Procedural experience and comfort level in internal medicine trainees.

BACKGROUND: The American Board of Internal Medicine (ABIM) has recommended a specific number of procedures be done as a minimum standard for ensuring competence in various medical procedures. These minimum standards were determined by consensus of an expert panel and may not reflect actual procedural comfort or competence. OBJECTIVE: To estimate the minimum number of selected procedures at which a majority of internal medicine trainees become comfortable performing that procedure. DESIGN: Cross-sectional, self-administered survey. SETTING: A military-based, a community-based, and 2 university-based programs. PARTICIPANTS: Two hundred thirty-two internal medicine residents. MEASUREMENTS: Survey questions included number of specific procedures performed, comfort level with performing specific procedures, and whether respondents desired further training in specific procedures. The comfort threshold for a given procedure was defined as the number of procedures at which two thirds or more of the respondents reported being comfortable or very comfortable performing that procedure. RESULTS: For three of seven procedures selected, residents were comfortable performing the procedure at or below the number recommended by the ABIM as a minimum requirement. However, residents needed more procedures than recommended by the ABIM to feel comfortable with central venous line placement, knee joint aspiration, lumbar puncture, and thoracentesis. Using multivariate logistic regression analysis, variables independently associated with greater comfort performing selected procedures included increased number performed, more years of training, male gender, career goals, and for skin biopsy, training in the community-based program. Except for skin biopsy, comfort level was independent of training site. A significant number of advanced-year house officers in some programs had little experience in performing selected common ambulatory procedures. CONCLUSION: Minimum standards for certifying internal medicine residents may need to be reexamined in light of house officer comfort level performing selected procedures.

Stimulation of CD28 triggers an association between CD28 and phosphatidylinositol 3-kinase in Jurkat T cells.

The T cell surface molecule CD28 can provide costimulatory signals that permit the full activation of T cells. Here we demonstrate that stimulation of CD28, either by B7, its natural ligand, or by the anti-CD28 monoclonal antibody 9.3, induces an association between CD28 and phosphatidylinositol 3-kinase (PI3-K) in Jurkat T cells, raising the possibility that an interaction with PI3-K contributes to CD28-mediated signaling. To examine the mechanism of the association, we synthesized tyrosine-phosphorylated oligopeptides corresponding to each of the four tyrosines in the CD28 cytoplasmic domain. When added to lysates of B7-stimulated Jurkat cells, the oligopeptide corresponding to Tyr 173 inhibits the coimmunoprecipitation of PI3-K with CD28; the other oligopeptides have no effect. Tyr 173 is contained within the sequence YMNM, a motif that is also found in the platelet-derived growth factor receptor and that, when phosphorylated, forms a high affinity binding site for the p85 subunit of PI3-K. These observations suggest that phosphorylation of Tyr 173 may mediate the interaction between CD28 and PI3-K. However, because CD28 is not known to be phosphorylated, it remains possible that CD28 interacts with PI3-K through a mechanism independent of tyrosine phosphorylation.

Ectopic vas deferens, imperforate anus and hypospadias: a new triad.

An ectopic vas deferens is a rare congenital anomaly frequently associated with rectal abnormalities. We describe 2 patients with ectopic vas deferens associated with an imperforate anus and hypospadias. There are 19 previous reports of patients with ectopic vas deferens, 5 of which were bilateral. One of our patients, a child with bilateral ectopic vas deferens, had the highest reported insertion of an ectopic vas deferens. The embryology and management of this rare condition are reviewed.