Introduction During the COVID-19 pandemic, third-year medical students were temporarily unable to participate in onsite clinical activities. We identified the curricular components of an internal medicine (IM) clerkship that would be compromised if students learned solely from online didactics, case studies, and simulations (i.e., prerounding, oral presentations, diagnostic reasoning, and medical management discussions). Using these guiding principles, we created a virtual rounds (VR) curriculum to provide IM clerkship students with clinical exposure during a virtual learning period. Methods Held three times a week for 2 weeks, VR consisted of three curricular components. First, clerkship students prerounded on an assigned hospitalized patient by remotely accessing the electronic health record and calling into hospital rounds. Second, each student prepared an oral presentation on their assigned patient. Third, using videoconferencing, students delivered these oral presentations to telemedicine VR small groups consisting of three to four students and three tele-instructors. Tele-instructors then provided feedback on oral presentations and taught clinical concepts. We assessed the effectiveness of VR by anonymously surveying students and tele-instructors. Results Twenty-nine students and 34 volunteer tele-instructors participated in VR over four blocks. A majority of students felt VR improved their prerounding abilities (86%), oral presentation abilities (93%), and clinical reasoning skills (62%). All students found small group to be useful. Discussion VR allowed students to practice rounding skills in a supportive team-based setting. The lessons learned from its implementation could facilitate education during future pandemics and could also supplement in-person clerkship education.

TD) enables remote triage and management of dermatology patients. Previous analyses of TD systems have demonstrated improved access to care but an inconsistent fiscal impact.OBJECTIVE To compare the organizationwide cost of managing newly referred dermatology patients within a TD triage system vs a conventional dermatology care model at the Zuckerberg San Francisco General Hospital and Trauma Center (hereafter referred to as the ZSFG) in California. DESIGN, SETTING, AND PARTICIPANTSA retrospective cost minimization analysis was conducted of 2098 patients referred to the dermatology department at the ZSFG between June 1 and December 31, 2017.INTERVENTION Implementation of the TD triage system in January 2015. MAIN OUTCOMES AND MEASURESThe main outcome was mean cost to the health care organization to manage newly referred dermatology patients with or without TD triage. To estimate costs, decision-tree models were constructed to characterize possible care paths with TD triage and within a conventional dermatology care model. Costs associated with primary care visits, dermatology visits, and TD visits were then applied to the decision-tree models to estimate the mean cost of managing patients following each care path for 6 months. The mean cost for each visit type incorporated personnel costs, with the mean cost per TD consultation also incorporating software implementation and maintenance costs. Finally, ZSFG patient data were applied within the models to evaluate branch probabilities, enabling calculation of mean cost per patient within each model. RESULTSThe analysis captured 2098 patients (1154 men [55.0%]; mean [SD] age, 53.4 [16.8] years), with 1099 (52.4%) having Medi-Cal insurance and 879 (41.9%) identifying as non-White. In the decision-tree model with TD triage, the mean (SD) cost per patient to the health care organization was $559.84 ($319.29). In the decision-tree model for conventional dermatology care, the mean (SD) cost per patient was $699.96 ($390.24). Therefore, the TD model demonstrated a statistically significant mean (SE) cost savings of $140.12 ($11.01) per patient. Given an annual dermatology referral volume of 3150 patients, the analysis estimates an annual savings of $441 378.CONCLUSIONS AND RELEVANCE Implementation of a TD triage system within the dermatology department at the ZSFG was associated with cost savings, suggesting that managed health care settings may experience significant cost savings from using TD to triage and manage patients.

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Background COVID-19 vaccines, primarily mRNA types, are administered to 2,000,000 individuals per day in the US under FDA emergency use authorization. Methods Observational cohort study of hospital workers who received their first SARS-CoV2 mRNA vaccination between December 14, 2020 and January 8, 2021, including cases reporting onset of an injection site reaction > 48 hours after administration of their first or second dose to an employee hotline. Results Thirteen female employees, who received mRNA-1273 SARS-CoV2 vaccine (Moderna) during the first three weeks of SARS-CoV2 vaccine rollout at San Francisco General Hospital, reported a pruritic rash at the injection site appearing 3-9 days after receiving their initial dose. Five had milder or similar reactions with earlier onset after the second dose. One additional female employee reported this delayed reaction only after the second dose. None of these 14 employees reported serious adverse events, such as anaphylaxis, or had symptoms severe enough to seek medical attention. These cases represented 1.1% of the 1,275 female employees who received their first mRNA-1273 dose, and 2.0% of the 557 who were 31-45 years old, during this initial vaccine rollout. None of 675 males initiating mRNA-1273 or 3,612 employees of either sex initiating BNT162b (Pfizer) vaccination during this period reported this delayed onset reaction. Conclusions These results suggest that delayed-onset, injection-site pruritic rashes after mRNA-1273 SARS-CoV2 vaccine administration, lasting up to a week, occur commonly in females, do not lead to serious sequela, and should not deter receipt of the second vaccine dose.

Purpose -To reveal the effect of each of company size, company profit, solvency and the size of public accountant on audit report lag for the infrastructure, utility and transportation sectors listed on the Indonesian Stock Exchange. Methodology -The population of this research are infrastructure, utility and transportation companies that are listed on and supervised officially by the Indonesian Stock Exchange from 2013-2015. The technique used for choosing the sample was purposive sampling. The sample consisted of 57 companies chosen from the population. The data was analysed using double regression analysis. Findings -The study finds that first, company size has a negative and significant effect on audit report lag. Second, company profit has a negative and significant effect on audit report lag. Third, solvency has no significant effect on audit report lag, and fourth, the size of public accountant has no significant effect on audit report lag. Conclusion -The magnitude of a company has is a significant negative influence on audit report lag. This case can be interpreted as the bigger the company is, the smaller the audit report lag will be.

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BackgroundOn 4th February 2015, a group of Senior High School students from Fanteakwa district presented to the emergency unit of the district hospital with complaints of abdominal pain, vomiting and diarrhoea. All the students had eaten from a specific food vendor and had neither eaten any other common meal that day nor the previous day. A foodborne disease outbreak was suspected. We investigated to verify the outbreak, determine its magnitude, identify the source and implement control measures.MethodsA retrospective cohort study was conducted. We reviewed medical records and interviewed patrons of the food vendor. We collected data on age, sex, signs and symptoms, date of illness onset, date of admission, date of discharge, treatments given and outcome. A case of foodborne disease was any person in the school with abdominal pain, vomiting and or diarrhoea from 4th to 11th February 2015 and had eaten from the food vendor. We conducted active case search to identify more cases. We conducted environmental assessment and collected clinical and food samples for laboratory testing. Descriptive and inferential statistical analyses were performed using Stata 12.0.ResultsA total of 68 cases were recorded giving overall attack rate of 35.79 % (68/190) with no death. Of these, 51.47 % (35/68) were males. Mean age of case-patients was 17.8 (standard deviation +/-1.62). The index case, a 17-year-old female student ate from the food vendor on 4th February at 9:00 am and fell ill at 3:40 pm later that day. Compared to those who ate other food items, students who drank water from container at the canteen were more likely to develop foodborne disease at statistically significant levels [RR = 2.6, 95 % CI = (2.11–3.15)]. Clostridium perfringens (C. perfringens) and Salmonella species (Salmonella spp) were isolated from water and stew respectively. Clinical features of case-patients were compatible with both organisms.ConclusionA foodborne gastroenteritis outbreak occurred in a Senior High School in Fanteakwa District from 4th to 7th February 2015. The most probable aetiologic agent was C. perfringens with contaminated water at canteen as the vehicle of transmission. Concurrent Salmonella spp infection could not be ruled out. Rapid outbreak response helped in controlling the outbreak.

Summary While previous studies have characterized the types of dermatological disease among people experiencing homelessness (PEH) in the outpatient setting, dermatological disease among hospitalized PEH has never been evaluated. Therefore, we performed a cross‐sectional analysis of hospitalized patients who received dermatology consultations at two San Francisco hospitals between March 2018 and March 2020 and compared the odds of diagnostic categories between PEH and patients with stable housing. In both unadjusted and adjusted analyses, PEH had significantly higher odds of bacterial skin infections [adjusted odds ratio (aOR) = 2.29, 95% CI 1.46–3.61], ectoparasitic disease (aOR = 9.43, 95% CI 3.79–23.47), psoriasis or seborrhoeic dermatitis (aOR = 2.50, 95% CI 1.43–4.36) and venous stasis or lymphoedema (aOR = 2.54, 95% CI 1.23–5.27) and significantly lower odds of drug reactions (aOR = 0.34, 95% CI 0.18–0.67). Overall, these findings highlight the unique dermatological challenges among hospitalized PEH and suggest potential strategies to facilitate equitable dermatology care delivery.