The association of students requiring remediation in the internal medicine clerkship with poor performance during internship.

PURPOSE: To determine whether the Uniformed Services University (USU) system of workplace performance assessment for students in the internal medicine clerkship at the USU continues to be a sensitive predictor of subsequent poor performance during internship, when compared with assessments in other USU third year clerkships. METHOD: Utilizing Program Director survey results from 2007 through 2011 and U.S. Medical Licensing Examination (USMLE) Step 3 examination results as the outcomes of interest, we compared performance during internship for students who had less than passing performance in the internal medicine clerkship and required remediation, against students whose performance in the internal medicine clerkship was successful. We further analyzed internship ratings for students who received less than passing grades during the same time period on other third year clerkships such as general surgery, pediatrics, obstetrics and gynecology, family medicine, and psychiatry to evaluate whether poor performance on other individual clerkships were associated with future poor performance at the internship level. Results for this recent cohort of graduates were compared with previously published findings. RESULTS: The overall survey response rate for this 5 year cohort was 81% (689/853). Students who received a less than passing grade in the internal medicine clerkship and required further remediation were 4.5 times more likely to be given poor ratings in the domain of medical expertise and 18.7 times more likely to demonstrate poor professionalism during internship. Further, students requiring internal medicine remediation were 8.5 times more likely to fail USMLE Step 3. No other individual clerkship showed any statistically significant associations with performance at the intern level. On the other hand, 40% of students who successfully remediated and did graduate were not identified during internship as having poor performance. CONCLUSIONS: Unsuccessful clinical performance which requires remediation in the third year internal medicine clerkship at Uniformed Services University of the Health Sciences continues to be strongly associated with poor performance at the internship level. No significant associations existed between any of the other clerkships and poor performance during internship and Step 3 failure. The strength of this association with the internal medicine clerkship is most likely because of an increased level of sensitivity in detecting poor performance.

Pituitary apoplexy: a review of clinical presentation, management and outcome in 45 cases.

OBJECTIVE: To review clinical presentation, management and outcomes following different therapies in patients with pituitary apoplexy. METHODS: Retrospective analysis of case-records of patients with classical pituitary apoplexy treated in our hospitals between 1983-2004. RESULTS: Forty-five patients (28 men; mean age 49 years, range 16-72 years) were identified. Only 8 (18%) were known to have pituitary adenomas at presentation. Thirty-four (81%) patients had hypopituitarism at presentation. CT and MRI identified pituitary apoplexy in 28% and 91% cases, respectively. Twenty-seven (60%) patients underwent surgical decompression, whilst 18 (40%) were managed conservatively. Median time from presentation to surgery was 6 days (range 1-121 days). Patients with visual field defects were more likely than those without these signs to be managed surgically (p = 0.01). Complete or near-complete resolution occurred in 93% (13/14), 94% (15/16) and 93% (13/14) of the surgically treated patients with reduced visual acuity, visual field deficit and ocular palsy, respectively. All patients with reduced visual acuity (4/4), visual field deficit (4/4) and ocular palsy (8/8) in the conservative group had complete or near-complete recovery. Only 5 (19%) patients in the surgical group and 2 (11%) in the conservative group had normal pituitary function at follow up. One (4%) patient in the surgical group and 4 (22%) in the conservative group had a recurrence of pituitary adenoma. CONCLUSIONS: This large series suggests that the patients with classical pituitary apoplexy, who are without neuro-ophthalmic signs or exhibit mild and non-progressive signs, can be managed conservatively in the acute stage.

Significance of early bronchoscopic airway abnormalities after lung transplantation.

Abnormal bronchoscopic allograft airway appearance with erythema, friability and sloughing-presumed to be ischemic-has been described early after lung transplantation, but its association with post-operative spirometry or other outcomes is largely unknown. We conducted a prospective cohort study to assess the impact of such airway changes in all lung transplant recipients from January 1997 to July 2000. Twenty-four (59%) of 41 patients were classified as having ischemic-appearing airways. Timing and value of peak pulmonary function tests, mortality, incidence of infection, rejection, anastomotic stricture and bronchiolitis obliterans syndrome were not significantly different when compared to patients with normal-appearing airways over a mean follow-up period of 761.2 +/- 412.4 days.

Bilateral external laryngoceles following radioiodine ablation for Graves disease.

A 28-year-old trumpet player underwent multiple treatments with radioactive iodine for Graves disease associated with an unusually large goiter. Following his second treatment, the patient developed acute neck pain and swelling. Radiographic studies and a laryngoscopy demonstrated bilateral symptomatic external laryngoceles, a very rare entity, not previously known to be associated with radioiodine treatment or Graves disease. The patient's profession placed him at risk for the development of a laryngocele, but the temporal relationship to goiter regression following radioiodine therapy suggests that this occurred as a result of this treatment. The patient's disease was managed nonsurgically, and he has subsequently done well. This represents the first known association of symptomatic laryngocele with radioiodine treatment for Graves disease.

Do specialists differ on do-not-resuscitate decisions?

STUDY OBJECTIVE: Opinions regarding do-not-resuscitate (DNR) decisions differ between individual physicians. We attempted to determine whether the strength of DNR recommendations varies with medical specialty and experience. DESIGN: Written survey. PARTICIPANTS: Physicians from the pulmonary/critical-care medicine (PCCM), cardiology, internal medicine, gastroenterology, hematology/oncology, and infectious disease services as well as the Department of Medicine house staff at our tertiary-care referral center participated in the study. INTERVENTIONS: Physicians were asked confidentially to quantify the strength of their opinions on discussing and recommending DNR orders for each of 20 vignettes made from the summaries of actual cases. Reasons for their opinions and demographic data also were recorded. MEASUREMENTS AND RESULTS: One hundred fifteen of 155 physicians (74%) responded. PCCM physicians (mean [+/- SD] DNR score, 157 +/- 22) more strongly recommended DNR orders than cardiologists (mean DNR score, 122 +/- 32; p = 0.006), house staff (mean DNR score, 132 +/- 24; p = 0.014), and general internists (mean DNR score, 129 +/- 30; p = 0.043). PCCM physicians also trended toward recommending DNR orders for more of the 20 patients described in the vignettes compared to cardiologists (mean DNR number, 16.5 +/- 3.0 vs 11.9 +/- 5.8, respectively; p = 0.066). There were no differences between PCCM physicians and hematology/oncology, infectious disease, and gastroenterology specialists. Among the house staff, the likelihood of recommending a DNR order correlated significantly with increasing years of experience (r = 0.45; p = 0.002). The opposite trend was present in the specialty staff groups. No significant differences in opinion by gender, religion, or personal experiences were found. CONCLUSIONS: The strength of DNR order recommendations varies with medicine specialty and years of training and experience. An awareness of these differences and the determination of the reasons behind them may help to target educational interventions and to ensure effective collaboration with colleagues and communication with patients.