Development and evaluation of a pre-clerkship spiral curriculum: data from three medical school classes.

Pre-clerkship curricula of most Liaison Committee on Medical Education (LCME)-accredited medical schools are divided into blocks by organ system, leaving a significant amount of information susceptible to loss due to prolonged nonuse. We describe the implementation of a formal Spiral Curriculum that periodically revisits material from previous blocks. Learners were surveyed on receptivity to the curriculum across three graduating classes at a single medical school. Medical school graduate classes of 2020, 2021, and 2022 were surveyed at the end of their pre-clerkship years (2018-2020). The class of 2022 actually received the Spiraled Curriculum intervention, for which the authors created 500 board exam style multiple-choice questions, periodically administered via mandatory in-class sessions ranging from 10 to 20 questions reviewing content from previous blocks with designated expert faculty. Response rates were 36% (n = 46), 45% (n = 52), and 32% (n = 40) for classes of 2020, 2021, and 2022, respectively. On a Likert scale (1 = strongly disagree, 5 = neutral, 10 = strongly agree), the classes of 2020, 2021, and 2022 provided statistically significant differences in their belief that a Spiraled Curriculum would/did help them retain information as 8.2 (SD 1.7), 8.2 (SD 2.2), and 5.0 (SD 3.0) (n < 0.05). All classes endorsed neutral confidence in the existing pre-clerkship curriculum in themselves to prepare for United Stated Medical Licensing Examination (USMLE) Step 1, and in their retention of previous block material with no statistically significant differences between classes. USMLE Step 1 scores did not differ significantly between classes (n = 0.21). Those who did not receive the Spiral Curriculum were highly receptive to it in theory, while those who actually received the intervention gave a neutral rating. Per survey comments, implementation of a Spiraling Curriculum would ideally be administered as either team-based or self-directed activities, and a Spiraling Curriculum may be difficult to implement in accelerated (18 month) pre-clerkship formats.Practice points Question: What is the receptivity of medical students to a formal Spiral curriculum that uses time-spaced repetition sessions of board exam style questions to revisit previous block content of their pre-clerkship years?Findings: In this single-center, quasi-experimental study, the two control group medical school classes had very positive theoretical reception to a Spiral curriculum proposal (rated 8 out of 10) while the class who actually received the Spiral curriculum provided a statistically significant lower neutral rating (rated 5 out of 10), citing preference for a team-based or self-directed format.Meaning: Medical students are strongly in favor of structured time-spaced repetition with board exam style questions to revisit previous material but prefer a format that does not interfere with time to personalize their medical school experience.

Parsimonious machine learning models to predict resource use in cardiac surgery across a statewide collaborative.

Objective: We sought to several develop parsimonious machine learning models to predict resource utilization and clinical outcomes following cardiac operations using only preoperative factors. Methods: All patients undergoing coronary artery bypass grafting and/or valve operations were identified in the 2015-2021 University of California Cardiac Surgery Consortium repository. The primary end point of the study was length of stay (LOS). Secondary endpoints included 30-day mortality, acute kidney injury, reoperation, postoperative blood transfusion and duration of intensive care unit admission (ICU LOS). Linear regression, gradient boosted machines, random forest, extreme gradient boosting predictive models were developed. The coefficient of determination and area under the receiver operating characteristic (AUC) were used to compare models. Important predictors of increased resource use were identified using SHapley summary plots. Results: Compared with all other modeling strategies, gradient boosted machines demonstrated the greatest performance in the prediction of LOS (coefficient of determination, 0.42), ICU LOS (coefficient of determination, 0.23) and 30-day mortality (AUC, 0.69). Advancing age, reduced hematocrit, and multiple-valve procedures were associated with increased LOS and ICU LOS. Furthermore, the gradient boosted machine model best predicted acute kidney injury (AUC, 0.76), whereas random forest exhibited greatest discrimination in the prediction of postoperative transfusion (AUC, 0.73). We observed no difference in performance between modeling strategies for reoperation (AUC, 0.80). Conclusions: Our findings affirm the utility of machine learning in the estimation of resource use and clinical outcomes following cardiac operations. We identified several risk factors associated with increased resource use, which may be used to guide case scheduling in times of limited hospital capacity.

The Extra Mile: Special Consideration of Atrial Fibrillation in Older Adults with Endurance Athletic History.

BACKGROUND Aerobic exercise is uniformly accepted as one of the most important modifiable factors to improve cardiovascular health, but endurance athletic training poses a significant risk factor for development of atrial fibrillation (AFib) in middle-aged and older adults. Ubiquitous risk assessment tools (CHADS2 and CHA2DS2-VASc) and US Preventive Services Task Force guidelines do not presently account for this association. A case is presented which illustrates a dire outcome of undiagnosed AFib in an elderly male patient who had run many marathons. CASE REPORT An 80-year-old male with well-controlled hypertension and hypercholesterolemia and a history significant for running many marathons throughout his life was brought in via ambulance after being found down with head trauma by his wife at home. A short run of AFib was recorded on telemetry and electrocardiogram (ECG) and a review of previous ECGs revealed evidence of interatrial block (Bayes Syndrome), though the patient had no history of AFib or anticoagulation. This coupled with imaging indicated thromboembolic stroke to the left middle cerebral artery leading to right-sided hemiplegia and a subsequent fall to the right, causing right-sided head trauma and intracranial hemorrhage. His clinical course did not improve, and on his fifth day of admission he was transferred to comfort care, extubated, and succumbed to his injuries. CONCLUSIONS This case and the accompanying summary of evidence strongly encourage further investigation and a higher index of suspicion for AFib in asymptomatic older adults with a history of endurance athletic training.

A Practical Two-Stage Frailty Assessment for Older Adults Undergoing Aortic Valve Replacement.

OBJECTIVES: Despite evidence, frailty is not routinely assessed before cardiac surgery. We compared five brief frailty tests for predicting poor outcomes after aortic valve replacement and evaluated a strategy of performing comprehensive geriatric assessment (CGA) in screen-positive patients. DESIGN: Prospective cohort study. SETTING: A single academic center. PARTICIPANTS: Patients undergoing surgical aortic valve replacement (SAVR) (n = 91; mean age = 77.8 y) or transcatheter aortic valve replacement (TAVR) (n = 137; mean age = 84.5 y) from February 2014 to June 2017. MEASUREMENTS: Brief frailty tests (Fatigue, Resistance, Ambulation, Illness, and Loss of weight [FRAIL] scale; Clinical Frailty Scale; grip strength; gait speed; and chair rise) and a deficit-accumulation frailty index based on CGA (CGA-FI) were measured at baseline. A composite of death or functional decline and severe symptoms at 6 months was assessed. RESULTS: The outcome occurred in 8.8% (n = 8) after SAVR and 24.8% (n = 34) after TAVR. The chair rise test showed the highest discrimination in the SAVR (C statistic = .76) and TAVR cohorts (C statistic = .63). When the chair rise test was chosen as a screening test (≥17 s for SAVR and ≥23 s for TAVR), the incidence of outcome for screen-negative patients, screen-positive patients with CGA-FI of .34 or lower, and screen-positive patients with CGA-FI higher than .34 were 1.9% (n = 1/54), 5.3% (n = 1/19), and 33.3% (n = 6/18) after SAVR, respectively, and 15.0% (n = 9/60), 14.3% (n = 3/21), and 38.3% (n = 22/56) after TAVR, respectively. Compared with routinely performing CGA, targeting CGA to screen-positive patients would result in 54 fewer CGAs, without compromising sensitivity (routine vs targeted: .75 vs .75; P = 1.00) and specificity (.84 vs .86; P = 1.00) in the SAVR cohort; and 60 fewer CGAs with lower sensitivity (.82 vs.65; P = .03) and higher specificity (.50 vs .67; P < .01) in the TAVR cohort. CONCLUSIONS: The chair rise test with targeted CGA may be a practical strategy to identify older patients at high risk for mortality and poor recovery after SAVR and TAVR in whom individualized care management should be considered. J Am Geriatr Soc 67:2031-2037, 2019.

Nrf2 at the heart of oxidative stress and cardiac protection.

The NFE2L2 gene encodes the transcription factor Nrf2 best known for regulating the expression of antioxidant and detoxification genes. Gene knockout approaches have demonstrated its universal cytoprotective features. While Nrf2 has been the topic of intensive research in cancer biology since its discovery in 1994, understanding the role of Nrf2 in cardiovascular disease has just begun. The literature concerning Nrf2 in experimental models of atherosclerosis, ischemia, reperfusion, cardiac hypertrophy, heart failure, and diabetes supports its cardiac protective character. In addition to antioxidant and detoxification genes, Nrf2 has been found to regulate genes participating in cell signaling, transcription, anabolic metabolism, autophagy, cell proliferation, extracellular matrix remodeling, and organ development, suggesting that Nrf2 governs damage resistance as well as wound repair and tissue remodeling. A long list of small molecules, most derived from natural products, have been characterized as Nrf2 inducers. These compounds disrupt Keap1-mediated Nrf2 ubquitination, thereby prohibiting proteasomal degradation and allowing Nrf2 protein to accumulate and translocate to the nucleus, where Nrf2 interacts with sMaf to bind to ARE in the promoter of genes. Recently alternative mechanisms driving Nrf2 protein increase have been revealed, including removal of Keap1 by autophagy due to p62/SQSTM1 binding, inhibition of ßTrCP or Synoviolin/Hrd1-mediated ubiquitination of Nrf2, and de novo Nrf2 protein translation. We review here a large volume of literature reporting historical and recent discoveries about the function and regulation of Nrf2 gene. Multiple lines of evidence presented here support the potential of dialing up the Nrf2 pathway for cardiac protection in the clinic.

Protective role of clusterin in preserving endothelial function in AL amyloidosis.

UNLABELLED: Misfolded immunoglobulin light chain proteins (LC) in light chain amyloidosis (AL) are toxic to vascular tissues. We tested the hypothesis that chaperone protein clusterin preserves endothelial function and cell survival during LC exposure. METHODS: LC (20 µg/mL) were given to human aortic endothelial cells (EC) for 24-h and clusterin protein/gene expression and secretion were measured. DNA fragmentation was measured with/without recombinant clusterin (Clu, 300 ng/mL). Adipose arterioles (non-AL subjects) were tested for dilator responses to acetylcholine/papaverine at baseline and after 1-h of LC ± Clu. RESULTS: LC reduced EC clusterin secretion, protein and gene expression while increasing DNA fragmentation. Clu attenuated LC-induced DNA fragmentation and restored dilator response to acetylcholine (logEC50: control -7.05 ± 0.2, LC + Clu -6.53 ± 0.4, LC -4.28 ± 0.7, p < 0.05 versus control, LC + Clu). CONCLUSIONS: LC induced endothelial cell death and dysfunction while reducing clusterin protein/gene expression and secretion. Exogenous clusterin attenuated LC toxicity. This represents a new pathobiologic mechanism and therapeutic target for AL amyloidosis.