Clinical Assessment Specialists: A New Faculty Role to Improve Clerkship Assessment.

INTRODUCTION: Ambulatory clerkships, including longitudinal integrated clerkships (LICs), face challenges to assessment, including time pressure and clinical demands on preceptors. High-quality clinical assessment is critical to implementing competency-based medical education, generating valid grades, and supporting learning. This importance is further heightened with the new pass/fail scoring for US Medical Licensing Exam Step 1, discontinuation of US Medical Licensing Exam Step 2 Clinical Skills, and the growing concern for bias in assessment. METHODS: The Kaiser Permanente Bernard J. Tyson School of Medicine's LIC spans the first 2 years with 50 students per class. In 2021-2022, the authors created a new faculty role, the clinical assessment specialist (CASp). CASps are highly trained clinical teachers who directly observe clerkship students in the ambulatory setting, provide feedback, and complete competency-based assessment forms. RESULTS: CASps completed 186 assessments of first-year (Y1) LIC students and 333 assessments of second-year (Y2) LIC students. Y2 students achieved average higher milestones and were rated as requiring less supervision compared to Y1 students. Y1 students rated CASps more favorably than Y2 students. Preceptors rated the contribution of CASps similarly across both years. Clerkship directors described benefits including identification of at-risk students and value of augmenting preceptor assessments. DISCUSSION: The CASp role may offer an innovative way to generate valid assessment of student performance, offset clinical pressures faced by preceptors, identify at-risk students, and mitigate bias, especially in an LIC. Future studies may examine assessment validity, including use in summative assessment. CONCLUSION: CASps are an innovative approach to clinical clerkship assessment.

Allograft discard risk index for lung transplantation.

BACKGROUND: The demand for donor lungs continues to outpace the supply, yet nearly 75% of donor lungs intended for lung transplantation are discarded. METHODS: We reviewed all donation after brain death organ donors listed within the UNOS Deceased Donor Database between 2005 and 2020. Univariable and multivariable analyses were run on the training set (n = 69,355) with the primary outcome defined as lung discard, and the results were used to create a discard risk index (DSRI). Discard data were assessed at DSRI value deciles using the validation set (n = 34,670), and differences in 1-year mortality were assessed using stratum-specific likelihood ratio (SSLR) analysis. RESULTS: Donor factors most associated with higher DSRI values included age > 65, PaO2 < 300, hepatitis C virus, and cigarette use. Factors associated with lower DSRI values included donor age < 40 and PaO2 > 400. The DSRI was a reliable predictor of donor discard, with a C-statistic of 0.867 in the training set and 0.871 in the validation set. The DSRI was not a reliable predictor of 30-day, 1-year, 3-year, and 5-year survival following transplantation (C-statistic 0.519-0.530). SSLR analysis resulted in three 1-year mortality strata (SSLR 0.88 in the 1st DSRI value decile, 1.03 in the 2nd-5th, & 1.19 in the 6th-10th). CONCLUSIONS: The factors leading to lung allograft discard are not the same as those leading to worse recipient outcomes. This suggests that with proper allocation, many of the grafts that are now commonly discarded could be used in the future donor pool with limited impact on mortality.

Role of early endoscopic evaluation in decreasing morbidity, mortality, and cost after caustic ingestion: a retrospective nationwide database analysis.

Caustic substance ingestion (CSI) is a serious medical problem with potentially devastating short- and long-term consequences. Early upper gastrointestinal endoscopy (EaEn) is recommended to evaluate the extent of injury and guide management but there has been controversy about the timing. There is no nationwide study evaluating adherence to EaEn and outcomes following CSI.Nationwide Inpatient Sample database 2003-2011 was used to identify all-age, nonreferral, urgent/emergent admissions with E-International Classification of Diseases Ninth Revision codes for CSI. We evaluated the association of undergoing late endoscopy (LaEn, >48 hours since admission) with poor clinical (death or systemic complications) and economic (cost for admission and length of stay above the 75th percentile) outcomes after controlling for other demographic and clinical factors using a multivariate analysis.We identified 21,682 patients with a median age of 37 years, 51% males, 43% Caucasians, with suicidal ingestion reported in 40%. Endoscopy was performed in 6011 patients (37%). The majority had EaEn (43% within 24, and 40% within 24-48 hours), whereas 17% had LaEn.Compared to EaEn group, the LaEn group was associated with a three-fold increase (OR = 2.7, P < 0.001) in the risk for poor clinical outcome: a fourfold increase (OR = 4.6, P < 0.001) in high cost admissions, and a fivefold increase (OR = 4.9, P < 0.001) in prolonged hospitalization. There was no significant difference in clinical outcomes based on endoscopy within 24, and 24-48 hours of admission.In this retrospective nationwide database analysis, undergoing LaEn was associated with both negative clinical and economic outcomes. More studies are needed to further examine the reasons for delaying endoscopy and subsequent management pathways based on the endoscopic findings. Early endoscopic evaluation could potentially improve the clinical outcomes and reduce costs of these admissions.

Cardiac magnetic resonance assessment of takotsubo cardiomyopathy.

Takotsubo cardiomyopathy is an important condition that can be difficult to differentiate from acute coronary syndrome on the basis of clinical, electrocardiogram, and cardiac enzyme assessment alone. Although coronary angiography remains important in the acute assessment of patients with suspected takotsubo cardiomyopathy, cardiac magnetic resonance (CMR) has emerged over the last decade as an important non-invasive imaging tool in the diagnosis and follow-up of this condition. We present a review highlighting the CMR features of takotsubo cardiomyopathy and its complications with particular focus on differentiating this condition from acute myocardial infarction and myocarditis.

Qualitative Assessment of Diffusion Weighted Imaging and Susceptibility Weighted Imaging of Myeloid Sarcoma Involving the Brain.

BACKGROUND AND PURPOSE: Myeloid sarcoma is a rare form of extramedullary leukemia, which can present with or without systemic leukemia. The purpose of this study was to evaluate characteristic computed tomography (CT) and magnetic resonance imaging (MRI) findings (including diffusion weighted imaging and susceptibility weighted imaging) of myeloid sarcoma involving the brain. MATERIALS AND METHODS: One hundred nine patients with pathologically proven myeloid sarcoma underwent pretreatment CT and MRI, which were retrospectively reviewed. Computed tomography and MRI characteristics reviewed include lesion location, shape, size, architecture, margins, ± multiplicity, ± bone destruction, pattern and degree of enhancement, ± restricted diffusion, and ± susceptibility artifact. RESULTS: Twenty-five patients (14 men, 11 women; mean age, 55 years; range, 9-80 years) met the inclusion criteria. Acute myeloid leukemia with subtypes M3 (44.4%) and M5 (22.2%) were the most common. On unenhanced CT, mean lesion size was 1.9 ± 0.4 cm; 60% were intra-axial hyperdense masses, 8% were intraventricular hyperdense masses, 12% were isodense intra-axial masses, and 20% of cases were extra-axial hyperdense nodular masses. There was no observable intralesional or perilesional calcium. On MRI, mean lesion size was 2.1 ± 0.6 cm. The lesions were isointense (80%) or hypointense (20%) on T1-weighted images with homogeneous (88%) or heterogeneous (12%) enhancement. On fluid-attenuated inversion recovery and T2-weighted images, lesions were hyperintense (96%) or isointense (4%) with mild vasogenic edema. Majority (96%) of cases demonstrated restricted diffusion, whereas only a few (16%) demonstrated susceptibility artifact. CONCLUSIONS: In patients with history of leukemia or myeloproliferative disorder, identification of homogenous mass hyperdense on unenhanced CT, T1 isointense, and T2/fluid-attenuated inversion recovery hyperintense with restricted diffusion and homogenous postcontrast enhancement without significant susceptibility artifact is suggestive of myeloid sarcoma.

Cardiac MR assessment of microvascular obstruction.

Microvascular obstruction (MVO) is usually seen in a proportion of patients with acute myocardial infarction following reperfusion therapy of an occluded coronary artery. It is characterized by damage and dysfunction of the myocardial microvasculature with a no-reflow phenomenon within the infarct zone. While MVO may be demonstrated via a number of different imaging modalities, cardiac MR (CMR) enables accurate identification of MVO and also permits assessment of infarct extent and overall left ventricular function during the same imaging examination. We present a pictorial review of the characteristic appearances of MVO on CMR and highlight the importance of this imaging diagnosis for patient outcome following acute myocardial infarction.

Cardiac MR assessment of cardiac myxomas.

Cardiac myxomas are the most common benign primary cardiac tumour to present in adulthood. While most patients present with symptoms of cardiac obstruction, embolic phenomena or constitutional impairment, up to a fifth of patients remain asymptomatic and are incidentally diagnosed on imaging. Although echocardiography is usually the initial imaging modality used to evaluate these patients, cardiac MRI (CMR) has emerged over the past decade as the primary imaging modality in the assessment of patients with cardiac tumours. The superior tissue characterization capability of CMR means that it is able to determine the nature of some tumours pre-operatively and performs well in differentiating myxomas from thrombus. We present a pictorial review highlighting the key CMR features of myxomas and show how these lesions can be differentiated from thrombus and other cardiac masses.

Value of cardiac 320-multidetector computed tomography and cardiac magnetic resonance imaging for assessment of myocardial perfusion defects in patients with known chronic ischemic heart disease.

The challenge for therapies targeting perfusion abnormalities is to identify and evaluate the region of interest. The aim of this study was to compare rest and stress myocardial perfusion measured by cardiac multi-detector computed tomography (MDCT) and cardiac magnetic resonance (CMR) imaging in patients with invasive coronary angiography demonstrated occluded vessels. Twenty-four patients with refractory angina due to occluded coronary arteries underwent perfusion imaging obtained by 320-MDCT scanner and 1.5 T MR scanner. Rest and adenosine stress images were obtained and interpreted using the modified 17-segment American Heart Association model. For the qualitative analysis, each segment was graded according to the following scoring system: 0 = no defect, 1 = hypoperfusion transmural extent <1/3, 2 = 1/3-1/2, 3 = >1/2, and 4 = infarct stigmata. In the semiquantitative analysis the perfusion was either scored 0 (normal) or 1 (abnormal). The summed rest and stress scores were calculated. MDCT and CMR had a high probability to identify perfusion defects. An excellent correlation between MDCT and CMR summed rest (r = 0.916) and stress scores (r = 0.915) was found. The interobserver reproducibility was high for MDCT and CMR images. The qualitative and semiquantitative MDCT against CMR analysis of rest and stress images showed high concordance to detect perfusion defects per vascular territory and on a per myocardial segment basis. 320-MDCT and CMR perfusion imaging can be used clinically to identify myocardial perfusion defects and potentially evaluate the effect of therapy targeting perfusion abnormalities.

Evaluation of fixation disparity curve parameters with the modified near mallett unit in symptomatic and asymptomatic university students.

BACKGROUND: Research suggests that fixation disparity data are extremely useful in the assessment of the binocular and accommodative systems. OBJECTIVES: The purpose of this study was to evaluate fixation disparity curve (FDC) parameters with a modified near Mallett unit in symptomatic and asymptomatic students of Paramedical Sciences School of Mashhad University of Medical Sciences in 2007. PATIENTS AND METHODS: In this analytical-descriptive study, 100 students were selected randomly and divided into symptomatic and asymptomatic groups. Fixation disparity curve parameters were determined for each subject and compared in symptomatic and asymptomatic groups. RESULTS: There were more subjects with exo fixation disparity than eso fixation disparity in the study sample. The means for fixation disparity, fixation disparity curve x-intercept, and slope with the modified Mallett unit were each significantly different by Mann-Whitney U test in the symptomatic and asymptomatic groups. Also there was a significant difference in the distributions of fixation disparity curve types in the two symptom groups by Chi-square test. CONCLUSIONS: The X-intercepts (point at which the FDC crosses the X-axis) were on average more in the base-in direction, Y-intercepts (point at which the FDC crosses the Y-axis) were shifted in the exo direction, and slopes were steeper in the symptomatic group.

Assessment of the accuracy of AortaScan for detection of abdominal aortic aneurysm (AAA).

BACKGROUND: AortaScan AMI 9700 is a portable 3D ultrasound device that automatically measures the maximum diameter of the abdominal aorta without the need for a trained sonographer. It is designed to rapidly diagnose or exclude an AAA and may have particular use in screening programs. Our objective was to determine its accuracy to detect AAA. METHODS: Subjects from our AAA screening and surveillance programs were examined. The aorta was scanned using the AortaScan and computed tomography (CT). RESULTS: Ninety-one subjects underwent imaging (44 AAA on conventional ultrasound surveillance and 47 controls). The largest measurement obtained by AortaScan was compared against the CT-aortic measurement. The mean aortic diameter was 2.8 cm. The CT scan confirmed the diagnosis of AAA in 43 subjects. There was one false positive measurement on conventional ultrasound. AortaScan missed the diagnosis of AAA in eight subjects. There were thirteen false positive measurements. The sensitivity, specificity, positive and negative predictive values were 81%, 72%, 72% and 81% respectively. CONCLUSION: A device to detect AAA without the need for a trained operator would have potential in a community-based screening programme. The AortaScan, however, lacks adequate sensitivity and significant technical improvement is necessary before it could be considered a replacement for trained screening personnel.

The clinical and cost effectiveness of bee honey dressing in the treatment of diabetic foot ulcers.

Honey is known, since antiquity, as an effective wound dressing. Emergence of resistant strains and the financial burden of modern dressings, have revived honey as cost-effective dressing particularly in developing countries. Its suitability for all stages of wound healing suggests its clinical effectiveness in diabetic foot wound infections. Thirty infected diabetic foot wounds were randomly selected from patients presenting to Surgery Department, Suez Canal University Hospital, Ismailia, Egypt. Honey dressing was applied to wounds for 3 months till healing, grafting or failure of treatment. Changes in grade and stage of wounds, using University of Texas Diabetic Wound Classification, as well as surface area were recorded weekly. Bacterial load was determined before and after honey dressing. Complete healing was significantly achieved in 43.3% of ulcers. Decrease in size and healthy granulation was significantly observed in another 43.3% of patients. Bacterial load of all ulcers was significantly reduced after the first week of honey dressing. Failure of treatment was observed in 6.7% of ulcers. This study proves that commercial clover honey is a clinical and cost-effective dressing for diabetic wound in developing countries. It is omnipresence and concordance with cultural beliefs makes it a typical environmentally based method for treating these conditions.

Assessment of the relation between prealbumin serum level and healing of skin-grafted burn wounds.

Nutritional status is an important factor in graft healing. Prealbumin (transthyretin) is a better nutritional marker than the widely used albumin serum level. Prealbumin serum levels were estimated in an endeavour to correlate them to graft healing and to serve as a predictor of graft healing in burn wounds. Fifty burned patients undergoing graft in the Suez Canal University Hospital Burn Unit were subjected to this cross-sectional study. Prealbumin levels were assessed on preoperative day and on the fourth postoperative day. Graft healing was considered complete when the take was 90% or more of the grafted area. The most significantly correlated factor to graft healing was serum prealbumin. Serum albumin levels were not in significant correlation with graft healing or prealbumin levels. In addition, serum prealbumin levels were significantly higher in the younger age group and significantly lower in patients with chronic diseases. Serum prealbumin level is a sensitive tool in predicting graft take in burned patients when all local conditions are favourable and optimised. Nevertheless, it seems less sensitive in the prediction of graft healing in small raw areas less than 5% of total body surface area (TBSA).

Assessment of amniotic and polyurethane membrane dressings in the treatment of burns.

As allograft and xenografts are not available in Islamic countries, amniotic membrane seems to be an effective alternative in the management of deep burns. Its proven bioactivities and modest price suggest that it might be superior to synthetic dressings. Forty-six patients were enrolled in this randomized, controlled clinical trial conducted in the Burn Unit at Suez Canal University Hospital, Ismailia, Egypt. All age groups and both gender were included in the study. Only patients with less than 50% total body surface area burned were included, thus minimizing the dropouts in both groups. All were either second or third degree. These patients were randomly assigned either to group I: amniotic membrane (Biomembrane) dressing, or group II: polyurethane membrane (Tegaderm) dressing. Those in group I demonstrated a significantly lower rate of infection and required less frequent dressing changes than those in group II. They also sustained less electrolyte and albumin loss. The rate of healing in the amniotic membrane group was significantly faster than in the polyurethane group. Furthermore, pain was significantly less when Biomembrane was used. Based on these findings, we recommend the use of lyophilized gamma-irradiated amniotic membrane as an effective alternative for allograft and xenografts in Islamic countries and the Jewish population.

Surveying disabilities in Mafraq District in Jordan in view of approaching community based rehabilitation.

Disabilities in Mafraq District in Jordan were identified using active case detection. The identified disabilities were characterized by type, sex and age of the disabled as well as other variables pertaining to the reproductive history of their mothers and certain socioeconomic variables pertaining to their families. The results indicated an unmet need regarding services addressing the disabled and that they belong to poor families with high prevalence of illiteracy. The results also showed that the prevalence of consanguineous marriages as well as pregnancy at the two extremes of women's reproductive life is associated with congenital disability. The results were availed to the responsible authorities to facilitate embarking on Community Based Rehabilitation (CBR) in the district.

Maternal mortality in Mafraq District in Jordan.

The present study followed a multidimensional approach to determine maternal mortality ratio in Mafraq district in Jordan. It included active case (maternal deaths) surveillance combined with Civil Registry and hospital records review. Mafraq, by virtue of its geographic and demographic characteristics, is supposed to have a very high toll of maternal deaths and hence, generalizations reflecting the maximum expected maternal mortality ratio in Jordan could be made. The ratio, and as an average for the five years 1987-1991 covered in retrospect by the study was 42 deaths per 100,000 live births, very close to the estimated one. Establishing a baseline maternal mortality ratio and outlining risks pertaining to maternal survival as done in this study is an important prerequisite for interventions to reduce these risks and monitor progress towards reduction of maternal mortality ratio by half by the year 2000 which is a global goal to which Jordan is committed. The multidimensional approach followed by this study is shown to be superior to single source approaches in determining maternal mortality ratio in instances where populations are small and death registration is weak. The study suggests that maternal deaths (preferably as circumstances around the death and not as ICD coded, to avoid under reporting) should be reported in the same manner as notifiable diseases until improvements in death registration are completed and registries are accurate and valid.