More specific feedback: why "confidence" in feedback is too ambiguous.

High quality feedback should be delivered in a timely manner, based on specific direct observation, and formulated to be actionable on the part of the trainee. Utilizing "confidence" as a point of feedback does not meet these criteria given the ambiguity and lack of actionable steps towards improvement. "Confidence"-based feedback makes a judgment about the trainee's internal state leading to potentially gender or culturally biased feedback. There is a risk of emotional harm for trainees when it is integrated into feedback and it is unclear if there is a role for the use of "confidence" in medical education. We are calling for a moratorium on the utilization of the word "confidence" in feedback in medical education until further studies are performed to assess its potential place. At this time, educators should refrain from "confidence"-based feedback and shift the focus towards more specific, actionable, behavioral-based feedback.

The use of vitamin D in preventing post-thyroidectomy hypocalcemia: An endocrinologist survey study.

OBJECTIVE: To evaluate the use of preoperative vitamin D levels and postoperative vitamin D supplementation among endocrinologists for the prevention of post-thyroidectomy hypocalcaemia. METHODS: Endocrinologist members of the American Thyroid Association (ATA) were contacted via email to complete a 21-question survey, which included both questions about demographic information, and preventing and managing postoperative hypocalcaemia after thyroidectomy. Univariate and multivariate analysis was performed to determine the respondents' use of preoperative vitamin D levels, dose and duration of preoperative vitamin D repletion, decision to delay surgery for low vitamin D levels in the case of a benign or malignant disease, and routine prescription of postoperative calcium or vitamin D supplementation. RESULTS: 225 endocrinologists who were ATA members responded to the questionnaire. When compared to endocrinologists practicing in other countries, those that practice in the United States were 2.5 times more likely to check preoperative vitamin D levels (95% CI[1.404, 4.535], P = .002), significantly more likely to replete vitamin D deficient patients with high-dose vitamin D (ie ≥50K IU/week), 4.458 times more likely to prescribe prophylactic supplemental calcium (95% CI[2.446, 8.126]; P < .0001) and 3.48 more likely to prescribe supplemental vitamin D (95% CI [1.906, 6.355]; P < .0001). Endocrinologists who have been in practice for >10 years were also 1.915 times more likely to prescribe supplemental vitamin D (95% CI (1.080, 3.395); P = .0263). Physicians that treat >50 thyroidectomy cases/year were 2.083 more likely to recommend a vitamin D repletion duration of >1 month than those that treat ≤50 cases/year ([1.036, 4.190], P = .0395). Lastly, if the patient has low preoperative vitamin D levels, 47.05% of respondents chose to delay surgery in a benign disease, while only 11.61% of respondents would do so in a case of malignant disease. CONCLUSIONS: Approximately one-half of surveyed endocrinologists reported using preoperative vitamin D levels to assess a patient's risk for post-thyroidectomy hypocalcaemia. Endocrinologists practicing in the United States, compared to those practicing in other countries, were more likely to both test for preoperative vitamin D levels and to recommend prophylactic post-thyroidectomy calcium and vitamin D supplementation.

A prospective observational study evaluating hypothalamic-pituitary-adrenal axis alteration and efficacy of intramuscular triamcinolone acetonide for steroid-responsive dermatologic disease.

BACKGROUND: The lack of recommendations regarding dosing and administration, an undetermined risk of hypothalamic-pituitary-adrenal axis alteration, and the unknown effectiveness of intramuscular (IM) corticosteroid injection to treat dermatologic disease may be deterrents to use. OBJECTIVE: We sought to evaluate presence and duration of iatrogenic Cushing syndrome and secondary adrenal insufficiency in patients receiving IM triamcinolone acetonide (TAC), and to assess physician- and patient-reported outcomes. METHODS: We conducted a prospective observational study of 14 patients given the diagnosis of steroid-responsive dermatologic disease who received either 1 or 2 doses 6 weeks apart of IM TAC. Baseline and follow-up cortisol, adrenocorticotropic hormone, Physician and Subject Global Assessments of Disease Activity Scale score, and the visual analog scale score of pruritus were evaluated at 6-week intervals. RESULTS: Although mean total cortisol was significantly decreased at 6 and 12 weeks compared with baseline, IM TAC did not result in iatrogenic Cushing syndrome or secondary adrenal insufficiency in any patient. Mean Physician and Subject Global Assessments of Disease Activity Scale scores were significantly improved at 6 and 12 weeks compared with baseline. Mean visual analog scale pruritus scores were significantly improved at 6 weeks compared with baseline. LIMITATIONS: The study was limited by the cohort size and a lack of a comparator group. CONCLUSION: IM TAC appears safe when administered as 2 injections at 6-week intervals. Significant improvement was noted across a number of steroid-responsive dermatoses. These results may provide a guide to dosing, frequency, and administration for dermatologists considering the use of IM TAC in the appropriate clinical contexts.

Diabetes Physical Examination.

The physical examination of the patient with diabetes may have revealed findings that confirm the diagnosis, classify the type of diabetes, and begin to evaluate for the macro- and microvascular complications of diabetes and significant comorbid conditions. While screening for the diagnosis of diabetes occurs with assessment for abnormal blood glucose, given the high rates of morbidity and mortality associated with diabetes, utilization of the physical examination plays a key role in identifying patients at risk for the complications of diabetes. The discussion of elements of the physical examination relevant to the patient with diabetes, both type 1 and type 2, will be discussed in this article.

Can You Hear Me Now? Helping Faculty Improve Feedback Exchange for Internal Medicine Subspecialty Fellows.

Introduction: Feedback is an important tool that describes an individual's performance in a specific activity. Trainees at all levels grow from feedback exchanges to develop knowledge, skills, and attitudes in their specialty. However, there is a dearth of faculty development on providing advanced trainees feedback effectively. Methods: We designed and delivered internal medicine subspecialty-focused 60- or 90-minute interactive workshop to train faculty to improve feedback exchange with fellows. The workshop included addressing barriers to feedback specific to fellowship, tool and skills for feedback exchange, and case-based skills practice specific to scenarios seen in each subspecialty fellowship program. We utilized surveys of faculty assessing comfort with feedback exchange with fellows before and after the workshop. Results: We delivered the workshop to two separate specialty sections, gastroenterology and endocrine. Overall, faculty (N = 14) self-reported comfort improved significantly from pretest to posttest (p < .01). Ten participants' comfort ratings increased, while four remained the same at posttest. The evaluation identified several common themes as important learning points including labeling feedback, setting expectations around feedback exchange, and identifying elements of high-quality feedback exchange. Discussion: This workshop for faculty was designed to improve the skills, knowledge, and attitudes related to feedback exchange specifically within an internal medicine subspecialty fellowship training program. Analysis of pre- and postsurvey data demonstrated increased faculty comfort providing fellows-in-training with feedback.

Gestational diabetes insipidus: Diagnosis and management.

In the pregnant patient, hypotonic polyuria in the setting of elevated serum osmolality and polydipsia should narrow the differential to causes related to diabetes insipidus (DI). Gestational DI, also called transient DI of pregnancy, is a distinct entity, unique from central DI or nephrogenic DI which may both become exacerbated during pregnancy. These three different processes relate to vasopressin, where increased metabolism, decreased production or altered renal sensitivity to this neuropeptide should be considered. Gestational DI involves progressively rising levels of placental vasopressinase throughout pregnancy, resulting in decreased endogenous vasopressin and resulting hypotonic polyuria worsening through the pregnancy. Gestational DI should be distinguished from central and nephrogenic DI that may be seen during pregnancy through use of clinical history, urine and serum osmolality measurements, response to desmopressin and potentially, the newer, emerging copeptin measurement. This review focuses on a brief overview of osmoregulatory and vasopressin physiology in pregnancy and how this relates to the clinical presentation, pathophysiology, diagnosis and management of gestational DI, with comparisons to the other forms of DI during pregnancy. Differentiating the subtypes of DI during pregnancy is critical in order to provide optimal management of DI in pregnancy and avoid dehydration and hypernatremia in this vulnerable population.

The effect of famotidine, esomeprazole, and ezetimibe on levothyroxine absorption.

BACKGROUND: Recent literature describing the effect of gastric acid suppression on levothyroxine absorption has been inconsistent. Also, ezetimibe, a lipid-lowering compound that inhibits intestinal absorption of cholesterol, may interfere with levothyroxine absorption. The objective of this study was to measure changes in levothyroxine absorption before and after famotidine, esomeprazole or single-dose ezetimibe." METHODS: We conducted levothyroxine absorption testing on 30 healthy volunteers, excluding those with thyroid disease. Subjects were randomized to receive one of three regimens: 1 week of either famotidine or esomeprazole, or a single dose of ezetimibe administered simultaneously with levothyroxine (n = 10 in each group). Baseline levothyroxine absorption testing was performed on all subjects using 600 mcg of Synthroid with thyroid hormone levels checked at 0, 2, 4, 6, and 8 hours after administration, and then repeated 6 weeks later, after administration of one of the three study drug regimens. The area under the curve (AUC) over 8 hours for serum thyroxine (T4), triiodothyronine (T3), and free T4 index, and the mean peak hormone levels achieved during levothyroxine absorption testing at baseline and following administration of one of the three study medications were compared using paired t-tests. RESULTS: Peak mean hormone levels and AUCs of T4, T3, and free T4 index during absorption testing before and after each of three study medications did not differ. Results for differences before and after study medication did not reach significance even when using the subtractive correction method of AUC calculation. CONCLUSIONS: No differences were noted in levothyroxine absorption after gastric acid suppression with 1 week of famotidine or esomeprazole. A simultaneously administered dose of ezetimibe did not significantly change levothyroxine absorption.

Diabetes insipidus during pregnancy.

Diabetes insipidus (DI) in pregnancy is a heterogeneous syndrome, most classically presenting with polyuria and polydipsia that can complicate approximately 1 in 30,000 pregnancies. The presentation can involve exacerbation of central or nephrogenic DI during pregnancy, which may have been either overt or subclinical prior to pregnancy. Women without preexisting DI can also be affected by the actions of placental vasopressinase which increases in activity between the 4th and 38th weeks of gestation, leading to accelerated metabolism of AVP and causing a transient form of DI of pregnancy. This type of DI may be associated with certain complications during pregnancy and delivery, such as preeclampsia. Management of DI of pregnancy depends on the pathophysiology of the disease; forms of DI that lack AVP can be treated with desmopressin (DDAVP), while forms of DI that involve resistance to AVP require evaluation of the underlying causes.

Re-examining Nelson's syndrome.

PURPOSE OF REVIEW: Nelson's syndrome is a rare complication that can occur during the course of management of Cushing's disease. This article summarizes the recent literature on the diagnosis, monitoring and treatment of this potentially life-threatening outcome. RECENT FINDINGS: Nelson's syndrome, with rising adrenocorticotropin hormone levels and corticotroph tumor progression on diagnostic imaging, can develop following treatment of refractory Cushing's disease with total bilateral adrenalectomy with/without radiotherapy. However, data showing that radiotherapy prevents Nelson's syndrome is inconsistent. In addition to the treatment of Nelson's syndrome with neurosurgery with/without adjuvant radiotherapy, selective somatostatin analogs and dopamine agonists, as well as other novel agents, have been used with increasing frequency in treating cases of Nelson's syndrome with limited benefit. The risk-benefit profile of each of these therapies is still not completely understood. SUMMARY: Consensus guidelines on the evaluation and management of Nelson's syndrome are lacking. This article highlights areas in the surveillance of Cushing's disease patients, and diagnostic criteria and treatment regimens for Nelson's syndrome that require further research and review by experts in the field.

Diabetes insipidus in pregnancy: etiology, evaluation, and management.

OBJECTIVE: To review the approach to a patient with diabetes insipidus during pregnancy. METHODS: This review examines the normal physiology of water homeostasis, the related changes that occur during pregnancy, and the pathophysiology of diabetes insipidus in pregnancy. Associated complications, evaluation, and management are discussed. RESULTS: Diabetes insipidus can complicate up to 1 in 30,000 pregnancies. Diabetes insipidus during pregnancy has a variety of causes, some that predate the pregnancy and others that begin during gestation. Polyuria and polydipsia can occur or be exacerbated in women with overt or subclinical central or nephrogenic diabetes insipidus. These women have either decreased central secretory reserve or impaired renal responsiveness to vasopressin. In addition, women can experience diabetes insipidus de novo in pregnancy through the actions of placental vasopressinase, which causes accelerated degradation of vasopressin. This form of diabetes insipidus may be associated with increased complications of pregnancy, including preeclampsia. Management of central diabetes insipidus and transient diabetes insipidus of pregnancy can be achieved with 1-deamino-8-D-arginine vasopressin (desmopressin acetate) (DDAVP), a vasopressin analogue. Nephrogenic diabetes insipidus is typically resistant to both DDAVP and vasopressin and underlying causes should be addressed. CONCLUSIONS: Increased awareness of diabetes insipidus in pregnancy may lead to early diagnosis and appropriate treatment that will reduce the risks of maternal and fetal morbidity. Overall, growing experience with DDAVP has shown that it is a safe and effective treatment for diabetes insipidus caused by a variety of factors.