Role of the San1 ubiquitin ligase in the heat stress-induced degradation of nonnative Nup1 in the nuclear pore complex

The nuclear pore complex (NPC) mediates the selective exchange of macromolecules between the nucleus and the cytoplasm. Neurodegenerative diseases such as amyotrophic lateral sclerosis are characterized by mislocalization of nucleoporins (Nups), transport receptors, and Ras-related nuclear proteins into nucleoplasmic or cytosolic aggregates, underscoring the importance of precise assembly of the NPC. The assembly state of large protein complexes is strictly monitored by the protein quality control system. The ubiquitin-proteasome system may eliminate aberrant, misfolded, and/or orphan components; however, the involvement of the ubiquitin-proteasome system in the degradation of nonnative Nups in the NPC remains unclear. Here, we show that in Saccharomyces cerevisiae, although Nup1 (the FG-Nup component of the central core of the NPC) was stable, C-terminally green fluorescent protein-tagged Nup1, which had been incorporated into the NPC, was degraded by the proteasome especially under heat stress conditions. The degradation was dependent on the San1 ubiquitin ligase and Cdc48/p97, as well as its cofactor Doa1. We also demonstrate that San1 weakly but certainly contributes to the degradation of nontagged endogenous Nup1 in cells defective in NPC biogenesis by the deletion of NUP120. In addition, the overexpression of SAN1 exacerbated the growth defect phenotype of nup120Δ cells, which may be caused by excess degradation of defective Nups due to the deletion of NUP120. These biochemical and genetic data suggest that San1 is involved in the degradation of nonnative Nups generated by genetic mutation or when NPC biogenesis is impaired.

Systems-Based Practice 20 Years On: Navigating the System for Better Care

ABSTRACT

Systems-based practice (SBP) was introduced as 1 of 6 core competencies in 1999 because of its recognized importance in the quality and safety of health care provided to patients. Nearly 25 years later, faculty and learners continue to struggle with understanding and implementing this essential competency, thus hindering the medical education community's ability to most effectively teach and learn this important competency.Milestones were first introduced in 2013 as one effort to support implementation of the general competencies. However, each specialty developed its milestones independently, leading to substantial heterogeneity in the narrative descriptions of competencies including SBP. The process to create Milestones 2.0, and more specifically, the Harmonized Milestones, took this experience into account and endeavored to create a shared language for SBP across all specialties and subspecialties. The 3 subcompetencies in SBP are now patient safety and quality improvement, systems navigation for patient-centered care (coordination of care, transitions of care, local population health), and physician's role in health care systems (components of the system, costs and resources, transitions to practice). Milestones 2.0 are also now supported by new supplemental guides that provide specific real-world examples to help learners and faculty put SBP into the context of the complex health care environment.While substantially more resources and tools are now available to aid faculty and to serve as a guide for residents and fellows, much work to effectively implement SBP remains. This commentary will explore the evolutionary history of SBP, the challenges facing implementation, and suggestions for how programs can use the new milestone resources for SBP. The academic medicine community must work together to advance this competency as an essential part of professional development.

Accreditation Council for Graduate Medical Education Milestone Training Ratings and Surgeons' Early Outcomes

Importance

National data on the development of competence during training have been reported using the Accreditation Council for Graduate Medical Education (ACGME) Milestones system. It is now possible to consider longitudinal analyses that link Milestone ratings during training to patient outcomes data of recent graduates.

Objective

To evaluate the association of in-training ACGME Milestone ratings in a surgical specialty with subsequent complication rates following a commonly performed operation, endovascular aortic aneurysm repair (EVAR).

Design, Setting, and Participants

This study of patient outcomes followed EVAR in the Vascular Quality Initiative (VQI) registry (4213 admissions from 208 hospitals treated by 327 surgeons). All surgeons included in this study graduated from ACGME-accredited training programs from 2015 through 2019 and had Milestone ratings 6 months prior to graduation. Data were analyzed from December 1, 2021, through September 15, 2023. Because Milestone ratings can vary with program, they were corrected for program effect using a deviation score from the program mean.

Exposure

Milestone ratings assigned to individual trainees 6 months prior to graduation, based on judgments of surgical competence.

Main Outcomes and Measures

Surgical complications following EVAR for patients treated by recent graduates during the index hospitalization, obtained using the nationwide Society for Vascular Surgery Patient Safety Organization's VQI registry, which includes 929 participating centers in 49 US states.

Results

The study included outcomes for 4213 patients (mean [SD] age, 73.25 [8.74] years; 3379 male participants [80.2%]). Postoperative complications included 9.5% major (400 of 4213 cases) and 30.2% minor (1274 of 4213 cases) complications. After adjusting for patient risk factors and site of training, a significant association was identified between individual Milestone ratings of surgical trainees and major complications in early surgical practice in programs with lower mean Milestone ratings (odds ratio, 0.50; 95% CI; 0.27-0.95).

Conclusions and Relevance

In this study, Milestone assessments of surgical trainees were associated with subsequent clinical outcomes in their early career. Although these findings represent one surgical specialty, they suggest Milestone ratings can be used in any specialty to identify trainees at risk for future adverse patient outcomes when applying the same theory and methodology. Milestones data should inform data-driven educational interventions and trainee remediation to optimize future patient outcomes.

Supersaturation dependent nucleation of methane + propane mixed-gas hydrate

Before hydrates can be widely used in industry, we should better understand the problematic issues of hydrate nucleation, particularly its stochastic nature. Here, we report on measurements of the nucleation probability of mixed-gas hydrates in which the guest molecules are a mixture of methane and propane. For the pure cases, at a supersaturation near 1.0, we had previously measured an induction time for the methane hydrate of about 1 h, whereas for the propane hydrate, it was over one day. Using the same experimental setup, we examine here the nucleation probability for a mixture of 90% methane and 10% propane as the guest gas for a range of supersaturations. For the experiments, the temperature was 274 ± 0.5 K and the stirring rate was about 300 rpm. The experiments were repeated at least ten times under the same condition, exchanging the sample water every time. We define the nucleation probability at a given time as the fraction of trials that nucleated by that time and then determine the nucleation probability distribution. The resulting nucleation frequency is found to have a power-law relation to supersaturation. Then, we examine how the nucleation frequency is affected by the existence of ultrafine bubbles in the initial water. We find that the ultrafine bubbles increase the nucleation frequency but much less than that of typical changes in supersaturation.

Detailed tracking of antigen and antibody levels during coronavirus disease 2019 treatment in an immunosuppressed patient with anti-neutrophil cytoplasmic autoantibody-associated vasculitis

A 67-year-old woman with anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis was not vaccinated against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and was on multiple immunosuppressive drugs. She was hospitalized because of interstitial shadowing in the lungs and diagnosed with persistent coronavirus disease 2019 (COVID-19). Despite treatment with a recombinant monoclonal antibody and antivirals, her symptoms persisted and she lacked a specific antibody response. She tested negative for SARS-CoV-2 antigen after the second antiviral treatment, and a subsequent chest radiograph showed improvement. However, the antibody levels did not change. This case highlights the importance of careful monitoring of the SARS-CoV-2 antigen and antibody levels during COVID-19 treatment in patients with immunosuppression.

The Association of Subspecialty and Sex with Industry Payments to Internal Medicine Physicians Who Recently Completed Training

BACKGROUND

Financial relationships with drug and medical device companies may impact quality of care and academic research. However, little is known when and how these financial relationships develop among newly independent physicians who recently completed from residency or fellowship programs in internal medicine (IM).

OBJECTIVE

To compare patterns of industry payments among IM graduates.

DESIGN

Retrospective, observational cohort study.

SUBJECTS

IM graduates from residency or fellowship programs between January 2015 and December 2019.

MAIN MEASURES

We analyzed Open Payments reports made between July 2015 and June 2021 to recent graduates of U.S. Accreditation Council for Graduate Medical Education (ACGME)-accredited residency and fellowship programs in IM. The primary outcome was general payments accepted by these physicians, stratified by procedural (i.e., critical care medicine/pulmonary medicine, cardiac/cardiovascular disease, and gastroenterology) and non-procedural (i.e., infectious disease, general internal medicine, and other specialties) subspecialties. The secondary outcomes included general payments stratified by sex and age at residency or fellowship training completion.

KEY RESULTS

There were 41,669 IM physicians with a median age of 33.0 years. In the first 3 years after completion, the proportion of physicians accepting any general payments was 72.6%, 91.9%, and 86.8% in Critical Care Medicine/Pulmonary Medicine, Cardiac/Cardiovascular Disease, and Gastroenterology, compared to 56.1%, 52.6%, and 52.3% in Infectious Disease, General Internal Medicine, and Other Specialties (p<0.0001). After adjusting for confounding variables, the procedural group showed an increased hazard ratio (HR) for accepting any general payments and at least $5000 of general payments compared to the non-procedural group. The HRs of accepting any general payments in the procedural subspecialty were 2.26 (95% CI, 2.11-2.42) and 2.83 (95% CI, 2.70-2.97) in female and male physicians, respectively (p-value < 0.0001).

CONCLUSION

Industry financial relationships among newly independent physicians in IM exist immediately after completion of training and are influenced by subspecialty, sex, and age.

The Association of ACGME Milestones With Performance on American Board of Surgery Assessments: A National Investigation of Surgical Trainees

OBJECTIVE

To determine the relationship between, and predictive utility of, milestone ratings and subsequent American Board of Surgery (ABS) vascular surgery in-training examination (VSITE), vascular qualifying examination (VQE), and vascular certifying examination (VCE) performance in a national cohort of vascular surgery trainees.

BACKGROUND

Specialty board certification is an important indicator of physician competence. However, predicting future board certification examination performance during training continues to be challenging.

METHODS

This is a national longitudinal cohort study examining relational and predictive associations between Accreditation Council for Graduate Medical Education (ACGME) Milestone ratings and performance on VSITE, VQE, and VCE for all vascular surgery trainees from 2015 to 2021. Predictive associations between milestone ratings and VSITE were conducted using cross-classified random-effects regression. Cross-classified random-effects logistic regression was used to identify predictive associations between milestone ratings and VQE and VCE.

RESULTS

Milestone ratings were obtained for all residents and fellows(n=1,118) from 164 programs during the study period (from July 2015 to June 2021), including 145,959 total trainee assessments. Medical knowledge (MK) and patient care (PC) milestone ratings were strongly predictive of VSITE performance across all postgraduate years (PGYs) of training, with MK ratings demonstrating a slightly stronger predictive association overall (MK coefficient 17.26 to 35.76, β = 0.15 to 0.23). All core competency ratings were predictive of VSITE performance in PGYs 4 and 5. PGY 5 MK was highly predictive of VQE performance [OR 4.73, (95% CI, 3.87-5.78), P <0.001]. PC subcompetencies were also highly predictive of VQE performance in the final year of training [OR 4.14, (95% CI, 3.17-5.41), P <0.001]. All other competencies were also significantly predictive of first-attempt VQE pass with ORs of 1.53 and higher. PGY 4 ICS ratings [OR 4.0, (95% CI, 3.06-5.21), P <0.001] emerged as the strongest predictor of VCE first-attempt pass. Again, all subcompetency ratings remained significant predictors of first-attempt pass on CE with ORs of 1.48 and higher.

CONCLUSIONS

ACGME Milestone ratings are highly predictive of future VSITE performance, and first-attempt pass achievement on VQE and VCE in a national cohort of surgical trainees.

[A Case of Long-Term Survival Achieved by Multimodal Treatments for Postoperative Lung Metastasis and Mediastinal Lymph Node Metastasis after Surgery for Ascending Colon Cancer]

A 52-year-old male patient with Stage Ⅲc ascending colon cancer underwent laparoscopic right hemicolectomy with D3 lymph node dissection. Adjuvant chemotherapy was administered for 6 months, and no recurrence was observed during the follow-up period. Left lung metastasis was detected and surgically removed 7 years after the initial surgery. He underwent open partial small bowel resection with lymph node dissection when mesenteric lymph node metastasis was identified 2 years later. Although chemotherapy was conducted on the identification of mediastinal lymph node metastasis 2 years later, the mediastinal lymph nodes increased. Although attempted, lymph node dissection was impossible because of the strong adhesion to the trachea. Subsequently, chemotherapy and radiation therapy were administered. However, an infiltration of the mediastinal lymph nodes into the trachea was observed. The patient underwent bronchoscopic laser tumor ablation. The patient died 4 months after the resumption of chemotherapy(18 years after the initial surgery). Mediastinal lymph node recurrence after curative resection for colon cancer is a rare clinical condition. Nevertheless, long-term survival could be achieved by multimodal treatments in such patients.

[A Case of pagetoid Carcinoma of the Breast with Pathological Complete Response by Neoadjuvant Chemotherapy]

We herein report a 63-year-old woman who presented with about 20 mm-sized mass in the right breast and the right nipple with erosion. Preoperative examinations revealed a diagnosis of HER2-type pagetoid carcinoma with axillary lymph node metastasis. After neoadjuvant chemotherapy(pertuzumab, trastuzumab, and docetaxel, followed by adriamycin and cyclophosphamide), a pathological complete response was achieved. The patient was treated with anti-HER2 therapy without recurrence.

An extremely energetic cosmic ray observed by a surface detector array

Cosmic rays are energetic charged particles from extraterrestrial sources, with the highest-energy events thought to come from extragalactic sources. Their arrival is infrequent, so detection requires instruments with large collecting areas. In this work, we report the detection of an extremely energetic particle recorded by the surface detector array of the Telescope Array experiment. We calculate the particle's energy as [Formula: see text] (~40 joules). Its arrival direction points back to a void in the large-scale structure of the Universe. Possible explanations include a large deflection by the foreground magnetic field, an unidentified source in the local extragalactic neighborhood, or an incomplete knowledge of particle physics.

Industry Payments Received by Residents During Training

Importance

Those responsible for medical education-specialties, sponsoring institutions, and program directors (PD)-are independently associated with the professional identity formation of the trainees with respect to potential conflicts of interest.

Objective

To identify the relative degree to which factors in the training environment are associated with resident acceptance of payments from pharmaceutical and medical device companies.

Design, Setting, and Participants

Cross-sectional, retrospective study of residents enrolled in the 3 largest primary-care specialties (internal medicine [IM], family medicine [FM], obstetrics and gynecology [OBGYN]) and 3 largest surgical disciplines (general surgery [GS], orthopedic surgery, and urology) during academic year 2020 to 2021. All analyses were conducted January through August 2023.

Exposures

Specialty, sponsoring institutions' ownership (nonprofit, for-profit, federal government, local government, or state government), and the number of payments PDs accepted.

Main outcomes and measures

Modified Poisson regression assessed the relative risk of ownership, specialty, and PD behavior on residents' acceptance of industry payments as recorded in the Open Payments Program (OPP) database.

Results

In total, there were 124 715 residents in all training programs during 2020 to 2021, 12% of whom received payments totaling $6.4 million. There were 65 992 residents in training during 2020 to 2021 in the 6 specialties evaluated in this study, with 4438 in orthopedics, 1779 in urology, 9177 in GS, 5819 in OBGYN, 14 493 in FM, and 30 286 in IM. OPP records $3.9 million in payments to the 8750 residents (13.4%) who received at least 1 industry payment. The record of all payments to residents in OPP totals $6.4 million. Compared with residents in federal sponsoring institutions, those affiliated with for-profit institutions were 3.50 (95% CI, 2.32-5.28) times more likely to accept industry payments, while those affiliated with nonprofit organizations were 2.00 (95% CI, 1.36-2.93) times more likely to accept payments. Compared with IM, residents in each of the following specialties have an elevated risk of accepting payments: orthopedics, 3.21 (95% CI, 2.73-3.77) times; urology, 2.95 (95% CI, 2.44-3.56) times; GS, 1.21 (95% CI, 1.00-1.45) times; OBGYN, 1.30 (95% CI, 1.05-1.62) times. The difference in the risk of accepting a payment between FM and IM residents was not statistically significant. The number of payments PDs accepted slightly elevated the risk of residents to accept a payment by 1.01 (95% CI, 1.01-1.01).

Conclusions and relevance

In this cross-sectional, retrospective study, receipt of industry payments by residents was associated with specialty, institutional control, and PD behavior.

Gender Bias and Ophthalmology Accreditation Council for Graduate Medical Education Milestones Evaluations

Importance

Women remain underrepresented in ophthalmology and gender-based disparities exist in salary, grant receipt, publication rates, and surgical volume throughout training and in practice. Although studies in emergency medicine and general surgery showed mixed findings regarding gender differences in Accreditation Council for Graduate Medical Education (ACGME) Milestones ratings, limited data exist examining such differences within ophthalmology.

Objective

To examine gender differences in ophthalmology ACGME Milestones.

Design, Setting, and Participants

This was a retrospective cross-sectional study of postgraduate year 4 (PGY-4) residents from 120 ophthalmology programs graduating in 2019.

Main Outcomes and Measures

PGY-4 midyear and year-end medical knowledge (MK) and patient care (PC) ratings and Written Qualifying Examination (WQE) scaled scores for residents graduating in 2019 were included. Differential prediction techniques using Generalized Estimating Equations models were performed to identify differences by gender.

Results

Of 452 residents (median [IQR] age, 30.0 [29.0-32.0] years), 275 (61%) identified as men and 177 (39%) as women. There were no differences in PC domain average between women and men for both midyear (-0.07; 95% CI, -0.11 to 0; P =.06) and year-end (-0.04; 95% CI, -0.07 to 0.03; P =.51) assessment periods. For the MK domain average in the midyear assessment period, women (mean [SD], 3.76 [0.50]) were rated lower than men (mean [SD], 3.88 [0.47]; P = .006) with a difference in mean of -0.12 (95% CI, -0.18 to -0.03). For the year-end assessment, however, the average MK ratings were not different for women (mean [SD], 4.10 [0.47]) compared with men (mean [SD], 4.18 [0.47]; P = .20) with a difference in mean of -0.08 (95% CI, -0.13 to 0.03).

Conclusions and Relevance

Results suggest that ACGME ophthalmology Milestones in 2 general competencies did not demonstrate major gender bias on a national level at the time of graduation. There were, however, differences in MK ratings at the midyear mark, and as low ratings on evaluations and examinations may adversely affect career opportunities for trainees, it is important to continue further work examining other competencies or performance measures for potential biases.

Association of Surgical Resident Competency Ratings With Patient Outcomes

PURPOSE

Accurate assessment of clinical performance is essential to ensure graduating residents are competent for unsupervised practice. The Accreditation Council for Graduate Medical Education milestones framework is the most widely used competency-based framework in the United States. However, the relationship between residents' milestones competency ratings and their subsequent early career clinical outcomes has not been established. It is important to examine the association between milestones competency ratings of U.S. general surgical residents and those surgeons' patient outcomes in early career practice.

METHOD

A retrospective, cross-sectional study was conducted using a sample of national Medicare claims for 23 common, high-risk inpatient general surgical procedures performed between July 1, 2015, and November 30, 2018 (n = 12,400 cases) by nonfellowship-trained U.S. general surgeons. Milestone ratings collected during those surgeons' last year of residency (n = 701 residents) were compared with their risk-adjusted rates of mortality, any complication, or severe complication within 30 days of index operation during their first 2 years of practice.

RESULTS

There were no associations between mean milestone competency ratings of graduating general surgery residents and their subsequent early career patient outcomes, including any complication (23% proficient vs 22% not yet proficient; relative risk [RR], 0.97, [95% CI, 0.88-1.08]); severe complication (9% vs 9%, respectively; RR, 1.01, [95% CI, 0.86-1.19]); and mortality (5% vs 5%; RR, 1.07, [95% CI, 0.88-1.30]). Secondary analyses yielded no associations between patient outcomes and milestone ratings specific to technical performance, or between patient outcomes and composites of operative performance, professionalism, or leadership milestones ratings ( P ranged .32-.97).

CONCLUSIONS

Milestone ratings of graduating general surgery residents were not associated with the patient outcomes of those surgeons when they performed common, higher-risk procedures in a Medicare population. Efforts to improve how milestones ratings are generated might strengthen their association with early career outcomes.

High-energy molecular-frame photoelectron angular distributions: a molecular bond-length ruler

We present a study on molecular-frame photoelectron angular distributions (MFPADs) of small molecules using circularly polarized synchrotron light. We find that the main forward-scattering peaks of the MFPADs are slightly tilted with respect to the molecular axis. This tilt angle is directly connected to the molecular bond length by a simple, universal formula. We apply the derived formula to several examples of MFPADs of C 1s and O 1s photoelectrons of CO, which have been measured experimentally or obtained by means of ab initio modeling. In addition, we discuss the influence of the back-scattering contribution that is superimposed over the analyzed forward-scattering peak in the case of homo-nuclear diatomic molecules such as N₂.

Trainee Physician Milestone Ratings and Patient Complaints in Early Posttraining Practice

Importance

Evaluation of trainees in graduate medical education training programs using Milestones has been in place since 2013. It is not known whether trainees who have lower ratings during the last year of training go on to have concerns related to interactions with patients in posttraining practice.

Objective

To investigate the association between resident Milestone ratings and posttraining patient complaints.

Design, Setting, and Participants

This retrospective cohort study included physicians who completed Accreditation Council for Graduate Medical Education (ACGME)-accredited programs between July 1, 2015, and June 30, 2019, and worked at a site that participated in the national Patient Advocacy Reporting System (PARS) program for at least 1 year. Milestone ratings from ACGME training programs and patient complaint data from PARS were collected. Data analysis was conducted from March 2022 to February 2023.

Exposures

Lowest professionalism (P) and interpersonal and communication skills (ICS) Milestones ratings 6 months prior to the end of training.

Main Outcomes and Measures

PARS year 1 index scores, based on recency and severity of complaints.

Results

The cohort included 9340 physicians with median (IQR) age of 33 (31-35) years; 4516 (48.4%) were women physicians. Overall, 7001 (75.0%) had a PARS year 1 index score of 0, 2023 (21.7%) had a score of 1 to 20 (moderate), and 316 (3.4%) had a score of 21 or greater (high). Among physicians in the lowest Milestones group, 34 of 716 (4.7%) had high PARS year 1 index scores, while 105 of 3617 (2.9%) with Milestone ratings of 4.0 (proficient), had high PARS year 1 index scores. In a multivariable ordinal regression model, physicians in the 2 lowest Milestones rating groups (0-2.5 and 3.0-3.5) were statistically significantly more likely to have higher PARS year 1 index scores than the reference group with Milestones ratings of 4.0 (0-2.5 group: odds ratio, 1.2 [95% CI, 1.0-1.5]; 3.0-3.5 group: odds ratio, 1.2 [95% CI, 1.1-1.3]).

Conclusions and Relevance

In this study, trainees with low Milestone ratings in P and ICS near the end of residency were at increased risk for patient complaints in their early posttraining independent physician practice. Trainees with lower Milestone ratings in P and ICS may need more support during graduate medical education training or in the early part of their posttraining practice career.

The Use of Learning Analytics to Enable Detection of Underperforming Trainees: An Analysis of National Vascular Surgery Trainee ACGME Milestones Assessment Data

OBJECTIVE

This study aims to investigate at-risk scores of semiannual Accreditation Council for Graduate Medical Education (ACGME) Milestone ratings for vascular surgical trainees' final achievement of competency targets.

SUMMARY BACKGROUND DATA

ACGME Milestones assessments have been collected since 2015 for Vascular Surgery. It is unclear whether milestone ratings throughout training predict achievement of recommended performance targets upon graduation.

METHODS

National ACGME Milestones data were utilized for analyses. All trainees completing 2-year vascular surgery fellowships in June 2018 and 5-year integrated vascular surgery residencies in June 2019 were included. A generalized estimating equations model was used to obtain at-risk scores for each of the 31 subcompetencies by semiannual review periods, to estimate the probability of trainees achieving the recommended graduation target based on their previous ratings.

RESULTS

A total of 122 vascular surgery fellows (VSFs) (95.3%) and 52 integrated vascular surgery residents (IVSRs) (100%) were included. VSFs and IVSRs did not achieve level 4.0 competency targets at a rate of 1.6% to 25.4% across subcompetencies, which was not significantly different between the 2 groups for any of the subcompetencies ( P = 0.161-0.999). Trainees were found to be at greater risk of not achieving competency targets when lower milestone ratings were assigned, and at later time-points in training. At a milestone rating of 2.5, with 1 year remaining before graduation, the at-risk score for not achieving the target level 4.0 milestone ranged from 2.9% to 77.9% for VSFs and 33.3% to 75.0% for IVSRs.

CONCLUSION

The ACGME Milestones provide early diagnostic and predictive information for vascular surgery trainees' achievement of competence at completion of training.

Giant Coronary Aneurysm with Coronary-Pulmonary Artery Fistula in a Jehovah's Witness

With an incidence of 3 in 100 million, giant coronary artery aneurysm (CAA) with coronary artery fistula (CAF) is a very rare condition. To prevent rupture, giant CAA with CAF should be swiftly treated. We present a Jehovah's Witness patient with giant CAA and coronary-pulmonary artery fistula. We resected the giant CAA in one piece, while ligating the CAF, without allogeneic blood transfusion. Due to rarity of these conditions, many thoracic surgeons lack direct experience in its surgical procedures. Herein, we share footage of this surgery as an example of how to safely resect CAA with minimal bleeding.

Predicting Performance at Graduation From Early ACGME Milestone Ratings: Longitudinal Learning Analytics in Professionalism and Communication in Vascular Surgery

OBJECTIVE

Program directors in surgical disciplines need more tools from the ACGME to help them use Milestone ratings to improve trainees' performance. This is especially true in competencies that are notoriously difficult to measure, such as professionalism (PROF) and interpersonal and communication skills (ICS). It is now widely understood that skills in these two areas have direct impact on patient care outcomes. This study investigated the potential for generating early predictors of final Milestone ratings within the PROF and ICS competency categories.

DESIGN

This retrospective cohort study utilized Milestone ratings from all ACGME-accredited vascular surgery training programs, covering residents and fellows who completed training in June 2019. The outcome measure studied was the rate of achieving the recommended graduation target of Milestone Level 4 (possible range: 1-5), while the predictors were the Milestone ratings attained at earlier stages of training. Predictive probability values (PPVs) were calculated for each of the 3 PROF and two ICS sub-competencies to estimate the probability of trainees not reaching the recommended graduation target based on their previous Milestone ratings.

SETTING

All ACGME-accredited vascular surgery training programs within the United States.

PARTICIPANTS

All trainees completing a 2 year vascular surgery fellowship (VSF) in June 2019 (n = 119) or a 5 year integrated vascular surgery residency (IVSR) in June 2019 (n = 52) were included in the analyses.

RESULTS

The overall rate of failing to achieve the recommended graduation target across all PROF and ICS sub-competencies ranged from 7.7% to 21.8% of all trainees. For trainees with a Milestone rating at ≤ 2.5 with 1 year remaining in their training program, the predictive probability of not achieving the recommended graduation target ranged from 37.0% to 71.5% across sub-competencies, with the highest risks observed under PROF for "Administrative Tasks" (71.5%) and under ICS for "Communication with the Healthcare Team" (56.7%).

CONCLUSIONS

As many as 1 in 4 vascular surgery trainees did not achieve the ACGME vascular surgery Milestones targets for graduation in at least one of the PROF and ICS sub-competencies. Biannual ACGME Milestone assessment ratings of PROF and ICS during early training can be used to predict achievement of competency targets at time of graduation. Early clues to problems in PROF and ICS enable programs to address potential deficits early in training to ensure competency in these essential non-technical skills prior to entering unsupervised practice.

[A Case of Rectal Cancer with Bladder Invasion Performed with Robot-Assisted Low Anterior Resection after TNT]

A 73-year-old woman was admitted with a chief complaint of weight loss. Colonoscopy revealed rectal cancer. After the placement of a colonic stent, the patient was referred to our department. Computed tomography, magnetic resonance imaging, and cystoscopy indicated extensive invasion of the bladder. Since total pelvic exenteration was necessary at the first diagnosis, total neoadjuvant therapy(TNT)was conducted. The diagnosis after TNT was ycT4bycN0ycM0. Low anterior resection with partial resection of the bladder and a diverting ileostomy were performed. The patient was discharged on the 16th day post-surgery with a good postoperative course. The pathological examination revealed a complete response, ypT0ypN0.

[A Case of Locally Advanced Rectal Cancer Treated Successfully with TNT]

Local control is important in the treatment of locally advanced rectal cancer(LARC). In Western countries, the standard therapy for LARC is preoperative chemoradiotherapy(CRT)followed by total mesorectal excision. Recently, addition of intensive chemotherapy to CRT known as total neoadjuvant therapy(TNT)is increasing. We herein report a 69-year-old woman who developed LARC(cT3N3M0, cStage Ⅲc). She was diagnosed as clinical complete response after TNT, and she chose"watch and wait". She did not have a recurrence for 16 months.

Trends in Industry Payments to Physicians in the First 6 Years After Graduate Medical Training

IMPORTANCE

Financial incentives and conflicts of interest may influence physician decision-making. It is important to understand financial interactions between the pharmaceutical and medical device industries and newly independent physicians who have recently completed their graduate medical education using a national transparency program.

OBJECTIVE

To identify trends in industry payments to recent graduates of Accreditation Council for Graduate Medical Education-accredited residency or fellowship programs in orthopedic surgery, neurosurgery, and internal medicine.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study analyzed Open Payments reports of industry payments made between July 1, 2015, and June 30, 2021, to newly independent physicians from residency or fellowship programs in neurosurgery, orthopedic surgery, and internal medicine who graduated between January 1, 2015, and December 31, 2019.

EXPOSURES

Specialties (neurosurgery and orthopedic surgery, with internal medicine as a comparison group).

MAIN OUTCOMES AND MEASURES

Industry payments to newly independent physicians, including any general payments (noninvestment or nonresearch) and at least $5000 of general payments in aggregate value per year, which are considered significant financial conflicts of interest. The percentage of newly independent physicians accepting general payments during the first 6 years after graduation was analyzed by specialty and sex using cumulative incidence curves and hazard ratios (HRs) in univariable and multivariable analyses.

RESULTS

There were 45 745 recent graduates (28 137 men [62%]; median age at graduation, 33.0 [IQR, 31.0-35.0 years]) in neurosurgery (n = 595), orthopedic surgery (n = 3481), and internal medicine (n = 41 669). In the first 2 years of independent practice, 95% (n = 3297), 92% (n = 546), and 59% (n = 24 522) of newly independent physicians in orthopedic surgery, neurosurgery, and internal medicine, respectively, accepted any general payments. A higher percentage of the newly independent physicians in orthopedic surgery and neurosurgery accepted any general payments (orthopedic surgery vs internal medicine: HR, 5.36 [95% CI, 4.42-6.51] for women and 7.01 [95% CI, 6.35-7.73] for men; neurosurgery vs internal medicine: HR, 3.25 [95% CI, 2.24-4.72] for women and 4.08 [95% CI, 3.37-4.94] for men; P = .03). A higher percentage of male physicians compared with female physicians accepted any general payments (orthopedic surgery, 2884 of 3026 [95%] vs 413 of 455 [91%]; P < .001; neurosurgery, 466 of 502 [93%] vs 80 of 93 [86%]; P = .01; and internal medicine, 15 462 of 24 609 [63%] vs 9043 of 17 034 [53%]; P < .001) and at least $5000 of general payments (orthopedic surgery, 763 of 3026 [25%] vs 71 of 455 [16%]; P < .001; neurosurgery, 87 of 502 [17%] vs 5 of 93 [5%%]; P < .001; and internal medicine, 882 of 24 609 [4%] vs 210 of 17 034 [1%]; P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study of newly independent physicians in orthopedic surgery, neurosurgery, and internal medicine, the financial relationship with potential conflicts of interest between newly independent physicians and industry began to develop soon after training programs and continued to expand in the early years of newly independent physician practice. Newly independent physicians in surgical specialties and male physicians accepted significantly higher industry payments. Further studies are needed to evaluate whether modifiable factors are associated with the future outcome of newly independent physicians accepting general payments.

Ruptured ileocolic artery pseudoaneurysm after laparoscopic appendectomy for acute appendicitis

Background

A pseudoaneurysm of the splanchnic vessels is considered to be rare, and in particular, very few cases of pseudoaneurysm in the ileocolic artery are reported. Here, we report a case of rupture of a pseudoaneurysm of the appendicular branch of the ileocolic artery after laparoscopic appendectomy.

Case presentation

A 52-year-old man was diagnosed as having phlegmonous appendicitis, and an emergency laparoscopic appendectomy was performed. Bleeding from the inter-appendicular ligament during detachment of adhesions was stopped by white coagulation and Z-suture, and the inter-appendicular ligament was treated. The postoperative course was uneventful, and there were no adverse events or findings suggestive of abscess formation. On postoperative day 30, he presented with a ruptured pseudoaneurysm of the appendicular branch of the ileocolic artery. A definitive diagnosis was made by computed tomography, and emergency interventional radiology was performed with hemostasis achieved by coiling. The patient’s postprocedure course was favorable, and he was discharged with no adverse events, such as intestinal ischemia.

Conclusions

We experienced a case of delayed pseudoaneurysm rupture after laparoscopic appendectomy. Care must be taken when handling the appendicular artery during the procedure, and the potential for pseudoaneurysm formation should be considered at postoperative follow-up.

Cell death signalling is competitively but coordinately regulated by repressor-type and activator-type ethylene response factors in tobacco (Nicotiana tabacum) plants

Ethylene response factors (ERFs) comprise one of the largest transcription factor families in many plant species. Tobacco (Nicotiana tabacum) ERF3 (NtERF3) and other ERF-associated amphiphilic repression (EAR) motif-containing ERFs are known to function as transcriptional repressors. NtERF3 and several repressor-type ERFs induce cell death in tobacco leaves and are also associated with a defence response against tobacco mosaic virus (TMV). We investigated whether transcriptional activator-type NtERFs function together with NtERF3 in the defence response against TMV infection by performing transient ectopic expression, together with gene expression, chromatin immunoprecipitation (ChIP) and promoter analyses. Transient overexpression of NtERF2 and NtERF4 induced cell death in tobacco leaves, albeit later than that induced by NtERF3. Fusion of the EAR motif to the C-terminal end of NtERF2 and NtERF4 abolished their cell death-inducing ability. The expression of NtERF2 and NtERF4 was upregulated at the early phase of N gene-triggered hypersensitive response (HR) against TMV infection. The cell death phenotype induced by overexpression of wild-type NtERF2 and NtERF4 was suppressed by co-expression of an EAR motif-deficient form of NtERF3. Furthermore, ChIP and promoter analyses suggested that NtERF2, NtERF3 and NtERF4 positively or negatively regulate the expression of NtERF3 by binding to its promoter region. Overall, our results revealed the cell death-inducing abilities of genes encoding activator-type NtERFs, including NtERF2 and NtERF4, suggesting that the HR-cell death signalling via the repressor-type NtERF3 is competitively but coordinately regulated by these NtERFs.

Evaluating the burden of the COVID-19 pandemic on patients with colorectal cancer

After the emergence of the coronavirus disease 2019 (COVID-19) pandemic, individuals needing medical help preferred to not go to the hospital to avoid the risk of severe acute respiratory syndrome coronavirus 2 infection. The present study investigated the influence of the COVID-19 pandemic on patients with colorectal cancer. Patients with colorectal cancer treated between January and December 2019 were classified as the pre-pandemic group (pre-group) and those treated between April 2020 and March 2021 as the post-pandemic group (pandemic group). The clinicopathologic features of patients who underwent surgery for colorectal cancer in the two groups were retrospectively compared. A total of 161 patients were enrolled: 79 In the pre-group and 82 in the pandemic group. Although no significant differences were observed in tumor location and surgical procedure between the two groups, circumferential lesions (P<0.001), colorectal stenting (P=0.016) and Stage IV classification (P=0.019) had a higher frequency in the pandemic group compared with the pre-group; additionally, surgical curability was significantly lower (P=0.036) in the pandemic group. The spread of COVID-19 has increased the incidence of patients with advanced colorectal cancer. To reduce this incidence, healthcare professionals should inform the general public not only about the risk of COVID-19, but also about the increased incidence of advanced colorectal cancer after the pandemic.

Treatment of thigh abscess caused by retroperitoneal perforation of cecal cancer: A case report

Introduction and importance

Iliopsoas and iliacus abscesses are caused by hematogenous and lymphatic infections and the spread of inflammation in neighboring organs. A small number of cases have been reported in which inflammation spread not only within the iliopsoas muscle but also to the thigh. Here we report a case of retroperitoneal infiltration and perforation of cecal cancer that caused extensive abscess formation from the iliacus muscle to the thigh.

Case presentation

An 80-year-old man who had undergone chemotherapy for cecal cancer had abdominal pain and right thigh pain without any particular attraction. CT images showed extensive abscess formation from the iliacus muscle to the subcutaneous part of the thigh due to retroperitoneal infiltration and perforation of cecal cancer. Ileocecal resection, colostomy, and retroperitoneal abscess drainage were performed for perforation of cecal cancer and pelvic abscess. Although the thigh was initially drained by a small incision, the infection did not heal. Extensive debridement and drainage were required for all of the contaminated areas, and after all the infection was completely cured.

Clinical discussion

The optimal treatment for an abscess that has spread from the inguinal region to the thigh is unclear. In this case, active debridement and drainage of the infected area were effective and should have been done early.

Conclusion

We believed that debridement and drainage should have been performed from the time of the first surgery not only by the small incision drainage but also for all of the contaminated areas when the infection had been widespread.

•

・The iliopsoas abscess may spread to the surrounding area in case its diagnosis is delayed.

•

・The optimal treatment for an abscess spreading from the inguinal region to the thigh is still controversial.

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・Drainage by the small incision is not helpful when the infection has been spreading to the thigh, and all of the contaminated areas should also be exposed and active debridement and drainage are required.

Efficacy of polyglycolic acid sheeting with fibrin glue for perforations related to gastrointestinal endoscopic procedures: a multicenter retrospective cohort study

OBJECTIVES

Gastrointestinal (GI) perforations are one of the major adverse events of endoscopic procedures. Polyglycolic acid (PGA) sheets with fibrin glue have been reported to close GI perforations. However, its clinical outcome has not yet been fully investigated; thus, we conducted a multicenter retrospective observational study to assess the efficacy of PGA sheeting for GI perforation.

METHODS

The medical records of patients who underwent PGA sheeting for endoscopic GI perforations between April 2013 and March 2018 in 18 Japanese institutions were retrospectively analyzed. PGA sheeting was applied when the clip closure was challenging or failed to use. Perforations were filled with one or several pieces of PGA sheets followed by fibrin glue application through an endoscopic catheter. Nasal or percutaneous drainage and endoscopic clipping were applied as appropriate. Clinical outcomes after PGA sheeting for intraoperative or delayed perforations were separately evaluated.

RESULTS

There were 66 intraoperative and 24 delayed perforation cases. In intraoperative cases, successful closure was attained in 60 cases (91%). The median period from the first sheeting to diet resumption was 6 days (interquartile range [IQR], 4-8.8 days). Large perforation size (≥ 10 mm) and duodenal location showed marginal significant relationship to higher closure failure of intraoperative perforations. In delayed perforation cases, all cases had successful closure. The median period from the first sheeting to diet resumption was 10 days (IQR, 6-37.8 days). No adverse events related to PGA sheeting occurred.

CONCLUSION

Endoscopic PGA sheeting could be a therapeutic option for GI perforations related to GI endoscopic procedures.

[Successful Surgical Correction of Partial Atrioventricular Septal Defect in an Elderly Patient:Report of a Case]

There are only few reports on surgery for partial atrioventricular septal defect( pAVSD) in patients aged over 70 years. This report is about successful surgical correction of pAVSD in a 79-year-old women. Echocardiography showed left-sided atrioventricular valve regurgitation with cleft and ostium primum atrial septal defect, but without ventricular septal defect. Accordingly, she was diagnosed with pAVSD. Treatment plan included direct cleft closure, patch closure for the ostium primum atrial septal defect, and right atrioventricular annuloplasty. The postoperative course was uneventful. She was followed up without complications for four years. To the best of our knowledge, our patient is the oldest to undergo such surgical techniques in Japan to date.

POS0670 EVALUATION OF UPADACITINIB IN RHEUMATOID ARTHRITIS PATIENTS WITH INADEQUATE RESPONSE TO FIRST-GENERATION JANUS KINASE INHIBITORS

Background

Janus kinase inhibitors (JAKi) are effective in the treatment of patients with difficult-to-treat rheumatoid arthritis (D2T RA), regardless of previous use of biological disease-modifying antirheumatic drugs (bDMARDs), and receive equal billing with biological therapies in the latest version of the EULAR recommendations for treatment of RA1. However, as with bDMARDs, cases of discontinuation due to intolerance or inadequate response have been observed in patients treated with the so-called first-generation JAKi, leading to the development of a new generation of JAKi that aims to maximize efficacy and improve safety by enhancing kinase selectivity. The results of randomized controlled trials and meta-analyses suggest that the efficacy and safety of Upadacitinib (UPA) treatment are favorable. Although there have been no head-to-head trials between JAKi, a matched-adjusted indirect comparative study has shown a difference in efficacy between JAKi2, suggesting that the new generation of JAKi may be effective in rheumatoid arthritis patients with intolerance or inadequate response to first-generation JAKi. It is already apparent that a clear need exists for a JAK-IR trial to give guidance in those difficult patients who are JAKi non-responders3.

Objectives

To evaluate real world efficacy of a second-generation JAK1-selective JAKi UPA in single-center cohort of RA patients who had discontinued first-generation JAKi.

Methods

Patients with RA who had discontinued tofacitinib and/or baricitinib due to inadequate response or intolerance, regardless of whether they had used bDMARDs or not, were eligible for the study if they had received UPA by October 2021 and had been followed up for at least 12 weeks. Endpoints were Kaplan-Meier survival rate with inadequate response or intolerance as reasons for discontinuation, various disease activity assessments (DAS28-ESR, SDAI, CDAI, etc.), and patient reported outcomes (visual analogue scales (VASs) such as pain and stiffness, HAQ-DI, FACIT-Fatigue Scale, etc.) at 12 weeks. In addition, the reasons for discontinuation were investigated.

Results

Fifty-one patients were included in the study, all of whom had D2T RA and had used at least one bDMARD as well as JAKi. The mean (median) age was 72.7 (77) years, disease duration 18.0 (17) years, number of bDMARDs used 3.34 (3), number of JAKi used 1.3(1), 5 patients with methotrexate, 6 patients with prednisolone, and DAS28-ESR 3.83 (3.9). At 12 weeks, the overall survival rate was 94% (94.6% in 37 cases used as 2nd JAKi and 92.9% in 14 cases used as 3rd JAKi). For reference, there was no significant difference from the 100% of the 15 cases used as the 1st JAKi (P=0.49). DAS28-ESR <3.2 and <2.6 were achieved in 60.8% and 29.4%, VASs for pain and stiffness decreased by a mean of 12.9 mm (9 mm) and 12.1 mm (7 mm), respectively, and FACIT-Fatigue scale improved by a mean of 3.0 (1). The reasons for discontinuation in the three patients were inadequate efficacy in two and leg cramps due to venous thromboembolism in one.

Conclusion

UPA is more selective for JAK1 than first generation JAKi, and is expected to reduce adverse reactions caused by inhibition of JAK family members other than JAK1. The present study suggests that UPA is effective and well tolerated, regardless of the number and type of first-generation JAKi used in the past, albeit for a short period of time. Limitations include the small number of cases and the short time frame for discussing adverse reactions.

References

[1]Smolen JS, Landewé BM, Bijlsma WJ et al., EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020;79:685–699.

[2]Christopher JE, Ruta S, Vishvas G et al. A Matching-Adjusted Indirect Comparison of Upadacitinib Versus Tofacitinib in Adults with Moderate-to-Severe Rheumatoid Arthritis. Rheumatol Ther 2021; 8:167–181.

[3]Peter Nash, Clinical use of Jak 1 inhibitors for rheumatoid arthritis. Rheumatology, Volume 60, Issue Supplement_2, May 2021, Pages ii31–ii38

Disclosure of Interests

None declared

Transcatheter aortic valve implantation with a balloon-expandable prosthesis in a patient with single coronary artery: a case report

BACKGROUND

Single coronary artery is a rare coronary artery anomaly with an incidence of <0.03%. The coexistence of coronary artery anomalies with severe aortic stenosis is extremely rare. Due to the singularity of the coronary artery orifice, the most concerning risk of transcatheter aortic valve implantation (TAVI) in such patients is coronary occlusion, which may very well be life-threatening.

CASE SUMMARY

An 83-year-old female complaining of chest pain was referred to our hospital for severe aortic stenosis. The multi-slice computed tomography showed a congenital single coronary artery originating from the right sinus of Valsalva. The left coronary artery branched off of the right coronary artery, and passed between the aorta and main pulmonary artery. The heart team of the hospital decided to perform TAVI via femoral artery with a balloon-expandable prosthesis, with coronary angioplasty devices on standby in case of coronary occlusion. The TAVI procedure was performed successfully without coronary occlusion.

DISCUSSION

Although there have been some case reports of TAVI in patients with single coronary artery, little is known about the safety of TAVI in such cases, and which device (such as the balloon-expandable or the self-expandable prosthesis) is preferable. From this particular case, and accumulation of past and various TAVI experience, the balloon-expandable prosthesis can be a safe device choice in carefully selected patients with coronary artery anomalies.

An Empirical Investigation Into Milestones Factor Structure Using National Data Derived From Clinical Competency Committees

PURPOSE

To investigate whether milestone data obtained from clinical competency committee (CCC) ratings in a single specialty reflected the 6 general competency domains framework.

METHOD

The authors examined milestone ratings from all 275 U.S. Accreditation Council for Graduate Medical Education-accredited categorical obstetrics and gynecology (OBGYN) programs from July 1, 2018, to June 30, 2019. The sample size ranged from 1,371 to 1,438 residents from 275 programs across 4 postgraduate years (PGYs), each with 2 assessment periods. The OBGYN milestones reporting form consisted of 28 subcompetencies under the 6 general competency domains. Milestone ratings were determined by each program's CCC. Intraclass correlations (ICCs) and design effects were calculated for each subcompetency by PGY and assessment period. A multilevel confirmatory factor analysis (CFA) perspective was used, and the pooled within-program covariance matrix was obtained to compare the fit of the 6-domain factor model against 3 other plausible models.

RESULTS

Milestone ratings from 5,618 OBGYN residents were examined. Moderate to high ICCs and design effects greater than 2.0 were prevalent among all subcompetencies for both assessment periods, warranting the use of the multilevel approach in applying CFA to the milestone data. The theory-aided split-patient care (PC) factor model, which used the 6 general competency domains but also included 3 factors within the PC domain (obstetric technical skills, gynecology technical skills, and ambulatory care), was consistently shown as the best-fitting model across all PGYs by assessment period conditions, except for one.

CONCLUSIONS

The findings indicate that in addition to using the 6 general competency domains framework in their rating process, CCCs may have further distinguished the PC competency domain into 3 meaningful factors. This study provides internal structure validity evidence for the milestones within a single specialty and may shed light on CCCs' understanding of the distinctive content embedded within the milestones.

Investigating charge-up and fragmentation dynamics of oxygen molecules after interaction with strong X-ray free-electron laser pulses

The X-ray-induced charge-up and fragmentation process of a small molecule is examined in great detail by measuring the molecular-frame photoelectron interference pattern in conjunction with other observables in coincidence.

[A Case of Synchronous Multiple Colorectal Cancer with Rectal Neuroendocrine Tumor and Ascending Colon Cancer]

A 43-year-old man who had no previous medical history or family history had positive fecal occult blood test in a local physician. Colonoscopy revealed a type 2 tumor of the ascending colon and a 10 mm submucosal tumor(SMT)of the lower rectum. Biopsy indicated moderately-differentiated adenocarcinoma of the ascending colon and neuroendocrine tumor (NET)of the lower rectum. No metastasis was detected by computed tomography. Therefore, the rectal SMT was resected first by endoscopic submucosal resection. Histopathologically, the lesion was localized in the submucosa and no lymphovascular invasion was found. Vertical margin was also negative. We decided not to perform additional intestinal resection for rectal NET. Thereafter, the patient underwent laparoscopic right hemicolectomy for ascending colon cancer. The histopathological findings were pT3, pN1, pM0, pStage Ⅲb. The patient received adjuvant chemotherapy. No relapse was found 18 months after surgery. We reported a rare case of a lower rectal NET with concomitant ascending colon cancer.

Longitudinal Reliability of Milestones-Based Learning Trajectories in Family Medicine Residents

IMPORTANCE

Longitudinal Milestones data reported to the Accreditation Council for Graduate Medical Education (ACGME) can be used to measure the developmental and educational progression of learners. Learning trajectories illustrate the pattern and rate at which learners acquire competencies toward unsupervised practice.

OBJECTIVE

To investigate the reliability of learning trajectories and patterns of learning progression that can support meaningful intervention and remediation for residents.

DESIGN, SETTING, AND PARTICIPANTS

This national retrospective cohort study included Milestones data from residents in family medicine, representing 6 semi-annual reporting periods from July 2016 to June 2019.

INTERVENTIONS

Longitudinal formative assessment using the Milestones assessment system reported to the ACGME.

MAIN OUTCOMES AND MEASURES

To estimate longitudinal consistency, growth rate reliability (GRR) and growth curve reliability (GCR) for 22 subcompetencies in the ACGME family medicine Milestones were used, incorporating clustering effects at the program level. Latent class growth curve models were used to examine longitudinal learning trajectories.

RESULTS

This study included Milestones ratings from 3872 residents in 514 programs. The Milestones reporting system reliably differentiated individual longitudinal patterns for formative purposes (mean [SD] GRR, 0.63 [0.03]); there was also evidence of precision for model-based rates of change (mean [SD] GCR, 0.91 [0.02]). Milestones ratings increased significantly across training years and reporting periods (mean [SD] of 0.55 [0.04] Milestones units per reporting period; P < .001); patterns of developmental progress varied by subcompetency. There were 3 or 4 distinct patterns of learning trajectories for each of the 22 subcompetencies. For example, for the professionalism subcompetency, residents were classified to 4 groups of learning trajectories; during the 3-year family medicine training period, trajectories diverged further after postgraduate year (PGY) 1, indicating a potential remediation point between the end of PGY 1 and the beginning of PGY 2 for struggling learners, who represented 16% of learners (620 residents). Similar inferences for learning trajectories were found for practice-based learning and improvement, systems-based practice, and interpersonal and communication skills. Subcompetencies in medical knowledge and patient care demonstrated more consistent patterns of upward growth.

CONCLUSIONS AND RELEVANCE

These findings suggest that the Milestones reporting system provides reliable longitudinal data for individualized tracking of progress in all subcompetencies. Learning trajectories with supporting reliability evidence could be used to understand residents' developmental progress and tailored for individualized learning plans and remediation.