Predictors of medical school clerkship performance: a multispecialty longitudinal analysis of standardized examination scores and clinical assessments.

BACKGROUND: Evidence suggests that poor performance on standardized tests before and early in medical school is associated with poor performance on standardized tests later in medical school and beyond. This study aimed to explore relationships between standardized examination scores (before and during medical school) with test and clinical performance across all core clinical clerkships. METHODS: We evaluated characteristics of 435 students at Mayo Medical School (MMS) who matriculated 2000-2009 and for whom undergraduate grade point average, medical college aptitude test (MCAT), medical school standardized tests (United States Medical Licensing Examination [USMLE] 1 and 2; National Board of Medical Examiners [NBME] subject examination), and faculty assessments were available. We assessed the correlation between scores and assessments and determined USMLE 1 cutoffs predictive of poor performance (≤10th percentile) on the NBME examinations. We also compared the mean faculty assessment scores of MMS students vs visiting students, and for the NBME, we determined the percentage of MMS students who scored at or below the tenth percentile of first-time national examinees. RESULTS: MCAT scores correlated robustly with USMLE 1 and 2, and USMLE 1 and 2 independently predicted NBME scores in all clerkships. USMLE 1 cutoffs corresponding to poor NBME performance ranged from 220 to 223. USMLE 1 scores were similar among MMS and visiting students. For most academic years and clerkships, NBME scores were similar for MMS students vs all first-time examinees. CONCLUSIONS: MCAT, USMLE 1 and 2, and subsequent clinical performance parameters were correlated with NBME scores across all core clerkships. Even more interestingly, faculty assessments correlated with NBME scores, affirming patient care as examination preparation. USMLE 1 scores identified students at risk of poor performance on NBME subject examinations, facilitating and supporting implementation of remediation before the clinical years. MMS students were representative of medical students across the nation.

Giant cell arteritis.

Giant cell arteritis (GCA) is a medium and large-vessel vasculitis, which is an important cause of secondary headache in older adults. While GCA has a classic presentation occurring after the age of 50, atypical presentations (eg, fever of unknown origin, cough, low or normal erythrocyte sedimentation rate) may lead to a delay in diagnosis. The topography of vascular involvement has implications for disease-related complications, which can result in neurologic disease at multiple levels of the nervous system. The most feared complication, vision loss, fortunately becomes uncommon after initiation of corticosteroids. Corticosteroid treatment should not be withheld while waiting the results of a temporal artery biopsy (TAB), which remains the gold standard for GCA diagnosis. Newer diagnostic modalities, including ultrasound, magnetic resonance imaging, and positron emission tomography can play an important role in directing treatment in cases with negative TAB. After successful control of the disorder, patients should be gradually tapered off corticosteroids, with careful monitoring using both clinical and laboratory parameters to assess for relapse. Corticosteroid-related treatment complications are not uncommon in GCA. There is mixed evidence for use of adjunct corticosteroid-sparing agents (eg, methotrexate), although these should be initiated in the setting of corticosteroid-related morbidity and/or cases with frequent relapse.

Management of migraine headache in the emergency department.

Headache is one of the more common reasons for adults to visit an emergency department. Most of these visits are for primary headache disorders, most commonly migraine headache. The authors discuss management options for patients presenting to the emergency department with prolonged, severe, or refractory migraine headaches. Particular attention is given to parenteral treatments and protocols that would not be options as an outpatient. The epidemiology, investigation, and outpatient management of migraine headache are discussed in other articles in this issue.

Chronic pain rehabilitation in chronic headache disorders.

This article reviews the treatment goals and efficacy of comprehensive pain rehabilitation programs for the treatment of chronic headache. Substantial data demonstrate improved outcomes from rehabilitative treatment for chronic noncancer pain. We present a discussion of the most relevant recent publications on pain rehabilitation in chronic headache disorders. This article describes pain rehabilitation, reviews outcome data for chronic pain patients treated in this setting, and describes the unique applicability of this treatment approach for patients with chronic headache. Particular attention is directed to the rationale for and the results of the withdrawal, in a pain rehabilitation setting, of opioids and simple analgesics, ergots, and triptans that contribute to medication overuse headaches. Additionally, a case example is reviewed that illustrates the structure and function of a pain rehabilitation program in the treatment of a patient with intractable headache.

Dynamic Quantification of Migrainous Thermal Facial Patterns - A Pilot Study.

This article documents thermophysiological patterns associated with migraine episodes, where the inner canthi and supraorbital temperatures drop significantly compared to normal conditions. These temperature drops are likely due to vasoconstriction of the ophthalmic arteries under the inner canthi and sympathetic activation of the eccrine glands in the supraorbital region, respectively. The thermal patterns were observed on eight migraine patients and meticulously quantified using advance computational methods, capable of delineating small anatomical structures in thermal imagery and tracking them automatically over time. These methods open the way for monitoring migraine episodes in nonclinical environments, where the patient maintains directional attention, such as his/her computer at home or at work. This development has the potential to significantly expand the operational envelope of migraine studies.

Chronic pain rehabilitation in chronic headache disorders.

This article reviews the treatment goals and efficacy of comprehensive pain rehabilitation programs for the treatment of chronic headache. Substantial data demonstrate improved outcomes from rehabilitative treatment for chronic noncancer pain. We present a discussion of the most relevant recent publications on pain rehabilitation in chronic headache disorders. This article describes pain rehabilitation, reviews outcome data for chronic pain patients treated in this setting, and describes the unique applicability of this treatment approach for patients with chronic headache. Particular attention is directed to the rationale for and the results of the withdrawal, in a pain rehabilitation setting, of opioids and simple analgesics, ergots, and triptans that contribute to medication overuse headaches. Additionally, a case example is reviewed that illustrates the structure and function of a pain rehabilitation program in the treatment of a patient with intractable headache.

Answers to frequently asked questions about migraine.

Migraine is a common primary headache disorder associated with pronounced disability and hence marked economic and public health Implications. Appropriate treatment is warranted to limit the associated disability migraineurs experience. Because of the heterogeneity of migraine, treatment plans must be individualized. The purpose of this article is to provide answers to frequently asked questions regarding the management of migraine.

Asymptomatic peripheral retinal hemorrhages as a manifestation of interferon beta 1a retinopathy.

We present a case of retinopathy found incidentally in an asymptomatic patient receiving treatment with interferon beta 1a for multiple sclerosis. She was found to have peripheral dot and blot hemorrhages with no cotton wool spots. It is possible that interferon beta 1a retinopathy is more common than previously reported, as it may be asymptomatic with patients having peripheral retinal hemorrhages.

Methotrexate induced seizures associated with acute reversible magnetic resonance imaging (MRI) changes in a patient with acute lymphoblastic leukemia.

A 27-year-old woman with acute lymphoblastic leukemia (ALL) had an episode of generalized tonic-clonic seizure after therapy with intrathecal and intravenous methotrexate (MTX). Magnetic resonance imaging (MRI) of her head showed meningeal, cortical and subcortical enhancement that was new when compared to a study done prior to therapy. Subsequent imaging 10 days later showed partial resolution of these findings. The association of seizures and MTX in ALL and the corresponding MRI changes are discussed.

Stroke and Stroke-Like Symptoms in Patients with Mutations in the POLG1 Gene.

Introduction/Methods Mutations in POLG1, the gene encoding mitochondrial polymerase gamma (Polγ), have been associated with a number of well-characterized phenotypes. In this study, we report two cases of patients with biallelic POLG1 mutations and stroke. We also performed a review of the literature and report on all clinical studies of patients with POLG1 mutations in which stroke was described in the phenotype. For each patient, genotype and phenotype are reported. Results Including our two patients, a total of 22 patients have been reported with POLG1 mutations and stroke. The average age of onset of stroke in these patients was 9 years with a range of 1-23 years. In cases where localization was reported, the occipital lobes were the primary location of the infarct. Mutations in the linker-linker or linker-polymerase domains were the most frequent genotype observed. Seizures (16/22) and hepatic dysfunction/failure (8/22) were the most commonly reported symptoms in the stroke cohort. Conclusion This article raises an underrecognized point that patients with POLG1 mutations may suffer a cerebrovascular accident at a young age. The most common location of the infarction is in the occipital lobe. The presentation may be similar to MELAS and can be misdiagnosed as a migrainous stroke.

Prophylaxis of migraine.

Migraine is a common primary headache disorder often associated with significant disability. While many individuals are able to limit therapy to acute treatment of attacks, others need medication to reduce the attack frequency and/or severity. Evidence-based guidelines exist regarding indications and goals for migraine preventive treatment. The specific prophylactic approach needs to be individualized taking into account multiple variables. Medications used in this task vary widely in proven efficacy and presumed mechanisms of action. This review's goal is to discuss the issues that guide the decision-making process in migraine preventive treatment.