Regional Lipid Expression Abnormalities Identified Using MALDI IMS Correspond to MRI-Defined White Matter Hyperintensities within Post-mortem Human Brain Tissues.

Periventricular white matter hyperintensities (pvWMHs) are a neurological feature detected with magnetic resonance imaging that are clinically associated with an increased risk of stroke and dementia. pvWMHs represent white matter lesions characterized by regions of myelin and axon rarefaction and as such likely involve changes in lipid composition; however, these alterations remain unknown. Lipids are critical in determining cell function and survival. Perturbations in lipid expression have previously been associated with neurological disorders. Matrix-assisted laser desorption/ionization (MALDI) imaging mass spectrometry (IMS) is an emerging technique for untargeted, high-throughput investigation of lipid expression and spatial distribution in situ; however, the use of MALDI IMS has been previously been limited by the need for non-embedded, non-fixed, fresh-frozen samples. In the current study, we demonstrate the novel use of MALDI IMS to distinguish regional lipid abnormalities that correlate with magnetic resonance imaging (MRI) defined pvWMHs within ammonium formate washed, formalin-fixed human archival samples. MALDI IMS scans were conducted in positive or negative ion detection mode on tissues sublimated with 2,5-dihydroxybenzoic acid or 1,5-diaminonaphthalene matrices, respectively. Using a broad, untargeted approach to lipid analysis, we consistently detected 116 lipid ion species in 21 tissue blocks from 11 different post-mortem formalin-fixed human brains. Comparing the monoisotopic mass peaks of these lipid ions elucidated significant differences in lipid expression between pvWMHs and NAWM for 31 lipid ion species. Expanding our understanding of alterations in lipid composition will provide greater knowledge of molecular mechanisms underpinning ischemic white matter lesions and provides the potential for novel therapeutic interventions targeting lipid composition abnormalities.

Evolution of Educational Commission for Foreign Medical Graduates Certification in the Absence of the USMLE Step 2 Clinical Skills Examination.

The United States Medical Licensing Examination Step 2 Clinical Skills (CS) was paused in 2020 because of the ongoing COVID-19 pandemic and discontinued in 2021. Step 2 CS was an important tool to assess readiness of international medical graduates (IMGs) to enter graduate medical education (GME) in the United States. This article describes the Educational Commission for Foreign Medical Graduates' (ECFMG's) response to the discontinuation of Step 2 CS. ECFMG certifies IMGs who seek eligibility for GME and licensure in the United States. Requirements for ECFMG certification include, among other factors, demonstration of adequate clinical skills and English proficiency, which were previously assessed as part of Step 2 CS. Beginning in June 2020 and during the next year, ECFMG modified the certification process with the introduction of 6 opportunities (pathways) for IMGs to demonstrate adequate clinical skills and a new test of English proficiency. In addition, permanent ECFMG certification is now granted only after the successful completion of the first year of residency, as determined by the program director. The COVID-19 pandemic and discontinuation of Step 2 CS caused a significant crisis for many IMGs who sought entrance into the United States, impacting the careers of those who had planned entry and those who would be eligible for U.S. training and the future workforce. Despite challenges due to the ongoing global pandemic, ECFMG certification continues to allow qualified physicians to enter U.S. GME and ensures that these individuals are ready to begin supervised training.

Microvessel stenosis, enlarged perivascular spaces, and fibrinogen deposition are associated with ischemic periventricular white matter hyperintensities.

Periventricular white matter hyperintensities (pvWMH) are neuroimaging abnormalities surrounding the lateral ventricles that are apparent on magnetic resonance imaging (MRI). They are associated with age, neurodegenerative disease, and cerebrovascular risk factors. While pvWMH ultimately represent a loss of white matter structural integrity, the pathological causes are heterogeneous in nature, and currently, cannot be distinguished using neuroimaging alone. pvWMH could occur because of a combination of small vessel disease (SVD), ependymal loss, blood-brain barrier dysfunction, and microgliosis. In this study we aimed to characterize microvascular stenosis, fibrinogen extravasation, and microgliosis within pvWMH with and without imaging evidence of periventricular infarction. Using postmortem neuroimaging of human brains (n = 20), we identified pvWMH with and without periventricular infarcts (PVI). We performed histological analysis of microvessel stenosis, perivascular spaces, microgliosis, and immunohistochemistry against fibrinogen as a measure of serum protein extravasation. Herein, we report distinctions between pvWMH with and without periventricular infarcts based on associations with microvessel stenosis, enlarged perivascular spaces, and fibrinogen IHC. Microvessel stenosis was significantly associated with PVI and with cellular deposition of fibrinogen in the white matter. The presence of fibrinogen was associated with PVI and increased number of microglia. These findings suggest that neuroimaging-based detection of infarction within pvWMH may help distinguish more severe lesions, associated with underlying microvascular disease and BBB dysfunction, from milder pvWMH that are a highly frequent finding on MRI.

Oxidized phosphatidylcholines found in multiple sclerosis lesions mediate neurodegeneration and are neutralized by microglia.

Neurodegeneration occurring in multiple sclerosis (MS) contributes to the progression of disability. It is therefore important to identify and neutralize the mechanisms that promote neurodegeneration in MS. Here, we report that oxidized phosphatidylcholines (OxPCs) found in MS lesions, previously identified as end-product markers of oxidative stress, are potent drivers of neurodegeneration. Cultured neurons and oligodendrocytes were killed by OxPCs, and this was ameliorated by microglia. After OxPC injection, mouse spinal cords developed focal demyelinating lesions with prominent axonal loss. The depletion of microglia that accumulated in OxPC lesions exacerbated neurodegeneration. Single-cell RNA sequencing of lesioned spinal cords identified unique subsets of TREM2high mouse microglia responding to OxPC deposition. TREM2 was detected in human MS lesions, and TREM2-/- mice exhibited worsened OxPC lesions. These results identify OxPCs as potent neurotoxins and suggest that enhancing microglia-mediated OxPC clearance via TREM2 could help prevent neurodegeneration in MS.

The Medical Education Commission Report 2008-2009: Louisiana GME plan is tracking U.S. averages.

Graduate medical education (GME) in Louisiana has evolved into the present status, the sum of institutions providing medical education, as in each of the states and the country as a whole. Louisiana reflects the United States (U.S.) averages in practically every GME parameter and measurement with relatively small variations. The record suggests that GME in Louisiana is moving forward in desirable growth and improvement. In 2005, Hurricanes Katrina and Rita produced major setbacks for GME in Louisiana. Now, the signs of recovery are robust and GME is getting back on track. Today, the health care delivery system is under scrutiny to be reformed, creating a difficult situation for all physicians and others in the medical fields and health care industry. The widely accepted reality of the growing shortage of all types of physicians may be worse by many reform proposals. This Medical Education Commission (MEC) report will provide data and comment on medical students, GME trends, and projections as background and guidance for the Louisiana plan for recovery and reform.

Reporting a Pass/Fail Outcome for USMLE Step 1: Consequences and Challenges for International Medical Graduates.

After extensive stakeholder discussion, the Federation of State Medical Boards and the National Board of Medical Examiners announced in February 2020 that United States Medical Licensing Examination Step 1 will transition to a pass/fail exam. Program directors have historically used Step 1 scores in deciding which residency applicants to interview. The lack of numerical scores will force changes to the residency selection process, which could have both positive and negative consequences for international medical graduates (IMGs). In this Invited Commentary, the authors discuss how some of the issues associated with the transition to Step 1 pass/fail are likely to impact IMGs. The authors also provide insights into how this and other policy changes could help spur the medical education community to improve the process by which medical school graduates transition to graduate medical education.

Prevalence of International Medical Graduates From Muslim-Majority Nations in the US Physician Workforce From 2009 to 2019.

Importance: Historically, the US physician workforce has included a large number of international medical graduates (IMGs). Recent US immigration policies may affect the inflow of IMGs, particularly those who are citizens of Muslim-majority nations. Objectives: To provide an overview of the characteristics of IMGs from Muslim-majority nations, including their contributions to the US physician workforce, and to describe trends in the number of applications for certification to the Educational Commission for Foreign Medical Graduates between 2019 and 2018, both overall and for citizens of Muslim-majority nations. Design, Setting, and Participants: This cross-sectional study, which included 1 065 606 US physicians listed in the 2019 American Medical Association Physician Masterfile and 156 017 applicants to the Educational Commission for Foreign Medical Graduates certification process between 2009 and 2018, used a repeated cross-sectional study design to review the available data, including country of medical school attended, citizenship when entering medical school, and career information, such as present employment, specialty, and type of practice. Exposures: Country of citizenship when entering medical school. Main Outcomes and Measures: Physician counts and demographic information from the 2019 American Medical Association Physician Masterfile and applicant data from the Educational Commission for Foreign Medical Graduates from 2009 to 2018. Results: Of 1 065 606 physicians in the American Medical Association Physician Masterfile, 263 029 (24.7%) were IMGs, of whom 48 354 were citizens of Muslim-majority countries at time of entry to medical school, representing 18.4% of all IMGs. Overall, 1 in 22 physicians in the US was an IMG from a Muslim-majority nation, representing 4.5% of the total US physician workforce. More than half of IMGs from Muslim-majority nations (24 491 [50.6%]) come from 3 countries: Pakistan (14 352 [29.7%]), Iran (5288 [10.9%]), and Egypt (4851 [10.0%]). The most prevalent specialties include internal medicine (10 934 [23.6%]), family medicine (3430 [7.5%]), pediatrics (2767 [5.9%]), and psychiatry (2251 [4.8%]), with 18 229 (38.1%) practicing in primary care specialties. The number of applicants for Educational Commission for Foreign Medical Graduates certification from Muslim-majority countries increased from 2009 (3227 applicants) to 2015 (4244 applicants), then decreased by 2.1% in 2016 to 4254 applicants, 4.3% in 2017 to 4073 applicants, and 11.5% in 2018 to 3604 applicants. Much of this decrease could be attributed to fewer citizens from Pakistan (1042 applicants in 2015 to 919 applicants in 2018), Egypt (493 applicants in 2015 to 309 applicants in 2018), Iran (281 applicants in 2015 to 182 applicants in 2018), and Saudi Arabia (337 applicants in 2015 to 163 applicants in 2018) applying for certification. Conclusions and Relevance: Based on the findings of this study, the number of ECFMG applicants from Muslim-majority countries decreased from 2015 to 2018. The US physician workforce will continue to rely on IMGs for some time to come. To the extent that citizens from some countries no longer seek residency positions in the US, gaps in the physician workforce could widen.

The medical education commission report 2007: GME is recovering from Katrina.

Before Hurricane Katrina, graduate medical education (GME) in Louisiana was growing slowly but steadily, similarly to the United States (US) average. Katrina's destructive force disrupted practically every aspect of GME, resulting in early quantitative rearrangement by geographic location and the heroic efforts to rescue programs across the state. This report provides evidence that the numbers have stabilized and are getting back on track. This year's successful match leads the way, with numbers of entering residents nearing pre-Katrina levels. Total GME gained some ground. National trends are noted, as primary care specialties are less in the national match, even as a national effort to increase the supply of physicians is underway. Institutional and state efforts to restore and increase GME are key to the long-term solution for physician recruitment in Louisiana, especially when a growing physician shortage is on the horizon.

The Medical Education Commission report 2005 and 2006: Katrina kinetics change Graduate Medical Education.

The destructive and disruptive force of Hurricane Katrina was an enormous challenge to Graduate Medical Education (GME) in Louisiana. Before Katrina hit, GME was successful, prospering, steady, and productive in the state professional workforce, provision of clinical care, and economic development. That GME survived as well as it did, especially in the hardest hit institutions in New Orleans, is indeed remarkable, and greatly assisted by all other GME institutions in LA and across the U.S. As documented in this report, hits taken resulted in some loss and redistribution. The last two matches are compared, 2005 to 2006, and although both filled after the scramble, '06 is smaller. The year before Katrina (2004 to 2005) data on GME are included, and 2005 to 2006 will be posted when available. The approximate loss (16%) and redistribution scenarios are presented. National trends are also noted, as primary care specialties are less in the national match, even as a national response is begun to increase the short supply of physicians.

Initial Match Rates of an Innovative International Partnership: The Ochsner Clinical School Experience.

BACKGROUND: Ochsner Clinical School (OCS) is a unique partnership between Ochsner Health System in New Orleans, LA, and The University of Queensland (UQ) School of Medicine in Brisbane, Australia. OCS trains physicians in global medicine and promotes careers in primary care through its unique structure. The purpose of this study was to determine how OCS graduates perform in the National Resident Matching Program (NRMP)-The Match-compared to applicants from other types of medical schools. METHODS: The match outcomes for all OCS graduates since the first graduating class in November 2012 were compared to the match outcomes in the NRMP database for graduates from other types of medical schools in the years 2013-2015. We also examined the number of OCS students electing residencies in primary care compared to the number of US medical school graduates overall during the same time period of 2013-2015. RESULTS: The cumulative match rate from 2013-2015 for applicants from OCS was 91.8%. The OCS graduates' match rate was greater than the match rate for US citizen graduates of international medical schools during the same period (53.0% vs 91.8% [z=6.066, P<0.0002]), greater than the match rate for applicants from US osteopathic medical schools (77.3% vs 91.8% [z=25.233, P<0.0002]), and greater than the match rate for applicants from Canadian medical schools (62.7% vs 91.8% [z=3.815, P<0.0002]). The OCS match rate was not significantly different from that of US medical school graduates: 94.0% vs 91.8% (z=-0.728, P=0.4666). During the 2013-2015 time frame, 44.3% of OCS graduates chose residencies in primary care fields compared to 38.3% of US graduates (z=-0.9634, P=0.337). CONCLUSION: Graduates of OCS are obtaining residency positions through The Match at rates comparable to those of US medical school graduates and at rates significantly greater than other groups, and we are seeing a trend in the number of graduates choosing careers in primary care.

The Medical Education Commission report 2004: the competition for physician recruitment is increasing.

The Louisiana annual match entry into graduate medical education (GME), the renewal of the practicing physician workforce, is consistent year to year and essentially parallel to the United States as a whole. The State of Louisiana Medical Education Commission offers reports compiling yearly and trend data and analysis which are published in the Journal of the Louisiana State Medical Society. The 2004 result of the match follows the trend of successful completion over the last 6 years. Louisiana is similar in many comparable categories to the United States; current trends continue to show a physician steady supply now stabilized and leveling and a growing shortage as demand increases. The GME system, and medical practice to follow, will be under an increasingly competitive environment. Physician recruitment at all levels will need to be augmented to meet national competition.

The Medical Education Commission Report 2003: GME production renews physician supply.

Louisiana data for the match entry into Graduate Medical Education, and the renewal of the practicing physician workforce, are essentially parallel to comparable data for the United States as a whole. The State of Louisiana Medical Education Commission offers reports and publications in the Journal of the Louisiana State Medical Society compiling yearly and trend data and analysis. The 2003 result of the match follows the trend of successful completion over the last five years. While Louisiana is similar in many comparable categories to the United States, the state is somewhat higher in primary care growth, now stabilized and leveling, as are total GME and total physicians. Relatively small changes may be baseline fluctuations, and not a trend of longer-term change. The GME system is remarkably stable and successful overall, though complex right down to individual variation.

The Medical Education Commission Report 2002: trends indicate a steady state supply of physicians.

This summary report for 2002 provides the detailed and updated data on all Graduate Medical Education (GME) residents and fellows in Louisiana for the last academic year. The 2002 match results and the trend in matching over the last 4 years depict the consistent successful match by Louisiana institutions. The totals and components of GME in Louisiana are steady. The infusion of gradually increasing numbers of physicians over the last 30 years in the United States and in Louisiana is quantified to indicate the present consistent steady state production and supply. The ripple effect into the physician population of this infusion now shows the expected beginning stabilization, although incomplete at this juncture. While demand for physician services for healthcare delivery is difficult to define and quantify, the inexorable increase of utilization of healthcare services portends a future mismatch of supply and demand, a shortage not a surplus.

Improving the transition of care in patients transferred through the ochsner medical center transfer center.

BACKGROUND: Patient transfers from other hospitals within the Ochsner Health System to the main campus are coordinated through a Transfer Center that was established in fall 2008. We analyzed the transfer process to assess distinct opportunities to enhance the overall transition of patient care. METHODS: We surveyed internal medicine residents and nocturnists to determine their satisfaction with transfers in terms of safety, efficiency, and usefulness of information provided at the time of transfer. After a kaizen event at which complementary goals for the institution and members of the study team were recognized and implemented, we resurveyed the group to evaluate improvement in the transfer process. RESULTS: The preintervention average satisfaction score was 1.18 (SD=0.46), while the postintervention score was 3.7 (SD=1.01). A t test showed a significant difference in the average scores between the preintervention and postintervention surveys (P<0.0001). CONCLUSIONS: By including residents in the transfer calls (a result of the kaizen event), data were collected that facilitated fewer and higher quality handoffs that were performed in less time. In addition, the process resulted in increased awareness of the value of resident participation in institutional quality improvement projects.

Consolidated academic and research exposition: a pilot study of an innovative education method to increase residents' research involvement.

BACKGROUND: Internal medicine residents at the Ochsner Clinic Foundation stay engaged with clinical work and have difficulty initiating and completing research and publishing their scholarly activities. Commonly cited barriers include lack of knowledge about institutional research programs, lack of confidence regarding medical writing skills, lack of time, and failure to understand the value of research. The residency directors at Ochsner initiated the Consolidated Academic and Research Exposition (CARE) program to teach basic research skills and encourage residents' interest and productivity in research. METHODS: The CARE program includes 4 core components: house staff mentoring and the Resident Career Development Program, a journal club, medical writing instruction, and research engagement. Particular emphasis is given to projects that could be completed within a 1-month period and result in publication, enabling residents to use a 1-month elective rotation during their first postgraduate year. The sessions are mandatory for residents, except for those on specified rotations, including the critical care service and the night float rotation and those who are postcall. RESULTS: In 2010-2011, 6 residents submitted abstracts to the Louisiana Chapter of the American College of Physicians Associates meeting; 2 abstracts were accepted for presentation. In 2011-2012, there were 14 submissions, 4 of which were accepted for presentation. In 2010-2011, there were 4 submissions to the Southern Hospitalist Conference, which increased to 7 submissions in 2011-2012. The second best presentation award at the Southern Hospitalist Conference was also earned by a resident of this institution. The program saw a 110% total increase in scholarly activity from 2010-2011 to 2011-2012. DISCUSSION: The CARE program has been in existence for approximately 1 year. Preliminary results were tabulated based on research proposals, posters, abstracts, case reports, and presentations submitted and/or accepted at leading medical conferences over the past year as compared to the same period 1 year ago. Residents, based on the Accreditation Council for Graduate Medical Education Resident Survey responses, were more satisfied with the opportunities provided to them to participate in research or scholarly activities. Our preliminary results suggest that an organized, structured research curriculum in internal medicine residency programs is critical to promoting, initiating, and completing scholarly activity during a residency program. CONCLUSION: Ochsner's CARE program has appreciably enhanced internal medicine residents' interest in research-related activity, resulting in a significant increase in resident-authored research papers, abstracts, posters, and case reports being accepted at leading national medical conferences.