Entrustment Decision Making in the Core Entrustable Professional Activities: Results of a Multi-Institutional Study.

PURPOSE: In 2014, the Association of American Medical Colleges defined 13 Core Entrustable Professional Activities (EPAs) that all graduating students should be ready to do with indirect supervision upon entering residency and commissioned a 10-school, 5-year pilot to test implementing the Core EPAs framework. In 2019, pilot schools convened trained entrustment groups (TEGs) to review assessment data and render theoretical summative entrustment decisions for class of 2019 graduates. Results were examined to determine the extent to which entrustment decisions could be made and the nature of these decisions. METHOD: For each EPA considered (4-13 per student), TEGs recorded an entrustment determination (ready, progressing but not yet ready, evidence against student progressing, could not make a decision); confidence in that determination (none, low, moderate, high); and the number of workplace-based assessments (WBAs) considered (0->15) per determination. These individual student-level data were de-identified and merged into a multischool database; chi-square analysis tested the significance of associations between variables. RESULTS: The 2,415 EPA-specific determinations (for 349 students by 4 participating schools) resulted in a decision of ready (n = 997/2,415; 41.3%), progressing but not yet ready (n = 558/2,415; 23.1%), or evidence against student progression (n = 175/2,415; 7.2%). No decision could be made for the remaining 28.4% (685/2,415), generally for lack of data. Entrustment determinations' distribution varied across EPAs (chi-square P < .001) and, for 10/13 EPAs, WBA availability was associated with making (vs not making) entrustment decisions (each chi-square P < .05). CONCLUSIONS: TEGs were able to make many decisions about readiness for indirect supervision; yet less than half of determinations resulted in a decision of readiness to perform this EPA with indirect supervision. More work is needed at the 10 schools to enable authentic summative entrustment in the Core EPAs framework.

Revisiting the Core Entrustable Professional Activities for Entering Residency.

The Core EPAs for Entering Residency Pilot project aimed to test the feasibility of implementing 13 entrustable professional activities (EPAs) at 10 U.S. medical schools and to gauge whether the use of the Core EPAs could improve graduates' performance early in residency. In this manuscript, the authors (members of the pilot institutions and Association of American Medical Colleges staff supporting the project evaluation) describe the schools' capacity to collect multimodal evidence about their students' performance in each of the Core EPAs and the ability of faculty committees to use those data to make decisions regarding learners' readiness for entrustment. In reviewing data for each of the Core EPAs, the authors reflected on how each activity performed as an EPA informed by how well it could be assessed and entrusted. For EPAs that did not perform well, the authors examined whether there are underlying practical and/or theoretical issues limiting its utility as a measure of student performance in medical school.

Medical management of the liver transplant recipient.

Long-term survival of liver transplant recipients has become the rule rather than the exception. As a result, the medical complications of long-term survival, including atherosclerotic cardiovascular disease, metabolic bone disease, and de novo malignancy, have accounted for an increasing proportion of late morbidity and mortality. Risk factors for these complications begin before transplant and are potentially modifiable but are exacerbated by the requirement for immunosuppressive medications after transplantation. Surveillance and early intervention programs administered by transplant hepatologists and other medical subspecialists may improve long-term outcomes in liver transplant recipients by ameliorating risk factors for atherosclerosis, bone fractures, and cancer.

Tolvaptan for the management of syndrome of inappropriate antidiuretic hormone secretion: lessons learned in titration of dose.

OBJECTIVE: To report a patient with idiopathic syndrome of inappropriate antidiuretic hormone secretion (SIADH) who developed profound aquaresis with symptomatic extracellular fluid depletion after initiation of therapy with tolvaptan who was later successfully treated with smaller doses of compounded tolvaptan to prevent rapid correction of serum sodium. METHODS: Case report and review of the literature. RESULTS: A 51-year-old woman was diagnosed with SIADH during admission for elective surgery resulting in multiple complications. The patient failed multiple therapies including fluid restriction, salt tablets, and demeclocycline. She was admitted to the hospital for initiation of tolvaptan therapy. After a 15-mg dose of tolvaptan, the patient had rapid increase in urine output and symptomatic hypotension. Sodium levels corrected rapidly overnight from 126 mEq/L to 139 mEq/L. A lower dose of tolvaptan resulted in similar symptoms and sodium correction. Due to continuing symptoms of hyponatremia including headaches, nausea, vomiting, and paresthesias after reinitiation of fluid restriction and salt tablets, tolvaptan was compounded to continue to titrate at lower doses. The patient was then admitted and tolvaptan was initiated at a dose of 1.5 mg with no significant improvement in sodium levels. Tolvaptan was titrated to 3 mg, which resulted in correction of sodium to 129 mEq/L with no associated symptoms of hypovolemia. CONCLUSIONS: Tolvaptan should be initiated in an inpatient setting with close monitoring of serum sodium levels. In patients who are not able to tolerate recommended dosages, consideration should be given to using a compounded formulation to further titrate to lower doses.

Significance of elevated parathyroid hormone after parathyroidectomy.

OBJECTIVE: To review the prevalence of parathyroid hormone elevation after parathyroidectomy for primary hyperparathyroidism and to discuss possible mechanisms. METHODS: A Medline search of the English-language literature published between 1990 and 2009 was performed using the search terms "elevated PTH after parathyroidectomy." All of the identified articles reported either prospective or retrospective studies without control groups. Studies that included patients with secondary or tertiary hyperparathyroidism were not reviewed. RESULTS: Within 1 week to 5 years after parathyroidectomy, 9% to 62% of patients with a normal serum calcium concentration are reported to have an elevated parathyroid hormone concentration. No evidence suggests that postoperative normocalcemic parathyroid hormone elevation is an indication of surgical failure and recurrent hypercalcemia. Preoperative findings in patients with postoperative parathyroid hormone elevation include lower vitamin D concentration, higher concentrations of bone turnover markers, and higher parathyroid hormone concentration. Potential mechanisms for parathyroid hormone elevation in the setting of normocalcemia include vitamin D deficiency, hungry bone syndrome, and parathyroid hormone resistance. Study findings suggest a possible benefit of postoperative calcium and vitamin D supplementation, but no randomized trials have been done. CONCLUSION: Elevation of parathyroid hormone commonly occurs after parathyroidectomy for primary hyperparathyroidism, although the underlying mechanism remains unclear.

Update on bazedoxifene: a novel selective estrogen receptor modulator.

In the elderly population, osteoporosis is a significant clinical problem leading to disability and even death. Many patients remain untreated, despite effective therapies, because of patients' unwillingness to take current therapies or inability to tolerate the therapies. For this reason, ongoing research continues to search for more effective and tolerable osteoporosis agents. Bazedoxifene is a selective estrogen receptor modulator (SERM) currently in development for osteoporosis prevention and treatment. A new drug application (NDA) for postmenopausal osteoporosis prevention was recently submitted to the FDA. Preclinical and clinical studies with bazedoxifene demonstrate more tissue selectivity than other SERMs. In particular, bazedoxifene has minimal if any agonist activity in the uterus and is able to antagonize effects of estrogen on the uterus. Animal studies and early clinical studies suggest effects in the bone similar to other SERMs with prevention of postmenopausal bone loss. Until more data on efficacy and safety are published, however, its role in osteoporosis is unknown.

Study of Selected Outcomes of Medical Students Who Fail USMLE Step 1.

PURPOSE: Passage of the United States Medical Licensing Exam (USMLE) is required to obtain a medical license in the United States. Currently the majority of US medical schools require passage of USMLE Step 1 for either promotion to the third year or graduation from medical school. Virginia Commonwealth University School of Medicine (VCUSOM) requires that students take the USMLE but does not require passing of USMLE Step 1 for promotion or graduation. This policy enabled the authors to analyze performance outcomes during clinical rotations and monitor the residency match for a group of students who failed USMLE Step 1 on the first attempt. METHODS: Third year clerkship grades and residency match results were reviewed for 64 students of the graduating classes of 1999-2005 who failed Step 1 on the first attempt. An equal number of students who passed Step 1 were randomly selected from each class as a comparison group. Average clinical performance ratings, NBME subject exam scores and final third year clerkship grades for the two groups were compared. Residency match rates and specialty certification were also compared. RESULTS: The USMLE Fail Group had more Pass and fewer Honors clerkship grades than the comparison group. Subject exam scores were significantly lower in the USMLE Fail Group in all clerkships. Clinical performance ratings were significantly lower in the Fail group in three out of six clerkships: Internal Medicine, Pediatrics, and Psychiatry. However, 82% of the USMLE Fail Group later passed USMLE Step 1 and 2. Fifty-nine of the 64 students in the USMLE Fail Group matched for a residency, whereas all of the students in the Pass Group matched for a residency. CONCLUSION: Students who fail USMLE Step 1 have lower final clerkship grades due in part to lower NBME subject exam scores. The majority of these students, however, successfully pass USMLE Step 1 prior to graduation, go on to graduate medical training, and become board certified in their specialty.

Novel therapies for osteoporosis.

Osteoporosis remains a significant clinical problem despite effective therapies. Many patients cannot or will not take currently available therapies. For this reason research continues in search of more effective and more tolerable agents. Anabolic agents offer a unique mechanism of action. The anabolic agents parathyroid hormone and strontium will be discussed. The investigational bisphosphonates ibandronate, minodronate and zoledronic acid may offer the advantage of less frequent dosing. Arzoxifene, bazedoxifene, lasofoxifene, MDL-103,323 and ospemifene are investigational selective oestrogen receptor modulators shown to be effective in animal studies and are now in clinical studies. Tibolone is a tissue-specific steroid that is currently used in Europe for prevention and treatment of osteoporosis. Multiple studies have shown efficacy in improving bone mineral density, but no fracture studies have been conducted to date. While studies of the effect of isoflavones on bone mineral density have been encouraging, a large, multi-centre study in Europe showed no effect of isoflavones on fractures. The newly described agent osteoprotegerin has been shown in early studies to inhibit bone turnover. Other agents with unique mechanisms of action in early development include cathepsin K inhibitors, integrin receptor inhibitors, nitrosylated non-steroidal anti-inflammatory agents and Src inhibitors. The efficacy of statins in bone continues to be debated with no prospective, randomised studies yet to confirm the suggestion of benefit seen in epidemiological studies.

Novel therapeutic options for osteoporosis.

Osteoporosis remains a significant clinical problem despite effective therapies. Many patients cannot or will not take currently available therapies. For this reason, research continues in search of more effective and more tolerable agents. Arzoxifene and TSE-424 are investigational selective estrogen receptor modulators that have been shown to be effective in animal studies and are now in clinical studies. Tibolone is a tissue-specific steroid that is currently used in Europe for the prevention and treatment of osteoporosis. Multiple studies have shown efficacy in improving bone mineral density, but no fracture studies have been conducted to date. Although studies of the effect of isoflavones on bone mineral density have been encouraging, a large multicenter study in Europe recently showed no effect of isoflavones on fractures. The investigational bisphosphonates ibandronate and zoledronic acid may offer the advantage of less frequent dosing. The newly described agent osteoprotegerin has been shown in early studies to inhibit bone turnover. Finally, the issue of efficacy of statins in bone continues to be debated with no prospective, randomized studies yet to confirm the suggestion of benefit seen in epidemiologic studies.

COPD and osteoporosis.

Osteoporosis, with resulting fractures, is a significant problem in patients with advanced COPD. The etiology for the bone loss is diverse but includes smoking, vitamin D deficiency, low body mass index, hypogonadism, sedentary lifestyle, and use of glucocorticoids. Effective strategies to prevent bone loss and/or to treat osteoporosis include calcium and vitamin D, hormone replacement when indicated, calcitonin, and bisphosphonate administration. However, many patients remain undiagnosed until their first fracture because of the lack of recognition of the disease. With an increased awareness by pulmonologists and the increased use of preventive strategies, the impact of osteoporosis on those patients with COPD should decrease.