Neil Kothari

Chief residents as educators: An effective method of resident development

Background: The importance of teaching residents how to instruct medical students is recognized, but time and logistics challenge the implementation of teaching skills programs. No study has described a dissemination model with chief residents as trainers and managers of a teaching skills program. Description: All chief residents in three departments (n = 16), participated in an 8-hr train-the-trainer teaching skills program and then trained 178 residents through seven 1-hr sessions. Outcome was measured through student surveys using a validated instrument with seven teaching domains and overall assessment of teaching effectiveness. Evaluation: Survey results revealed a significant improvement in the vast majority of teaching domains 9 months after implementation of the program in all three departments. Student perceptions of overall teaching effectiveness improved in two departments and trended upwards in the third. Conclusion: A resident teaching skills program utilizing chief residents as trainers resulted in improved 3rd-year medical student ratings of resident teaching.

Lupus nephritis: an update

Lupus nephritis (LN) is an inflammatory condition of the kidneys that encompasses various patterns of renal disease including glomerular and tubulointerstitial pathology. It is a major predictor of poor prognosis in patients with systemic lupus erythematosus (SLE). Genetic factors, including several predisposing loci, and environmental factors, such as EBV and ultraviolet light, have been implicated in the pathogenesis. It carries a high morbidity and mortality if left untreated. Renal biopsy findings are utilized to guide treatment. Optimizing risk factors such as proteinuria and hypertension with renin-angiotensin receptor blockade is crucial. Immunosuppressive therapy is recommended for patients with focal or diffuse proliferative lupus nephritis (Class III or IV) disease, and certain patients with membranous LN (Class V) disease. Over the past decade, immunosuppressive therapies have significantly improved long-term outcomes, but the optimal therapy for LN remains to be elucidated. Cyclophosphamide-based regimens, given concomitantly with corticosteroids, have improved survival significantly. Even though many patients achieve remission, the risk of relapse remains considerably high. Other treatments include hydroxychloroquine, mycofenolate mofetil, and biologic therapies such as Belimumab, Rituximab, and Abatacept. In this paper, we provide a review of LN, including pathogenesis, classification, and clinical manifestations. We will focus, though, on discussion of the established as well as emerging therapies for patients with proliferative and membranous lupus nephritis.

Albumin and Furosemide Combination for Management of Edema in Nephrotic Syndrome: A Review of Clinical Studies.

The treatment of edema in patients with nephrotic syndrome is generally managed by dietary sodium restriction and loop diuretics. However, edema does not improve in some patients despite adequate sodium restriction and maximal dose of diuretics. In such patients, combination of albumin and a loop diuretic may improve edema by diuresis and natriuresis. The response to this combination of albumin and a diuretic has not been observed in all studies. The purpose of this review is to discuss the physiology of diuresis and natriuresis of this combination therapy, and provide a brief summary of various studies that have used albumin and a loop diuretic to improve diuretic-resistant edema. Also, the review suggests various reasons for not observing similar results by various investigators.

Integrating a Resident-Driven Longitudinal Quality Improvement Curriculum Within an Ambulatory Block Schedule.

BACKGROUND Quality improvement (QI) is essential in clinical practice, requiring effective teaching in residency. Barriers include lack of structure, mentorship, and time. OBJECTIVE To develop a longitudinal QI curriculum for an internal medicine residency program with limited faculty resources and evaluate its effectiveness. METHODS All medicine residents were provided with dedicated research time every 8 weeks during their ambulatory blocks. Groups of 3 to 5 residents across all postgraduate year levels were formed. Two faculty members and 1 chief resident advised all groups, meeting with each group every 8 weeks, with concrete expectations for each meeting. Residents were required to complete didactic modules from the Institute for Healthcare Improvement. Current residents and alumni were surveyed for feedback. RESULTS Over 3 years, all eligible residents (92 residents per year in 2012-2014, 102 in 2014-2015) participated in the curriculum. Residents worked on 54 quality assessment and 18 QI projects, with 6 QI projects showing statistically significant indicator improvements. About 50 mentoring hours per year were contributed by 2 faculty advisors and a chief resident. No other staff or IT support was needed. A total of 69 posters/abstracts were produced, with 13 projects presented at national or regional conferences. Survey respondents found the program useful; most (75% residents, 63% alumni) reported it changed their practice, and 71% of alumni found it useful after residency. CONCLUSIONS Our longitudinal QI curriculum requires minimal faculty time and resulted in increased QI-related publications and measurable improvements in quality indicators. Alumni reported a positive effect on practice after graduation.

Perspectives on Cancer Screening Among Latino Community Members and Internal Medicine Residents

Background: Latinos have lower rates of cancer screening, partially because of cultural beliefs that conflict with those of health care professionals. Moreover, established programs for training physicians in cultural competency often fail to incorporate input from the community. Methods: To explore beliefs about cancer and cancer screening among Latino community members and internal medicine residents. Three focus groups of Latino community members (n = 31) and one focus group of internal medicine residents (n = 9) were conducted to compare ideas regarding cancer and cancer screening. Results: We identified clear disconnects between residents and Latino community members regarding their understandings of cancer, ideas about risk and etiological factors, and barriers to screening. Notably, residents more often spoke of cancer in terms of risk factors, whereas Latinos attributed cancer to life circumstances and experiences. Conclusions: The results from these focus groups will inform development of a community-minded cultural competency cancer education training program for medical residents designed to increase screening rates and improve satisfaction with care among Latinos.

Resident Wellness: An Intervention to Decrease Burnout and Increase Resiliency and Happiness

Introduction Despite the national focus on trainee burnout, effective wellness programs that can easily be incorporated into training curriculums are lacking. Strategies such as mindfulness and positive psychology, linked with deep breathing, have been shown to increase resiliency. We hypothesized that education about the neuroscience literature, coupled with teaching about well-being using short, easy-to-practice evidence-based exercises, would increase acceptance of this curriculum among residents and that providing protected time to practice these exercises would help trainees incorporate them into their daily lives. Methods Residents were asked to attend a 60-minute didactic featuring both the concepts and science behind well-being. Residents then attended 15-minute booster sessions during protected didactic time each week for a 12-week curriculum. The booster sessions were peer-led by wellness champions. Additionally, there were monthly competitions using free phone apps to promote physical fitness through steps and flights challenges. Results The 12-week curriculum was offered to 272 residents across five subspecialties of internal medicine, general surgery, anesthesiology, psychiatry, and physical medicine and rehabilitation. A total of 188 residents (69%) participated in the initial didactic component. The curriculum was positively received, with four of the five residency programs participating in weekly sessions. Residents in four participating departments then chose to continue the weekly sessions on a voluntary basis after the initial 12-week curriculum. Discussion It is feasible to implement a low-cost, peer-led wellness curriculum to educate residents and foster an environment during residency training where mindfulness, optimism, gratitude, and social connectedness are the norm.

Abstract 2639: Survival prognosis of MGUS patients by clinical and risk subgroup: a result from a nationally representative prospective cohort

Introduction: Monoclonal gammopathy of unknown significance (MGUS) is a premalignant disorder preceding multiple myeloma that is present in 2.4% of the general population ages 50 years or older. MGUS can be categorized into conventional MGUS that includes IgM MGUS and non-IgM MGUS, and light chain MGUS (defined as those with abnormal free light chain ratio with complete lack of immunoglobulin heavy chain expression on immunofixation). Our objective was to investigate the prognosis of MGUS patients by clinical subgroup and risk stratification suggested by Mayo Clinic. Methods: Data is obtained from National Health and Nutrition Examination Survey (NHANES) III and NHANES 1999-2004, a nationally representative health survey with follow-up mortality data updated in December 2011. Subjects who were diagnosed with MGUS were included in the study. They were divided into three groups; IgM MGUS, non-IgM MGUS, and light chain MGUS (LC-MGUS). Median overall survival of three groups was obtained using log-rank test and age-adjusted hazard ratio for death between the groups was obtained using cox-proportional regression model. Finally, we also analyzed median survival and age adjusted hazard ratio on conventional MGUS subjects by Mayo clinic MGUS risk stratification based on risk factors of M-protein>1.5g/dL, non-IgG MGUS, and abnormal free light chain (FLC) ratio. Analyses were performed in R software version 3.2.2, and a P-value Results: 22,523 subjects in the cohort were screened for MGUS with serum protein electrophoresis, serum protein immunofixation, serum FLC assay, and M-protein typing. There were 483 subjects with MGUS (47 IgM-MGUS, 385 non-IgM MGUS, and 51 LC-MGUS). The median ages of total MGUS subjects, and subgroups were 70, 72.3, 69 and 73 years old, respectively. Median follow-up was 116 months. Median overall survival was 117 months for IgM MGUS, 173 months for non-IgM MGUS, and 109 months for LC-MGUS (p = 0.03). However, the age adjusted hazard ratio (aHR) did not show significant difference between the sub-groups. Likewise, median overall survival of Mayo Clinic MGUS risk group 0, 1, 2 and 3 was 185 months, 163 months, 137 months, and 76.5 months, respectively (p Conclusion: There was no statistically significant mortality difference between MGUS subgroup. Only high-risk group defined by the Mayo Clinic MGUS risk stratification showed inferior survival and higher risk of death compared to rest of MGUS subjects. Further prospective studies are needed to validate our findings and to investigate whether early interventions for MGUS patients by clinical subgroup and risk stratification are needed rather than the current standard management of watchful-waiting. Citation Format: Hyun-Seok Kim, Jieqi Liu, Brittany L. Gladney, Neil Kothari, Noa Biran, Victor Chang, David S. Siegel. Survival prognosis of MGUS patients by clinical and risk subgroup: a result from a nationally representative prospective cohort. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2639.