Effect of an integrated nutrition curriculum on medical education, student clinical performance, and student perception of medical-nutrition training.

BACKGROUND: Ninety-eight percent of medical schools report nutrition as a component of medical education. However, most schools do not have an identifiable nutrition curriculum. Medical schools that do include nutrition have not evaluated its effect on clinical skills. OBJECTIVE: The objective was to determine the efficacy of an integrated undergraduate medical curriculum to increase the quantity of nutrition instruction and to advance nutrition clinical skills demonstrated by medical students. DESIGN: A quasiexperimental design was constructed to determine whether an integrated nutrition curriculum increased the performance on nutrition-oriented clinical examinations of medical school classes that received 1, 2, or 3 y of the curriculum. The evaluation of the curriculum focused on 3 areas: 1) hours of nutrition instruction, 2) the application of nutrition within a clinical setting, and 3) perceptions about the nutrition curriculum. The Objective Structured Clinical Examination (OSCE) nutrition score was compared between graduating classes by use of analysis of variance. Data from the American Association of Medical Colleges were analyzed to determine the change in the proportion of students who reported that the amount of time devoted to nutrition was adequate. RESULTS: The implementation of the integrated nutrition curriculum resulted in a doubling of the total hours of required instruction in the medical curriculum (35 compared with 75 h). The mean (+/-1 SEM) OSCE nutrition score significantly improved after the implementation of the curriculum (41.7 +/- 0.9% compared with 50.6 +/- 1.1%) and the percentage of students who reported that the amount of nutrition taught during medical school was inadequate decreased (68.4% compared with 11.5%). CONCLUSION: Medical students improved their clinical nutrition practice skills through participation in an integrated nutrition curriculum.

Phase I clinical trials of aroA aroD and aroA aroD htrA attenuated S. typhi vaccines; effect of formulation on safety and immunogenicity.

PBCC211, an aroA aroD derivative of S. typhi strain CDC10-80, was tested in phase I trials as a single dose typhoid fever vaccine. Three different vaccine preparations, reconstituted lyophilized bacteria, freshly grown bacteria or lyophilized bacteria reconstituted from sachets, were orally administered to a total of 86 adult volunteers. An aroA aroD htrA strain, PBCC222, was also tested in 38 volunteers. Formulation impacted on the determination of a safe and immunogenic dose; reconstituted lyophilized cultures required higher doses than the broth cultures to stimulate seroconversion. In general, doses which seroconverted the majority of group members produced undesirable symptoms regardless of attenuation or formulation. The inability to separate the presence of symptoms from achieving significant immunogenicity in these aroA aroD or aroA aroD htrA strains precludes their use as single dose typhoid vaccines in the formulations tested. Multiple doses of these strains at a lower, safe level may be effective as vectors for foreign antigens.

Correlations of family medicine clerkship evaluations and Objective Structured Clinical Examination scores and residency directors' ratings.

BACKGROUND AND OBJECTIVES: This study validated the evaluation methods used in a family medicine clerkship by comparing students' scores to how students are rated in their first year of residency by residency directors. The clerkship evaluations consisted of three components: problem solving in small groups, clinical evaluations, and a final examination. These components were combined to form a composite clerkship score. Residency director ratings consisted of 20 individual scores and an overall average. METHODS: Scores received by students in the clerkship were correlated with ratings by residency directors given toward the end of the first year of residency. The correlations between Objective Structured Clinical Examination (OSCE) scores and residency directors' ratings were used as comparison. RESULTS: The composite clerkship score correlated with the director's rating, overall average, at r = .278. The highest individual component correlation was achieved by the clerkship final exam (r = .269). The total OSCE score correlated with the director's rating overall average at r = .304. CONCLUSIONS: This study provides evidence that, while not perfect, the family medicine clerkship evaluations perform nearly as well as the OSCE as a predictor of how students will be rated by their residency directors in their first year of residency.

Performances of underrepresented-minority students at the University of Arizona College of Medicine, 1987-1991.

PURPOSE: To compare the academic performances of underrepresented-minority (African American, Native American, and Hispanic) students and all other students at the University of Arizona College of Medicine. METHOD: The performances of 42 underrepresented-minority and 368 other students who graduated between 1987 and 1991 were compared using the following variables: undergraduate science, non-science, and overall grade-point average (GPA); scores on the Medical College Admission Test (MCAT); subtest and total scores on the National Board of Medical Examiners (NBME) Part I and Part II examinations; and three types of evaluations from a required family practice clerkship. In addition, a comparison was made of scores on an objective structured clinical examination (OSCE) taken in the fourth year by 25 underrepresented-minority and 165 other students. Data were analyzed using a three-way analysis of variance and Pearson correlation analysis. RESULTS: The underrepresented-minority students earned significantly lower GPAs and scored significantly lower on all standardized paper-and-pencil tests and the family practice clerkship final examination. There was no significant group difference in the family practice clerkship clinical evaluations or the majority of the OSCE scores. For both groups, overall GPAs and MCAT scores correlated equally well with NBME total scores but were not significantly corrected with OSCE scores or family practice clerkship clinical evaluations. CONCLUSION: While the underrepresented-minority students entered medical school with significant educational disadvantages and continued to score lower than the other students on paper-and-pencil tests, their clinical performances on the OSCE and family practice clerkship were nearly equivalent to those of the other students.

Correlations of family medicine clerkship evaluations with scores on standard measures of academic achievement.

BACKGROUND: The family medicine clerkship at the University of Arizona uses three methods to evaluate students. The purpose of this study is to 1) look for possible sources of bias in each method, 2) validate the evaluation methods by correlating with other measures of academic achievement, and 3) measure the amount of correlation between the three evaluation methods. METHODS: The three clerkship evaluation methods include a final exam, clinical evaluations, and problem-solving scores. The clerkship evaluations received by 482 students were correlated with undergraduate grade point averages, MCAT scores, National Board of Medical Examiners parts I and II subtests and total scores, gender, age, race, college major, and timing of the clerkship. RESULTS: Females and older students scored higher on problem solving and minority students scored lower on the final exam. Students in the second half of the year scored higher on the final exam. There were significant correlations found between the final exam score and all the scores on standard measures of academic performance except the MCAT quantitative subtest. Problem-solving scores correlated only with NBME part II. The clinical evaluations correlated with five NBME part I subtest scores, three NBME part II subtest scores, and both parts I and II total scores. All three evaluation methods correlated significantly with each other. CONCLUSIONS: These analyses highlight the need to examine all evaluation methods used in order to improve their validity and reliability and to find potential biases. In addition, more work is needed to document the predictive validity of clerkship evaluations by correlating them with future clinical performance.

Characteristics influencing career decisions of academic and nonacademic emergency physicians.

STUDY OBJECTIVE: To determine characteristics motivating physicians to choose careers in academic and nonacademic emergency medicine. DESIGN: A written survey of 1,017 active members of the Society for Academic Emergency medicine and of a random sample of 2,000 members of the American College of Emergency Physicians was performed. Questions were asked regarding medical school, residency, and fellowship training; the importance of specific factors in influencing career decisions; and perceived obstacles to emergency medicine research. Responses from nonfaculty and adjunct, clinical, and research faculty were compared using chi 2 analysis for discrete variables and a four-group analysis of variance for continuous variables. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Responses were obtained from 1,203 physicians (41.3%). Those choosing academic careers were significantly more likely to complete a residency in emergency medicine or internal medicine and fellowship training in research or toxicology compared with nonacademic physicians. Nonfaculty and clinical faculty considered family obligations, leisure time, and personal income to be the most important factors influencing their career decisions; research faculty considered role models and the value of research to be most important. There was no difference in indebtedness among the groups. Finding time and funding, administrative obligations, and pressures to do clinical work were the most important obstacles to research productivity. CONCLUSION: Factors influencing career decisions can be used to plan strategies to meet the future needs of academic emergency medicine.

Phorbol ester-induced contractions of swine carotid artery are supported by slowly cycling crossbridges which are not dependent on calcium or myosin light chain phosphorylation.

This study determined if phorbol ester-induced contraction of vascular smooth muscle requires calcium-dependent myosin light chain (MLC) phosphorylation and, if not, whether the mechanical characteristics of the contraction in terms of stiffness and crossbridge cycling are similar to those during a calcium- and MLC phosphorylation-dependent contraction. Carotid arterial strips were exposed to 1.0 microM phorbol 12,13-dibutyrate (PDBu) in the presence of normal physiological salt solution (PSS) or after calcium depletion in calcium-free PSS and compared with contraction elicited by calcium-containing 110 mM KCl-PSS. PDBu induced maximal stress in both the presence and absence of calcium. While there was a temporal correlation between MLC phosphorylation and shortening velocity during KCl depolarization, shortening velocity was dissociated from MLC phosphorylation during PDBu stimulation. The stress-stiffness relationship was not different during KCl and PDBu stimulation, suggesting similar crossbridge interactions even though MLC phosphorylation levels were significantly different. These results demonstrate that PDBu-induced contraction of the swine carotid artery is not dependent on calcium or MLC phosphorylation. We suggest the possibility that activation of a calcium-independent PKC isoform may result in the expression of an inherent level of actin-activated myosin ATPase activity resulting in the slow development of stress.

Beliefs and practices of emergency medicine faculty and residents regarding professional interactions with the biomedical industry.

STUDY OBJECTIVES: To examine emergency medicine resident training and understanding of general bioethics and resident and faculty attitudes and behavior regarding professional interactions with the biomedical industry. DESIGN: Two companion questionnaire surveys. SETTING: Annual resident in-service examination and written director survey with telephone follow-up. PARTICIPANTS: Emergency medicine residents and program directors. INTERVENTIONS: chi 2 analysis was used for questions involving relationships among variables with dichotomous or categorical response. An analysis of variance or Pearson Product Moment Correlation was calculated for questions with continuous variables. MEASUREMENTS AND MAIN RESULTS: The surveys were completed by 1,385 of 1,836 (75%) residents and 80 of 81 (99%) residency directors. On average, residents receive eight hours of bioethical instruction per year but believe that they need 12 hours per year. Seventy-five percent of residents believe that company representatives sometimes cross ethical boundaries. The amount of resident understanding of bioethical concepts correlated with the number of hours of bioethics training they received. A sensitivity to bioethical conflicts index was correlated with the residents' behavior. CONCLUSION: There is wide variation in beliefs and practices regarding the interaction between emergency medicine residents and directors and the biomedical industry. Our results suggest that residents need training regarding conflicts of interest, accepted standards of practice, and dealing with potential conflicts with the biomedical industry.

Endothelin differentially affects rat gastric longitudinal and circular smooth muscle.

We have determined the response of two types of rat gastric smooth muscle to the cumulative addition of endothelin-1 (ET-1). Both the longitudinal smooth muscle (tonic) from the forestomach and the circular smooth muscle (phasic) from the fundus were used in this study. Longitudinal smooth muscle contracted in a concentration-dependent manner in response to ET-1. The ET-1-induced contractions were abolished by the use of either nifedipine or calcium-free solutions. The maximal stress developed was 1.13 +/- 0.12 x 10(5) N/m2, or about 61% of the maximal carbachol response in this tissue. The EC50 for the ET-1-induced contraction was 11.4 +/- 2.3 nM. In contrast to the contractile effect on longitudinal smooth muscle, ET-1 produced a potent concentration-dependent inhibition of both the spontaneous phasic activity and carbachol-stimulated activity of the circular smooth muscle. The maximal inhibitory effect in response to ET-1 occurred at about 10 nM. The abolition of phasic activity lasted about 15 minutes before phasic activity returned. ET-1 also inhibited carbachol-induced increases in the phasic activity of circular smooth muscle with a similar potency. Inhibitors of arachidonic acid products, indomethacin or nordihydroguaiaretic acid, did not affect the response to ET-1 of either longitudinal or circular smooth muscle. Similarly, inhibition of nitric oxide, vasoactive intestinal peptide (VIP) calcitonin-related peptide (CGRP) and inhibition of endogenous neural pathways by tetrodotoxin (TTX), atropine, hexamethonium, cold storage or phentolamine did not reverse the inhibitory response of the circular smooth muscle to ET-1.(ABSTRACT TRUNCATED AT 250 WORDS)

Retrieval of an aspirated bullet fragment by flexible bronchoscopy in a mechanically ventilated patient.

We report the case of a 28-year-old man who aspirated a bullet fragment following a gunshot. Review of the literature indicates this to be a rare finding. Bedside flexible bronchoscopy provided visualization of the foreign body and facilitated its removal while the patient was on a ventilator. The benefits of flexible bronchoscopy in similar conditions are discussed.

The role of early tracheostomy in blunt, multiple organ trauma.

During a 9-year period, 101 patients sustaining blunt, multiple organ injury underwent tracheostomy. Group I consisted of 32 patients who underwent tracheostomy within the first 4 days of injury (early tracheostomy) and Group II comprised 69 patients who underwent tracheostomy more than 4 days after surgery (late tracheostomy). There was no statistical difference between the two groups in terms of age, Injury Severity Score, Glasgow Coma Score, and associated injuries. The mean time of mechanical ventilatory support was 6.0 +/- 3.4 days in Group I as compared to 20.6 +/- 12.2 days in Group II (P less than 0.001). Early weaning from the ventilator was accomplished in 32 (100%) patients who underwent early tracheostomy versus 43 (62%) of those who underwent late tracheostomy (P less than 0.001). Finally, the incidence of nosocomial pneumonias was also significantly less in patients undergoing early tracheostomy. There were three nonlethal complications associated with tracheostomy. The authors conclude that early tracheostomy helps in early weaning from the ventilator and reduces the incidence of nosocomial pneumonias and time of mechanical ventilatory support in patients with blunt, multiple organ injury.

Factors influencing resident career choices in emergency medicine.

OBJECTIVE: To assess the attitudes of residents in emergency medicine regarding a career in academics. DESIGN: A 22-item questionnaire was administered to residents in conjunction with the yearly American Board of Emergency Medicine inservice examination. Demographic information and factors influencing career intent were elicited. Respondents were classified by intent on a career in emergency medicine. A three-way analysis of variance was used to address group differences for eight specific factors impacting on career decision. Chi-square analysis was used to address questions involving relationships among variables with dichotomous or categorical responses. RESULTS: The survey was distributed to 1,654 residents, and 1,238 (75%) completed the questionnaire. Motivating factors demonstrating significant differences between those residents planning an academic career and those not interested in academe were a desire to do research, desire to teach, desire to make a contribution to medicine, and exposure to role models, with less emphasis on the need for free time for other interests and less concern regarding practice location. More than 80% of those not going into academic emergency medicine believed they were adequately exposed to research in residency compared with 65% of those intent on a career in academe (P less than .01). Research in medical school, residency, and authorship of a research paper were significantly more prevalent for those residents desiring a career in academe (P less than .01). Twenty-six percent of residents responded that their role models for research were less than adequate. Seventeen percent of residents intend to take fellowship training. The most popular fields for fellowships were toxicology (25%), emergency medical services (21%), pediatrics (15%), and research (9%). CONCLUSION: The results of this survey address attitudes among residents toward a career in academic emergency medicine. Factors such as motivation, role models, and exposure to research may help academicians plan strategies to meet the future needs of academic emergency medicine.

A model for the assessment of students' physician-patient interaction skills on the surgical clerkship.

Physician-patient interaction skills are predominantly taught by successful role modeling but are rarely evaluated formally and systematically. This study describes a new model for the assessment of student physician-patient interaction skills and reports results of use in 78 third-year medical students on clerkships at two institutions. A single nurse instructor at each institution evaluated these skills using an 18-item checklist during student performance of wound care and dressing changes. Students were focused on the evaluation of their technical skills and were unaware of the evaluation of their interaction skills. Immediate feedback on performance was provided. The mean percentage score for the interaction skills was 35%, and no improvement was noted with greater clinical experience (later rotations). We conclude that there is a striking deficiency in physician-patient interaction skills among third-year students. The model described is effective for both evaluation and feedback.

Structural equation modeling in clinical assessment research with children.

The use of structural equation modeling has gained increased interest in recent years in the social and behavioral sciences. This article reviews the basic tenets of structural modeling in relation to issues in research and practice involving clinical assessment and compares this approach with more traditional psychometric approaches to the validation of assessment instruments with children. Arguments for and against the inclusion of nonexperimental variables in causal studies aimed at establishing construct validity are also discussed. An illustrative example of the application of structural equation modeling in clinical assessment research is provided, and a comparison is made between this approach and traditional psychometric procedures. Implications and suggestions for the use of structural modeling are discussed for both the practitioner and the clinical researcher.

Sharing of information by students in an objective structured clinical examination.

Increasing numbers of medical schools are using Objective Structured Clinical Examinations (OSCEs) to evaluate students. An Objective Structured Clinical Examination employs a multiple-station format and standardized patients to document students' clinical skills. A lengthy format is necessary; testing an entire class often necessitates multiple repetitions of the same examination. This dictates a need to minimize sharing of information among students. We studied six administrations of an Objective Structured Clinical Examination designed to measure skills. Analyses were conducted to detect changes in scores over the administrations as well as over the 8.5 hours of each day of testing. An increase in either might indicate information sharing had occurred. No significant increase occurred. If information was shared, it had no significant effect on scores. Skills a student uses to approach a patient should not change even if the patient's complaints are known.