Student-run free clinic volunteers: who they are and what we can learn from them.

BACKGROUND: Initiatives employing medical students' volunteerism and idealism, such as the Student-Run Free Clinics (SRFC) program, are prevalent in US medical schools. Many studies evaluated various aspects of volunteering, sometimes resulting in conflicting evidence. This study simultaneously sought to identify the characteristics of volunteers vs. non-volunteers, and to characterize the volunteers' perception of the SRFC. METHODS: We administered a survey to the Long School of Medicine (LSOM) Class of 2018 before their third year of medical school. The authors compared and contrasted the findings of the SRFC volunteers with their non-volunteering counterparts by analyzing their demographics, volunteering history, academic performance, and clinical skills. The volunteers were also asked about their SRFC experiences. RESULTS: While most volunteers were female (62 %) and non-traditional students (67 %), the difference was not statistically significant (p = 0.15 and p = 0.38, respectively). Additionally, there were no statistically significant differences between the two groups in measures of academic performance (p = 0.25). Most of the volunteers learned about the SRFC program prior to starting medical school. Further, while SRFC volunteers were more likely to engage in additional local volunteering initiatives, the difference was not statistically significant (p = 0.03, prespecified  α= 0.006). Importantly, volunteers agreed/strongly agreed that SRFC volunteering emphasized aspects that were missing or underemphasized in the formal medical school curriculum. CONCLUSIONS: Medical students' age, gender, undergraduate major, and non-traditional status were not statistically different between volunteers vs. non-volunteers. However, there may be tendencies for volunteers to be female, non-traditional, and locally engaged. Further, the timing of knowledge of the SRFC program may not affect student involvement in the SRFC, either. Most importantly, however, while volunteering does not affect the students' academic performance, it may provide improvements in clinical competencies.

Surgical treatment of an extrarenal pseudoaneurysm after kidney transplantation.

A 69-year-old man who underwent a kidney transplantation developed a large pseudoaneurysm at the anastomosis between the right external iliac artery and renal transplant artery. After an unsuccessful attempt using percutaneous thrombin injection, the patient underwent open exploratory laparotomy and surgical ligation of the pseudoaneurysm with preservation of renal graft function.

Senior medical student "Boot Camp": can result in increased self-confidence before starting surgery internships.

OBJECTIVE: Surgical residents often begin the internship without prerequisite skills necessary for appropriate patient care. The purpose of this study was to develop a surgical internship readiness elective or senior medical student (SMS) "Boot Camp" for fourth-year medical students to prepare them for the rigors of surgery internship. DESIGN: Sixteen fourth-year medical students completed a series of clinical and didactic sessions over a 4-week elective. Students evaluated the effectiveness of the elective with a pre- and post-survey that focused on confidence levels in 4 areas: anatomic dissection, administrative skills, technical skills, and patient management. Students also participated in a focus group session that identified strengths and weaknesses of the elective. Students were also assessed on performance by anesthesiology faculty in the mock patient code and by nursing faculty in mock nursing page sessions. RESULTS: Upon completion of the elective, students rated themselves as more confident in all 57 categories on the survey. During the focus group session, students identified several strengths of the elective and offered recommendations for improvements in the elective. CONCLUSION: The SMS "Boot Camp" gave fourth-year medical students confidence and an opportunity to develop necessary prerequisite skills to begin the surgery internship.

A multicenter, prospective study of C2-monitored cyclosporine microemulsion in a U.S. population of de novo renal transplant recipients.

BACKGROUND: Monitoring cyclosporine microemulsion (CsA-ME; Neoral) exposure 2 hours postdose (C2) has been reported to optimize the efficacy and safety of CsA-ME therapy. The addition of induction therapy to a maintenance regimen including CsA-ME C2 monitoring has not been evaluated. METHODS: In all, 123 adult renal transplant recipients were recruited at 14 U.S. centers for this 6-month study. CsA-ME dose was to be titrated to attain C2 targets of 1700 and 1500 ng/ml during posttransplant months 1 and 2, respectively. After 2 months, patients were randomized to one of two groups with different, decreasing C2 targets. Basiliximab, mycophenolate mofetil, and corticosteroids completed the study immunosuppression. RESULTS: Of the 119 evaluable patients, 76% were male, 22% African American, and 66% deceased donor recipients. Biopsy-proven acute rejection occurred in 10 patients (9.3%); there were two failed grafts and one death. Serum creatinine and calculated GFR values suggest good renal function, with month 6 medians of 1.5 ng/ml and 67 ml/min/1.73 m. Safety and tolerability assessments revealed no unexpected outcomes. Observed C2 levels were generally lower than protocol targets, particularly in the first weeks posttransplantation. CONCLUSIONS: The striking efficacy and outcomes may have been achieved in this study with lower C2 levels of CsA-ME because of the addition of basiliximab induction.

Severe, late-onset graft-versus-host disease in a liver transplant recipient documented by chimerism analysis.

A 52-year-old liver transplant recipient presented 8 months after transplantation with oral thrush, then 3 days later with oral ulcers and a diffuse rash, and 5 days later with an acutely reduced white blood cell count, rash, fever, and diarrhea. Bone marrow biopsy revealed severe aplasia. Although graft-versus-host disease (GVHD) was considered, the late onset of these symptoms was felt to render this etiology unlikely because GVHD usually occurs 2 to 6 weeks after transplantation. All potentially myelosuppressive medications were discontinued, and the patient was treated with high doses of hematopoietic growth factors. Because his symptoms continued, chimerism analysis was performed, which indicated that 96% of the peripheral blood mononuclear cells were of liver-donor origin. Ultimately, the patient underwent an allogeneic peripheral blood hematopoietic progenitor cell transplant from a human leukocyte antigen-identical brother, but he died 5 days after transplantation of overwhelming Candida kruseii infection. To our knowledge, this is the first chimerism-analysis-documented case of severe acute GVHD presenting so late after liver transplantation. It is of note that the patient had no known risks for GVHD in that he was relatively young and shared only one major human leukocyte antigen with his donor. Consideration should be given to GVHD as a cause of bone marrow aplasia at any time after organ transplantation. Storage of cell pellets from all transplant recipients and donors is highly recommended to facilitate the diagnostic evaluation.

A university system's approach to enhancing the educational mission of health science schools and institutions: the University of Texas Academy of Health Science Education.

BACKGROUND: The academy movement developed in the United States as an important approach to enhance the educational mission and facilitate the recognition and work of educators at medical schools and health science institutions. OBJECTIVES: Academies initially formed at individual medical schools. Educators and leaders in The University of Texas System (the UT System, UTS) recognized the academy movement as a means both to address special challenges and pursue opportunities for advancing the educational mission of academic health sciences institutions. METHODS: The UTS academy process was started by the appointment of a Chancellor's Health Fellow for Education in 2004. Subsequently, the University of Texas Academy of Health Science Education (UTAHSE) was formed by bringing together esteemed faculty educators from the six UTS health science institutions. RESULTS: Currently, the UTAHSE has 132 voting members who were selected through a rigorous, system-wide peer review and who represent multiple professional backgrounds and all six campuses. With support from the UTS, the UTAHSE has developed and sustained an annual Innovations in Health Science Education conference, a small grants program and an Innovations in Health Science Education Award, among other UTS health science educational activities. The UTAHSE represents one university system's innovative approach to enhancing its educational mission through multi- and interdisciplinary as well as inter-institutional collaboration. CONCLUSIONS: The UTAHSE is presented as a model for the development of other consortia-type academies that could involve several components of a university system or coalitions of several institutions.

Educational debt of physicians-in-training: determining the level of interest in a loan repayment program for service in a medically underserved area.

PURPOSE: The amount of financial debt incurred by Texas medical students and residents during training was examined as well as the impact of this debt on these trainees' career choices. METHOD: An invitation to participate was sent in a Web-based survey to medical students and residents at 6 university programs in Texas during the 2005-2006 academic year. RESULTS: Overall, 818 students (20%) and 529 residents (14%) responded to the survey. Of these, 96% of students and 85% of residents had taken out educational loans, and approximately 62% of students and residents expected their debt to exceed $100,000. More than half of students and residents expected educational debt to influence their choice of practice type and practice area and to affect important personal decisions. Approximately 52% of students and 38% of residents indicated an interest in participating in a loan repayment program that involved service in a medically underserved area. In general, women and members of minority groups were more likely to express such an interest. CONCLUSIONS: Medical students and residents incur considerable financial debt, which seems to affect their career choices. Approximately half of the students and one third of the residents surveyed indicated that they would consider participating in a loan repayment program that required practice in an underserved area.

Use of a silastic silo for closure of the abdominal wall in a pediatric patient receiving a cadaveric split liver.

Presented is the successful management of a difficult abdominal wall closure after pediatric liver transplantation. A 5-week-old boy with biliary atresia underwent urgent cadaveric split liver transplantation. The left lateral segment of an adult donor was utilized. Postoperatively, abdominal skin and fascia could not be closed. A SILASTIC (Dow Corning, Midland, MI) silo was applied, and complete closure was possible 6 days later.

Liver transplantation at the University of Texas Health Science Center/University Hospital in San Antonio.

Liver transplantation is the only potentially curative treatment for patients with end-stage liver disease. An extensive medical and psychosocial evaluation is performed in an attempt to determine which patients are likely to have acceptable outcomes with the procedure. The limited number of donor livers relative to patients that need a liver transplant, and the occurrence of significant deaths in the waiting group, has motivated many transplant programs to agree to put living donors at risk to help solve this problem. Other complex operative techniques such as splitting livers for use in 2 patients have improved the organ availability for pediatric and adult patients. Growth of a liver transplant program from a small program to a large program necessitates institutional, hospital capacity and infrastructure support at many levels to be successful. This requires a strong partnership between the physicians and the hospital system. 1. The University of Texas Health Science Center/University Hospital in San Antonio has performed 610 liver transplants over ten years. Overall one- and 5-year patient survival rates were 88% and 75%, respectively, despite transplanting a relatively advanced population of patients based on MELD scoring. 2. The most frequent indication for liver transplantation was hepatitis C (52% of patients) and the one-, 5-, and 10-year survival rates for transplantation for hepatitis C was equivalent to survival rates after liver transplantation for other indications, despite significant recurrent hepatitis C liver injury. 3. Technical refinements have decreased operative times and immunosuppressive advances have decreased the side effects while maintaining excellent outcomes. Veno-venous bypass and the placement of biliary T-tubes are not currently used. Standard immunosuppression is lower dose Prograf, Cellcept and steroids with Cellcept being weaned off at 3 months and steroids weaned off by one year. 4. Strategies to increase the donor pool including the use of older donors, the use of steatotic livers, the use of split livers and living liver donors for children and adults are all being used successfully at UTHSCSA.

Radiofrequency tissue ablation: effect of hepatic blood flow occlusion on thermal injuries produced in cirrhotic livers.

BACKGROUND: Radiofrequency thermal ablation has been used as a treatment for several types of hepatic malignancies. Many of these lesions exist in the presence of cirrhosis. Limitations exist to the size of the ablations and, subsequently, the efficacy of treatment. Hepatic vascular inflow occlusion has been advocated as an adjunctive measure to increase the efficacy of the ablation. We present a model in the human cirrhotic liver that demonstrates the advantage of blood flow occlusion during radiofrequency ablation. METHODS: Five patients with advanced endstage liver disease scheduled to have orthotopic liver transplantation were enrolled in this study. After laparotomy and before hepatectomy, radiofrequency ablation was performed without and with hepatic blood flow occlusion. After hepatectomy, the liver was sectioned, the area of ablation was measured in three dimensions, and the volume of ablation calculated. RESULTS: Three of the patients had had previously placed transjugular intrahepatic portosystemic shunt. The mean volume of the ablation without blood flow occlusion was 22.5 +/- 7.4 cm(3) and that with blood flow occlusion was 48.4 +/- 24.0 cm(3) (P =.05). CONCLUSIONS: Ablation area is increased significantly with hepatic blood flow occlusion in the human cirrhotic liver. This result may have application in the treatment of larger (>3 cm) hepatic malignancies.

Sonographically observed echogenic response during intraoperative radiofrequency ablation of cirrhotic livers: pathologic correlation.

OBJECTIVE: We performed a study to determine the correlation between the diameter of the echogenic response observed with intraoperative sonography during radiofrequency ablation of the cirrhotic liver and the mean diameter of tissue necrosis. SUBJECTS AND METHODS: A total of 22 intraoperative radiofrequency ablations were created in 11 cirrhotic livers. The largest diameter of the sonographically observed echogenic response surrounding and perpendicular to the radiofrequency probe was measured. The subsequent zone of necrosis observed at pathology in the hepatectomy specimens after liver transplantation was measured in three planes and compared with the measured diameter of the echogenic response. RESULTS: During all except three ablations, a hyperechoic region was visualized surrounding the radiofrequency probe. The diameter of the echogenic response correlated significantly with the mean diameter of necrosis (correlation coefficient, 0.84). However, the echogenic response overestimated the minimal diameter of necrosis (mean difference, 0.8 +/- 0.4 cm) in 18 of 22 ablations and underestimated the maximum diameter of necrosis (mean difference, 0.9 +/- 0.8 cm) in 16 of 22 ablations. CONCLUSION: The diameter of the echogenic response observed with intraoperative sonography during radiofrequency ablation of the cirrhotic liver correlates closely with the mean diameter of the subsequent area of tissue necrosis. However, the solitary diameter of the echogenic response as measured in our study was often greater than the smallest diameter and less than the largest diameter of the area of tissue necrosis. Therefore, the echogenic response associated with radiofrequency ablation of the cirrhotic liver should be viewed only as a rough approximation of the area of induced tissue necrosis; the final assessment of the adequacy of ablation should be deferred to an alternative imaging technique.