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Sateesh B Arja, Samir Fatteh, Sailaja Nandennagari, Sai Sarath Kumar Pemma, Kumar Ponnusamy, Sireesha B Arja Avalon University School of Medicine, Willemstad, CuracaoCorrespondence: Sateesh B Arja, Tel +599 96965682, Email sarja@avalonu.orgPurpose: COVID-19 pandemic and closure of campuses have required a significant and rapid shift in teaching and training methods across health professions education, including remote teaching replacing face-to-face teaching. This study aims to investigate if emergency remote teaching implemented in the first two years of the medical school at Avalon University School of Medicine served the purpose during the COVID-19 pandemic. The effectiveness of emergency remote teaching and on-campus teaching were compared using course evaluations (students’ feedback) and students’ performance in assessments.Methods: This is a concurrent mixed research method. The quantitative data collected are course evaluations and students’ performance in assessments between the two semesters September 2019 (on-campus teaching) and May 2020 (emergency remote teaching). There are three semesters in the first year and two semesters in the second year of the medical program. Each semester has around 10– 20 students at any given time. Quantitative data were analyzed for p-values and statistical significance using a t-test. The qualitative data were analyzed using thematic analysis.Results: Results have shown no statistically significant difference (p< 0.05) between two semesters (between on-campus teaching and emergency remote teaching) for course evaluations. Even if there is any difference, the mean values were better in May 2020 semester with emergency remote teaching. There was no statistically significant difference (p< 0.05) even on students’ performance in assessments between two semesters (between on-campus teaching and emergency remote teaching) except for two courses. The thematic analysis of interviews revealed the advantages and disadvantages of online teaching.Conclusion: Emergency remote teaching served the purpose in the first two years of medical school during the COVID-19 pandemic. The advantages of online teaching are flexibility and comfort, and students can save time. The disadvantages are technical challenges, students lacking motivation, lack of personal interaction, and limitations on lab and hands-on experiences.Keywords: COVID-19, medical education, basic science, teaching and learning, evaluation

Allergy/immunology specialists in the United States prescribing allergy immunotherapy (AIT) have placed a heavy value on practical experience and anecdotal evidence rather than research-based evidence. With the extensive research on AIT conducted in the last few decades, the time has come to better implement evidence-based medicine (EBM) for AIT. The goal of this review was to critically assess EBM for debated concepts in US AIT practice for respiratory allergies in the context and quality of today's regulatory standards. Debated topics reviewed were the efficacy and safety of AIT in various subgroups (eg, polyallergic patients, older patients, patients with asthma, and pregnant women), diagnosis topics (eg, skin prick test vs allergen-specific serum IgE, factors affecting skin prick tests, use of nasal or conjunctival allergen challenges, and telemedicine for diagnosis), and dosing topics (eg, optimal dosing for subcutaneous immunotherapy and sublingual immunotherapy tablets, US liquid allergen extract history, duration of treatment, and biomarkers of efficacy). In addition, EBM for patient-centered AIT issues (eg, adherence, use of practice guidelines, and pharmacoeconomics) and the approach to implementation of AIT EBM in future clinical practice were addressed. The EBM for each concept was briefly summarized, and when possible, a practical, concise recommendation was given., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Hereditary angioedema (HAE) is often caused by low serum levels or functional deficiency in C1 inhibitor (C1-INH); however, in some cases, C1-INH serum level and function are measured as normal (HAE-nl-C1INH). Management of HAE-nl-C1INH is similar to management of HAE with C1-INH deficiency, including on-demand therapy for angioedema attacks and, potentially, prophylaxis. Recombinant human C1 esterase inhibitor (rhC1-INH) is indicated for treatment of acute HAE attacks. This study assessed the clinical profile and treatment outcomes in an HAE-nl-C1INH population with a history of rhC1-INH treatment., Methods: Medical records containing patient-reported outcomes from ten US treatment centers were analyzed retrospectively for medical history, angioedema attack characteristics, attack treatments, and clinical outcomes., Results: Twenty-three patients were included, with wide US geographic representation. Most patients (87.0%) were female; median age was 36.0 years (range, 19-67 years). Of 20 patients with available data, 4 had their first angioedema attack during childhood (aged <12 years), 3 during adolescence (aged 12-17 years), and 13 during adulthood (aged 18-29 years, n = 7; aged ≥30 years, n = 6). Median age at HAE-nl-C1INH diagnosis was 31.5 years (range, 9-59 years). Previous failed treatments included high-dose antihistamines (n = 20) and corticosteroids (n = 20). Use of US Food and Drug Administration (FDA)-approved HAE therapy positively impacted patient-reported assessments of angioedema attacks. Most patients were taking rhC1-INH or lanadelumab as prophylaxis and icatibant or rhC1-INH for acute management. Most patients reported improved disease control with these therapies, including reductions in angioedema attack frequency and severity. Although most patients were receiving prophylactic therapy, availability of treatment for breakthrough attacks was important., Conclusion: Findings from this retrospective study support use of FDA-approved HAE medications for prophylaxis and acute treatment of HAE attacks in patients with HAE-nl-C1INH. Individualized HAE treatment regimens were needed to optimize therapeutic outcomes., Competing Interests: Douglas H. Jones reports being a consultant for and receiving consulting fees from BioCryst, Pharming Technologies BV, and Takeda Pharmaceutical Company Ltd. Priya Bansal reports serving as a speaker and consultant for and receiving speaker honoraria from AstraZeneca and ALK; serving as a speaker for and receiving speaker honoraria from Regeneron and Teva Pharmaceutical Industries Ltd; serving as a consultant for and receiving consulting fees from Pfizer Inc.; and serving as a consultant and speaker for and receiving consulting fees and speaker honoraria from CSL Behring, Pharming Technologies BV, and Takeda Pharmaceutical Company Ltd. Jonathan A. Bernstein reports serving as a consultant for, receiving consulting fees from, and performing research for BioCryst, KalVista Pharmaceuticals, and Ionis Pharmaceuticals; and serving as a consultant and speaker for, receiving consulting fees and speaker honoraria from, and performing research for CSL Behring, Pharming Technologies BV, and Takeda; and serving as a board member for AAAAI Foundation (vice chair), World Allergy Organization, Joint Task Force, Allergists for Israel (chair), and Interasma. Shahnaz Fatteh reports serving as a consultant, speaker, and advisory board member for Pharming Technologies BV; and serving on the Broward County Medical Association. Joseph Harper and Nami Park report being employees of Pharming Healthcare Inc. F. Ida Hsu reports serving as a consultant for and receiving consulting fees from BioCryst and Takeda Pharmaceutical Company Ltd; serving as a speaker for and receiving speaker honoraria from CSL Behring and Pharming Technologies BV; and performing contracted research for Takeda Pharmaceutical Company Ltd. Maeve O'Connor reports serving as a consultant and speaker for and receiving consulting fees and speaker honoraria from AstraZeneca, BioCryst, CSL Behring, GlaxoSmithKline, Pharming Technologies BV, Sanofi, and Teva Pharmaceuticals Industries Ltd. Daniel Suez reports serving as a consultant for and receiving consulting fees from Pharming Technologies BV; and performing contracted research for BioCryst., (© 2021 The Authors.)

Background: Caribbean graduates contribute significantly to the US healthcare workforce. The accreditation requirements of local governments vary from one Caribbean island to another island. The Educational Commission for Foreign Medical Graduates (ECFMG) requirement that all future applicants be graduates from accredited medical schools drove Caribbean medical schools to seek accreditation. Accreditation has been found to significantly impact the educational processes of Canadian medical schools. Our study aims at investigating Caribbean medical school leaders' perceptions of the impact of accreditation on their school's processes., Methods: This qualitative study and data analysis were done using a framework analysis. Academic leaders and faculty members from three different types of Caribbean medical schools (accredited, denied-accreditation schools, never applied for accreditation) were interviewed using semi-structured interviews., Results: A total of 12 participants from six different Caribbean medical schools participated in the interview process. Themes of processes influenced by accreditation at Caribbean medical schools were similar to those found in the Canadian context and align with best practices of Continuous Quality Improvement (CQI)., Conclusions: Caribbean medical schools are changing their educational processes as a result of accreditation requirements. Some processes are not maintained in a continuous manner, raising questions about the development of a true CQI culture., Competing Interests: Conflicts of Interest: All authors do not report any conflict of interest related to this work., (© 2021 Arja, Arja, Fatteh, Challa, Somagutta, Blouin; licensee Synergies Partners.)

Introduction: The COVID-19 pandemic has caused a significant toll on healthcare across the globe. The pandemic caused many other consequences, including economic implications and teaching consequences, notably in higher education throughout the world. COVID-19 and the resulting closure of university campuses have had many impacts on Health Professions Education (HPEd), affecting all aspects, including teaching methods, assessment methods, curricula, student-teacher relationships, student selection processes, and student well-being. It has had significant effects on the setting in which students are required to learn more skills such as psychomotor skills. This manuscript aims to investigate the changes implemented in medical education during the pandemic and describe one medical school's response to medical education changes during the pandemic., Methods: This study was a combination of a case study done by in-depth investigation of the current context at one medical school during the pandemic and action research done by gathering information to change a condition in a particular place., Results: Many changes were implemented in medical education, including online teaching for basic science courses (first two years of the program) and online assessments (video-based remote proctoring) in the program's first two years. Such courses as Clinical Skills are using telemedicine/telehealth concepts in training. There were changes such as video-based remote proctoring of NBME shelf-examinations even in the assessments of clerkships/clinical rotations., Conclusions: Adaptations of medical education during this pandemic is highly dependent on technology. Most of the changes will be practiced until the campuses are open. We need to understand that these changes were made over this unprecedented period, i.e. the pandemic as an emergency rather than as a normal change process., Competing Interests: Conflict of Interest: The authors declares that they have no conflict of interest., (Copyright: © Journal of Advances in Medical Education & Professionalism.)

Introduction: The incidence of acyclovir-induced hypersensitivity is rare. To our knowledge, there are four published case reports of oral acyclovir desensitization in adults. Evidence-based guidelines prompt the use of acyclovir for herpes simplex virus (HSV) prophylaxis and treatment. Literature on the cross-reactivity of structurally similar antiviral agents is conflicting, presenting a clinical challenge when choosing an alternative agent. This is a case of successful acyclovir desensitization in an allogeneic stem cell transplant patient., Case Report: A 69-year-old female patient, diagnosed with myelodysplastic/myeloproliferative neoplasm, presented to the hospital for donor mismatch allogeneic bone marrow transplant. The patient reported acyclovir-induced angioedema while receiving treatment for non-complicated herpes zoster (shingles) infection. Management & Outcome: After the acyclovir oral desensitization was conducted in an ICU setting with 1:1 patient-nurse ratio, the patient was successfully started on acyclovir therapy, 800mg by mouth twice daily for HSV prophylaxis with no further complications. Discussion: Oral acyclovir desensitization can provide an option for HSV therapy in patients reporting severe allergy.

Introduction: There are two popular methods of clinical skills teaching. One is Peyton's method, and the other one is Robert Gagne's method. A hybrid model which is a combination of both teaching methods is developed and implemented at Avalon University School of Medicine in Clinical Skills. The aim of the study was to evaluate the hybrid model of clinical skills teaching., Methods: This is a quasi-experimental study where a control group with a sample size of 26 was compared with two study groups; one group included 24 participants, and as the other one consisting of 16 subjects selected without randomization. All students in the class were included in the study, except for those withdrew voluntarily. The quantitative data were gathered in the form of a questionnaire on the Likert scale which was collected as the end of course evaluations. The quantitative data for the responses on the Likert scale was analyzed for descriptive statistics: Mean, Median, and Mode. The quantitative data also included the students' performance on assessments of clinical skills which was analyzed using ANOVA test. The qualitative data were gathered in the form of open-ended questions in the end of course evaluations. The qualitative data were also collected from the faculty members who were the examiners for the clinical skills course as the feedback taken from them., Results: There was a significant improvement in the feedback of students (end of course evaluations) after implementing the hybrid model of clinical skills teaching which was shown by increased Mean, Median, Mode for the most pointers on the Likert scale. Also, there was a notable improvement in the performance of students with a significant p-value (p<0.05) on ANOVA test., Conclusion: The hybrid model is very effective in teaching clinical skills. This teaching method can be evaluated by replicating this study at larger institutions with more number of students.

Background: Skin prick/puncture testing (SPT) is widely accepted as a safe, dependable, convenient, and cost-effective procedure to detect allergen-specific IgE sensitivity. It is, however, prone to influence by a variety of factors that may significantly alter test outcomes, affect the accuracy of diagnosis, and the effectiveness of subsequent immunotherapy regimens. Proficiency in SPT administration is a key variable that can be routinely measured and documented to improve the predictive value of allergy skin testing., Methods: Literature surveys were conducted to determine the adherence to repeated calls for development and implementation of proficiency testing standards in the 1990's, the mid-2000's and the 2008 allergy diagnostics practice parameters., Results: Authors publishing clinical research in peer-reviewed journals and conducting workshops at annual scientific meetings have recommended proficiency testing based primarily on its potential to reduce variability, minimize confounding test results, and promote more effective immunotherapeutic treatments. Very few publications of clinical studies, however, appear to report proficiency testing data for SPT performance. Allergen immunotherapy recommendations are updated periodically by the Joint Task Force on Practice Parameters representing the American Academy of Allergy, Asthma and Immunology (AAAAI), the American College of Allergy, Asthma and Immunology (ACAAI), and the Joint Council of Allergy, Asthma and Immunology (JCAAI)., Conclusions: Despite consensus that all staff who perform SPT should meet basic quality assurance standards that demonstrate their SPT proficiency, the gap between recommendations and daily practice persists. By embracing standards, the accuracy of SPT and allergy diagnosis can be optimized, ultimately benefiting patients with allergic disease.

Aim: To evaluate clinical outcomes and identify factors predictive for recurrence in patients with 1988 (FIGO) stage IA uterine endometrioid carcinoma., Patients and Methods: Patients who underwent hysterectomy for stage IA carcinoma were identified in our database. Fisher's exact and χ(2) tests were used to identify factors that influenced outcome. Survival plots were generated according to Kaplan-Meier product-limit method and the log-rank test was used to determine significance., Results: A total of 121 patients were identified. Eighty-seven percent (n=105) had tumor FIGO grade 1, 9% (n=11) grade 2, and 4% (n=5) grade 3 tumors. Six patients (5%) experienced recurrence. The 5-year recurrence-free survival (RFS), disease-specific survival (DSS) and overall survival (OS) were 93%, 95%, and 85%, respectively. On univariate analysis, tumor FIGO grade 2/3 was strongly associated with tumor recurrence (p=0.003), DSS (p=0.016), and OS (p=0.023). The 5-year RFS, DSS, and OS were 65.1%, 73.9%, and 63.9% respectively for patients with grade 2 and 3 tumors, which were significantly less than the corresponding rates of 97.5% (p ≤ 0.0001), 98.6% (p=0.001), and 87.7% (p=0.024) for patients with grade 1 tumors., Conclusion: In this large cohort of patients, RFS, DSS and OS were excellent. Patients with FIGO grade 2/3 tumors had worse outcomes compared to those with grade 1 tumors. Therefore, while most patients with stage IA disease do not need adjuvant treatment after hysterectomy, our results suggest that patients with higher-grade tumors have an increased likelihood for recurrence and they may benefit from counseling regarding adjuvant therapies.

Cutaneous metastases from colorectal carcinomas occur infrequently, usually in the setting of disseminated disease. They most commonly appear on the abdominal wall or perineal area; metastases to other locations of the skin are rare. We describe a case of colorectal signet ring carcinoma with metastasis to the upper lip. To the authors' knowledge, this is the second reported case of colorectal carcinoma with metastasis to the lip and first with signet ring features. Because of the rarity of cutaneous metastases, the primary physician or pathologist may overlook this diagnosis. However, this entity should be considered in the differential diagnosis of adnexal tumors as it may be the initial presentation of the colon carcinoma.

A 39-year-old man presented with a 2-cm, mildly tender mass in the right breast of many years' duration. Microscopic examination showed a syringocystadenoma papilliferum. Because of its location in the breast, we studied the lesion for immunohistochemical markers for apocrine differentiation. Gross cystic disease fluid protein-15 (GCDFP-15) staining yielded negative results in the cystic luminal epithelial cells, whereas GCDFP-15 and lysozyme staining yielded strongly positive results in the epithelial cells of adjacent tubular apocrine glands. Focal strong lysozyme positivity was seen in the cystic luminal epithelial cells. These findings do not support apocrine differentiation in this case, despite its location in the breast, an organ rich in specialized apocrine (lactiferous) glands. To our knowledge, this represents the first reported case of syringocystadenoma papilliferum of the male breast. We present the clinical and pathologic features of this unusual case and a review of the literature.

Objective: After identifying a metastatic glycogen-rich balloon cell malignant melanoma, originally thought to be a benign clear cell tumor of the lung, we investigated the extent of positive reactions, or "positivity," of malignant melanoma to periodic acid-Schiff (PAS) staining., Methods: Frequency, intensity, and distribution of PAS positivity was studied in 61 excisional biopsy specimens from 58 patients with malignant melanoma. For comparison, 17 benign nevi from 10 patients were examined., Results: Positivity for PAS was seen in all cases. All malignant melanomas and benign nevi were characterized by weak, diffuse, diastase-resistant PAS positivity. Additionally, focal or diffuse, strong diastase-sensitive PAS positivity was observed in 9 of 61 melanomas (15%); 7 were metastatic and 2 were primary invasive melanomas. Strong diastase-sensitive PAS positivity was seen in all lesions with 30% or more balloon cell features and only in advanced primary or metastatic lesions. The presence of glycogen was confirmed by transmission electron microscopy., Conclusions: Cutaneous malignant melanomas have weak, diastase-resistant PAS positivity. Strong diastase-sensitive PAS positivity, consistent with the presence of intracytoplasmic glycogen, is seen in many primary and metastatic melanomas with balloon cell features. Depending on the content of the balloon cells, these melanomas are best categorized as either glycogen-rich malignant melanomas or glycogen-rich balloon cell malignant melanomas. Because many tumors with clear cell features contain glycogen, such content often is an unreliable differential feature.

Kyrle's disease is an uncommon dermatologic entity with characteristic clinical and histopathologic features. A case is recorded in a 63-year-old man undergoing hemodialysis for chronic renal failure. Systemic isotretinoin treatment for 13 weeks resulted in a complete clearance of the cutaneous lesions. Systemic treatment is effective and could be considered preferred therapy.

We describe a case of a solitary dermal cylindroma with focal malignant transformation. The scalp tumor measured 3 cm in greatest dimension and was successfully surgically excised. The patient has been followed up for the last two years with no recurrences. Changes of malignant transformation included loss of peripheral palisading, destruction of the hyaline sheath, areas of necrosis, and pleomorphism of nuclei with frequent mitosis. We reviewed data on 12 other reported cases of dermal cylindromas with malignant transformation. Morphologic features of both benign cylindromas and their malignant counterparts are described. The literature was reviewed regarding the controversy of the cell of origin.

Malignant lymphoma developed in the dorsum of the hand in a patient with a long-standing postmastectomy lymphedema. The tumor subsequently spread to involve skin of the forearm and arm. Growth and spread of malignant cells within the stagnant dilated lymphatics are the likely cause of the characteristic nodular dissemination of the tumor in a lymphedematous extremity, regardless of the type of neoplasm.