subjective or objective sleep measures. Logistic regression showed no significant associations between most sleep variables and falls risk, except for average awakening length, where each additional minute was associated with a 1.8% increase in fall likelihood (OR = 1.02, 95% CI [1.00-1.03], P  = .037). Conversely, higher awakening frequency was associated with reduced falls risk in the simple timed up-and-go task ( R ² = .21, β = -.69, P  = .009, 95% CI [-1.20 to -0.18]). Findings suggest no significant differences in sleep health or falls risk between residential and community-dwelling older adults, though specific sleep disruptions showed minor associations with falls risk., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Describe medical student perspectives on framework learning and develop a free, online, mobile-friendly framework website., Methods: Internal medicine clerkship students were surveyed at a single U.S. medical school regarding how they learn frameworks. We used Draw.io to create frameworks, which were edited by expert clinicians. Frameworks were hosted online through an academic server, and Google analytics was used to track website activity., Results: Most medical students report learning frameworks from attending clinicians. We developed 87 frameworks on the "Penn Frameworks'' website, which was visited by 9,539 unique users from 124 countries over three years., Conclusions: Most medical students perceive that they learn frameworks during clinical rotations from attending clinicians. We found that it is feasible to develop a low-cost, expert-curated, mobile-friendly resource to supplement in-person learning., (© 2023 Walter de Gruyter GmbH, Berlin/Boston.)

Objective: Contextually embedded and sanctioned gender minimization and sexual abuse toward female personnel within the military appears widespread. Left unabated, mental health complications of female personnel will challenge care responsibilities for military organizations., Method: Interview data from six ex-military women that sought positive and negative interpretations of gender minimization and sexual abuse while in the military was analyzed using interpretative phenomenological analysis., Results: Analysis revealed two superordinate themes: (a) Immature Culture, and (b) Ejection and Growth. These overarched four subordinate themes that explored fostered patriarchy and male privilege in the military. Participants expressed experiencing relentless belittling that eroded early adolescent goals of success and aborted their ability to thrive psychologically. By association, interpersonal violence compounded by organizational complicity triggered internalized shame and narcissistic defenses. Discharging from the military is remembered as a painful, isolated struggle for these participants as they sought to make sense of their fragmented identities as women. With time, all participants acknowledged pride in skills achieved during military life, and the strength to speak out against embedded organizational abuse. A persistent ruminative struggle to make sense of complex systemic biases against women that allowed organizational abuse to flourish facilitated posttraumatic growth., Conclusions: For these participants, personal experiences of gender minimization and sexual abuse in the military incubated a betrayal of hope and moral safety. As women, they felt violated at an organizational level seemingly orchestrated by male privilege and patriarchy. Clinical priorities include reparative validation and holistic trauma support underpinned by trauma and posttraumatic growth frameworks. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Introduction: Ubrogepant is an oral, small-molecule calcitonin gene-related peptide receptor antagonist approved for the acute treatment of migraine. The efficacy and safety of ubrogepant were demonstrated in two pivotal phase 3, single-attack, randomized, placebo-controlled trials (ACHIEVE I and ACHIEVE II)., Methods: We conducted a post hoc analysis of pooled data from the ACHIEVE trials to evaluate the efficacy, safety, and tolerability of ubrogepant 50 mg (the only dose evaluated in both trials) versus placebo across a large population of participants with migraine. The coprimary efficacy outcomes were pain freedom and absence of the most bothersome migraine-associated symptom (including photophobia, phonophobia, and nausea) at 2 h post dose. Secondary outcomes included pain relief at 2 h post dose, sustained pain relief and pain freedom from 2 to 24 h, and absence of specific migraine-associated symptoms at 2 h post dose., Results: A total of 2240 eligible participants were randomized to placebo (n = 1122) or ubrogepant 50 mg (n = 1118) in the ACHIEVE trials. Pain freedom at 2 h was reported in 13.0% of participants in the pooled placebo group and 20.5% in the pooled ubrogepant 50 mg group (odds ratio [OR] 1.72; 95% confidence interval [CI] 1.34, 2.22; P < 0.001). Absence of the most bothersome migraine-associated symptom at 2 h was reported by 27.6% in the pooled placebo group and by 38.7% in the pooled ubrogepant 50 mg group (OR 1.68; 95% CI 1.37, 2.05; P < 0.001). Adverse events (AEs) within 48 h after the initial or optional second dose were reported by 11.5 and 11.2% of participants in the pooled placebo and pooled ubrogepant 50 mg groups, respectively. The most common AE was nausea (1.8 and 1.9%, respectively). No serious AEs related to treatment or discontinuations due to AEs were reported., Conclusion: These results further support the efficacy, safety, and tolerability of ubrogepant for the acute treatment of migraine., Trial Registration: ClinicalTrials.gov Identifiers: ACHIEVE I: NCT02828020; ACHIEVE II: NCT02867709.

Objective: To describe headache characteristics, medication use, disability, and quality of life in a large patient cohort from the United States who have chronic migraine (CM) and medication overuse headache (MOH)., Methods: In all, 610 adult patients were enrolled into the Medication Overuse Treatment Strategy trial from 34 healthcare clinics, including headache specialty, general neurology, and primary care clinics. Descriptive statistics characterize baseline demographics, headache characteristics, medication use, disability (Headache Impact Test 6 [HIT-6] and Migraine Functional Impact Questionnaire [MFIQ]), pain interference (PROMIS Pain Interference), and quality of life (EQ-5D-5L). Relationships with headache frequency were assessed., Results: Mean age was 45 years (SD 13) and 531/608 (87.3%) were females. Mean headache days per 30 was 24.3 (SD 5.5), including 13.6 (SD 7.1) with moderate to severe headache. Daily headaches were reported by 36.1% (219/607) of patients. Acute headache medications were used on 21.5 (SD 7.5) per 30 days. The most commonly overused medications were simple analgesics (378/607, 62% of patients), combination analgesics (246/607, 41%), and triptans (128/607, 21%). HIT-6, MFIQ, PROMIS Pain Interference, and EQ-5D-5L scores demonstrated substantial negative impact from CM with MOH on patient functioning and quality of life. Higher headache frequency was associated with more moderate-severe headache days, more frequent acute headache medication use, greater headache-related disability, and lower quality of life. Only 272/606 (44.9%) were taking migraine preventive medication., Conclusions: CM with MOH is associated with a large burden on patients in the United States. Higher headache frequency is associated with greater impact on functioning, pain interference, and quality of life., (© 2021 American Headache Society.)

Introduction: Triptans, the most commonly prescribed acute treatments for migraine attacks are, per FDA labeling, contraindicated in cardiovascular (CV) disease patients and have warnings and precautions for those with CV risk factors., Methods: Headache specialists, cardiologists, and health economics and outcomes researchers convened to identify diagnostic codes for: (1) CV diseases contraindicating triptans based on FDA labeling; (2) conditions comprising "other significant underlying CV disease"; and (3) CV risk factors included as warnings and precautions for triptans. A retrospective, cross-sectional analysis of commercially insured adult US migraine patients in the 2017 Optum ® Clinformatics ® Data Mart (CDM) and the 2017 IBM ® Watson Health MarketScan ® Commercial Claims database was used to estimate the proportion of migraine patients with CV contraindications and warnings and precautions to triptans., Results: Of the 56,662 migraine patients analyzed from Optum CDM, 13.5% had ≥1 CV disease as specified in triptan labeling and an additional 8.5% had ≥1 "other CV disease" judged by the panel to constitute a "significant underlying CV disease" (total: 22.0% migraine patients). Of 176 724 migraine patients analyzed from MarketScan, 12.2% had ≥1 CV disease as specified in the labeling and an additional 8.0% had ≥1 "other significant underlying CV disease" (total: 20.2% of migraine patients). An additional 25.4% and 25.1% of migraine patients had ≥2 CV risk factors in Optum CDM and MarketScan. In total, 47.4% and 45.3% of migraine patients in both databases had a CV disease specified as a contraindication, an "other CV disease" endorsed as significant, or ≥2 CV risk factors identified as warnings and precautions to triptans., Conclusions: Analyses of more than 230,000 people with migraine showed that ≥20% of commercially insured US migraine patients have a CV condition that specifically contraindicates triptan treatment, and an additional 25% have ≥2 CV risk factors identified as warnings and precautions to triptans.

In the self-magnetic-pinch diode, the electron beam, produced through explosive field emission, focuses on the anode surface due to its own magnetic field. This process results in dense plasma formation on the anode surface, consisting primarily of hydrocarbons. Direct measurements of the beam's current profile are necessary in order to understand the pinch dynamics and to determine x-ray source sizes, which should be minimized in radiographic applications. In this paper, the analysis of the C IV doublet (580.1 and 581.2 nm) line shapes will be discussed. The technique yields estimates of the electron density and electron temperature profiles, and the method can be highly beneficial in providing the current density distribution in such diodes.

Purpose: The Chiefs' Service (CS), a structured approach to inpatient teaching rounds, focuses on resident education and patient-centered care without disrupting patient census sizes or admitting cycles. It has five key elements: morning huddles; bedside rounds; diagnostic "time-outs"; day-of-discharge rounds; and postdischarge follow-up rounds. The authors hypothesized the CS model would be well received by residents and considered more effective than more-traditional rounds., Method: The CS was implemented on Penn Presbyterian Medical Center's general medicine inpatient service using a quasi-experimental design. Its first year (January 2013-January 2014) was evaluated with a mixed-methods approach. Residents completed end-of-rotation evaluation questionnaires; 20 CS and 10 traditional service (TS) residents were interviewed. Measures of resident agreement on questionnaire items were compared across groups using independent sample t testing. A modified grounded theory approach was used to assess CS residents' perspectives on the CS elements and identify emergent themes., Results: The questionnaires were completed by 183/188 residents (response rate 97%). Compared with TS residents, CS residents reported significantly greater satisfaction in the domains of resident education and patient care, and they rated the overall value of the rotation significantly higher. The majority of CS residents found the CS elements to be effective. CS residents described the CS as focused on resident education, patient-centered care, and collaboration with an interdisciplinary team., Conclusions: The CS approach to inpatient rounding is seen by residents as valuable and is associated with positive outcomes in terms of residents' perceptions of learning, interdisciplinary communication, and patient care.