The Annual Institutional Review-Key Performance Measures and Processes.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires sponsoring institutions to demonstrate effective oversight through an annual institutional review (AIR). The ACGME only requires 3 elements to be reported, and it is up to the discretion of the designated institutional official (DIO) whether other supporting information should be included. This leads to uncertainty and inconsistency for DIOs as they decide what to report. OBJECTIVE: We surveyed DIOs in an effort to provide national data on key performance indicators and other relevant components of the AIR process. METHODS: In July 2019, we conducted a national survey of 847 DIOs. The survey had 16 questions that explored basic institutional demographics, timelines, and processes for the AIR and key performance indicators. Written answers were grouped by similar responses, and we performed descriptive statistics on all variables to assess distributions of responses. We also explored associations between variables using cross-tabulation and chi-square statistics. RESULTS: A total of 267 DIOs responded to the survey (32% response rate). There were 7 institutional performance measures that achieved over 50% consensus. These reviews required the majority of DIOs (62%, 167 of 267) 5 to 20 hours to complete. Less than one-third of sponsoring institutions reported diversity data. The majority of DIOs (68%, 182 of 267) felt the AIR process added substantial value. CONCLUSIONS: This survey reports key performance measures and processes included by DIOs in the AIR. Our results show a wide range of institutional responses though consensus was achieved on 7 key performance measures.

Introducing a Novel Applicant Ranking Tool to Predict Future Resident Performance: A Pilot Study.

The purposes of this study are to (1) introduce our novel Applicant Ranking Tool that aligns with the Accreditation Council for Graduate Medical Education competencies and (2) share our preliminary results comparing applicant rank to current performance. After a thorough literature review and multiple roundtable discussions, an Applicant Ranking Tool was created. Feasibility, satisfaction, and critiques were discussed via open feedback session. Inter-rater reliability was assessed using weighted kappa statistic (κ) and Kendall coefficient of concordance (W). Fisher's exact tests evaluated the ability of the tool to stratify performance into the top or bottom half of their class. Internal medicine and anesthesiology residents served as the pilot cohorts. The tool was considered user-friendly for both data input and analysis. Inter-rater reliability was strongest with intradisciplinary evaluation (W = 0.8-0.975). Resident performance was successfully stratified into those functioning in the upper vs. lower half of their class within the Clinical Anesthesia-3 grouping (p = 0.008). This novel Applicant Ranking Tool lends support for the use of both cognitive and noncognitive traits in predicting resident performance. While the ability of this instrument to accurately predict future resident performance will take years to answer, this pilot study suggests the instrument is worthy of ongoing investigation.

Myelodysplasia and Mast Cell Leukemia with t(9;22).

INTRODUCTION: Mast cell leukemia (MCL) is a rare variant of systemic mastocytosis. Most cases of mast cell leukemia do not have cytogenics performed. Furthermore, there is no consistent chromosomal abnormality identified in MCL. This is the first reported case of MCL with a (9;22) translocation. CASE REPORT: An 80-year-old female presented with pancytopenia and was diagnosed with MDS. Over time, she required hospitalizations for platelet transfusions with increased frequency. She developed fatigue and weakness along with gastrointestinal symptoms. On exam, she had diffuse abdominal tenderness and a maculopapular rash. Her lab results revealed a new basophilia. A bone marrow biopsy showed 100% cellularity with many aggregates of mast cells. Chromosomal analysis showed t(9;22) with confirmed BCR/ABL1 fusion by fluorescence in situ hybridization (FISH). DISCUSSION: MCL has a poor prognosis due to the aggressive nature of the disease and ineffective therapies. Translocation (9;22) is known to be associated with MDS transformations to acute leukemia; however, this translocation has never been reported in MCL. Further research on the relationship between t(9;22) and MCL could lead to development of improved therapeutic options.

Clinical indicators associated with HIV acquisition in the United States Air Force.

Mandatory HIV screening of United States Air Force (USAF) personnel every two years effectively identifies incident cases, however testing frequency limits the ability to detect early HIV infection. Identifying clinical indicators of HIV in the USAF population is necessary to develop a supplemental provider-based targeted testing strategy. We conducted a matched case-control study of male active duty USAF personnel with a new HIV diagnosis (n = 452) between 1996 and 2011 matched to five randomly selected controls (n = 2176). The relationship between clinical diagnoses, determined by ICD-9 codes, and HIV infection was assessed using conditional logistic regression. In unadjusted analyses of ICD-9 codes ever and within the last two years before HIV diagnosis, the conditional odds of HIV infection were greater in those with clinical signs and symptoms of HIV (cOR 5.05, 95% CI 4.00-6.39), mental health diagnoses (cOR 2.61, 95% CI 1.86-3.67), and STI diagnoses (cOR 2.33, 95% CI 1.50-3.60). Compared to those with ≤10 medical encounters in the two years prior to HIV diagnosis, individuals with 11-35 medical encounters (cOR 2.19, 95% CI 1.73-2.79) and >35 medical encounters (cOR 4.15, 95% CI 2.69-6.39) had a higher odds of HIV acquisition. In multivariate analyses, clinical signs and symptoms of HIV within the last two years of HIV diagnosis (cOR 4.10, 95% CI 3.22-5.22) and ever having a mental health diagnosis (cOR 1.97, 95% CI 1.44-2.70) remained significant (p < .01). Clinical encounters, particularly those featuring clinical signs and symptoms of HIV or a history of mental health complaints, provide an opportunity for targeted testing as a supplement to mandated testing at two-year intervals. Provider education to increase HIV testing in persons at risk would enhance early HIV diagnosis and potentially reduce forward transmission in the USAF population.

Nonalcoholic Steatohepatitis and Endpoints in Clinical Trials.

Nonalcoholic fatty liver disease (NAFLD) is now the leading cause of liver disease in developed countries, and the rates of NAFLD continue to rise in conjunction with the obesity pandemic. While the majority of patients with isolated steatosis generally have a benign course, a diagnosis of nonalcoholic steatohepatitis (NASH) carries a significantly higher risk for progression of disease, cirrhosis, and death. Pharmacologic therapeutic interventions in NASH have largely proven to be ineffective or unappealing due to long-term side-effect profiles, and the majority of patients cannot achieve or sustain targeted weight loss goals, necessitating an urgent need for therapeutic trials and drug development. The complex molecular mechanisms leading to NASH and the long duration of time to develop complications of disease are challenges to developing meaningful clinical endpoints. Because of these challenges, surrogate endpoints that are linked to all-cause mortality, liver-related death, and complications of cirrhosis are much more likely to be beneficial in the majority of patients.

Noninvasive imaging methods to determine severity of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.

Nonalcoholic fatty liver disease (NAFLD) is now the most common form of liver disease in developed countries, with an estimated prevalence of 20%-30% and increasing to as high as 90% in diabetics. As the rates of NAFLD continue to rise in parallel with those of the obesity pandemic, it is increasingly important to differentiate those patients with the highest risk of progression to fibrosis and cirrhosis. In fact, those patients with nonalcoholic steatohepatitis (NASH) and fibrosis are at the greatest risk of progression to advanced disease, cirrhosis, and hepatocellular cancer and are more likely to develop liver-related mortality. Thus, it is critically important to distinguish between NASH and non-NASH NAFLD. Whereas liver biopsy remains the gold standard for staging of disease, complications of this procedure and other well-recognized limitations make it impractical for widespread use given the overall NAFLD disease burden. Noninvasive imaging modalities are increasingly being utilized to evaluate and stage NAFLD in patients with such a wide spectrum of disease. In this article, the role of these new and promising noninvasive imaging modalities to assess disease severity in NAFLD are reviewed. (Hepatology 2016;64:2234-2243).

Effect of Weight Loss, Diet, Exercise, and Bariatric Surgery on Nonalcoholic Fatty Liver Disease.

Nonalcoholic fatty liver disease (NAFLD) is the hepatic manifestation of the metabolic syndrome. NAFLD is the most common liver disease in developed countries. Weight reduction of 3% to 5% is associated with improved steatosis; reductions of 5% to 7% are necessary for decreased inflammation; with 7% to 10%, individuals may experience NAFLD/NASH remission and regression of fibrosis. No specific dietary intervention has proven beneficial beyond calorie restriction. Physical activity without weight loss seems to decrease hepatic steatosis. Bariatric surgery is associated with decreased cardiovascular risk and improved overall mortality in addition to reduction in hepatic steatosis, inflammation, and fibrosis.

Lifestyle and Dietary Interventions in the Management of Nonalcoholic Fatty Liver Disease.

NAFLD is the leading cause of chronic liver disease in the Western world with an estimated prevalence of 20-30 %. Lifestyle interventions targeted at weight loss through dietary interventions and exercise are the most effective treatment, but only a minority of patients are able to achieve and sustain the necessary intervention targets. Weight loss of 3-5 % has been associated with a reduction of hepatic steatosis while weight loss of ≥5-7 % has correlated with resolution of NASH in some studies. Greater reductions in weight loss (≥10 %) may improve hepatic fibrosis. In the absence of weight loss, no specific diet has demonstrated superiority. Physical activity can improve hepatic steatosis and metabolic indices even without weight loss. Diet coupled with exercise can produce significant weight loss and may improve histologic components of the NAFLD activity score. While formal guidelines for diet and exercise in NAFLD are lacking, adherence to diet and exercise recommendations similar to those from the American Diabetes Association for diabetic care seems reasonable. Dietary supplementation with vitamin E in non-diabetics with biopsy-proven NASH has been shown to improve NAFLD activity score. The role for other macronutrients, micronutrients, antioxidants, and probiotics in the treatment of NAFLD remains limited.

Pulmonary Microscopic Polyangiitis Presenting as Acute Respiratory Failure from Diffuse Alveolar Hemorrhage.

Microscopic polyangiitis and granulomatosis with polyangiitis are rare anti-neutrophilic cytoplasmic antibody-associated systemic vasculitides that predominantly affect small to medium sized vessels of the lungs and kidneys. These syndromes are largely confined to older adults and often present sub-acutely following weeks to months of nonspecific prodromal symptoms. While both diseases often manifest within multiple organ systems concurrently, the disease spectrum of microscopic polyangiitis almost always includes the kidneys, while granulomatosis with polyangiitis is most commonly associated with pulmonary disease. We present two cases of rapid onset respiratory failure secondary to diffuse alveolar hemorrhage in young active duty military personnel. After serological testing and surgical lung biopsy, both patients were diagnosed with microscopic polyangiitis with isolated pulmonary involvement.

Challenge of surrogate endpoints.

Surrogate endpoints are biomarkers that are intended to substitute for clinical endpoints. They have been used to find novel therapeutic targets, improve the statistical power and shorten the duration of clinical trials, and control the cost of conducting research studies. The more generalized use of surrogate endpoints in clinical decision making can be hazardous and should be undertaken with great caution. This article reviews prior work with surrogate endpoints and highlights caveats and lessons learned from studies using surrogate endpoints.