Novel Formative Approach of the ESAP-ITE Provides Strong Predictive Value for ABIM Certification Outcomes.

BACKGROUND: The Endocrine Self-Assessment Program In-Training Examination (ESAP-ITE) has the novel formative approach of allowing open access to all questions and answers after secure examination administration is complete, resulting in the creation of an entirely new in-training examination annually. OBJECTIVE: To determine whether scores on the novel ESAP-ITE predict pass/fail outcomes on the American Board of Internal Medicine Endocrinology, Diabetes, and Metabolism Certification Examination (ABIM-ECE). METHODS: All endocrine fellows-in-training who took the ESAP-ITE between 2016 and 2019 and then subsequently attempted the ABIM-ECE within the same calendar year were included (n = 982). Primary analyses used the ESAP-ITE score from the final year of fellowship training. Covariates included sex, age on date of ABIM-ECE, medical school country, fellowship program region, pass/fail outcomes on the ABIM Internal Medicine Certification Examination, and ESAP-ITE score. All variables were analyzed using multivariable logistic regression. RESULTS: ESAP-ITE score (P < 0.001), ABIM Internal Medicine Certification Examination outcome (P < 0.001), and age (P = 0.005) were each significant predictors of passing the ABIM-ECE on the first attempt. ESAP-ITE score was the strongest predictor of passing the ABIM-ECE, and this relationship was such that a score of 75% correct yielded a 97% probability of passing the ABIM-ECE, whereas a score of 50% correct generated only a 70% probability of doing so. Sex, fellowship program region, and medical school country were not significant predictors of ABIM-ECE outcomes. CONCLUSIONS: In addition to serving as an important learning instrument for endocrine fellowship programs, ESAP-ITE is a robust predictive tool for pass/fail outcomes on the ABIM-ECE.

Giant myelolipomas and inadvertent bilateral adrenalectomy in classic congenital adrenal hyperplasia.

UNLABELLED: Myelolipomas have been reported in patients with congenital adrenal hyperplasia (CAH). ACTH excess, as seen with non-adherence to glucocorticoid therapy, may be responsible for tumor development. We report a case of a 51-year-old man with classic salt-wasting CAH managed on prednisone 7.5 mg daily and fludrocortisone who presented with chronic back pain and was found to have giant bilateral retroperitoneal masses. On computed tomography (CT) imaging, the masses were heterogeneous, but contained predominantly low-density fat attenuation. The tumors were resected due to concern for malignancy and mass symptoms. Pathologic examination identified both retroperitoneal masses as myelolipomas. The left tumor was 34×20×13 cm and weighed 4.7 kg and the right tumor was 20 cm in the largest dimension. Adrenal tissue was present in the specimen. The patient reported long-term compliance with glucocorticoid treatment. However, no biochemical monitoring of ACTH levels had occurred. Therefore, it is unclear if ACTH excess contributed to the development of these large tumors in this patient. It was presumed that both adrenal glands were inadvertently removed during surgery and the patient was treated with physiologic replacement doses of hydrocortisone and fludrocortisone postoperatively. In this case, the bilateral adrenalectomy was inadvertent. However, adrenalectomy can be considered as a treatment option in patients with classical CAH under certain circumstances to avoid complications of glucocorticoid excess. LEARNING POINTS: Myelolipomas should be considered in the differential diagnosis of adrenal or retroperitoneal masses in patients with CAH.On CT imaging, myelolipomas are seen as heterogeneous masses with low-density mature fat interspersed with more dense myeloid tissue.Myelolipomas are usually unilateral and measure <4 cm; however, very large and bilateral tumors have been reported.Treatment of CAH typically involves using supraphysiologic doses of glucocorticoid to suppress adrenal hyperandrogenism. Bilateral adrenalectomy is an alternative treatment option in patients with CAH.There is an association between ACTH excess and increased incidence of adrenal myelolipoma but the direct causal link remains to be established.

A case of an unusual subtrochanteric fracture in a patient receiving denosumab.

OBJECTIVE: Bisphosphonates are the most common class of medications used to treat osteoporosis. Their widespread use has uncovered rare complications, including atypical femoral fractures (AFF). The pathogenesis of AFF is incompletely understood; however, if oversuppression of bone remodeling contributes to AFF, it is plausible that other potent antiresorptive agents, such as denosumab, could be associated with AFF as well. METHODS: We report a case of an 81-year-old woman with densitometric osteopenia, chronic kidney disease, and hyperparathyroidism, who was initiated on denosumab for elevated fracture risk. Approximately 6 months after her initial denosumab injection, she developed severe right groin and thigh pain without prior trauma. RESULTS: A femoral radiograph was normal, without cortical thickening, but a magnetic resonance imaging revealed a transverse subtrochanteric insufficiency fracture with a medial defect involving 25% of the femoral cortex. She did not receive any further doses of denosumab. Bone turnover markers did not suggest oversuppression. Her fracture was treated conservatively with nonweight bearing status with resultant full recovery. CONCLUSION: This fracture does not meet the current definition of an AFF as, for that definition, a lateral femoral location is required. This case does not provide conclusive evidence for a causal relationship between treatment with denosumab and this unusual fracture. It clearly illustrates, however, the occurrence of an unusual, nontraumatic subtrochanteric fracture in a patient treated with the potent antiresorptive agent denosumab with many features in common with bisphosphonate-associated AFF.