Transforming primary care training--patient-centered medical home entrustable professional activities for internal medicine residents.

INTRODUCTION: The U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice. AIM: We address two key questions regarding the training of internal medicine residents for practice in PCMHs. First, what are the educational implications of practice transformations to primary care home models? Second, what must we do differently to prepare internal medicine residents for their futures in PCMHs? PROGRAM DESCRIPTION: The 2011 Society of General Internal Medicine (SGIM) PCMH Education Summit established seven work groups to address the following topics: resident workplace competencies, teamwork, continuity of care, assessment, faculty development, 'medical home builder' tools, and policy. The output from the competency work group was foundational for the work of other groups. The work group considered several educational frameworks, including developmental milestones, competencies, and entrustable professional activities (EPAs). RESULTS: The competency work group defined 25 internal medicine resident PCMH EPAs. The 2011 National Committee for Quality Assurance (NCQA) PCMH standards served as an organizing framework for EPAs. DISCUSSION: The list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.

Does exclusive enteral nutrition reduce the rate of stoma formation in patients requiring ileocolic resection for Crohn's disease? A single center experience.

BACKGROUND AND AIM: Nutrition has a role in achieving and maintaining remission in Crohn's disease. The aim of this study was to determine the impact of a strategy of steroid-avoidance and Exclusive Enteral Nutrition (EEN) for 6 weeks (with a minimum of 4 weeks) in adult patients presenting with acute small bowel Crohn's disease followed by an interval ileocolic resection 4-6 weeks later. METHODS: Retrospective review of prospectively collected data. Patients were administered exclusive enteral nutrition (EEN) for at least 4 weeks prior to surgery. RESULTS: 24 EEN patients included. Median age of 45 (range 23-73). 17/24 patients tolerated Modulen for at least 4 weeks, 5 were switched to Ensures and 2 a liquid diet. 6 patients underwent surgery earlier than planned. Prior to surgery, there was no change in the mean BMI, albumin increased from a mean of 36 g/L (range 25-43) to 40 g/L (range 30-48). CRP levels decreased by a mean of 35.8 mg/L overall. 19 (79%) of operations were performed laparoscopically. 6 of the cases were re-do operations. All but 3 patients avoided a stoma at the time of the original operation. There were 5 post-operative complications: 1 anastomotic leak in a patient with a BMI of 42, 3 cases of paralytic ileus and 2 wound infections. Median length of stay was 7 days (range 3-76 days). Only 2 patients were readmitted within the 30-day post-operative period. CONCLUSION: The pre-operative use of EEN appears to avoid unnecessary stoma formation with acceptable clinical outcomes.

A UK cost of care model for inflammatory bowel disease.

OBJECTIVES: There are an estimated 620 000 patients with inflammatory bowel disease (IBD) in the UK. The rising incidence of IBD combined with its incurability has significant cost implications. The aim of this cost of care model was to calculate the annual cost per adult patient of treating ulcerative colitis (UC) and Crohn's disease (CD) from a NHS perspective, and to enable areas of potential cost savings to be explored. DESIGN: The cost of IBD was calculated by summing the costs of treatment, treatment side effects and disease-related complications, accounting for the proportions of patients incurring these costs. Default input values for costs, the percentage of patients receiving each treatment, and the percentage of patients experiencing treatment-related side effects or disease-related complications were determined from national sources and published literature. However, the model permitted the user to input local or alternative data. SETTING: The model was designed to be used by NHS trusts in the UK. RESULTS: Using default input values, the annual cost of treating any patient with UC was estimated to be £3084. For a patient with UC in remission, in relapse with mild-to-moderate UC or in relapse with severe UC, annual cost per patient was estimated to be £1693, £2903 and £10 760, respectively. The annual cost for any patient with CD was estimated to be £6156 (£1800 for patients in remission; £10 513 for patients in relapse). CONCLUSIONS: While IBD remains a costly condition with modest potential cost savings, this model facilitates calculation of annual costs per patient with UC and CD, and its customisability will help hospitals identify areas where savings could be made.

Chondroid choriostoma of palatine tonsil - a rare entity.

A choristoma or heterotopias is an aggregate of microscopically normal cells or tissues which occurs in aberrant locations. A choristoma is a tumour like mass, whereas heterotopias refers to a displaced tissue which is necessarily not a swelling or a neoplasm. We are reporting a case of a 24 year old female who presented with recurrent tonsillitis and halitosis. On examination, the tonsils were found to be enlarged. Because of the persistent symptoms, a tonsillectomy was performed. The histopathological examination showed features of chronic tonsillitis, along with presence of mature islands of hyaline cartilage which were surrounded by lymphoid follicles and focal areas of calcification and osseous metaplasia.

Proapoptotic effects of NARC 1 (= PCSK9), the gene encoding a novel serine proteinase.

BACKGROUND: NARC 1/PCSK9 encodes a novel serine proteinase known to play a role in cholesterol homeostasis. NARC 1 mRNA expression in cerebellar granule neurons (CGNs) was discovered to be induced following an apoptotic injury. Coregulation of known apoptotic mediators (caspase-3 and death receptor 6) raises the possibility that NARC 1 might be involved in the propagation of apoptotic signaling in neurons. METHODS: CGNs were transfected with EGFP-fusion constructs of wild-type and mutant NARC 1, and a laser scanning cytometry-based method of scoring cell death in transfectants was applied. Use of the poly-caspase inhibitor BAF allowed assessment of the caspase-dependence of the NARC 1 proapoptotic effect. RESULTS: Wild-type NARC 1 was found to have substantial proapoptotic effects that were only partially reversible by BAF. Mutation of the active site serine or deletion of the catalytic domain resulted in a reduced level of cell death, consistent with loss of the BAF-sensitive component of cell death. NH(2)-terminal deletion constructs of NARC 1 had effects similar to wild-type, both in the absence and presence of BAF, whereas expression of COOH-terminal deletion mutants produced a rate of cell death similar to wild-type in the absence of BAF treatment, but which lacked the capacity to be reduced by treatment with BAF. CONCLUSION: The mechanism by which NARC 1-EGFP over-expression induces cell death in cultured CGNs remains unclear. Mutation analysis established a positive correlation between the presence of the Narc 1 active site serine in the transiently expressed protein and induction of the BAF-sensitive component of the cell death phenotype. A caspase-independent component proved sufficiently complex to map discretely within the Narc 1 protein.