Reimagining a pass/fail clinical core clerkship: a US residency program director survey and meta-analysis

Pass/fail (P/F) grading has emerged as an alternative to tiered clerkship grading. Systematically evaluating existing literature and surveying program directors (PD) perspectives on these consequential changes can guide educators in addressing inequalities in academia and students aiming to improve their residency applications. In our survey, a total of 1578 unique PD responses (63.1%) were obtained across 29 medical specialties. With the changes to United States Medical Licensure Examination (USMLE), responses showed increased importance of core clerkships with the implementation of Step 2CK cutoffs. PDs believed core clerkship performance was a reliable representation of an applicant's preparedness for residency, particularly in Accreditation Council for Graduate Medical Education's (ACGME)Medical Knowledge and Patient Care and Procedural Skills. PDs disagreed with P/F core clerkships because it more difficult to objectively compare applicants. No statistically significant differences in responses were found in PD preferential selection when comparing applicants from tiered and P/F core clerkship grading systems. If core clerkships adopted P/F scoring, PDs would further increase emphasis on narrative assessment, sub-internship evaluation, reference letters, academic awards, professional development and medical school prestige. In the meta-analysis, of 6 studies from 2,118 participants, adjusted scaled scores with mean difference from an equal variance model from PDs showed residents from tiered clerkship grading systems overall performance, learning ability, work habits, personal evaluations, residency selection and educational evaluation were not statistically significantly different than from residents from P/F systems. Overall, our dual study suggests that while PDs do not favor P/F core clerkships, PDs do not have a selection preference and do not report a difference in performance between applicants from P/F vs. tiered grading core clerkship systems, thus providing fertile grounds for institutions to examine the feasibility of adopting P/F grading for core clerkships.

Using Free-Breathing MRI to Quantify Pancreatic Fat and Investigate Spatial Heterogeneity in Children

BACKGROUND

MRI acquisition for pediatric pancreatic fat quantification is limited by breath-holds (BH). Full segmentation (FS) or small region of interest (ROI) analysis methods may not account for pancreatic fat spatial heterogeneity, which may limit accuracy.

PURPOSE

To improve MRI acquisition and analysis for quantifying pancreatic proton-density fat fraction (pPDFF) in children by investigating free-breathing (FB)-MRI, characterizing pPDFF spatial heterogeneity, and relating pPDFF to clinical markers.

STUDY TYPE

Prospective.

POPULATION

A total of 34 children, including healthy (N = 16, 8 female) and overweight (N = 18, 5 female) subjects.

FIELD STRENGTH AND SEQUENCES

3 T; multiecho gradient-echo three-dimensional (3D) stack-of-stars FB-MRI, multiecho gradient-echo 3D Cartesian BH-MRI.

ASSESSMENT

A radiologist measured FS- and ROI-based pPDFF on FB-MRI and BH-MRI PDFF maps, with anatomical images as references. Regional pPDFF in the pancreatic head, body, and tail were measured on FB-MRI. FS-pPDFF, ROI-pPDFF, and regional pPDFF were compared, and related to clinical markers, including hemoglobin A1c.

STATISTICAL TESTS

T-test, Bland-Altman analysis, Lin's concordance correlation coefficient (CCC), one-way analysis of variance, and Spearman's rank correlation coefficient were used. P < 0.05 was considered significant.

RESULTS

FS-pPDFF and ROI-pPDFF from FB-MRI and BH-MRI had mean difference = 0.4%; CCC was 0.95 for FS-pPDFF and 0.62 for ROI-pPDFF. FS-pPDFF was higher than ROI-pPDFF (10.4% ± 6.4% vs. 4.2% ± 2.8%). Tail-pPDFF (11.6% ± 8.1%) was higher than body-pPDFF (8.9% ± 6.3%) and head-pPDFF (8.7% ± 5.2%). Head-pPDFF and body-pPDFF positively correlated with hemoglobin A1c.

DATA CONCLUSION

FB-MRI pPDFF is comparable to BH-MRI. Spatial heterogeneity affects pPDFF quantification. Regional measurements of pPDFF in the head and body were correlated with hemoglobin A1c, a marker of insulin sensitivity.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 2.

Residency Program Director Perspectives on Changes to US Medical Licensing Examination

This survey study examines the perspectives of residency program directors regarding reporting the US Medical Licensing Examination (USMLE) Step 1 as pass/fail and discontinuing Step 2 Clinical Skills.

Antigenic characterization of an Arkansas isolate of infectious bursal disease virus

The s977 strain of infectious bursal disease virus (IBDV) was isolated in northwest Arkansas in 1977 from the bursae of young broilers with high maternal antibody titers to the Moulthrop strain of IBDV (BursaVac). The comparison of a plaque-purified isolate of s977 with other IBDV serotype 1 and serotype 2 strains using virus neutralization indicates that s977 is a subtype of serotype 1 vaccine viruses and the MD variant strain of IBDV and has no relatedness to the Delaware Variant A (VarA) virus. In vivo cross-protection studies in specific-pathogen-free white leghorn chickens showed that an inactivated vaccine using s977 antigen was 2.5 times more protective against challenge with s977 than was an inactivated IBDV Variant E (VarE) vaccine. The vaccination of maternally immune broiler chicks with live s977 did not provide protection against subsequent challenge, indicating that s977 does not have enough antigenic difference to break through maternal immunity. Analysis of denatured viral polypeptides using polyacrylamide gel electrophoresis showed that s977 and two reported variant strains, 51 and VarE, share three protein bands, 90 kD (VP1), 40 kD (VP2), and 31 kD (VP3), that were not observed in BursaVac. BursaVac and s977 shared a 74 kD precursor band that was absent or very faint in the VarE and 51 strains. The most unique characteristic of s977 was the relative abundance of a wide, 56-63 kD band that contained two distinct immunoreactive bands when blotted with antiserum to s977. BursaVac contained a 56 kD band that failed to react with s977 antiserum. Analysis of polypeptide bands using laser densitometry indicated the presence of a number of bands between 20 kD and 25 kD in the s977, 51, and VarE preparations but only a 25 kD band in BursaVac. The number of bands decreased with the degree of relatedness to standard vaccine strains. It appears that, antigenically, S977 may hold an intermediate position between the classic virus strains and the more recently reported serotype 1 variants.

Pathogenicity studies of an Arkansas variant infectious bursal disease virus

A variant infectious bursal disease virus (IBDV), IBDV-s977, was blind passaged in cell culture, plaque purified, and attenuated by serial passage at a high multiplicity of infection (MOI) in chick embryo fibroblasts (CEF). Cell culture passages of virus caused less bursal atrophy and splenomegaly than did the original isolate and retained immunogenicity; however, virus tended to persist for a longer time in the bursa and spleen of birds infected with the highest CEF passages. Antibody to both low MOI and high MOI passages of IBDV-s977 poorly neutralized virus that was isolated from bursal tissue 28 days postinfection (PI). The spleens of chickens infected with the eighteenth CEF passage were negative for virus at 3 and 7 days PI but had high titers of virus at 14 and 28 days PI. There was also more virus in the bursa of birds infected with the fifteenth and eighteenth CEF passages at 28 days PI than at 7 or 14 days PI. Defective interference (DI) was demonstrated when cell cultures were coinfected with a constant amount of low MOI virus and serial dilutions of high MOI virus. There was an increase in interference score with increased passage number in CEF, and there was more interference in virus passaged at a high MOI. There was an inverse relationship between interference score and bursal lesion score and splenomegaly at 7 days PI, indicating that DI particles may be involved in virus attenuation. There was a positive relationship between interference and viral persistence in the bursa and spleen at 28 days PI. Antiserum to s977 was shown to enhance the nonlytic replication of s977 in CEF, presumably within macrophages, providing a possible mechanism for the pathotypic variation seen in emerging strains of IBDV.

Use of virulent hemorrhagic enteritis virus for the induction of colibacillosis in turkeys

Three hundred fifty 1-day-old large white turkeys were reared in brooding batteries to 10 days of age, after which they were moved to floor pens on litter. At 7 weeks of age, poults were allotted into four treatment groups as follows: 1) virulent hemorrhagic enteritis virus (HEV) alone (100 turkeys), 2) Escherichia coli alone (100 turkeys), 3) HEV + E. coli (100 turkeys), and 4) negative controls (50 turkeys). HEV was given orally at 7 weeks of age, followed by E. coli challenge in the drinking water 2 days later for 10 consecutive days. All groups were observed daily for mortality, both during and after challenge. Turkeys that died or were moribund were necropsied, and cultures were taken from the liver and bone marrow for bacterial isolation. Total mortality rates were 23% in the HEV + E. coli group, 10% in the HEV-only group, 3% in the E. coli-only group, and 0% in the negative control group. Cumulative mortality values were significantly different from those of the negative controls (P < or = 0.05) for HEV only and the HEV + E. coli group. E. coli was isolated from the liver and bone marrow of almost all turkeys that died.

Determination of infectious bursal disease virus titration and neutralization endpoints using fluorogenic staining

An automated method for determining infectious bursal disease virus (IBDV) titration and neutralization endpoints is described. The method employs the fluorogenic ester carboxyfluorescein-diacetate (CFDA) to stain cell monolayers in 96-well plates and a fluorescence-concentration analyzer. Titration results are compared with immunofluorescence and plaque assay titers. Virus-neutralization endpoint determination is objective, and the endpoints of replicate tests were equivalent or within one dilution of variability. Tests can be automatically screened as any percentage of a positive control or any standard deviation from a negative control.

Variability in a commercially available enzyme-linked immunosorbent assay system. I. Assay variability

Three experiments were conducted to characterize the variation in enzyme-linked immunosorbent assay (ELISA) kits for infectious bronchitis virus (IBV) and infectious bursal disease virus (IBDV). Expt. 1 was carried out to determine the variation in assay results when the same pools of low-, medium-, and high-titered serum were assayed. Significant variation occurred among separate lots and among test plates within the same lots for the IBV and IBDV assays. In most cases, variability between days and among technicians was not significant. Coefficients of variation were larger than is acceptable for immune-type assays. In the IBDV assay with high-titered serum, most of the wells in the plates reached maximum absorbance and were not capable of detecting titers above 1:8000-1:9000. Expt. 2 was conducted to determine the effects of varying the length of the ortho-phenylene-diamine (OPD) incubation time upon assay results. Either 7-, 12-, or 15-minute OPD incubation times were used. Incubation time significantly affected mean titer at all combinations of assay types and times, except determinations on the low-titered IBV samples. Expt. 3 was conducted to determine the effects of three different dilution methods on observed IBDV titer. The use of non-standard dilutions had significant effects on observed titer. In the medium- and high-titered samples, the use of two different dilution methods at 1:5000 rather than 1:500 resulted in titers that were three to four times those observed at the 1:500 dilution.

Variability in a commercially available enzyme-linked immunosorbent assay system. II. Laboratory variability

An experiment was conducted to determine the amount of variability that occurred in enzyme-linked immunosorbent assays when samples from common serum pools were assayed in five different labs on three consecutive days. Low- (approximately 1:2000), medium- (approximately 1:4000), and high-titered (approximately 1:8000) serum pools were distributed to five poultry industry laboratories that cooperated in the study. Results varied significantly among different laboratories and among different days in the same lab. Variation among days within the same laboratory and among laboratories were large. The greatest variability occurred among labs. Correlations between mean daily titer and laboratory ambient temperature were small and not significant. The amount of variability within and among different laboratories that were observed indicate that single determinations on individual serum samples are not likely to give a reliable estimate of antibody titer. The large variability within labs further indicates the need for standard reference pools of positive serum to be included in assays in order to substantiate assay results.

Development of an enzyme-linked immunosorbent assay for Bordetella avium

A Bordetella avium enzyme-linked immunosorbent assay (ELISA) was developed to detect serum antibodies in 1-day-old poults, experimentally infected turkeys, and naturally infected turkeys. The optimized procedure included use of a suspension of whole bacteria coated onto plastic microtiter plates, a 1:200 serum dilution, a 1:3200 dilution of commercially available goat anti-turkey IgG (heavy and light chain) conjugated with horseradish peroxidase, and 0.04% orthophenylenediamine as substrate. A sample/negative (S/N) ratio method of analysis was used to estimate antibody titer from absorbance values. The regression equation used to estimate antibody titers was derived from the testing of naturally infected turkey sera. The equation was derived by plotting the log10 titer of the sera against the S/N ratio at a 1:200 serum dilution. The ELISA was an effective method for detecting antibody to B. avium, and the procedure should prove useful for laboratories equipped for high-volume ELISA testing.

Application of the positive/negative ratio method of analysis to quantitate antibody responses to infectious bursal disease virus using a commercially available ELISA

An enzyme-linked immunosorbent assay (ELISA) test kit has been developed for infectious bursal disease virus (IBDV), and it is widely used for the detection and quantification of IBDV antibody. With results obtained using the commercial kit, a method of analysis was performed utilizing a positive/negative (P/N) ratio standard curve. A prediction equation was derived from this analysis by which the ELISA titer of a serum sample could be determined using one serum dilution. Values obtained using this method were compared with values obtained by the virus-neutralization equivalent method recommended by the kit manufacturer. The results were comparable in that the trends in titer were similar. The P/N ratio standard curve method is another way of determining titer using the IBDV ELISA test kit.

Comparison of the hemagglutination-inhibition test with the constant-virus diluting-serum microneutralization test for detecting antibody to avian infectious bronchitis virus

An evaluation was made of the hemagglutination-inhibition test and the constant-virus diluting-serum microneutralization test, two serological techniques that are used in detecting antibodies to avian infectious bronchitis. The repeatabilities and sensitivities of both tests were similar. Both tests compared favorably when testing high-titered antisera, but antibody titers detected varied when low-titered sera were used.