Citations

Purpose To examine how qualitative narrative comments and quantitative ratings from end-of-rotation assessments change for a cohort of residents from entry to graduation, and explore associations between comments and ratings. Method The authors obtained end-of-rotation quantitative ratings and narrative comments for 1 cohort of internal medicine residents at the University of Illinois at Chicago College of Medicine from July 2013–June 2016. They inductively identified themes in comments, coded orientation (praising/critical) and relevance (specificity and actionability) of feedback, examined associations between codes and ratings, and evaluated changes in themes and ratings across years. Results Data comprised 1,869 assessments (828 comments) on 33 residents. Five themes aligned with ACGME competencies (interpersonal and communication skills, professionalism, medical knowledge, patient care, and systems-based practice), and 3 did not (personal attributes, summative judgment, and comparison to training level). Work ethic was the most frequent subtheme. Comments emphasized medical knowledge more in year 1 and focused more on autonomy, leadership, and teaching in later years. Most comments (714/828 [86%]) contained high praise, and 412/828 (50%) were very relevant. Average ratings correlated positively with orientation (β = 0.46, P < .001) and negatively with relevance (β = −0.09, P = .01). Ratings increased significantly with each training year (year 1, mean [standard deviation]: 5.31 [0.59]; year 2: 5.58 [0.47]; year 3: 5.86 [0.43]; P < .001). Conclusions Narrative comments address resident attributes beyond the ACGME competencies and change as residents progress. Lower quantitative ratings are associated with more specific and actionable feedback.

e13119 Background: Tyrosine kinase inhibitors (TKIs) are routinely used in the treatment of metastatic RCC and Sunitinib is approved for the use in adjuvant setting. Arterial thromboembolic events (ATEs) have been described with these agents, although the overall risk remains unclear. We did a systematic review and meta-analysis to determine the incidence associated with the use of FDA approved TKIs used in treatment of RCC. Methods: PubMed, EMBASE, Cochrane Central and Scopus databases were searched to identify phase 2 and 3 RCTs of TKI therapy in RCC. Trials were included if they reported ATEs defined as arterial thrombosis, cerebral ischemia or infarction, myocardial ischemia and myocardial infarction. The DerSimonian-Laird random effects meta-analysis was performed using CMAv3 software to derive pooled estimates of incidence rates of ATEs with its 95% confidence interval (CI). I2 statistic was computed to express the percentage of the total observed variability due to study heterogeneity. Risk for bias was assessed using the Cochrane Collaboration’s tool. Results: 1755 studies retrieved in the initial search, and 13 phase 2 and 3 clinical trials (n = 4983) were included in the quantitative analysis. The trials had open label design which can potentially result in bias. Risk of bias was low in all other domains. TKIs used for the treatment of RCC included sunitinib (n = 2632), sorafenib (n = 981), cabozantinib (n = 78), pazopanib (n = 844), axitinib (n = 189) and tivozanib (n = 259). The incidence of ATEs with the use of TKIs was 2.9% (95% CI: 2-3%). Cabozantinib was associated with the highest rate of ATEs (11.5%, 95% CI: 6-21%), followed by sunitinib (2.6%, 95% CI:2-3%) pazopanib (2.6%, 95% CI:2-4%) and axitinib (2.1%, 95% CI: 1-6%). The TKI with lowest event rate of ATE was tivozanib (0.8%, 95% CI:0.2-3%). Conclusions: The use of TKIs is associated with increased risk of developing ATEs. Clinicians should be aware of the possibility of increased ATEs and counsel the patients about this increased risk to enhance the process of informed decision making.

e13096 Background: Several studies have reported the association between atrial fibrillation (AF) and malignant cancer. Recently, results from a large cohort within the Women’s Health Study showed increased incident risk of breast, colon and lung cancer in patients with AF. Therefore, we performed a systematic review to assess the available evidence and a meta-analysis to define the strength of this association. Methods: MEDLINE, Cochrane and Scopus databases were searched for all prospective studies that reported the association between AF and presence of cancer. The HR for incident risk of common cancers was recorded (Breast, Lung, Colorectal) in patients with and without AF. Lung cancer was excluded because the data required for the analysis was not consistently reported. The DerSimonian-Laird random effects meta-analysis was performed to derive pooled Hazard Ratio (HR) estimates for incident risk of colorectal and breast cancer in patients with AF. Q-test was used to assess between-study heterogeneity; I2 statistic was computed to expresses the percentage of the total observed variability due to study heterogeneity. Results: A total of 390,479 participants in 3 prospective studies were included in the analysis. Mean age of participants was 66.3 ± 6.5 with mean follow up for 12.6 years. Patients with atrial fibrillation had 27% more risk of developing colorectal cancer [HR 1.27 (1.07-1.51) p < 0.005, I2= 73%] and 14% more risk of developing breast cancer [HR 1.14 (1.03-1.26) p = 0.01, I2= 37%] as compared to those without atrial fibrillation. Applying these hazard ratios to age adjusted yearly incidence ratios from 2000-2015, one in 5824 new onset AF cases will develop CRC and one in 7474 new onset AF cases will develop breast cancer. Conclusions: There is small but statistically significant increase in risk of subsequent diagnosis of colorectal or breast cancer diagnosis in patients with AF. Shared risk factors such as old age or systemic disease processes may explain this association. While the results of this analysis raise interesting questions for future search, these results should not be used as basis to initiate cancer screening for an occult cancer in a patient with AF.

Background: The goal of this study was to assess patient perspectives and satisfaction with the MiniMed 670G insulin pump. Those participants who used the pump as part of a hybrid closed loop were also asked to provide their views on the automatic feature (auto mode). Methods: Adults with type 1 diabetes mellitus using the Medtronic™ 670G pump were asked about their experience with the device using a semi-structured survey developed by the research team. Responses were quantified to identify emergent themes. Results: Seventeen participants used the pump as part of a hybrid closed loop system, while four participants used the pump in combination with a nonintegrated continuous glucose monitoring system. Overall, participants indicated a high level of satisfaction with the pump (14/21) mostly because of improvements in blood glucose (BG) control (15/21). Least liked features were physical design and structure (6/21), frequency of user input (5/21), alert frequency (4/21), and difficulty of use (3/21). Those using the hybrid closed loop were satisfied with the auto mode feature (11/17), mostly because of improvements in BG control (9/17). The least liked features of the auto mode technology were that blood glucose levels remained elevated (5/17) and the frequency of alerts (4/17). Conclusion: Participants indicated a high level of satisfaction with the pump and its auto mode featured mostly because of improvements in BG control. They also pointed out some key aspects of the device that are of potential clinical or commercial relevance. Additional research is needed to further evaluate users' perspectives on this new device.

Substantial research has illuminated the clinical reasoning processes involved in diagnosis (diagnostic reasoning). Far less is known about the processes entailed in patient management (management reasoning), including decisions about treatment, further testing, follow-up visits, and allocation of limited resources. The authors’ purpose is to articulate key differences between diagnostic and management reasoning, implications for health professions education, and areas of needed research. Diagnostic reasoning focuses primarily on classification (i.e., assigning meaningful labels to a pattern of symptoms, signs, and test results). Management reasoning involves negotiation of a plan and ongoing monitoring/adjustment of that plan. A diagnosis can usually be established as correct or incorrect, whereas there are typically multiple reasonable management approaches. Patient preferences, clinician attitudes, clinical contexts, and logistical constraints should not influence diagnosis, whereas management nearly always involves prioritization among such factors. Diagnostic classifications do not necessarily require direct patient interaction, whereas management prioritizations require communication and negotiation. Diagnoses can be defined at a single time point (given enough information), whereas management decisions are expected to evolve over time. Finally, management is typically more complex than diagnosis. Management reasoning may require educational approaches distinct from those used for diagnostic reasoning, including teaching distinct skills (e.g., negotiating with patients, tolerating uncertainty, and monitoring treatment) and developing assessments that account for underlying reasoning processes and multiple acceptable solutions. Areas of needed research include if and how cognitive processes differ for management and diagnostic reasoning, how and when management reasoning abilities develop, and how to support management reasoning in clinical practice.