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How Well Do Accreditation Council for Graduate Medical Education Milestones Track Readiness for Anesthesiology Certifying Examinations in a National Resident Cohort?
No full textBACKGROUND: Milestones evaluation is mandated by the Accreditation Council for Graduate Medical Education (ACGME) to help training programs measure residents\u27 progress toward competency and identify specific areas for trainee improvement. Data from training programs raised concerns that Milestones ratings may reflect the year of training more than resident progress toward competency. We examined the relationship between residents\u27 Milestones ratings toward the end of residency training and their performance on the American Board of Anesthesiology (ABA) examinations, widely considered as the gold standard of competency.
METHODS: We compared Milestones 2.0 ratings and board scores of all anesthesiologists who completed an ACGME-accredited residency program between July 2021 and June 2022 (AY22) and had their first-time ABA ADVANCED Examination (written), Standardized Oral Examination (SOE) and Objective Structured Clinical Examination (OSCE) performance available by 2023. We first assessed the correlation between the average rating achieved across all 23 Milestones during the last 6 months of residency training and the Z-scores of these three examinations among first-time takers. Then, we evaluated the correlations between 9 specific Milestones and their conceptually related domains tested by the ADVANCED, the SOE, and the OSCE; we calculated Pearson and polychoric correlation coefficients for continuous and ordinal data, respectively.
RESULTS: All 23 Milestones 2.0 AY22 ratings were available for 1849 Post Graduate Year (PGY)-4, Clinical Anesthesia Year 3 (CA-3) residents. These were matched to 1799 first-time ADVANCED and 1383 first-time SOE and OSCE takers. The average ACGME Milestones ratings across all competencies were significantly correlated with examination Z-scores (all P \u3c .001)-the ADVANCED (r = 0.135 [95% confidence interval {CI}, 0.089-0.180], the SOE (r = 0.117 [0.065-0.169]), and the OSCE (r = 0.112 [0.060-0.164]). For the domain-specific comparisons, scores on the ADVANCED Examination correlated modestly with the Medical Knowledge Milestone domain (r = 0.289, P \u3c .001), but there were no statistically significant associations between SOE task ratings and their related Milestones domains (ρ = 0.027 to 0.091, P = .31 to 0.81). In comparisons of similar domains evaluated by OSCE stations and the Milestones, 2 were statistically significantly correlated with a weak magnitude (Interpretation of Monitors and Echocardiograms [ρ = 0.093, P = .031] and Ethical Issues [ρ = 0.049, P = .003]) while 2 others were not statistically significant (Application of Ultrasonography [ρ = 0.052, P = .775] and Communication with other Professionals [ρ = 0.052, P = .086]).
CONCLUSIONS: There was a modest correlation between the last Medical Knowledge Milestone achieved and the ADVANCED Examination. However, the weak correlations between residency Milestones and the SOE or OSCE performance suggest that the Milestones system, as currently implemented by anesthesiology training programs, does not predict certifying examination performance
Artificial Intelligence in Medical Education
No full textArtificial intelligence (AI) provides tremendous opportunities for growth in medical education. With advances in technology, AI systems can now augment a variety of workflows critical to education. This article reviews the scope and some key use cases for AI in medical education. It first demonstrates the utility of AI in curating educational content. It then explores provision and coordination of feedback and competency assessment. It then explores educational use cases including ultrasound training and virtual reality teaching environments. Finally, it discusses areas for concern and opportunities for improvement in future AI systems
Clinical Outcomes for Closure of Iatrogenic Atrial Septal Defects Following Transseptal SAPIEN Mitral Valve-in-Valve Procedures.
No full textBACKGROUND: Iatrogenic atrial septal defects (iASD) are created during transseptal (TS) mitral valve-in-valve (MViV) implantation to facilitate access. Although most iASD remain untreated, the outcomes of closing iASD during TS MViV are unclear. This study evaluates outcomes of concomitant iASD closure during TS MViV.
METHODS: Patients undergoing TS MViV with SAPIEN 3/Ultra/Resilia valves from June 2015 to September 2023 were identified using the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. To reduce patient selection bias in the primary analysis, MViV patients without iASD closure were chosen from sites that did not perform iASD closures. Propensity score matching accounted for baseline characteristics, and analyses evaluated procedural success, complications, and 1-year clinical outcomes.
RESULTS: Among 5363 TS MViV patients, 472 (8.8%) underwent iASD closure at 173 of 494 sites (35.0%). Propensity matching yielded 468 patient pairs (34% male, 66% female). No significant differences were observed in procedural success, complications, stroke (3.3% vs 5.2%; P = .26), or mortality (18.8% vs 17.3%; P = .54). Rates of New York Heart Association class III/IV and heart failure rehospitalization were also similar. However, in patients with severe pulmonary hypertension (mean pulmonary artery pressure, 47.4 ± 8.6 mm Hg), iASD closure was associated with higher 30-day mortality (9.7% vs 3.9%; P = .03) and 1-year cardiac readmission rates (14.1% vs 4.1%; P = .008).
CONCLUSIONS: Iatrogenic atrial septal defect closure during the index hospitalization for TS MViV patients is a well-tolerated procedure when performed in carefully selected individuals. However, no significant clinical benefits were observed in the iASD closure group. Additionally, patients with significant pulmonary hypertension did not demonstrate any clinical advantage from iASD closure, and the procedure may even pose potential harm in this subgroup
Evaluating birthing individual and infant healthcare utilization and costs among individuals experiencing perinatal mood and anxiety disorders
No full textIMPORTANCE: The maternal-infant connection is fundamental, not only for the psychological wellbeing of both individuals in the dyad, but for their overall health. Yet, their health outcomes are often reported as separate entities. This study offers a novel exploration about how healthcare utilization and costs are interconnected for the dyad. To address this critical gap, our study purpose was to evaluate parallel healthcare utilization outcomes and costs for the birthing person-infant dyad during the postpartum period for those with and without PMAD. The study objectives were to 1) describe healthcare utilization use and costs in the dyad and 2) assess the association of PMAD status with healthcare use and costs in the dyad.
OBJECTIVE: To evaluate parallel healthcare utilization outcomes and costs for the birthing person-infant dyad during the postpartum period for those with and without perinatal mood and anxiety disorders (PMAD).
DESIGN: A cross-sectional analysis of healthcare utilization and costs in the postpartum period for birthing individuals and their infants between 2016-2020.
SETTING: Private insurance data of delivering women in all 50 US states.
PARTICIPANTS: The study sample included individuals with evidence of a delivery from 2016 to 2020 who delivered a live singleton newborn. Specifically, we included individuals coded as female, aged 15-44, and with continuous enrollment in a single health plan during the calendar year before and after delivery.
RESULTS: The sample consisted of 101,306 birthing individuals and 108,438 infants representing 108,438 unique dyads. Most birthing individuals were between the ages of 25-39 and categorized as White (71.7% of deliveries). Births to White and Black perinatal individuals had the highest percentage with a PMAD diagnosis (21.9% of deliveries to White individuals and 17.9% of deliveries to Black individuals), either in the prenatal or postpartum period. Individuals with pre- or post-delivery PMAD had higher rates of NICU admissions (13.6% and 11.4%, respectively) than those without PMAD (9.9%). Emergency department visits and outpatient utilization decreased over time for both birthing individuals and infants overall. Odds of outpatient services utilization were highest among deliveries with post-PMAD present (newborn Outpatient services aOR: 1.687, CI: 1.274, 2.233 and birthing individual Outpatient services aOR: 6.48, CI: 5.490, 7.648). The PMAD + SUD group had the highest dyadic OOPC (median: 316.20, 505.95, IQR: 1,169.01), a difference of almost $300.
CONCLUSION: Results from this study demonstrate significant differences among PMAD groups (i.e., pre-delivery, post-delivery, co-occurring PMAD + SUD) compared to a group without PMAD. This might suggest that PMAD status influences changes in healthcare use or costs. Additionally, the percentage of both birthing individuals and their infants using outpatient services remained nearly identical during the study period, further emphasizing the connection between the dyad and healthcare use
Balancing Immunity: GSK-3\u27s Divergent Roles in Dendritic Cell-Mediated T-Cell Priming and Memory Responses
No full textGlycogen synthase kinase-3 (GSK-3)-particularly the GSK-3β isoform-plays a pivotal role in regulating dendritic cell (DC) functions, including maturation, cytokine production, and antigen presentation. In immature DCs, GSK-3β is continuously active, and its inhibition has been shown to enhance DC maturation and function. As a key upstream kinase of β-catenin, GSK-3 inhibition activates β-catenin in both human and murine DCs-a pathway traditionally linked to its immunomodulatory effects. However, our recent findings challenge this paradigm by uncovering β-catenin-independent, dual roles of GSK-3β in DCs. Our study reveals that while GSK-3β enhances DC-mediated cross-priming of CD8 T cells, it concurrently impairs the generation of memory CD8 T cells. These findings have significant implications for vaccine development and cancer immunotherapy, where both effective T-cell priming and durable memory responses are critical. This mini-review provides an in-depth analysis of mechanistic insights into GSK-3β\u27s paradoxical functions and discusses potential strategies to fine-tune GSK-3 activity for optimized immunotherapeutic outcomes
Undifferentiated Pleomorphic Sarcoma: A Diagnosis of Exclusion
No full textA 43-year-old male patient presented with a progressively enlarging mass in his right lateral tibia over the course of one month. The mass measured 4 x 7 cm in size on examination. Aspiration of the lesion was performed, revealing 30 cc of dark blood, leading to an initial diagnosis of hematoma. Three months later, the mass had enlarged with mild pain. Physical examination revealed a 12 x 9 cm fluctuant mass on the right lateral lower leg, which was warmer than surrounding skin and tender upon palpation. Subsequent imaging was ambiguous, with a broad differential diagnosis consisting of expanding hematoma, abscess, neoplasm, and arteriovenous malformation (AVM). A biopsy was performed revealing pleomorphic cells consistent with an undifferentiated pleomorphic sarcoma (UPS). This case report highlights the challenges of diagnostic workup, management, and follow-up of an unusual presentation of a UPS
Early life adversity increases risk for chronic post-traumatic pain, data from humans and rodents
No full textTraumatic stress exposures (TSEs) are common in life. Although most individuals recover after a TSE, a substantial subset develop adverse post-traumatic neuropsychiatric sequelae such as chronic post-traumatic musculoskeletal pain (CPMP). Vulnerability factors for CPMP are poorly understood, which hinders identification of high-risk individuals for targeted interventions. One known vulnerability factor for many pain types is exposure to early life adversity (ELA), but few studies have assessed whether ELA increases risk for CPMP. This study used data from the Advancing Understanding of RecOvery afteR traumA study, a prospective human cohort study of TSE survivors, to test the hypothesis that ELA increases risk for CPMP. In addition, in secondary analyses, we assessed which subtypes of ELA (including childhood bullying) were most predictive of CPMP and whether a rat ELA model consisting of neonatal limited bedding, combined with single prolonged stress (SPS) in adulthood, would accurately model human findings. In Advancing Understanding of RecOvery afteR traumA study participants (n = 2480), using multinomial logistic regression modeling of 4 identified latent pain classes, we found that ELA increased vulnerability to the high unremitting pain class (odds ratio [OR] = 1.047, P \u3c 0.001), the moderate pain class (OR = 1.031, P \u3c 0.001), and the moderate recovery pain class (OR = 1.018, P = 0.004), with physical abuse, emotional abuse, and bullying being the strongest predictors of high pain class assignment. Similarly, in male and female Sprague Dawley rats, in comparison with SPS alone, neonatal limited bedding combined with SPS caused increased baseline sensitivity and prolonged mechanical hypersensitivity (F(11,197) = 3.22, P \u3c 0.001). Further studies in animals and humans are needed to understand mechanisms by which ELA confers vulnerability to CPMP
An Unusual Cause of Abdominal Pain: Mesenteric Lymphadenopathy Secondary to Sarcoidosis Without Pulmonary Involvement
No full textSarcoidosis is a systemic disease that affects multiple organs in the body but rarely affects the gastrointestinal (GI) tract. The symptoms of GI sarcoidosis may be nonspecific or silent. Often, it is discovered on computed tomography (CT) or esophagogastroduodenoscopy (EGD), and a biopsy is needed for diagnosis. Initial management is typically with prednisone; however, here, we present a rare case of GI sarcoidosis with mesenteric lymphadenopathy in the absence of pulmonary involvement, diagnosed via biopsy and treated successfully with methotrexate
Attitudes of Gastroenterologists Regarding Preoperative Anxiety Prior to Colonoscopy: A Cross-Sectional Study
No full textBACKGROUND: Colonoscopy is often considered by patients to be an anxiety-provoking procedure. Studies have investigated different approaches to help alleviate anxiety prior to colonoscopies. However, there have been no investigations of gastroenterologists and their attitudes towards pre-procedural anxiety of patients. This study presents the largest survey assessing these attitudes.
AIMS: The aim of our study is to determine attitudes and practices of gastroenterologists towards pre-procedural anxiety before colonoscopies.
METHODS: An anonymous questionnaire was sent online to gastroenterologists of the American College of Gastroenterology to assess views regarding pre-procedural anxiety.
RESULTS: Of the 280 complete responses, most respondents were male (n = 205, 73.21%), in practice between 0 and 9 years (n = 133, 47.50%), at the attending/faculty level (n = 69.53%, 194), and practiced in the academic setting (n = 124, 44.28%). Most respondents did not ask their patients about pre-operative anxiety prior to colonoscopy (n = 149, 53.79%), although many responded that they would use a pre-procedural anxiety rating scale if one was available (n = 124, 44.73%). Techniques gastroenterologists implemented to reduce anxiety about colonoscopies in their patients included pre-operative education about the procedure (n = 223, 82.90%), permitting family members to be present (n = 90, 33.46%), and playing music (n = 77, 28.62%). On a weighted scale, most responded that the endoscopist has the most responsibility for the patient\u27s anxiety, followed by anesthesiologists/CRNAs.
CONCLUSIONS: The majority of gastroenterologists did not regularly measure pre-operative anxiety prior to colonoscopy and almost half would be open to the use a tool to help assess their patient\u27s anxiety. Future directions may include the development of a specific tool for anxiety measurement specific to colonoscopy
Head and neck tumor organoid grown under simplified media conditions model tumor biology and chemoradiation responses
No full textHead and neck squamous cell carcinoma (HNSCC) is a prevalent and often fatal malignancy associated with significant treatment-related toxicity. There is an urgent need for a preclinical model to assess therapeutic options and guide clinical decision-making. To define conditions for establishing patient-derived organoid (PDO) models that faithfully recapitulate morphological, histopathological, and genomic characteristics of HNSCC patients and can predict radiation and chemotherapy responses in patients, PDOs were generated from a group of HNSCC patients. The morphological, histological, mutational, and biological characteristics and treatment responses were evaluated. We demonstrate that the PDOs closely resemble resected tumors from which they were derived with respect to histopathology, differentiation state markers, p16 status, and mutation profiling. We observe patient-to-patient variation in cell proliferation rates. Additionally, they exhibit differential responses to radiotherapy and chemotherapy, which were examined using a cell viability assay. This methodology offers potential for drug screening in a pre-clinical context with the potential to mirror clinical outcomes. Our WNT-free growth conditions maintained the differentiation status of PDOs and enabled rapid assessment of drug response and the development of new models to identify new treatment options for head and neck cancer patients