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Use of entrustable professional activities for reliable overall entrustment decisions
No full textPurpose: Entrustable professional activities (EPAs) detail essential activities within a given specialty. Although 17 general pediatrics EPAs have been defined, it is not known how many are needed to make high-reliability overall entrustment decisions about resident readiness for practice at the time of graduation and initial certification. This study sought to determine how many general pediatrics EPAs are needed.
Method: During the 2021 to 2022, 2022 to 2023, and 2023 to 2024 academic years, the authors collected entrustment-supervision levels, determined by clinical competency committees biannually, for the 17 general pediatrics EPAs for residents at 48 U.S. pediatric residency training programs. Midyear reports were collected between November and January of each year, and end-of-year reports were collected between May and July. The authors conducted generalizability and decision studies to determine the number of EPAs needed to make a reliable overall entrustment decision.
Results: A total of 166,077 individual entrustment-supervision levels were collected for 4,250 pediatric residents across the 17 general pediatrics EPAs. Across all data reporting cycles, the authors found that assessing 6 EPAs yields a generalizability coefficient of 0.8 and assessing 12 EPAs yields a generalizability coefficient of 0.9. However, results differed for midyear compared with end-of-year data collection timepoints as well as by postgraduate year. At graduation, 9 to 13 EPAs are needed to make a highly reliable (generalizability coefficient of 0.9) overall decision about degree of entrustment for unsupervised practice.
Conclusions: This study provides rich insight into the number of EPAs needed to make reliable entrustment decisions about resident readiness to provide patient care. Although readiness can be determined with as few as 9 general pediatrics EPAs (an assessment task), more may be needed to inform a comprehensive curriculum that ensures focus in all areas important to developing general pediatricians during residency training (a curricular task).Teaser text: This study sought to determine how many entrustable professional activities are necessary to make high reliability overall entrustment decisions about pediatric resident readiness for unsupervised practice
Middle meningeal artery embolization for subdural hematoma: CT/MRI end points of the EMBOLISE trial
No full textBackground: Chronic subdural hematomas (cSDHs) are associated with high recurrence risks following surgical evacuation. The EMBOLISE trial demonstrated that, compared with surgery alone, adjunctive middle meningeal artery embolization (MMAE) significantly reduced reoperation rates. However, given the limitations of the clinical end points of the trial, which may be subject to interrater variability and certain biases, the quantitative imaging metrics need to be evaluated.
Purpose: To evaluate the prespecified imaging end points of the EMBOLISE trial and assess the long-term resolution of cSDH through quantitative imaging analyses.
Materials and Methods: EMBOLISE was a multicenter, randomized, interventional trial conducted across 39 U.S. sites between December 2020 and August 2023. Prespecified secondary imaging end points included changes in hematoma volume and thickness and midline shifts from 24 hours to 90 days after the procedure at CT and MRI. The post hoc analyses performed herein extended the assessment to 180 days and included absolute hematoma metrics. Mixed-effects modeling was employed to adjust for confounders.
Results: Four hundred patients were enrolled in the EMBOLISE study, among whom 352 were included (mean age, 72 years ± 10.4 [SD]; 256 men). The mean cSDH volume was 126 mL at screening, with no intergroup differences. At 90 and 180 days, the MMAE plus surgery group had lower cSDH volumes (20.6 mL vs 28.9 mL [P = .03] and 19.4 mL vs 31.5 mL [P = .04], respectively). Mixed-effects models revealed a 6.9 mL (95% CI: -13.5, -0.40; approximately 25%) greater volume reduction and an 8.4 mL (95% CI: -15.2, -1.6; approximately 30%) lower absolute volume at 90 days in the MMAE group There was no evidence of a difference in the prespecified secondary imaging end points between the groups.
Conclusion: While the prespecified secondary imaging end points did not significantly differ, the absolute 90- and 180-day hematoma volumes were significantly lower in patients who received MMAE and surgery. Confounder-adjusted mixed-effects analysis indicated a greater reduction in hematoma volume with adjunctive MMAE
Inside Aurora Sinai Medical Center, 2003 July
No full textAurora Sinai Medical Center, Milwaukee, WI: Internal employee newsletter with workplace anniversaries, news, and events.https://institutionalrepository.aah.org/alldocuments/2253/thumbnail.jp
Inside Aurora Sinai Medical Center, 2003 March
No full textAurora Sinai Medical Center, Milwaukee, WI: Internal employee newsletter with workplace anniversaries, news, and events.https://institutionalrepository.aah.org/alldocuments/2249/thumbnail.jp
ACR appropriateness criteria® thoracic venous occlusions-suspected superior vena cava syndrome
No full textSuperior vena cava (SVC) syndrome occurs in approximately 15,000 people in the United States each year. It most commonly occurs secondary to thoracic malignancies, mostly primary lung cancer and lymphoma. The cause is occlusion of the SVC or brachiocephalic veins. The following recommendations for initial imaging evaluation of acute or chronic SVC syndrome are presented. Contrast-enhanced chest CT scans, particularly CT angiography/venography, with or without simultaneous inclusion of the neck are recommended studies. MRI with contrast and MR venography/MRA chest with or without contrast are also recommended studies. The recommended CT and MR studies work well to diagnose and evaluate the cause and extent of superior vena cava or brachiocephalic vein occlusion. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation
Outcomes in surgical management of Graves\u27 disease: Transcervical versus transoral thyroidectomy
No full textObjective: To compare surgical outcomes of patients with Graves\u27 disease undergoing total thyroidectomy through the transoral endoscopic thyroidectomy vestibular approach versus the transcervical approach.
Study design: Retrospective cohort study.
Setting: Tertiary care academic institution.
Methods: Patients were offered a choice of either approach, undergoing surgery between September 2016 (when TOETVA was first offered) and March 2024. Patients were excluded if they were under 18 years old or received a neck dissection or re-operation. Collected data includes demographics, clinical and surgical variables, pathology, and postoperative complications.
Results: In total, 152 transcervical and 81 transoral cases were included. The transoral group was younger (36.1 vs 45.3 years, P \u3c .0001) and had more females (95.1% vs 77.0%, P = .0003) but had comparable body mass index to the transcervical group. There were no significant differences in the median maximum lobe size (5.9 (transcervical) vs 5.6 (transoral) cm, P = .647). Complication rates were similar between groups. Of the minor complications, temporary hypoparathyroidism was the most prevalent with 12 (7.9%) cases in the transcervical and 7 (8.6%) in the transoral groups. There were 2 (1.3%) and 4 (5.0%) cases of major complications in transcervical and transoral groups, respectively. Multivariable regression for age, sex, length of admission, and surgery duration confirmed no significant associations between approach and complication rates.
Conclusion: Transcervical and transoral approaches for surgical management of Graves\u27 disease show statistically comparable rates of minor and major complications, even early in the learning curve. The choice of approach should involve shared decision-making between surgeon and patient, as highly motivated patients may not be excellent candidates
Stress hormone dysregulation in overweight male adults with obstructive sleep apnea
No full textIntroduction: Obstructive sleep apnea (OSA) may influence the hypothalamic-pituitary-adrenal (HPA) axis and result in subsequent physiological dysregulation. Given the inconsistent findings of the current literature and the lack of investigations on stress hormones, this study explored the potential impact of OSA on stress markers of adrenocroticotrophic hormone (ACTH), cortisol, and dehydroepiandrosterone (DHEA)/DHEA-S in male overweight OSA patients.
Methods: This prospective, single-blind, cross-sectional study enrolled male overweight (body mass index \u3e25 kg/m2) OSA patients. The patients were grouped into mild/moderate and severe OSA groups based on the apnea/hypopnea index to investigate the differences in stress hormones. The inter-relationships among ACTH, cortisol, and DHEA in both groups were further analyzed in detail with Pearson\u27s correlations to determine the potential impact of OSA severity.
Results: Overall, 144 subjects were recruited. DHEA in saliva and serum DHEA-S were found significantly lower in the severe OSA group compared to the mild/moderate OSA group. Pearson\u27s correlations demonstrated that in both groups, ACTH and cortisol concentrations (morning and night) showed significant positive correlations. Significant relationships between night ACTH and DHEA-S in saliva (r = 0.368, p = 0.023) and blood (r = 0.361, p = 0.017) were also found in mild/moderate OSA group, but neither was noted in the severe group.
Conclusion: Severe OSA may impact the HPA axis by reducing concentrations of DHEA and DHEA-S without affecting cortisol and ACTH concentrations in male overweight OSA patients. This could possibly imply the dysregulation of DHEA/DHEA-S production in a much severe sleep disturbance situation
Iterative modification and finalization of a patient decision-aid for immunosuppressive medication treatment decision-making in systemic lupus erythematosus by a racially diverse patient group
No full textObjective: To describe the patient-feedback process for iterative modification and finalization of the systemic lupus erythematosus (SLE) decision-aid.
Methods: We invited SLE patients during their regular outpatient visits to review the English or Spanish version of the SLE decision-aid on a touchpad computer. They provided qualitative and quantitative feedback on style, content, and usefulness of SLE decision-aid.
Results: Twenty-two racially diverse SLE patients, from 2 academic medical centers, reviewed the SLE decision-aid. Most patients found SLE decision-aid easily understandable, clear, and concise. Patients found a variety of different content interesting, such as the sections on steroids, and premenopausal women, and how the graphs helped them understand the information. The content helped patient understanding and provided clarity about SLE management. All the people with SLE found the information in the lupus decision-aid important. Most respondents (\u3e75%) each agreed that the use of SLE decision-aid would have made a difference in their initial treatment or strongly agreed that it is important to start treatment to prevent kidney damage.
Conclusion: Patient feedback contributed significantly to iterative modification and finalization of the SLE decision-aid, which kept it relevant to all SLE patients
Multicenter study on the safety of pulsed field ablation in over 40,000 patients: MANIFEST-US
No full textBackground: Pulsed field ablation (PFA) is emerging as the preferred energy source for atrial fibrillation ablation, largely because of its promising safety profile, including lower risks of esophageal injury, pulmonary vein stenosis, and phrenic nerve injury. However, rare complications may only emerge after treating many thousands of patients.
Objectives: This study sought to determine the real-world utilization and safety profile of the pentaspline PFA catheter in the United States.
Methods: In this retrospective analysis, invitations were sent to U.S. centers performing PFA with the pentaspline catheter. Centers submitted data on patient demographics, procedural details, and adverse events (AEs). The main outcomes included the incidence of major and minor procedure-related AEs.
Results: Of the 435 centers contacted, 102 participated, averaging 5.1 operators per center (range 1-16 operators per center). Each center treated a median of 412 patients (range 26-1,961 patients), totaling 41,968 patients between February 2024 and July 2025. The median patient age was 68 years (range 17-99 years), and 56% were male. Most patients underwent first-time ablation (73%), primarily for paroxysmal (54%) or persistent atrial fibrillation (37%). Pulmonary vein isolation was performed in 93% of patients, with extravenous lesions on the posterior wall (57%), cavotricuspid isthmus (31%), or mitral isthmus (14%). Major AEs occurred in only 0.63% of patients, including cardiac tamponade (0.16%), vascular injury requiring intervention (0.18%), and stroke (0.10%). Importantly, no cases of esophageal fistula, persistent phrenic nerve paralysis, or pulmonary vein stenosis occurred. Mortality at 30 days was rare (0.04%), but there was a potential signal for rare (0.019%) unexplained sudden death/cardiac arrest. Rare AEs included coronary spasm (0.10%) and acute renal failure requiring dialysis (0.02%). Minor complications were reported in 2.05%, mainly vascular issues (0.96%), pericarditis (0.52%), and self-limited esophageal dysmotility (0.04%).
Conclusions: In a real-world setting of unselected U.S. patients, PFA demonstrated a safety profile consistent with preferentiality to functional myocardial tissue ablation, without evidence of esophageal fistula or pulmonary vein stenosis. The major complication rate was ∼0.6%-mostly vascular AEs and pericardial tamponade. Stroke (∼1 in 1,000) and death (∼1 in 2,000) were rare. These data indicate that the initial implementation of pentaspline PFA has been overall safe
Simulation-based education for extracorporeal membrane oxygenation and strategies for implementation: A systematic scoping review
No full textSimulation-based education (SBE) in health care is expanding in both scope and relevance. As on-the-job training is challenging in extracorporeal membrane oxygenation (ECMO), SBE features strongly in its curricula, yet little is known regarding its efficacy. We searched 4 databases through May 13, 2022 and conducted a narrative synthesis of 28 studies investigating SBE in ECMO. Notably, there were no standardized SBE ECMO curricula among studies. Nonetheless, taken together, these articles suggest that simulation improves competency scores, confidence, teamwork, troubleshooting emergencies, and times to critical actions and cannulation. Though the reporting of SBE in ECMO is heterogeneous, simulation may be comparable to, or more effective than, conventional training methods. Retention of knowledge and skills over time remains unclear though regular simulation training may be beneficial. There is a need to establish standardized ECMO curricula, of which SBE should be a core component