Faculty Bibliography

BACKGROUND:Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) may occur after infection. How often people develop ME/CFS after SARS-CoV-2 infection is unknown. OBJECTIVE:To determine the incidence and prevalence of post-COVID-19 ME/CFS among adults enrolled in the Researching COVID to Enhance Recovery (RECOVER-Adult) study. DESIGN, SETTING, AND PARTICIPANTS/METHODS:RECOVER-Adult is a longitudinal observational cohort study conducted across the U.S. We included participants who had a study visit at least 6 months after infection and had no pre-existing ME/CFS, grouped as (1) acute infected, enrolled within 30 days of infection or enrolled as uninfected who became infected (n=4515); (2) post-acute infected, enrolled greater than 30 days after infection (n=7270); and (3) uninfected (1439). MEASUREMENTS/METHODS:Incidence rate and prevalence of post-COVID-19 ME/CFS based on the 2015 Institute of Medicine ME/CFS clinical diagnostic criteria. RESULTS:The incidence rate of ME/CFS in participants followed from time of SARS-CoV-2 infection was 2.66 (95% CI 2.63-2.70) per 100 person-years while the rate in matched uninfected participants was 0.93 (95% CI 0.91-10.95) per 100 person-years: a hazard ratio of 4.93 (95% CI 3.62-6.71). The proportion of all RECOVER-Adult participants that met criteria for ME/CFS following SARS-CoV-2 infection was 4.5% (531 of 11,785) compared to 0.6% (9 of 1439) in uninfected participants. Post-exertional malaise was the most common ME/CFS symptom in infected participants (24.0%, 2830 of 11,785). Most participants with post-COVID-19 ME/CFS also met RECOVER criteria for long COVID (88.7%, 471 of 531). LIMITATIONS/CONCLUSIONS:The ME/CFS clinical diagnostic criteria uses self-reported symptoms. Symptoms can wax and wane. CONCLUSION/CONCLUSIONS:ME/CFS is a diagnosable sequela that develops at an increased rate following SARS-CoV-2 infection. RECOVER provides an unprecedented opportunity to study post-COVID-19 ME/CFS.

IMPORTANCE/UNASSIGNED:Increasing underrepresented in medicine (URIM) physicians among historically underserved communities helps reduce health disparities. The concordance of URIM physicians with their communities improves access to care, particularly for American Indian and Alaska Native, Black, and Hispanic or Latinx individuals. OBJECTIVES/UNASSIGNED:To explore county-level racial and ethnic representation of US internal medicine (IM) residents, examine racial and ethnic concordance between residents and their communities, and assess whether representation varies by presence of academic institutions or underserved settings. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This retrospective cross-sectional study collected data from the Association of American Medical Colleges, Accreditation Council for Graduate Medical Education (ACGME), Area Health Resources Files, and US Department of Education data on ACGME-accredited US IM residency programs and their associated county populations. Self-reported racial and ethnic data from 2018 for 4848 residents in 393 IM programs in 205 counties were used. Data were analyzed between February 15 and September 20, 2024. EXPOSURE/UNASSIGNED:County-level presence for academic health centers (AHCs), minority-serving institutions (MSIs), health professional shortage areas (HPSAs), and rurality. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Main outcomes were representation quotients (RQs) or the ratio of the proportion of IM residents and their concordant county-level racial and ethnic populations. Quantile linear regression models on median representation were used to identify the association with URIM, Asian, and White residents by US Census division and county-level AHCs, MSIs, HPSAs, and rurality. RESULTS/UNASSIGNED:Among 4848 residents, 4 (0.08%) self-identified as American Indian or Alaskan Native, 1709 (35.3%) as Asian, 289 (6.0%) as Black, 211 (4.4%) as Hispanic or Latinx, 2 (0.04%) as Native Hawaiian or Other Pacific Islander, and 2633 (54.3%) as White. A total of 761 (15.7%) were classified as URIM. Among URIM groups, American Indian and Alaska Native (mean [SE] RQ, 0.00 [0.04]), Black (mean [SE] RQ, 0.09 [0.20]), Hispanic and Latinx (mean [SE] RQ, 0.00 [0.04]), and Native Hawaiian and other Pacific Islander (mean [SE] RQ, 0.00 [0.26]) residents were grossly underrepresented compared with their training sites' county-level representation. Fifty-one of 205 counties (24.8%) with IM programs had no URIM residents. Black and Hispanic or Latinx residents had higher representation in counties with more MSIs (mean [SD] RQ, 0.19 [0.24]; P = .04; mean [SD] RQ, 0.15 [0.04]; P < .001, respectively), and Hispanic or Latinx residents were less represented in counties with more AHCs (mean [SD] RQ, 0.00 [0.06]; P < .001). Asian residents had lower RQs in counties with more MSIs (mean [SD] RQ, 6.00 [0.65]; P < .001), and White residents had higher representation in counties with greater presence of AHCs (mean [SD] RQ, 0.77 [0.04]; P = .007). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cross-sectional study, URIM IM residents remained underrepresented compared with their program's county populations. These findings should inform racial and ethnic diversity policies to address the continuing underrepresentation among graduate medical education physicians, which adversely impacts the care of historically underserved communities.

INTRODUCTION/BACKGROUND:Pouchitis and Crohn's like disease of the pouch (CLDP) are common in patients who undergo ileal pouch anal anastomosis for ulcerative colitis (UC). We conducted separate systematic reviews to evaluate the effectiveness of available interventions to prevent and treat pouchitis and CLDP. METHODS:Through systematic literature reviews, we identified studies that evaluated the effectiveness of probiotics, antibiotics, 5-aminosalicylates, non-systemic oral corticosteroids, and advanced therapies for prevention and treatment of pouchitis and CLDP for meta-analysis. Primary outcomes were occurrence of pouchitis for pouchitis prevention and clinical response for pouchitis and CDLP treatment. We estimated the relative effectiveness of these interventions using the existing placebo response rates or hypothetical spontaneous improvement rates derived from clinical trials of pouchitis, UC and Crohn's disease. RESULTS:Probiotics were effective for primary (RR 0.18; 95% CI 0.05-0.62) and secondary prevention (RR 0.17; 95% CI 0.09-0.34) of pouchitis. Antibiotics were effective for treatment of acute and chronic pouchitis (12 cohorts; RR 1.67; 95% CI 1.34-2.01; response rate 65%; 95% CI 52-75) with ciprofloxacin and metronidazole-based regimens being more effective than rifaximin. Advanced therapies were effective for treatment of chronic antibiotic-refractory pouchitis (31 cohorts; RR 1.71; 95% CI 1.28-2.56; response rate 50%; 95% CI 43-57) and CLDP (10 cohorts; RR 2.49; 95% CI 1.87-3.73; response rate 74%; 95% CI 68-79) without significant difference between classes. CONCLUSION/CONCLUSIONS:Multiple medical interventions are effective for prevention and treatment of pouchitis and CLDP. Given the overall low quality of data, further research is needed to confirm these findings.

Adrenal masses are being found more and more often over the years. Given the association of these masses with advancing age, the decision to perform surgery in older, sometimes asymptomatic patients presents a clinical dilemma. These patients are potentially more vulnerable to adverse postoperative outcomes due to increased frailty. Therefore, this study aimed to compare the postoperative course after adrenalectomy in patients aged 70 years and older to that of a younger cohort. This single center retrospective study included patients aged ≥ 70 years who underwent adrenalectomy between 2000-2020, and propensity-score matched younger patients (< 70 years). Patients were matched based on hormonal overproduction, malignant diagnosis, surgical approach and year of surgery. The study included 77 elderly patients (median age 74 years) and 77 younger patients (median age 52 years; p < 0.001). Serious complications (Clavien-Dindo ≥ 3) occurred in 9.1% of elderly patients and 6.5% of the matched younger cohort (p = 0.773). The overall complication rate was 44.2% in elderly and 40.3% in younger patients (p = 0.771), with similar duration of hospital admission and mortality in both groups. Elderly patients experienced mostly infectious (33.8%) or cardiovascular complications (27.0%), and cardiovascular complications were more frequent in elderly than in younger patients (6.7%, p = 0.039). In conclusion, patients aged 70 years and older who undergo adrenalectomy have a similar postoperative course and complication rate as younger patients, with most postoperative complications being minor, and mortality being minimal. Therefore, older age itself should not be a reason to refrain from adrenalectomy.

BACKGROUND:Suboptimal support for colleagues experiencing discrimination can adversely impact clinician well-being and patient care. AIM/OBJECTIVE:To describe resident performance and experience during an Objective Structured Clinical Examination (OSCE) case centered on supporting a trainee facing discrimination to inform enhanced, supportive learning environments. SETTING/METHODS:Formative, internal medicine OSCE at a simulation center. PARTICIPANTS/METHODS:148 second-year residents across 2018, 2019, 2021, 2022. PROGRAM DESCRIPTION/METHODS:Residents had 10 min to support a Muslim standardized intern (SI) experiencing discrimination from a patient. The SI rated resident performance across Supervision, Relationship Development, and Support domains and provided written feedback. Post-OSCE evaluations elicited resident reflections on case challenges. PROGRAM EVALUATION/RESULTS:Proficient residents (≥ 80% average score across domains, n = 85) performed better in all items, except in not acting defensive and collaborating with SI to develop follow-up plan, compared to non-proficient residents (n = 65). The SI described effective approaches to feeling supported, including using empathetic statements, stating personal stance on discrimination, exhibiting supportive body language, and verbalizing support. Stating knowledge of situation upfront was an area of improvement. Residents found engaging the distressed SI difficult. DISCUSSION/CONCLUSIONS:Use of an explicit discrimination OSCE case can help identify effective approaches to supporting targets of discriminatory patients to inform future training.

The baroreflex system is involved in modulating several physiological functions of the cardiovascular system and can modulate cardiac output, blood pressure, and cardiac electrophysiology directly and indirectly. In addition, it is involved in regulating neurohormonal pathways involved in the cardiovascular function, such as the renin-angiotensin-aldosterone system and vasopressin release. Baroreflex dysfunction is characterized by sympathetic overactivation and parasympathetic withdrawal and is associated with several cardiovascular diseases, such as hypertension, heart failure, and coronary artery disease. Targeting the baroreflex system via invasive (eg, baroreflex activation therapy and endovascular baroreceptor amplification) and noninvasive approaches (eg, slow breathing exercises and exercise training) has emerged as a novel pathway to manage cardiovascular diseases. Studies examining the long-term safety and efficacy of such interventions in various cardiovascular diseases are needed.

Hepatitis D (HDV) is a severe infection with well-recognised clinical ramifications that remains relatively neglected and underdiagnosed; consequently, the epidemiology of HDV is poorly characterised, both in the United States and globally. In 2022, a pilot project involving eight healthcare institutions was undertaken to ascertain the prevalence of HDV in healthcare institutions with an HBV seropositivity of at least 1%, describe the characteristics of patients testing positive for HDV, and evaluate diagnostic and laboratory processes of HDV screening. From August 2022 to April 2024, a total of 106,693 patients were tested for HBsAg, of whom 65,341 (61.2%) were female and 40,863 (38.3%) were male, with a mean age of 47 years. The overall HBsAg positivity rate was 1.04% (n = 1112). Among the HBsAg+ samples, 645 (58.0%) underwent HDV Ab testing. The HDV Ab positivity rate was 0.81% (n = 9), with 2 cases of HDV RNA positivity (0.18%). The incomplete testing reflects several challenges associated with screening for both HBV and HDV. Further research is necessary to better understand the epidemiology and burden of HDV in the United States and considerations for implementation.

BACKGROUND:Patients with disabilities face widespread barriers to accessing surgical care given inaccessible health systems, resulting in poor clinical outcomes and perpetuation of health inequities. One barrier is the lack of education, and therefore awareness, among trainees/providers, of the need for reasonable accommodations for surgical patients with disabilities. METHODS:We conducted a scoping review of the literature on the current state of disabilities curricula in medical education and graduate residency curriculum. RESULTS:While the literature does demonstrate a causal link between reasonable accommodation training and positive patient-provider relationships and improved clinical outcomes, in practice, disability-focused curricula are rare and often limited in time and to awareness-based didactic courses in medical education and surgical training. CONCLUSIONS:The absence of structured curricula to educate on anti-ableism and care for patients with disabilities promotes a system of structural "ableism." Expanding disability curricula for medical students and trainees may be an opportunity to intervene and promote better surgical care for all patients.

BACKGROUND:Unannounced standardized patients (USPs) have long been used to measure clinical performance in situ. These incognito actors capture data on clinician skills during an encounter, as well as patient experience more broadly. A robust USP program requires extensive preparation and standardization efforts. Given the widespread expansion of USPs for education, research, and improvement efforts, we conducted a systematic review with the goal of capturing the breadth of uses of USPs across settings, along with the standardization measures employed across studies. METHODS:In collaboration with a medical librarian, we conducted systematic searches across six databases. Two independent researchers screened each report for inclusion. Three coders extracted and reviewed study characteristics and data from the studies deemed eligible for inclusion. We extracted data on: target population, setting, and assessed skills. We also captured the reliability and fidelity measures described in each study, including USP detection, USP training methods, and assessment measures. RESULTS:128 articles were included. Individual clinicians were the most frequently targeted population (n = 114, 89 %). Common clinician roles included physicians (n = 92, 72 %) and pharmacists (n = 12, 9 %). The collective care team was the target in two studies (2 %), and systems and larger healthcare facilities were targeted in only 1 (1 %) and 13 (10 %) studies, respectively. Studies were primarily conducted in ambulatory settings (n = 118, 92 %). History gathering (n = 76, 59 %), communication (n = 55, 43 %), counseling (n = 51, 40 %), and patient education (n = 49, 38 %) were commonly assessed, as were correct diagnosis (n = 34, 27 %), appropriate ordering of labs/tests (n = 30, 23 %), referrals (n = 35, 27 %), and prescriptions (n = 36, 28 %). USP detection reporting was variable across studies; however, no detection information was provided for 48 studies. 62 % of articles reported incorporating a measure of reliability or fidelity into their study, while the remainder either failed to provide adequate information on use of these measures. CONCLUSIONS:We explored USP use across settings and describe the scope and limitations of the literature. USPs capture a range of data domains but a lack uniform report of reliability measures can potentially undermine findings. Future studies should incorporate and uniformly report out on detection, training, and assessment.