Promoting Longitudinal and Developmental Computer-Based Assessments of Clinical Reasoning: Validity Evidence for a Clinical Reasoning Mapping Exercise

PURPOSE

Clinical reasoning is vitally important for practitioners across the health professions. However, the assessment of clinical reasoning remains a significant challenge. Combined with other assessment methods, non-workplace-based assessment can increase opportunities to address multiple components of clinical reasoning, evaluate growth, and foster learning, but tools with validity evidence to assess clinical reasoning outside the workplace are scare. This study examined validity evidence for a novel clinical reasoning mapping exercise (CResME).

METHOD

Data include CResME performance scores from 120 third-year medical students at the University of Central Florida for 3 topics in May 2022. Each CResME was scored by 2 physician raters based on a scoring rubric that included a combined diagnosis and sequence score. Descriptive statistics were used to examine trends in scores. The authors gathered validity evidence for response process, internal structure, and relations to other variables.

RESULTS

The overall mean (SD) score across cases was 66 (29). Internal consistency reliability of cases (Cronbach α) ranged from 0.75 to 0.91. The Phi and G coefficients were 0.45 and 0.56, respectively. Students accounted for 10% of the total variance, indicating the ability to differentiate high and low clinical reasoning skills; the interaction between learner and case accounted for 8.1% of the variance, demonstrating case specificity. There was a moderate correlation between the overall CResME scores and the mean overall score of patient encounter notes from an objective structured clinical examination performed at the end of the third year (0.46; P = .001). Significant associations were also found between the CResME scores and subject exam scores.

CONCLUSIONS

The CResME can be used to facilitate the assessment of clinical reasoning, supporting the developmental progress of learners throughout the curriculum. Future research is needed to gather validity evidence for CResMEs with different learners across different settings and formats.

Multiparametric assessment of the intraprocedural result after transcatheter mitral valve edge-to-edge repair proceduret

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Research grant

OnBehalf

n/a

Background. Quantification of residual mitral regurgitation (MR) after transcatheter edge-to-edge mitral valve repair (TMVr) is challenging.

Objectives.  To evaluate the feasibility and the performance of an intraprocedural multiparametric approach based on echocardiographic and invasive hemodynamic parameters and to develop a multiparametric scoring system for MR grading after TMVr, and to compare this approach against currently recommended methods. 

Methods. Ninety-three consecutive patients treated with MitraClip (April 2019-July 2020) were enrolled. The protocol of MR evaluation included: 2D and 3D color-Doppler (3D-vena contracta area- 3D-VCA), pulsed-wave Doppler (pulmonary vein- PV flow, stroke volume), continuous-wave Doppler (jet density), morphological parameters (spontaneous echocontrast) and invasive hemodynamic (mean left atrial pressure-LAP, V-wave) at baseline and after clip implantation. A multiparametric score (M-score) was calculated by including the significant predictors (3D-VCA, dense jet on CWD, final LAP, final V wave) of primary endpoint (CV death or HF related hospitalization) at one year follow-up, weighted according to the corresponding odds ratio, to predict the clinical outcome at one-month and one-year follow-up. 

Results. The final study population included 86 pts (mean age 78.3 +8.9yrs, 54.6% primary MR). Procedural success was achieved in 78 pts (90.7%). 3D-VCA (AUC 0.808) and current method for MR grading (AUC 0.801) were comparable predictors of lack of symptom improvement (<5 point change in KCCQ-OS score) at one-month (p = 0.398, DeLong’s test). The M-score performed similarly as predictor of one-month follow-up but was a better predictor of primary endpoint at 1-year (AUC 0.919) compared to single parameters (p = 0.005 vs 3D-VCA DeLong"s test) and currently recommended methods for MR grading (p = 0.006 DeLong"s test). The optimal cut-off was 2 points with 86.7% sensitivity and 83.1% specificity.

Conclusion. We evaluated intraprocedural TMVr result in a multiparametric approach showing that 3D-VCA alone is comparable to current recommended method for MR grading. However, the integration of echocardiographic and invasive hemodynamic parameters into a multiparametric score provided a further added value for predicting clinical outcome  at one-year compared to currently recommended methods for MR grading and to 3D-VCA.

Lessons Learned in the Design and Implementation of Virtual Telemedicine Curriculum for Third Year Medical Students Incorporating New AAMC Telehealth Competencies

This article was migrated. The article was marked as recommended. Background: Telehealth, including Telemedicine, is the use of electronic communications technology to provide healthcare at a distance. There is a growing need to train future physicians to be adept and knowledgeable of telehealth. The Association of American Medical Colleges (AAMC) recently defined six core competency domains for Telehealth for medical residents and attending physicians. Methods: A multidisciplinary team of medical educators, Telemedicine practitioners, instructional technology experts and a senior medical student designed a Telemedicine curriculum centered on five primary educational activities. Training moved progressively from novice Telemedicine experiences to Telemedicine encounters with standardized patients and post-encounter debriefs to promote active learning, engagement, and self-regulation. The Telemedicine curriculum was prioritized and delivered to the entire class of 2022 (114 third-year medical students). Results: Student satisfaction surveys and post formative quiz items were used to assess the impact of the Telemedicine Curriculum. Over 95% of surveyed students agreed or strongly agreed the course was organized and helpful in developing clinical skills in preparation for clerkship. Students particularly valued the opportunity to engage in patient encounters while learning Telemedicine-specific patient safety and communication skills. Conclusion: With careful attention to instructional design, active learning formats that are historically successful in face-to-face settings can be equally successful in virtual settings. Standardized patients and peers can be trained to provide appropriate feedback in the right virtual setting.

Subacute postoperative atrial fibrillation after heart surgery: incidence and predictive factors in cardiac rehabilitation

Funding Acknowledgements

Type of funding sources: None.

Background. Postoperative atrial fibrillation (POAF) is the most common arrhythmic complication following cardiac surgery. It may occur between the second and fourth postoperative days as acute POAF, or within 30 days as subacute POAF (sPOAF). The incidence varies from 15% to 60%, with the highest rates observed in patients undergoing valvular surgery. POAF is associated with longer hospital stay and higher thromboembolic risk, which consistently increase patients’ morbidity and mortality. Identification of high-risk categories may allow optimization of in-hospital prevention and treatment, possibly improving clinical outcomes.

Aim of the study. The aim of this study was to assess the incidence of sPOAF and to identify possible predictors in patients performing Cardiovascular Rehabilitation (CR) after Cardiac Surgery (CS).

Methods. A single-centre retrospective study was performed on 383 post-cardiac surgery patients hospitalised in our CR Unit for inpatient rehabilitation. The entire population was on sinus rhythm at the admission in CR and continuous monitoring with 12-lead ECG telemetry was performed during the hospital stay. We calculated the incidence of sPOAF and then evaluated the predictive value of the following variables: anamnestic data, type of cardiac intervention, clinical course in both CS and CR Unit, laboratory parameters including baseline neutrophil-to-lymphocyte ratio (NLR).

Results. Median age was 65 years (63% male). sPOAF was documented in 122 cases (31.9%). Patients developing sPOAF were older [median age 69 (63-76) vs. 61 (51-70); p < 0.001)], more frequently underwent complex surgical procedures (50% vs. 36%; p = 0.009) and were known for previous episodes of atrial fibrillation (27.9% vs. 11.2%; p < 0.001). On the first day after surgery (T1), sPOAF group showed higher values of glycemia [median 155 (126.5–186.8) vs. 129 (106.5–164); p < 0.001] and troponin T [median 721.5 (470.1–1084.3) vs. 488 (301.6-776.2); p < 0.001]. The multivariate analysis identified advanced age (OR 1.04, 95% CI 1.01-1.08; p = 0.023), acute POAF in the Cardiac Surgery Unit (OR 3.51, 95% CI 1.62-7.59; p = 0.001), baseline NLR (OR 1.46, 95% CI 1.10-1.93; p = 0.008) and T1-troponin > 552 ng/L (OR 4.16 95% CI 1.50-11.53; p = 0.006) as independent risk predictors of sPOAF during the CR period.

Conclusions. sPOAF is common after cardiac surgery occurring in 31.9% of patients during CR. Age, acute POAF, baseline NLR and elevated troponin T on the first postoperative day were shown predictors of increased sPOAF risk. Recognition of new predictors of POAF could be helpful to better stratify patients, improving management strategies and outcomes.

Escitalopram Induced Torsade de Pointes and Cardiac Arrest in a Patient With Surgically Treated Mitral Valve Prolapse

A 54-year-old female, with a history of prosthetic mitral valve replacement due to mitral valve prolapse one year prior, was admitted after suffering a cardiopulmonary arrest. Her initial rhythm demonstrated Torsade de Pointes with the initial electrocardiogram (ECG) showing a prolonged QT interval. Laboratory test results were normal including potassium and magnesium serum levels, and imaging did not show significant abnormalities. A review of patients' medicines showed that the patient started taking escitalopram one month prior to the presentation for major depressive disorder. Selective serotonin reuptake inhibitors (SSRI) are widely prescribed and continue to be a mainstay of treatment for multiple psychiatric conditions. It is important to keep the potential cardiovascular side effects of SSRIs in mind when prescribing. Consideration of underlying cardiac conditions is vital to decrease the likelihood of poor outcomes.

Cardiovascular rehabilitation after valvular heart surgery: predictive factors of major complications

Background

The population of patients affected by valvular heart disease is growing and for many of them valvular surgery is still considered the gold standard treatment. Cardiovascular Rehabilitation (CR) following intervention is fundamental for the post-surgical functional recovery and for the monitoring and management of complications that may occur after surgery.

Aim of the study

We aimed at identifying predictors of major complications in patients who underwent valvular surgery and subsequently were involved in an in-patient CR program. Major complications were defined as those requiring an in-patient management: severe anemia needing transfusions, infection of the sternal surgical wound requiring an antibiotic treatment, a positive hemoculture in the presence of systemic signs of infection and pericardial effusion requiring surgical drainage.

Methods and statistical analysis

1600 patients who have been hospitalized in our CR Unit after valvular surgery were enrolled (median age 64 years; 60% males). We examined the demographic data, the cardiovascular risk factors, the main comorbidities, the type of heart surgery (type of valvular surgery and the presence of concomitant other cardiac intervention), the complications developed in Cardiac Surgery Unit and in the CR Unit, the in-hospital length of stay, the 6 minutes-walking tests and principal blood tests.

Results

At multivariate analysis we found that chronic renal dysfunction [OR 1,902 (CI 1,103–3,280), p=0,021], complex cardiac intervention [OR 1,554 (CI 1,030–2,344), p=0,036], sternal re-synthesis [OR 4,671 (CI 1,659–13,152), p=0,004], early post-surgical transfusions [OR 1,670 (CI 1,083–2,573), p=0,020] are independent risk factors for major complications, while a higher hemoglobin value at CR admission [OR 0,677 (CI 0,566–0,810), p<0,001] resulted an independent protective factor.

Conclusions

We identified predictors of major complications during CR after valvular surgery. These factors may help in defining the patients at major risk tailoring the patient management, adopting an individualized clinical and instrumental monitoring. A tailored CR period gives the possibility to optimize the use of hospital economic resources and to achieve a better final outcome.

Funding Acknowledgement

Type of funding source: None

P271 Hypoplastic posterior mitral leaflet associated with Marfan syndrome

Picture legend

(A) Mid-esophageal 4-chamber view shows severe hypoplasia of PML (red arrow) and the posterior ventricular myocardial shelf (green arrow). (B) Mid-esophageal commissural view shows a large central MR jet. (C) 3D ventricular perspective of the mitral valve: an almost complete absence of the PML can be appreciated in the central and lateral scallops (grey arrows). (D) CT 3 chamber view shows the myocardial shelf which takes the role of the posterior mitral annulus (blue arrow) and direct PML chordal insertion into the ventricular wall (yellow arrow). (E) CT reconstruction of the mitral valve shows a virtually absent P1 (< 1mm), a P2 length of 4.1 mm, and a P3 length of 5 mm.

Abstract P271 Figure. Hypoplastic posterior mitral leaflet

1183 Three-dimensional echocardiographic paramenters for mitral valve quantification: a feasibility and validation study

Introduction

Mitral regurgitation (MR) severity affects prognosis and a correct quantification is key for surgical indication. A multiparametric approach (MPA) is recommended, as singular parameters suffer pitfalls. Recently suggested three-dimensional echocardiographic (3DE) parameters lack clear reference values. No studies have assessed the feasibility of regurgitant volume (RV) and fraction (RF) using the 3D planimetric area of the mitral annulus (MAA) and of the left ventricular outflow tract (LVOTA).

Purpose

To assess the feasibility and reliability of 3DE, RV and RF obtained by doppler volumetric method using MAA and LVOTA, compare results with 2DE and 3D vena contracta area (VCA) and propose cut-offs for these parameters using MPA as gold standard.

Methods

Patients referred to our Department for MR assessment were enrolled from September 2018 to February 2019 without more than mild aortic regurgitation or severe stenosis, mitral stenosis and previous valvular surgery. Transthoracic 2DE was used to calculate a multiparametric index of MR severity including: jet area/left atrium (LA) area, CW characteristics, 2D vena contracta, PISA, pulmonary vein flow, LA volume and systolic pulmonary artery pressure. Transoesophageal 3DE was used to assess MAA and LVOTA from a 3D dataset. RV and RF were calculated by Doppler volumetric method using the planimetric areas instead of diameters. VCA 3D was calculated from a 3D color dataset as the cross-sectional area of the regurgitant jet. We compared the results between 2DE and 3DE and between functional and organic MR. ROC curves were analyzed to assess diagnostic performance and identify cut-offs for severity prediction. Intraclass correlation coefficient was calculated to assess variability in measurements.

Results

Population was composed by 87 patients (56 male, 65 ± 13 years), 72% organic MR. MAA was larger in 2DE (10.4 ± 3.2 vs 9.8 ± 2.9 cm2,) as was the RV (76.6 ± 36.1 vs 66.4 ± 31.9 ml) and RF (55.4 ± 12.4 vs 50.4 vs 10.9%, all p < 0.0001), while LVOTA was smaller (3.9 ± 0.98 vs 4.1 ± 1.0 cm2, p < 0.0001). RV 2D and RF 2D were larger in the organic MR group (p < 0.0001), meanwhile VCA 3D, RV 3D and RF 3D did not show a significant difference (all p > 0.1). VCA 3D had a good correlation with RV 3D (r = 0.593, p < 0.0001) and RF 3D (r = 0.576, p < 0.0001).

We proposed a cut-off value of 41.5 mm2 for VCA 3D (94% sens, 96% spec, AUC 0.978), 52 ml for RV 3D (84% sens, 78% spec, AUC 0.901) and 47.6% for RF 3D (91% sens, 90% spec, AUC 0.966) to predict MR severity as assessed by MPA.

Intraclass correlation coefficient was 0.980 for MAA and 0.985 for LVOTA for intra-observer variability, while for inter-observer variability it was 0.951 for MAA and 0.962 for LVOTA.

Conclusion

2DE overestimates MA dimensions and underestimates LVOT dimensions thus overestimating RV and RF. 3DE measures are relatively simple and reproducible. Proposed cut-offs for RV, RF and VCA 3D have a good diagnostic power.

428 Prognostic implications of the relationship between effective regurgitant orifice area and left ventricle end diastolic volume in patients with functional mitral regurgitation treated with MitraClip

Funding Acknowledgements

none

Background

The distinction between proportionate and disproportionate functional mitral regurgitation (FMR), based on the relationship between effective regurgitant orifice area (EROA) and left ventricle end diastolic volume (LVEDV), has recently been proposed as a possible new clinical and physiopathological framework to identify patients that could likely benefit from transcatheter mitral repair.

Purpose The aim of our study was to explore the possible prognostic implications of the EROA/LVEDV ratio in patients with FMR treated with MitraClip.

Methods – Baseline EROA/LVEDV was calculated in 137 patients with at least moderate-to-severe, symptomatic FMR treated with MitraClip. All patients underwent clinical, biochemichal and echocardiographic evaluation before MitraClip. EROA was calculated using PISA method. The primary outcome was a composite end-point of all-cause death or re-hospitalization for heart failure (HF).

Results – The median follow-up was 1.1 years. The primary outcome occurred in 59 patients (43 %). Population study showed a LVEDVi 113.52± 32.16 mL/m2, LVEF 29.75± 10.06% and EROA 39.45± 15.43 mm2.. The cut-off value of EROA/LVEDV ratio for primary outcome, identified by receiver operating characteristic curve, was 0.15 (AUC 0,65, p = 0.002) with a sensitivity and specificity of 78% and 52%, respectively. Patients were divided in two groups according to the identified cut-off. Patients with higher ratio (Group I, n = 88) presented a less dilated LV (LVEDVi: 105.1 ± 29.6 mL/m2 vs 128.2 ± 31.9 mL/m2, p < 0.001; LVESVi: 73.1 ± 27.7 mL/m2 vs 94.9 ± 29.05 mL/m2, p < 0.001), and a more severe MR (EROA: 47.9 ± 12.1 mm2 vs 25.1 ± 8.3 mm2, p < 0.001; vena contracta: 7.2 ± 1.3 mm vs 6.5 ± 1.3 mm, p = 0.008). There were no significant differences of left ventricle ejection fraction, right ventricle systolic function and systolic pulmonary pressure between the groups. At univariate analysis, EROA/LVEDV ratio >0.15 (HR = 2.223, 95% CI 1.121-4.411, p = 0.022), baseline evidence of atrial fibrillation (HR = 1.949, 95% CI 1.156-3.283, p = 0.012) and baseline pro-BNP (HR= 1.000, 95% CI 1.000-1.000, p = 0,001) were associated with a worse clinical outcome. At multivariate Cox-regression analysis, both EROA/LVEDV ratio >0.15 and baseline pro-BNP values were identified as independent predictors (HR 2.941, 95% CI 1.035-8.353, p = 0.043; HR = 1.000, 95% CI 1.000-1.000, p = 0.002, respectively). At Kaplan-Meier survival analysis, patients with EROA/LVEDV >0.15 had a significant lower freedom from composite endpoint (log-rank χ2 =5.517, p= 0.019; Fig. 1).

Conclusion

Our data show that EROA/LVEDV ratio was an independent predictor of adverse clinical outcome in FMR patients treated with MitraClip. This preliminary experience shows that this index could help to identify subgroups of patients with potential different clinical benefits from Mitraclip therapy. However, further and extended data are needed to provide more precise evidence.

Abstract 428 Figure. Fig. 1

P43673D analysis of mitral annular reshape with third generation MitraClip XTr in functional and degenerative mitral regurgitation

The 3rd generation Mitraclip XTr was recently introduced to improve device performance, through longer clip arms that should allow better grasping of the mitral leaflets, thus improving coaptation and results eventually. Several studies have demonstrated additional effects such as the reshape of the mitral annulus immediately after clip implantation.

The aim of our study was to evaluate the mitral valve (MV) annular remodelling with MitraClip XTr.

Between March 2018 and November 2018, 75 consecutive patients were enrolled. The population was divided in two groups: functional mitral regurgitation (FMR) and degenerative mitral regurgitation (DMR).

The 3D MV datasets at baseline and immediately after the procedure were acquired and then analysed with semiautomatic MVQ software (QLAB Cardiac 3DQ v.10.0; Philips Medical Systems).

The software provides the following parameters: annular diameters (antero-posterior, AP, and inter-commissural, IC), circumference, area, height and ellipsicity (IC/AP ratio as percentage); saddle-index, defined as annular height to IC diameter ratio was derived.

The 3D post-processing was feasible in 54 patients (108 3D datasets): 28 had FMR (52%) and 26 had DMR (48%).

An average of 1.8 clips per patient were implanted: 2 clips in 38 (70%), 1 clip in 14 (26%) and 3 clips in 2 (4%) patients. The position was central in 93% of the procedures.

Results are reported in table 1. In the FMR group, a reduction in the AP diameter (p=0.001), an increase in both IC diameter (p=0.001) and annular ellipsicity (p<0.001) were observed.

In the DMR group, an increase in annular ellipsicity (p=0,008) and in saddle-index (p<0.05) were observed.

Table 1 Functional mitral regurgitation (N=28) Degenerative mitral regurgitation (N=26) Pre-clip Post-clip P-value Pre-clip Post-clip P-value IC diameter (mm) 39.3±4.2 41.9±4.1 0.001 40.9±6.5 41.8±5.8 0.257 AP diameter (mm) 32.8±4.6 30.4±3.2 0.001 32.6±4.8 31.7±4.5 0.199 Annular Height (mm) 5.1±1.8 5.4±1.8 0.336 4.8±1.9 5.7±2.2 0.026 3D circumference (mm) 122.7±15.1 123.5±11 0.718 123.5±19.0 124.0±17.1 0.812 3D area (mmq) 1128.0±280 1113.7±206 0.752 1160±346.7 1156.8±318.0 0.926 Annular ellipsicity (%) 121.5±12.2 138.5±11.8 0.0005 125.9±9.6 132.4±10.7 0.008 Saddle index 13.0±4 13.0±4 0.957 11.8±4.2 13.6±4.2 0.048

Our study demonstrates that the XTr implantation produces a MV annular remodelling both in FMR and DMR probably with different mechanisms. In FMR the MV annulus resulted more elliptical, wheras in DMR the geometrical modifications involve both the ellipsicity and the saddle-shape morphology.

P4728Prognostic implications of the relationship between effective regurgitant orifice area and left ventricle end diastolic volume in patients with functional mitral regurgitation treated with MitraClip

Background

The distinction between proportionate and disproportionate functional mitral regurgitation (FMR), based on the relationship between effective regurgitant orifice area (EROA) and left ventricle end diastolic volume (LVEDV), has recently been proposed as a possible new clinical and physiopathological concept to identify patients that could likely benefit from transcatheter mitral repair.

Purpose

The aim of our study was to explore the possible prognostic implications of the EROA/LVEDV ratio in patients with FMR treated with MitraClip.

Methods

Baseline EROA/LVEDV ratio was calculated in 72 patients with moderate-to-severe, symptomatic FMR treated with MitraClip. All patients underwent clinical, biochemichal and echocardiographic evaluation before MitraClip. EROA was calculated using PISA method. The primary outcome was a composite end-point of all-cause death or re-hospitalization for heart failure (HF).

Results

The median follow-up was 1 year. The primary outcome occurred in 25 patients (34.7%). The cut-off value of EROA/LVEDV ratio for primary outcome, identified by receiver operating characteristic curve, was 0.15 (p=0.007) with a sensitivity and specificity of 72 and 68%, respectively. Patients were divided in two groups according to the identified cut-off. Patients with higher ratio (Group I, n=35) presented a less dilated LV (LVEDVi: 113.2±33.4 mL vs 129.3±29.3 mL, p=0.033; LVESV: 140.7±49.0 mL vs 171.1±47.4 mL, p=0.010), a better LV systolic function (LVEF: 31.9±9.5% vs 27.8±5.8%, p=0.028) and a more severe MR (EROA: 44.5±12.9 mm2 vs 24.5±6.8 mm2, p<0.001; vena contracta: 7.4±1.5 mm vs 6.7±1.0 mm, p=0.045). Patients with lower ratio (Group II, n=37) showed a reduced prevalence of MV annular dilation (57.1% vs 91.7%, p=0.005) and a worse RV function (s'TDI: 9.2±2.2 cm/s vs 10.5±2.9 cm/s, p=0.039). At univariate analysis, EROA/LVEDV ratio >0.15 (HR = 2.467, 95% CI 1.017–5.982, p=0.046) and severe pulmonary hypertension (HR = 2.481, 95% CI 1.030–5.976, p=0.043) were associated with a worse clinical outcome. At multivariate Cox-regression analysis, both EROA/LVEDV ratio >0.15 and severe pulmonary hypertension were identified as independent predictors (HR 3.203, 95% CI 1–310–7.832, p=0.011; HR = 3.280, 95% CI 1.326–8.116, p=0.010, respectively).

Figure 1

Conclusion

Our data show that EROA/LVEDV ratio was an independent predictor of adverse clinical outcome in FMR patients treated with MitraClip. This preliminary experience shows that this index could help to identify subgroups of patients with potential different clinical benefits from MitraClip therapy. However, further and extended data are needed to provide more precise evidence.

Acknowledgement/Funding

None

P4385Diaphragm dysfunction following cardiac surgery: role of ultrasound imaging for initial and follow-up assessment during cardiac rehabilitation

Background

Diaphragm dysfunction is a common complication of cardiac surgery, often underdiagnosed. Ultrasonography (US) is a promising technique for diaphragmatic assessment. Few trials have been conducted using US after heart surgery and no clear data exist on the recovery of diaphragm function after cardiovascular rehabilitation (CR).

Purpose

The aim of this study is to evaluate post-cardiac surgery diaphragm dysfunction using US and to assess the impact of an inpatient CR programme on its functional recovery.

Methods

In a single-centre prospective cohort study 97 consecutive patients hospitalised in our CR Unit were enrolled. 14 patients underwent aortic valve replacement, 38 mitral valve repair or replacement, 14 coronary artery bypass grafting (CABG), 22 combined surgery, and 9 other surgical interventions. We performed diaphragm US at admission and after 10 rehabilitative sessions. The following parameters were assessed: thickening fraction (TF) in B-mode on the right intercostal projections, and excursion, time of inspiration, time of a respiratory cycle and contraction velocity in M-mode on right anterior subcostal projections.

Results

After cardiac surgery, the incidence of diaphragm dysfunction and paralysis were 60% and 1%, respectively. Patients with TF <20% at admission showed a significant improvement in TF (13.30%, IQR 8.69–17.39 vs 27.27%, IQR 21.05–31.58; p<0.001), excursion (1.67cm, IQR 1.3–2.1 vs 2.23cm, IQR 1.9–2.7; p<0.001), time of inspiration (0.9s, IQR 0.9–1.07 vs 1.01s, IQR 0.87–1.13; p=0.005), time of a respiratory cycle (2.67s, IQR 2.38–3.05 vs 3.07s, IQR 2.68–3.35; p<0.001) and velocity (1.81cm/s, IQR 1.14–2.33 vs 2.24cm/s, IQR 1.92–2.76; p<0.001). On the contrary, in patients with a TF>20%, no additional improvement was observed. In both groups, there was a significant improvement in the parameters of physical performance.

In particular, in the group with a TF<20%, the distance covered during the 6MWT (300m, IQR 205–370 vs 555m, IQR 450–612; p<0.001) and the energy cost of physical activity (2.60, IQR 2.13–2.92 vs 4.09, IQR 3.44–4.50; p<0.001) increased while the perception of exertion (Borg Scale 11, IQR 11–13 vs 13, IQR 12–13; p=0.011) was reduced. At the 10th day assessment, 51.5% of the total population had a recovery of diaphragm function, whilst 48.5% had a failure of recovery (TF relative change between admission and discharge <60%). The multivariate analysis identified CABG as an independent predictor of failure of diaphragm recovery (OR 5.44; CI 1.10–26.84, p=0.037).

Conclusion

US might be a valuable part of routine clinical practice for initial and follow-up assessment of patients after open-heart surgery. CR showed to be an effective strategy to improve diaphragm parameters in patients with post-surgical dysfunction. Progressive evaluation of diaphragm function may drive personalised rehabilitation programmes.

P2522A new scoring system to stratify post-surgical valvular patients during cardiovascular rehabilitation: derivation and validation study

Background

Guidelines underline the importance of Cardiovascular Rehabilitation (CR) in post-surgical valvular patients both for the functional recovery and the monitoring of complications. However, there are no established indicators to better categorise their risk and to identify the real probability of recovery.

Purpose

The aim of this study is to propose and validate a scoring system to appropriately stratify post-surgical valvular patients in order to individualise CR programmes.

Methods

A retrospective study was conducted on 1480 post-surgical valvular patients hospitalized in our CR Unit (902 M – 578 F; median age of 64 years, IQR 53–73). 485 patients underwent single heart valve repair, 408 single heart valve replacement, 237 single heart valve surgery and additional interventions, 249 multiple valve interventions and 101 multiple heart valves and additional interventions. Subjects were randomised in two groups for data analysis: a Derivation (D; n=1000) and a Validation (V; n=480) group. Initially, in group D we assessed the predictive value of anamnestic, clinical and laboratory variables for major complications and functional recovery. We created two scoring systems for these outcomes and, subsequently, we validated them on group V. Finally, we interlaced them in an operative algorithm.

Results

Chronic kidney disease (OR 2.588; 95% CI 1.232–5.436; p=0.012), sternal surgical re-synthesis (OR 7.757; 95% CI 2.042–29.471; p=0.003), post-surgical transfusions (OR 2.419; 95% CI 1.407–4.161; p=0.001) and Troponin T peak >1400 μg/L (OR 2.441; 95% CI 1.418–4.200; p=0.001) were independent predictors for the occurrence of major complications in group D. Age (OR 0.958; 95% CI 0.9339–0.977; p<0.001), post- surgical transfusions (OR 1.981; 95% CI 1.160–3.380; p<0.001) and METS at admission (OR 0.032; 95% CI 0.017–0.061; p<0.001) were independent predictors of a higher functional recovery in group D. When the two scoring systems were validated on group V, we obtained a z score of 0.07 (p=0.941) for the major complications risk score and a z score of 1.23 (p=0.219) for the functional recovery stratification system, respectively, indicating a very reliable model. We proceeded to build an operative algorithm to stratify patients and propose personalised CR strategies.

Conclusions

We identified predictors to stratify the risk of complications and to define the probability of recovery in post-surgical valvular patients undergoing CR. The proposed final operative algorithm may be a unique tool to support the cardiologist to tailor rehabilitation programmes. This may lead to better outcomes and reduction of healthcare expenditure with optimisation in the use of available resources.

Acknowledgement/Funding

None

Pre-clerkship medical students' perceptions of medical professionalism

BACKGROUND

Professionalism instruction and assessment is a core component of medical education, and essential for professional identity formation (PIF). Thus, understanding the socialization of medical students to the values of the profession (i.e., medical professionalism), and how these may evolve, warrants continued understanding.

METHODS

The purpose of this study was to examine and compare pre-clerkship (first and second year) medical students' perceptions of professionalism. First and second year medical students participate in this study. This was a two-phase mixed-methods cohort study conducted across two academic years (2014-2015 and 2015-2016). In Phase I, first and second year medical students participated in a nominal group technique (NGT) session. NGT data was analyzed qualitatively to generate a card-sorting exercise of professionalism attributes for Phase II. In Phase II, data from the sorting task was analyzed using Principle Component Analysis (PCA).

RESULTS

The PCA for first year students derived a 7-factor solution. Factors (i.e., professionalism domains) identified were: Self-management and patient-centeredness, ethics and professional reputation, dependability, self-awareness and self-improvement, image, proficiency and lifelong learning and integrity. The PCA for second year students derived a 5-factor solution; factors identified were: "Good Doctor" attributes, responsibility, ethics, innovation and self-improvement and unbiased.

CONCLUSIONS

Identification and organization of attributes into an overarching professionalism mental model provide a window into the active reconstruction of students' professional identity during the nascent stages of medical education. M1 professionalism domains were more consistent with the conventional professional image of the physician (e.g. Ethics and Professional reputation, Dependability, Integrity), whereas, M2 domains reflected a more global view (e.g., "Good Doctor" attributes, Responsibility, Ethics). This study provides a lens into the dynamic nature of students' PIF and encourages educators to evaluate PIF pedagogy at their own institutions.

Intra-procedural monitoring protocol using routine transthoracic echocardiography with backup trans-oesophageal probe in transcatheter aortic valve replacement: a single centre experience

Aim

The aim of this study is to describe our 9-year experience in transcatheter aortic valve replacement (TAVR) using transthoracic echocardiography (TTE) as a routine intra-procedural imaging modality with trans-oesophageal echocardiography (TEE) as a backup.

Methods and results

From January 2008 to December 2017, 1218 patients underwent transfemoral TAVR at our Institution. Except the first 20 cases, all procedures have been performed under conscious sedation, with fluoroscopic guidance and TTE imaging monitoring. Once the TTE resulted suboptimal for final result assessment or a complication was either suspected or identified on TTE, TEE evaluation was promptly performed under general anaesthesia. Only 24 (1.9%) cases required a switch to TEE: 6 cases for suboptimal TTE prosthetic valve leak (PVL) quantification; 12 cases for haemodynamic instability; 2 cases for pericardial effusion without haemodynamic instability; 4 cases for urgent TAVR. The 30-days and 1-year all-cause mortality were 2.1% and 10.2%, respectively. Cardiac mortality at 30-days and 1-year follow-up were 0.6% and 4.1%, respectively. Intra-procedural and pre-discharge TT evaluation showed good agreement for PVL quantification (k agreement: 0.827, P = 0.005).

Conclusion

TTE monitoring seems a reasonable imaging tool for TAVR intra-procedural monitoring without delay in diagnosis of complications and a reliable paravalvular leak assessment. However, TEE is undoubtedly essential in identifying the exact mechanism in most of the complications.

The Clinical Reasoning Mapping Exercise (CResME): a new tool for exploring clinical reasoning

INTRODUCTION

National organizations have identified a need for the creation of novel approaches to teach clinical reasoning throughout medical education. The aim of this project was to develop, implement and evaluate a novel clinical reasoning mapping exercise (CResME).

METHODS

Participants included a convenience sample of first and second year medical students at two US medical schools: University of Central Florida (UCF) and Uniformed Services University of Health Sciences (USUHS). The authors describe the creation and implementation of the CResME. The CResME uses clinical information for multiple disease entities as nodes in different domains (history, physical exam, imaging, laboratory results, etc.), requiring learners to connect these nodes of information in an accurate and meaningful way to develop diagnostic and/or management plans in the process.

RESULTS

The majority of medical students at both institutions felt that the CResME promoted their understanding of the differential diagnosis and was a valuable tool to compare and contrast elements of a differential diagnosis. Students at both institutions recommended using the CResME for future sessions.

DISCUSSION

The CResME is a promising tool to foster students' clinical reasoning early in medical school. Research is needed on the implementation of the CResME as an instructional and assessment strategy for clinical reasoning throughout medical school training.

Quantitative and Qualitative Analysis of the Impact of Adoption of a Mobile Application for the Assessment of Professionalism in Medical Trainees

PURPOSE

Capturing either lapses or excellence in behaviors related to medical professionalism is difficult. The authors report a mixed-methods analysis of a novel mobile platform for assessing medical professionalism in a training environment.

METHOD

A mobile Web-based platform to facilitate professionalism assessment in a situated clinical setting (Professional Mobile Monitoring of Behaviors [PROMOBES]) was developed. A professionalism framework consisting of six domains (reliability, adaptability, peer relationships, upholding principles, team relationships, and scholarship) encompassing 25 subelements underpins the reporting structure. This pilot study involved 26 faculty supervising 93 medical trainees at two sites from January 12 to August 8, 2016. Notable professionalism behaviors were linked to the framework domains and elements; narrative details about incidences were captured on mobile devices. Surveys gauged the technological functionality and impact of PROMOBES on faculty assessment of professionalism. Qualitative focus groups were employed to elucidate user experience.

RESULTS

Although users anticipated PROMOBES's utility would be for reporting lapses in professionalism, 94.7% of reports were for commendation. Comfort assessing professionalism (P = .04) and recognition of the reporting procedures for professionalism-related concerns (P = .01) improved. PROMOBES attained high acceptance ratings. Focus group analysis revealed that the explicit connection to the professionalism framework was powerful; similarly, the near real-time reporting capability, multiple observer inputs, and positive feedback facilitation were strengths.

CONCLUSIONS

Making the professionalism framework visible and accessible via a mobile platform significantly strengthens faculty knowledge and behaviors regarding assessment. The strong desire to capture positive behaviors was an unexpected finding.

Contextual Influences of Trainee Characteristics and Daily Workload on Trainee Learning Preferences

We previously defined teaching domains necessary for successful inpatient medicine attending rounds from the trainees' perspective in Role Modeling, Learning Environment, Teaching Process and Team Management. We sought to understand whether trainee characteristics and daily fluctuations in workload influence the prioritization of these domains. We conducted a prospective observational study in general medicine inpatient wards at a university, Veterans Affairs, and a county hospital affiliated with one academic institution over the course of 6 months. All student and resident trainees on internal medicine inpatient wards were eligible to participate. We designed a daily assessment tool on which trainees were asked to identify the teaching domain most important to them, along with information on sex, training level, call-cycle day, patient census, and number of team members absent during rounds. We examined associations between training level and workload factors with the prioritized teaching domain using Pearson's chi-square analysis, adjusted for clustering effects. We collected 1,378 daily assessment cards evaluating 53 (91%) attending physicians. Students valued Teaching Process (𝑃 < 0.001), while senior residents sought Team Management (𝑃 < 0.001). On most days, Teaching Process was prioritized (𝑃 = 0.005). On post-call days and days with a high patient census, Team Management was prioritized (𝑃 < 0.001). Attending physicians may consider tailoring rounds in response to work-related pressures. Days with a high workload are better suited for demonstrating efficient and effective patient care skills.

Health Maintenance in Postmenopausal Women

Cardiovascular disease is the leading cause of death and disability in postmenopausal women older than 50 years. Clinicians should use the pooled cohort risk assessment equations or another risk calculator every three to five years to estimate a woman's 10-year risk of atherosclerotic cardiovascular disease, including myocardial infarction and stroke. Major guidelines concur that women at average risk of breast cancer benefit from screening mammography at least every other year from 50 to 74 years of age. Several effective options for colorectal cancer screening are recommended for women 50 to 75 years of age. Cervical cancer screening should occur at three- or five-year intervals depending on the test used, and can generally be discontinued after 65 years of age or total hysterectomy for benign disease. Screening for ovarian cancer is not recommended. Clinicians should consider screening for sexually transmitted infections in older women at high risk. Postmenopausal women should be routinely screened for depression, alcohol abuse, and intimate partner violence.

Paraganglioma of the Urinary Bladder: A Rare Cause of Hypertension and Urinary Tract Infections

Pheochromocytoma is a neoplasm, which develops from cells of the chromaffin tissues that are derived from the ectodermic neural system and mostly situated within the adrenal medulla. Approximately 15% of pheochromocytoma cases arise from extra-adrenal chromaffin tissue. Pheochromocytoma of the bladder is rare and accounts for less than 0.06% of all bladder neoplasms and less than 1% of all pheochromocytomas. We report a case of a young woman who presented with uncontrolled hypertension, recurrent urinary tract infections and micturition attacks and was found to have a metastatic bladder paraganglioma. In addition, we provide a summary table of the clinical manifestations of paragangliomas based on anatomic locations.

When Nothing Else Works: Fresh Frozen Plasma in the Treatment of Progressive, Refractory Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema

Angioedema is a severe form of an allergic reaction characterized by the localized edematous swelling of the dermis and subcutaneous tissues. Angiotensin-converting enzyme inhibitor-induced angioedema (ACEI-IA) is an allergic reaction that can be severe in some cases requiring advanced management measures. Fresh frozen plasma has been used off-labeled in some case reports to improve and to prevent worsening of the angioedema in a few cases of ACEI-IA. We are reporting this case to increase the awareness of physicians and to widen their therapeutic options when encountering this clinically significant condition.

Medical Students' Attitudes Toward Non-Adherent Patients Before and After a Simulated Patient-Role Activity and Small-Group Discussion: Revisited

Introduction

This study seeks to explore whether the documented decline in medical student empathy can be prevented or slowed using simulated patient-role activities and small-group discussions about the patient experience of living with a chronic illness.

Methods

First-year students (M1, n = 118) at the University of Central Florida College of Medicine (UCFCOM) participated in a simulated patient-role activity resembling the experience of a patient with Type 2 diabetes mellitus. The activity included taking daily “medication,” participating in moderate exercise, and maintaining a low carbohydrate diet. At the end of the simulated patient-role activity, students took part in a small-group discussion about their experiences. Students completed the Jefferson Scale of Physician Empathy: Student Version (JSPE:S) before and after the activity. Additionally, fourth-year students (M4) at UCFCOM completed the JSPE:S to serve as the control, as this class completed the curriculum without any simulated patient-role activities.

Results

A total of 86 responses out of 118 possible M1 participants (73% response rate) were received. Of these, 62 surveys were completed and were therefore used for statistical analysis. A dependent sample t-test revealed no statistically significant increase on pre-activity (M = 111.15, SD = 8.56) and post-activity (M = 111.38, SD = 9.12) empathy scores (p = .78). A positive correlation was revealed to exist between pre- and post-activity empathy scores (r = 0.72, p < 0.001). Empathy comparisons for the full sample M1 post-activity results (n = 62) and the M4 results (n = 16, M = 106.56, SD = 10.61) revealed no statistically significant difference (p = .11).

Discussion

Although previous authors have shown that patient role-playing activities, such as those performed in this study, should maintain and/or increase empathy in medical students, our findings suggest that on a short-term scale, empathy levels were not affected by the activity.

Impact of an educational intervention on provider knowledge, attitudes, and comfort level regarding counseling women ages 40-49 about breast cancer screening

Background

Mammography screening for women under the age of 50 is controversial. Groups such as the US Preventive Services Task Force recommend counseling women 40–49 years of age about mammography risks and benefits in order to incorporate the individual patient’s values in decisions regarding screening. We assessed the impact of a brief educational intervention on the knowledge and attitudes of clinicians regarding breast cancer screening.

Methods

The educational intervention included a review of the risks and benefits of screening, individual risk assessment, and counseling methods. Sessions were led by a physician expert in breast cancer screening. Participants were physicians and nurses in 13 US Department of Veterans Affairs primary care clinics in Alabama. Outcomes were as follows: 1) knowledge assessment of mammogram screening recommendations; 2) counseling practices on the risks and benefits of screening; and 3) comfort level with counseling about screening. Outcomes were assessed by survey before and after the intervention.

Results

After the intervention, significant changes in attitudes about breast cancer screening were seen. There was a decrease in the percentage of participants who reported that they would screen all women ages 40–49 years (82% before the intervention, 9% afterward). There was an increase in the percentage of participants who reported that they would wait until the patient was 50 years old before beginning to screen (12% before the intervention, 38% afterward). More participants (5% before, 53% after; P<0.001) said that they would discuss the patient’s preferences. Attitudes favoring discussion of screening benefits increased, though not significantly, from 94% to 99% (P=0.076). Attitudes favoring discussion of screening risks increased from 34% to 90% (P<0.001). The comfort level with discussing benefits increased from a mean of 3.8 to a mean of 4.5 (P<0.001); the comfort level with discussing screening risks increased from 2.7 to 4.3 (P<0.001); and the comfort level with discussing cancer risks and screening preferences with patients increased from 3.2 to 4.3 (P<0.001). (The comfort levels measurements were assessed by using a Likert scale, for which 1= not comfortable and 5= very comfortable.)

Conclusion

Most clinicians in the US Department of Veterans Affairs ambulatory practices in Alabama reported that they routinely discuss mammography benefits but not potential harms with patients. An educational intervention detailing recommendations and counseling methods affected the knowledge and attitudes about breast cancer screening. Participants expressed greater likelihood of discussing screening options in the future.

Teaching behaviors that define highest rated attending physicians: a study of the resident perspective

BACKGROUND

Better understanding teaching behaviors of highly rated clinical teachers could improve training for teaching. We examined teaching behaviors demonstrated by higher rated attending physicians.

METHODS

Qualitative and quantitative group consensus using the nominal group technique (NGT) among internal medicine residents and students on hospital services (2004-2005); participants voted on the three most important teaching behaviors (weight of 3 = top rated, 1 = lowest rated). Teaching behaviors were organized into domains of successful rounding characteristics. We used teaching evaluations to sort attending physicians into tertiles of overall teaching effectiveness.

RESULTS

Participants evaluated 23 faculty in 17 NGT sessions. Participants identified 66 distinct teaching behaviors (total sum of weights [sw] = 502). Nineteen items had sw ≥ 10, and these were categorized into the following domains: Teaching Process (n = 8; sw = 215, 42.8%), Learning Atmosphere (n = 5; sw = 145, 28.9%), Role Modeling (n = 3; sw = 74, 14.7%) and Team Management (n = 3; sw = 65, 12.9%). Attendings in the highest tertile received a larger number of votes for characteristics within the Teaching Process domain (56% compared to 39% in lowest tertile).

CONCLUSIONS

The most effective teaching behaviors fell into two broad domains: Teaching Process and Learning Atmosphere. Highest rated attending physicians are most recognized for characteristics in the Teaching Process domain.

Succeeding as a Clinician Educator: useful tips and resources

Clinician Educators (CEs) play an essential role in the education and patient care missions of academic medical centers. Despite their crucial role, academic advancement is slower for CEs than for other faculty. Increased clinical productivity demands and financial stressors at academic medical centers add to the existing challenges faced by CEs. This perspective seeks to provide a framework for junior CEs to consider with the goal of maximizing their chance of academic success. We discuss six action areas that we consider central to flourishing at academic medical centers: 1. Clarify what success means and define goals; 2. Seek mentorship and be a responsible mentee; 3. Develop a niche and engage in relevant professional development; 4. Network; 5. Transform educational activities into scholarship; and 6. Seek funding and other resources.

Using cognitive mapping to define key domains for successful attending rounds

BACKGROUND

Ward attending rounds are an integral part of internal medicine education. Being a good teacher is necessary, but not sufficient for successful rounds. Understanding perceptions of successful attending rounds (AR) may help define key areas of focus for enhancing learning, teaching and patient care.

OBJECTIVE

We sought to expand the conceptual framework of 30 previously identified attributes contributing to successful AR by: 1) identifying the most important attributes, 2) grouping similar attributes, and 3) creating a cognitive map to define dimensions and domains contributing to successful rounds.

DESIGN

Multi-institutional, cross-sectional study design.

PARTICIPANTS

We recruited residents and medical students from a university-based internal medicine residency program and a community-based family medicine residency program. Faculty attending a regional general medicine conference, affiliated with multiple institutions, also participated.

MAIN MEASURES

Participants performed an unforced card-sorting exercise, grouping attributes based on perceived similarity, then rated the importance of attributes on a 5-point Likert scale. We translated our data into a cognitive map through multi-dimensional scaling and hierarchical cluster analysis.

KEY RESULTS

Thirty-six faculty, 49 residents and 40 students participated. The highest rated attributes (mean rating) were "Teach by example (bedside manner)" (4.50), "Sharing of attending's thought processes" (4.46), "Be approachable-not intimidating" (4.45), "Insist on respect for all team members" (4.43), "Conduct rounds in an organized, efficient & timely fashion" (4.39), and "State expectations for residents/students" (4.37). Attributes were plotted on a two-dimensional cognitive map, and adequate convergence was achieved. We identified five distinct domains of related attributes: 1) Learning Atmosphere, 2) Clinical Teaching, 3) Teaching Style, 4) Communicating Expectations, and 5) Team Management.

CONCLUSIONS

We identified five domains of related attributes essential to the success of ward attending rounds.

Effects of chronic elevation of atrial natriuretic peptide and free fatty acid levels in the induction of type 2 diabetes mellitus and insulin resistance in patients with mitral valve disease

BACKGROUND AND AIMS

The relationship between atrial natriuretic peptide (ANP), increased free fatty acid (FFA) and insulin resistance in patients with mitral valve disease (MVD), a group characterised by elevated atrial pressure and increased ANP levels, is not defined. The present study was performed to evaluate, in MVD patients, the relationship between increased ANP and FFA levels and insulin resistance and the role of mitral valve replacement/repair in ameliorating these metabolic alterations. Conversely, coronary heart disease (CHD) patients were evaluated before and after coronary artery bypass grafting (CABG), since they are known to be insulin resistant in the presence of chronic FFA increase.

METHODS AND RESULTS

Fifty MVD patients and 55 CHD patients were studied before and 2 months after surgery and compared with 166 normal subjects. Before surgery, 56% of MVD patients had impaired glucose tolerance or newly diagnosed type 2 diabetes after a standard oral glucose load and this percentage decreased to 46% after surgery. In CHD, impaired glucose tolerance (IGT) or newly diagnosed type 2 diabetic patients were 67% of patients before and after CABG. In MVD, left atrial (LA) volume, ANP, FFA incremental area and insulin levels were higher and Insulin Sensitivity (IS) index significantly reduced while after surgery, LA volume, ANP and FFA significantly decreased and IS index significantly improved. In CHD, insulin resistance and hyperinsulinaemia were present both before and after surgery with increased tumour necrosis factor (TNF)-α and interleukin (IL)-6 levels.

CONCLUSION

In MVD, a higher degree of abnormal glucose tolerance and insulin resistance are associated to increased levels of ANP and FFA, while these metabolic alterations are improved by mitral valve replacement/repair surgery. Clinical Trial.gov registration number NCT 00520962.

Preparing for oral scientific and clinical vignette presentations

BACKGROUND

Little is known about how faculty, residents, and fellows practice for oral presentations at academic meetings. We sought to categorize presenters' practice styles and the impact of feedback.

METHODS

We surveyed oral presenters at 5 annual academic general internal medicine meetings between 2008 and 2010, using a cross-sectional design. Main measures were frequency and settings of practice, most helpful practice setting, changes made in response to feedback, impact of feedback, and perceived quality of presentation.

RESULTS

The response rate was 63% (333/525 responders). Respondents represented 59 academic medical centers. Presenters reported practicing in a mean ± SD of 2.3 (±1.3) of 5 different settings. Of the 46% of presenters (152/333) who practiced in front of a group of more experienced colleagues, 80% of presenters (122/152) reported it was the most helpful setting. Eighty-one percent of presenters (268/333) practiced alone, and 25% of presenters (82/333) reported practicing alone was the most helpful setting. The mean numbers of change types reported by faculty were fewer than those reported by residents and fellows (mean 2.3 ± 1.8, and 3.1 ± 2.0, respectively; P < .001). Practicing alone was not associated with changes in content (P  =  .30), visual aids (P  =  .12), or delivery style (P  =  .53).

CONCLUSIONS

Practicing in front of a group of experienced colleagues was the most helpful setting in which to prepare for an oral academic meeting presentation, but it was not universally utilized. Feedback given at these sessions was more likely to result in changes made to the presentation; however, broader implementation of such sessions 5 require institutional support.

Characterization of innate responses elicited by neoadjuvant radio-chemotherapy for rectal cancer

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Background: The neoadjuvant chemo-radiotherapy (CT-RT) has improved the treatment of locally advanced rectal cancer reducing the local recurrence. However a survival benefit has not been reached yet. In order to increase the rate of pathological complete remissions in our Institution we intensified both the CT schedule adding oxaliplatin to 5-FU and the RT program with tomotherapy. The aim of this study was to verify: whether the pattern of innate response elicited by the neoadjuvant CT-RT is heterogeneous among pts and whether this information can be used to identify which pts will benefit from the treatment. Methods: We collected samples of T3N+M0 rectal cancer pts before, during and after neoadjuvant CT-RT (3 cycles of oxaliplatin + 5-FU; 45 Gy). At each time point we characterized circulating monocytes by flow cytometry, infiltrating macrophages by immunoistochemistry (IHC) and selected inflammatatory molecules by ELISA.Results: We recruited so far 25 pts, of whom 10 have reached the surgery with three pathological complete remission and four down staging. No substantial changes were detectable in the number of circulating monocytes. In contrast we observed a clear expansion of CD14/CD86 and CD14/CD163 double positive subsets. This event was transient and apparently causally related to the treatment since it abated at the later time point. Moreover, it correlated with sensitivity to the treatment: 5/7 pts who underwent disease regression had an early and transitory increase of the number of CD14/CD86 and CD14/CD163 positive cells, which was absent or negligible in non responder pts. The IHC study revealed a massive tumoral infiltration by macrophages which displayed clear features of alternative M2 polarization as assessed by expression of the CD163 and 206 scavenger receptors. A subset of pts had elevated PTX3 and low CRP concentration at the onset of treatment. PTX3 concentration abated after the first CT cycle. Conclusions: These data suggest that neoadjuvant CT-RT modulates the cellular components of innate immune responses, that could represent valuable predictive factors.

No significant financial relationships to disclose.