Practical Tips for Undergraduate Medical Education Advisors in Residency Application Signaling.

Objectives: The residency application process has become increasingly complex for medical students and advisors to navigate. Program signaling was piloted to improve applicants' abilities to obtain interview offers at programs they were strongly interested in. The initial positive results led to expansion of signaling to additional specialties over the next two application cycles. Despite the benefits of program signaling, the variation in signaling practices among specialties has presented challenges for both advisors and students when determining how to best allocate signals. The aim of this study is to identify students' perceptions of the signaling process, how this may impact outcomes, and to guide future educational programming. Methods: This is an exploratory original survey study of students in a US allopathic medical school applying in ERAS for the 2023 residency cycle. The survey was developed to determine students' understanding of how programs would use signals in the application process and assess strategies students used to allocate signals. We compared program signals to student interview offers and match outcomes using descriptive statistics. Results: 57 of 96 eligible students completed the survey. 51% signaled a range of programs based on their perceived competitiveness for the program while 40% signaled programs of interest regardless of perceived competitiveness. 53% of students thought sending a signal would increase their chance of an interview, while 42% were unsure how the signal would be used by residency programs. Students received interviews at 49% of the programs signaled, which increased to 56.5% when specialties offering more than 7 signals were excluded. 35% of students matched at a signaled program. Conclusions: Students' perceptions and strategies related to the signaling process are varied and may impact interview offers. Advisors should monitor and review internal institutional trends to help inform future educational programming to optimize signal allocation for their students.

The outcomes of simultaneous liver and kidney transplantation using donation after cardiac death organs.

BACKGROUND: There has been a remarkable increase in simultaneous liver and kidney transplantations (SLK). As organ demand has increased, so has the use of donation after cardiac death (DCD). However, little is known about the outcomes of DCD in SLK. METHODS: We performed a retrospective analysis using the United Network for Organ Sharing database to compare the outcomes of DCD SLK to donation after brain death (DBD) and determine the impact of donor and recipient factors on allograft and patient survival. RESULTS: Between 2002 and 2011, a total of 3,026 subjects received SLK from DBD and 98 from DCD. Kidney, liver, and patient survival from DCD donors were inferior to DBD at 1, 3, and 5 years (P=0.0056, P=0.0035, and P=0.0205, respectively). With the use of the Cox model, DCD was a significant risk factor for kidney and liver allograft failure and patient mortality. Recipient factors that were associated with worse allograft and patient outcomes included black race, diabetes, being on a ventilator, hospitalization, delayed graft function, hepatocellular carcinoma, and intensive care unit stay. Older age of the donor was also associated with worse outcomes. CONCLUSION: Despite the decreased allograft and patient survival compared with DBD, DCD SLK provides an acceptable option for SLK, with a survival probability of more than 50% at 5 years.

The Patient-Centered Medical Neighborhood: Transformation of Specialty Care.

The growing need for coordinated care of those with medically complex diseases is becoming more important in today's health care system, wherein reimbursement changes are driving methods to improve quality and cost. This article discusses the 6 key processes that, according to the American College of Physicians, define an effective medical neighborhood; the evidence supporting the need for this coordinated system; and pilot medical neighborhood strategies being implemented.

Effect of a non-calcium-based phosphate binder on fibroblast growth factor 23 in chronic kidney disease.

BACKGROUND: Elevated fibroblast growth factor 23 (FGF23) levels are associated with progression of chronic kidney disease (CKD) and increased mortality. Studies in individuals without CKD suggest that FGF23 levels are regulated by dietary phosphorus; however, the effect of pharmacologic phosphorus restriction on FGF23 in CKD patients is uncertain. METHODS: We performed a prospective cohort study examining the effect of phosphorus reduction with sevelamer carbonate on FGF23 levels in CKD patients. Adults with an estimated glomerular filtration rate <60 ml/min/1.73 m(2) according to MDRD (Modification of Diet in Renal Disease) and hyperphosphatemia were enrolled. Subjects were started on sevelamer carbonate 800 mg by mouth with meals and the dose was titrated to achieve a serum phosphorus between 2.7 and 4.6 mg/dl for those with CKD stages III and IV, and between 3.5 and 5.5 mg/dl for CKD stage V. FGF23 levels were measured at baseline and 3 months. Results were analyzed as percent change from baseline. RESULTS: 40 patients completed the study. Mean estimated glomerular filtration rate by MDRD at entry was 21.2 ± 10.5, serum phosphorus 4.8 ± 0.8, and FGF23 level 602.3 ± 1,074.6. Mean serum phosphorus and FGF23 levels after 3 months were 4.4 ± 0.9 and 599.2 ± 720.9, respectively. No significant difference was seen in FGF23 (p = 0.76) despite a significant difference in phosphorus (p = 0.001). CONCLUSION: The patients treated with sevelamer carbonate did not have a significant change in plasma FGF23 levels despite a significant reduction in phosphorus. It is possible that once overt hyperphosphatemia develops, FGF23 levels may not be reduced by phosphorus reduction alone in CKD patients.

Effect of renin-angiotensin-aldosterone system blockade therapy on incidence of contrast-induced nephropathy in patients with chronic kidney disease.

INTRODUCTION: The incidence of contrast-induced nephropathy (CIN) ranges between 10% and 50% among high-risk patients. Whether medications that affect rennin-angiotensin-aldosterone system (RAAS) have any impact on the development of CIN remains uncertain. MATERIALS AND METHODS: We performed a retrospective study of patients with CKD stages 3 and 4 who were either on or off RAAS blockade therapy at the time of coronary angiography. Development of CIN was defined by a 25% increase of serum creatinine from baseline or an increase in serum creatinine by 0.5 mg/dL from baseline. Serum creatinine values were recorded before contrast exposure and for 5 days after coronary angiography. RESULTS: A total of 178 patients with CKD who had coronary angiography during the study period were included, of whom 62 (35%) were on ACE inhibitors, 12 (7%) were on ARBs, and 1 (1%) was on combination of ACE inhibitors and ARBs. The estimated glomerular filtration rate was 44.0 ± 11.5 mL/min. The odds ratio of acute kidney failure on day 5 was 0.73 (95% confidence interval, 0.31 to 1.69) for the ACE inhibitors and 0.46 (95% confidence interval, 0.06 to 3.70) for ARBs. Multivariable analysis revealed the findings to be independent of demographic variables, comorbidities, type of contrast medium, and the prophylactic strategies. CONCLUSIONS: Patients on RAAS blockade therapy before contrast exposure did not have an increased incidence of CIN. There was also no increased incidence of CIN with ACE inhibitors or ARBs in the subgroups at higher risk, such as those with diabetes mellitus.

Binding and neutralization efficiencies of monoclonal antibodies, Fab fragments, and scFv specific for L1 epitopes on the capsid of infectious HPV particles.

We compared the neutralization abilities of individual monoclonal antibodies (MAb) of two large panels reactive with L1 epitopes of HPV-11 or HPV-16. Binding titers were compared using both L1-only VLPs and L1/L2 pseudovirions. While the VLPs were antigenically similar to the pseudovirions, clear differences in the surface exposure of some epitopes were evident with the HPV-16 particles. To determine whether all antibody binding events are equivalent in their neutralizing effect on infectious HPV virions or pseudovirions, the binding and neutralization titers for individual MAbs were used to calculate the relative neutralization efficiency for each antibody. HPV neutralization was achieved by all MAbs capable of strong binding to either linear or conformation-sensitive epitopes on pseudovirus particles. Our data suggest, however, that some L1 epitopes may be more neutralization-sensitive than other surface epitopes, in that successful infection can be blocked by varying degrees of epitope saturation. Additionally, the effective neutralization of virions by several monovalent Fab fragments and single-chain variable fragments (scFv) demonstrates that viral neutralization does not require HPV particle aggregation or L1 crosslinking. Identification of capsid protein structures rich in neutralization-sensitive epitopes may aid in the development of improved recombinant vaccines capable of eliciting effective and long-term antibody-mediated protection against multiple HPV types.