An Early Evaluation of Remote Site Visits for ACGME Program Applications.

Background: Prior to the COVID-19 pandemic, accreditation site visit interviews occurred in-person. In response to the pandemic, the Accreditation Council for Graduate Medical Education (ACGME) developed a remote site visit protocol. Objective: To perform an early assessment of the remote accreditation site visits for programs applying for initial ACGME accreditation. Methods: A cohort of residency and fellowship programs that had remote site visits was evaluated from June to August 2020. Surveys were sent to program personnel, ACGME accreditation field representatives, and executive directors following the site visits. Comparison of accreditation decisions (Initial Accreditation or Accreditation Withheld) was completed for matched residency or fellowship programs having in-person site visits in 2019. Results: Surveys were sent to all program personnel from the 58 residency and fellowship programs that had remote site visits for new program applications, as well as the accreditation field representatives who performed the remote visits. The survey response rate was 58% (352 of 607). Ninety-one percent of all respondents were extremely or very confident that remote site visits provided a thorough assessment of proposed residency or fellowship programs. Fifty-four programs having remote site visits were matched by specialty to programs having had in-person program application site visits in 2019. Forty-six programs that had remote site visits received Initial Accreditation, and 52 programs that had in-person site visits in 2019 received Initial Accreditation (P=.093, 95% CI 0.91-22.38). Conclusions: Most program personnel and accreditation field representatives were confident that remote site visits conducted for program applications provided fair and thorough assessments of the program.

Reasons for Data-Prompted Site Visits: Field Staff Findings and Review Committee Decisions.

BACKGROUND: A major component of the ACGME's Next Accreditation System (NAS) is the annual review of key performance indicators by each review committee (RC) for all programs under its oversight. The RC may request a site visit that is data-prompted for either a full review of all common and specialty-specific program requirements or a focused review of specific concerns for programs identified as underperforming. OBJECTIVE: The aims of this study were to: (1) identify the reasons that RCs requested data-prompted site visits; (2) describe the findings by accreditation field representatives as reflected in their site visit reports; and (3) summarize the accreditation decisions of RCs that followed the data-prompted site visits (DPSVs). METHODS: RC letters to programs informing them of a DPSV, site visit reports, and RC letters with accreditation decisions were reviewed for all programs having DPSVs from 2015 to 2020. RESULTS: DPSVs were performed in 312 programs, including 59 hospital-based, 122 medical-based, and 131 surgery-based programs; 214 programs had a single DPSV, and 98 programs had repeat DPSV. The most frequent reason that RCs requested a DPSV was noncompliance on the annual ACGME Resident/Fellow Survey. Notification of a DPSV prompted a change in program director in 7% of programs in the single DPSVs group and 57% of programs in the repeat DPSVs group. Surgery-based programs in the single and repeat DPSVs groups were more likely to receive an unfavorable accreditation status. The majority of programs in the single DPSVs group (78%) and repeat DPSVs group (70%) had a status of continued accreditation as of March 2020. CONCLUSIONS: Noncompliance on the Resident/Fellow survey was the most frequent reason that RCs requested a DPSV. The majority of programs in the single and repeat DPSV groups achieved a favorable accreditation status.

Medical decision analysis: indications for tympanostomy tubes in RAOM by age at first episode.

OBJECTIVE: To compare utility estimates between tympanostomy tubes (TT) and short-courses of antibiotics in children with recurrent acute otitis media (RAOM) stratified by age at first episode. STUDY DESIGN AND SETTING: Formal decision analysis. RESULTS: The model recommended TT sooner in children with a history of a first episode of AOM occurring early in life. In children over 12 months old at onset, TT were recommended with seven episodes in 24 months, five episodes in 12 months, and three episodes in six months. In children under six months old at onset, TT were recommended with three episodes in 24 months and two episodes in a six-month or 12-month time span. CONCLUSIONS: Earlier TT may be indicated in children who developed a first episode of AOM at a very young age because of the higher risk of AOM recurrence. SIGNIFICANCE: This study is the first formal decision analysis to compare tympanostomy tubes and short-courses of antibiotics stratified by age at onset of the first AOM episode.

Risk acceptance in laryngeal transplantation.

PURPOSE: Advancements in the fields of head and neck surgery and immunology have paved the way for new quality of life-improving procedures such as larynx transplantation. To quantitatively assess the risks versus benefits in larynx transplantation, we used a questionnaire-based survey (Louisville Instrument For Transplantation [LIFT]) to measure the degree of risk individuals are willing to accept to receive different types of transplantation procedures. METHODS: The LIFT contains 237 standardized questions incorporating standard gamble and time tradeoff outcome measures as well as questions assessing body image perception, depression, self-esteem, optimism, socially desirable responding, and demographics. Respondents were questioned on the extent to which they would trade off specific numbers of life-years, or sustain other costs, in exchange for receiving seven different types of transplant procedures. For this study, we questioned 243 individuals in three study populations with differing life experiences: healthy individuals, organ transplant recipients, and laryngectomees. RESULTS: All populations questioned perceived risks differently based on their varied life experiences and would accept differing degrees of risk for the different transplant procedures. Organ transplant recipients were the most risk-tolerant group, whereas laryngectomees were the least risk-tolerant. CONCLUSIONS: By questioning individuals with life experiences directly relevant to the risks and benefits associated with larynx transplantation, this study provides an empiric basis for assessing risk versus benefit in this new quality of life-improving procedure.

Risk acceptance in composite-tissue allotransplantation reconstructive procedures.

Composite-tissue allotransplantation (CTA) is a new therapeutic modality to reconstruct major tissue defects of the face, larynx, and extremities. Unlike most life-saving organ-transplantation procedures, CTA is considered to improve quality of life. Therefore, the question arises, do the risks posed by the immunosuppression drugs that patients must take to prevent rejection justify the benefits of these procedures? The purpose of this study was to assess the relative risk that individuals are willing to accept in order to receive the benefits of CTA procedures. We used a psychometrically reliable and valid instrument to question two primary populations of individuals: those who live with the risks of immunosuppression, and healthy individuals. The level of risk acceptance for the seven transplant procedures tested (foot, single hand, double hand, larynx, kidney, hemiface, and full face) showed significant differences in research participants' risk acceptance for the different transplant procedures, but no significant differences between groups. Based on these findings, we conclude that certain CTA procedures convey benefits to recipients that are perceived by subjects, including individuals who live with the risks of immunosuppression, to warrant the risks of these procedures.

Program directors in surgery agree that residents should be formally trained in business and practice management.

BACKGROUND: Surgical residents typically receive limited exposure to business and practice management during their training. As a result, residents are ill-prepared for issues related to starting a practice, coding, collecting, and taking a meaningful role within the medical community in promoting quality and safety and in containing health care costs. With the introduction of the core competencies and the current overhaul of surgical education, we believe there is an opportunity to include business and practice management into resident training. METHODS: Program directors in general surgery (189 of 242) responded to a 9-question mailed survey inquiring about their opinions regarding training surgical residents in business and practice management. RESULTS: Most program directors agreed or strongly agreed (87%) that residents should be trained in business and practice management. Seventy percent believed that their current trainees were inadequately trained in this area. Over half (63%) believed that this training should begin during postgraduate years 2 to 5. CONCLUSIONS: Development of simple curricula aimed at preparing surgical residents for business and practice management could promote the contemporary education of surgeons.

SR147778 [5-(4-bromophenyl)-1-(2,4-dichlorophenyl)-4-ethyl-N-(1-piperidinyl)-1H-pyrazole-3-carboxamide], a new potent and selective antagonist of the CB1 cannabinoid receptor: biochemical and pharmacological characterization.

Based on binding, functional, and pharmacological data, this study introduces SR147778 [5-(4-bromophenyl)-1-(2,4-dichloro-phenyl)-4-ethyl-N-(1-piperidinyl)-1H-pyrazole-3-carboxamide] as a highly potent, selective, and orally active antagonist for the CB1 receptor. This compound displays nanomolar affinity (Ki = 0.56 and 3.5 nM) for both the rat brain and human CB1 recombinant receptors, respectively. It has low affinity (Ki = 400 nM) for both the rat spleen and human CB2 receptors. Furthermore, it shows no affinity for any of the over 100 targets investigated (IC50 > 1 microM). In vitro, SR147778 antagonizes the inhibitory effects of CP 55,940 [(1R,3R,4R)-3-[2-hydroxy-4-(1,1-dimethylheptyl)phenyl]-4-(3-hydroxypropyl)cyclohexan-1-ol] on both the mouse vas deferens contractions (pA2 value = 8.1) and on forskolin-stimulated adenylyl cyclase activity in the U373 MG cell lines (pA2 value = 8.2) but not in Chinese hamster ovary (CHO) cells permanently expressing the human peripheral cannabinoid receptor (hCB2). SR147778 is able to block the mitogen-activated protein kinase activity induced by CP 55,940 in the CHO cell line expressing human brain cannabinoid receptor (IC50 = 9.6 nM) but was inactive in cells expressing hCB2. After oral administration, SR147778 displaced the ex vivo [3H]-CP 55,940 binding to mouse brain membranes (ED50 = 3.8 mg/kg) with a long duration of action, whereas it did not interact with the CB2 receptor expressed in the mouse spleen. Using different routes of administration, SR147778 (0.3-3 mg/kg) is shown to antagonize pharmacological effects (hypothermia, analgesia, and gastrointestinal transit) induced by R-(+)-(2,3-dihydro-5-methyl-3-[[4-morpholinyl]methyl] pyrol [1,2,3-de]-1,4-benzoxazin-6-yl)(1-naphthalenyl) methanone in mice. Finally, per se, SR147778 (0.3-10 mg/kg) is able to reduce ethanol or sucrose consumption in mice and rats and food intake in fasted and nondeprived rats.

On the ethics of facial transplantation research.

Transplantation continues to push the frontiers of medicine into domains that summon forth troublesome ethical questions. Looming on the frontier today is human facial transplantation. We develop criteria that, we maintain, must be satisfied in order to ethically undertake this as-yet-untried transplant procedure. We draw on the criteria advanced by Dr. Francis Moore in the late 1980s for introducing innovative procedures in transplant surgery. In addition to these we also insist that human face transplantation must meet all the ethical requirements usually applied to health care research. We summarize the achievements of transplant surgery to date, focusing in particular on the safety and efficacy of immunosuppressive medications. We also emphasize the importance of risk/benefit assessments that take into account the physical, aesthetic, psychological, and social dimensions of facial disfiguration, reconstruction, and transplantation. Finally, we maintain that the time has come to move facial transplantation research into the clinical phase.