Standardized residency training in China: the new internal medicine curriculum

China formally established a system of national standardized medical residency training in 2014, which affects the health of its 1.4 billion people. Accompanying this system were new guidelines and standards for internal medicine residency training. However, the majority of the standards focused on process measurements, such as minimum case requirements of diseases and procedural skills, rather than describing broader physician competencies in the domains of professionalism, patient care, communication, teamwork, quality improvement, and scholarship. While China has taken a large step forward with standardization of certain aspects of internal medicine residency training, the next step should focus on outcome measures and creating a system that is competency-based.

Abuse in the workplace: experience of specialist registrars

Aims and Method

A survey was conducted to determine the experience of verbal and physical abuse among specialist registrars and the availability of training on managing abusive patients. A self-report questionnaire was sent to all specialist registrars working in the Northern Deanery.

Results

Completed surveys were received from 30 out of the 49 trainees (61% response rate). Twenty-three respondents (77%) reported being abused; all reported verbal abuse and 2 (9%) reported physical abuse. The experience of trainees of abuse differed between White doctors and those from other ethnic groups. The majority of trainees had received no training to deal with abuse.

Clinical Implications

In view of the high prevalence of abuse experienced by trainees, interventions to prevent both verbal and physical abuse should be identified. There should also be formal support for managing abuse and improved recording of abusive incidents.

Effect of the Factor V Leiden Mutation on the Clinical Expression of Severe Hemophilia A

To determine whether the factor V Leiden mutation is associated with decreased bleeding in individuals with severe hemophilia A, factor concentrate utilization, maximum annual number of bleeding episodes, and the prevalence of hemophilic arthropathy between carriers and non-carriers of the factor V Leiden mutation were compared. Heterozygosity for the factor V Leiden mutation was found in 6 of 137 subjects (4.4%). Carriers of the factor V Leiden mutation utilized less factor concentrate (geometric mean: 310 vs. 1185 units/kg/year) and had fewer bleeding episodes than non-carriers (proportion with 10 or fewer bleeding episodes in their worst year: 50 vs. 11%). However, the factor V Leiden mutation was not associated with the absence of arthropathy. The intron 22 inversion mutation of the factor VIII gene was tested for in a subgroup of 80 subjects, but it was not found to be a significant variable for any of the bleeding endpoints. The results of this small study are consistent with the hypothesis that the factor V Leiden mutation imparts a protective effect; however, a larger confirmatory study in which the factor VIII molecular defects can be controlled for is needed. Furthermore, most severe hemophiliacs who used fewer than 200 units/kg/year of factor concentrate or who had experienced 10 or fewer bleeding episodes per year did not carry the factor V Leiden mutation, suggesting that the proportion of severe hemophiliacs whose mild clinical course can be attributed to the factor V Leiden mutation is small.

The rise and potential fall of pancreas transplantation

BACKGROUND

The aim of this review is to bring pancreatic transplantation out of the specialist realm, informing practitioners about this important procedure, so that they feel better equipped to refer suitable patients for transplantation and manage, counsel and support when encountering them within their own speciality.

SOURCES OF DATA

Narrative review conducted in May 2017. OVID interface searching EMBASE and MEDLINE databases, using Timeframe: Inception to June 1, 2017. Articles were assessed for clinical relevance and most up to date content with articles written in english as the only inclusion criteria. Other sources, used included conference proceedings/presentations, unpublished data from our institution (Oxford Transplant Centre).

AREAS OF AGREEMENT

Pancreas transplantation has evolved from an experimental procedure to the gold standard of care for patients with type 1 diabetes and uraemia. Currently, it remains the most effective method of establishing and maintaining euglycemia over the longer term, halting and potentially reversing many of the secondary complications associated with diabetes. Significant improvements to quality of life and better life expectancy make it in the longer term, a lifesaving procedure compared to waiting candidates.

AREAS OF CONTROVERSY

The future of solid organ pancreas transplantation remains uncertain, with extensive comorbidity and advances in alternative therapies makes the long-term growth of the procedure questionable.

GROWING POINTS AND AREAS TIMELY FOR DEVELOPING RESEARCH

Therapies to alleviate problems associated with ischaemia reperfusion injury, graft pancreatitis and more effective monitoring methods for detecting and treating organ rejection are the key areas of growth.

Splenic artery pseudoaneurysm causing delayed gastrointestinal bleeding after gastrocolonic fistula following sleeve gastrectomy

Delayed gastrointestinal bleeding in the context of a gastric fistula is a very rare complication of longitudinal sleeve gastrectomy. We report the case of a patient who presented with massive gastrointestinal bleeding from a pseudoaneurysm arising from the splenic artery following complications after a longitudinal sleeve gastrectomy several months previously. The case was successfully managed with angiographic embolisation and we present our experience with recommendations for managing this rare but life-threatening complication.

How do clinical competency committees use different sources of data to assess residents' performance on the internal medicine milestones?A mixed methods pilot study

PURPOSE

This study examines how Clinical Competency Committees (CCCs) synthesize assessment data to make judgments about residents' clinical performances.

METHODS

Between 2014 and 2015, after four six-month reporting periods to the Accreditation Council for Graduate Medical Education (ACGME), 7 of 16 CCC faculty at Rush University Medical Center completed questionnaires focused on their perspectives about rating residents on their achievement of the milestones and participated in a focus group. Qualitative data were analyzed using grounded theory. Milestones ratings for two six-month ACGME reporting cycles (n = 100 categorical residents) were also analyzed.

RESULTS

CCC members weighted resident rotation ratings highest (weight = 37%), followed by faculty rotation comments (weight = 27%) and personal experience with residents (weight = 14%) for making judgments about learner's milestone levels. Three assessment issues were identified from qualitative analyses: (1) "design issues" (e.g. problems with available data or lack thereof); (2) "synthesis issues" (e.g. factors influencing ratings and decision-making processes) and (3) "impact issues" (e.g. how CCC generated milestones ratings are used).

CONCLUSIONS

Identifying factors that affect assessment at all stages of the CCC process can contribute to improving assessment systems, including support for faculty development for CCCs. Recognizing challenges in synthesizing first and second-hand assessment data is an important step in understanding the CCC decision-making process.

Abstract P1-05-01: Landscape of somatic mutations in inflammatory breast cancer whole-genome sequences

Goal: Inflammatory breast cancer (IBC) is a rare, aggressive form of breast cancer that is characterized by a highly metastatic phenotype. Numerous previous attempts failed to identify, recurrent, IBC-specific gene expression or DNA copy number alterations. We performed whole genome sequencing (WGS) of IBC biopsies obtained before any therapy to define a comprehensive genomic landscape of this disease.

Methods: Illumina paired-end whole genome sequencing (WGS) of 20 IBC (n=9 ER+, n=11 ER-) and matched normal samples were performed with median coverage of 60X and 40X for cancer and normal, the percentages of mapped reads were 99.3% and 99.2%, respectively. We identified germ-line and somatic variants, indels as well as large scale structural variants, using GATK Haplotype Caller, MuTect and CREST, respectively. We performed the same analysis on WGS data from 23, age, race and ER and HER2 matched, non-IBC (n=12 ER+, n=11 ER-) from the TCGA for comparison. Variants in both coding and noncoding sequences were categorized by FunSeq to identify potential drivers. Mutation clustering in each gene, as well as significantly mutated non-coding regulatory modules, were identified using LARVA. DeconstructSigs were used to decompose the mutational spectrum of each cancer into 30 validated, mutational signatures provided by COSMIC. Contributions of each validated signature to mutations in IBC vs. non-IBC were compared using Welch's t-test.

Results: We identified 118,818 somatic variants in the IBC samples (median: 3,856; minimum: 1,109; maximum: 24,815) including 1,060 variants (~0.9%) in coding regions. 5,287 somatic indels and 5,959 large scale structural variants were detected including 1,028 insertions and 1,857 deletions. Recurrent, non-synonymous mutations were detected in the coding region of GRIN2A gene in 3/20 IBC samples (15%), (previously reported as a potential driver mutation in 1.7% of breast cancers). Other significant mutations in coding regions included GRHL1, PIK3R2, ESR1, FLG2 and etc. Three DNase I hypersensitive sites (DHSs) in non-coding regions were altered in 20% (4/20) IBC samples vs. fewer than 8.7% (2/23) in non-IBC. Mutational frequency of GATA3 is 80.0% vs. 47.8% (p=0.03), and PTEN is 45.0% vs. 73.9% (p=0.05), in IBC vs. non-IBC samples when including both coding and non-coding variants. Contributions of mutational signature 9, that is associated with polymerase η , were significantly higher in IBC cohort than non-IBC cohort (p-value=0.056).

Conclusion: This is the first whole genome sequencing analysis of IBC and comparison with the results from non-IBC. We identified promising candidate drivers in the coding sequence and in non-coding regulatory modules of expressed genes. We also identified mutational signature 9, and mutations in several DHS as significantly more frequent alterations in IBC compared to non-IBC.

Citation Format: Li X, Krishnamurthy S, Kumar S, Reddy S, Woodward W, Reuben J, Hatzis C, Ueno NT, Gerstein M, Pusztai L. Landscape of somatic mutations in inflammatory breast cancer whole-genome sequences [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-05-01.

Revisiting the Rationing of Medical Degrees in the United States

Degree rationing is good for U.S. med school graduates, even as it exacerbates physician shortages.