The Effect of Geographic Cohorting of Inpatient Teaching Services on Patient Outcomes and Resident Experience.

BACKGROUND: Geographic cohorting is a hospital admission structure in which every patient on a given physician team is admitted to a dedicated hospital unit. Little is known about the long-term impact of this admission structure on patient outcomes and resident satisfaction. OBJECTIVE: To evaluate the effect of geographic cohorting on patient outcomes and resident satisfaction among inpatient internal medicine teaching services within an academic hospital. DESIGN AND INTERVENTION: We conducted an interrupted time series analysis examining patient outcomes before and after the transition to geographic cohorting of our 3 inpatient teaching services within a 520-bed academic hospital in November 2017. The study observation period spanned from January 2017 to October 2018, allowing for a 2-month run-in period (November-December 2017). PARTICIPANTS: We included patients discharged from the inpatient teaching teams during the study period. We excluded patients admitted to the ICU and observation admissions. MAIN MEASURES: Primary outcome was 6-month mortality adjusted for patient age, sex, race, insurance status, and Charlson Comorbidity Index (CCI) analyzed using a linear mixed effects model. Secondary outcomes included hospital length of stay (LOS), 7-day and 30-day readmission rate, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, and resident evaluations of the rotation. KEY RESULTS: During the observation period, 1720 patients (mean age 64, 53% female, 56% white, 62% Medicare-insured, mean CCI 1.57) were eligible for inclusion in the final adjusted model. We did not detect a significant change in 6-month mortality, LOS, and 7-day or 30-day readmission rates. HCAHPS scores remained unchanged (77 to 80% top box, P = 0.19), while resident evaluations of the rotation significantly improved (mean overall score 3.7 to 4.0, P = 0.03). CONCLUSIONS: Geographic cohorting was associated with increased resident satisfaction while achieving comparable patient outcomes to those of traditional hospital admitting models.

A single type of varus knee does not exist: morphotyping and gap analysis in varus OA.

PURPOSE: To achieve a higher level of satisfaction in patients having undergone Total Knee Arthroplasty (TKA), a more personalized approach has been discussed recently. It can be assumed that a more profound knowledge of bony morphology and ligamentous situation would be beneficial. While CT/MRI can give 3D information on bone morphology, the understanding of the ligamentous situation in different flexion angles is still incomplete. In this study, the dynamic gap widths of a large number of varus knees were assessed in various flexion angles, to find out whether all varus knees behave similar or have more individual soft tissue patterns. Additionally, it was investigated whether the amount of varus deformity or other patient factors have an effect on joint gap widths. METHODS: A series of 1000 consecutive TKA patients, including their CAS data and patient records were analyzed. Joint gap widths in multiple flexion angles (0°, 30°, 60°, 90°) were measured in mm and differences between the joint gaps were compared. A "standard" varus knee was defined as follows: (1) Lateral extension gap greater than medial, (2) lateral flexion gap greater than medial, and (3) flexion gap greater than extension gap. The percentage of fulfillment was tested for each and all criteria. To measure the influence of varus deformity on gap width difference, three subgroups were formed based on the deformity. Data were analyzed at 0°, 30°, 60° and 90° flexion. The effect of patient factors (gender, BMI, age) on gap sizes was tested by performing subgroup analyses. RESULTS: Only 444 of 680 (65%) patients met all three varus knee criteria. The lateral extension gap (4.1 mm) was significantly larger than the medial extension gap (0.6 mm) in 657 (97%) patients and the gap difference highly correlated with the amount of varus deformity (r2 = 0.62). In all flexion positions, however, no correlation between gap differences and varus deformity existed. Women had significantly larger extension and flexion gaps. Age and BMI showed no significant effect on gap widths. CONCLUSION: Varus knees show a large inter-individual variability regarding gap widths and gap differences. The amount of varus deformity correlates highly with the medio-lateral gap difference in extension, but not in any flexion angle. As varus knees are not all alike, a uniform surgical technique will not treat all varus knees adequately and the individual gap sizes need to be analyzed and addressed accordingly with an individualized balancing technique. Which final balancing goal should be achieved needs to be analyzed in future studies. LEVEL OF EVIDENCE: Level III.

Grit Does Not Predict Burnout among First-Year Internal Medicine Residents.

OBJECTIVES: Grit, defined as passion and perseverance for long-term goals, has been associated with the avoidance of burnout among residents in a number of specialties. We aimed to evaluate the relationship between grit and burnout among first-year Internal Medicine residents. METHODS: During the 2018-2019 academic year, the authors recruited 75 first-year Internal Medicine residents within a large academic program to complete the Short Grit Scale (Grit-S) and the Maslach Burnout Inventory General Survey (MBI-GS) at baseline and after 6 and 12 months. The primary outcome was the association between baseline Grit-S and MBI-GS scores within the domains of emotional exhaustion (EE) or cynicism (CYN) over time using linear mixed models. Secondary outcomes included the association between grit and high burnout at 6 or 12 months, grit and persistently high burnout, and the association of baseline high burnout with later high scores at 6 and 12 months using logistic regression models and trends in grit over time using repeated-measures analysis of variance. RESULTS: A total of 53 of 75 (71%) first-year residents completed the Grit-S and MBI-GS at baseline and at least one other time point. There was no association between grit and EE (P = 0.44) or CYN (P = 0.61) burnout domain scores. High baseline EE and high baseline CYN significantly increased the odds of later high burnout scores within each domain (EE odds ratio 9.66, 95% confidence interval 1.16-80.83; CYN odds ratio 13.37, 95% confidence interval 1.52-117.75). Grit scores and professional efficacy scores remained stable throughout the year (P = 0.15 and 0.46, respectively), while EE and CYN significantly increased (both P < 0.01). CONCLUSIONS: In this single-center study, grit was not associated with burnout among first-year Internal Medicine residents; however, our findings highlight the value of baseline burnout scores in helping to identify first-year residents who may be at higher risk of later burnout.

Professionalism and inter-communication skills (ICS): a multi-site validity study assessing proficiency in core competencies and milestones in medical learners.

BACKGROUND: Interpersonal and Communication Skills (ICS) and Professionalism milestones are challenging to evaluate during medical training. Paucity in proficiency, direction and validity evidence of assessment tools of these milestones warrants further research. We validated the reliability of the previously-piloted Instrument for Communication skills and Professionalism Assessment (InCoPrA) in medical learners. METHODS: This validity approach was guided by the rigorous Kane's Framework. Faculty-raters and standardized patients (SPs) used their respective InCoPrA sub-component to assess distinctive domains pertinent to ICS and Professionalism through multiple expert-built simulated-scenarios comparable to usual care. Evaluations included; inter-rater reliability of the faculty total score; the correlation between the total score by the SPs; and the average of the total score by two-faculty members. Participants were surveyed regarding acceptability, realism, and applicability of this experience. RESULTS: Eighty trainees and 25 faculty-raters from five medical residency training sites participated. ICC of the total score between faculty-raters was generally moderate (ICC range 0.44-0.58). There was on average a moderate linear relationship between the SPs and faculty total scores (Pearson correlations range 0.23-0.44). Majority of participants ascertained receiving a meaningful, immediate, and comprehensive patient-faculty feedback. CONCLUSIONS: This work substantiated that InCoPrA was a reliable, standardized, evidence-based, and user-friendly assessment tool for ICS and Professionalism milestones. Validating InCoPrA showed generally-moderate agreeability and high acceptability. Using InCoPrA also promoted engaging all stakeholders in medical education and training-faculty, learners, and SPs-using simulation-media as pathway for comprehensive feedback of milestones growth.

The use of ultrasound improves the accuracy of epidural needle placement in cadavers.

PURPOSE: To investigate whether epidural-prepuncture ultrasound imaging improves the accuracy and quality of epidural needle placement or not? METHODS: By recruiting 15 cadavers, a total of 90 epidural needle punctures to access epidural space in study group with the help of ultrasound imaging at lumbar and thoracic spinal segments were attempted. A similar number of punctures in a control group were also performed without ultrasound imaging involving the intervertebral spaces adjacent to the ones used for ultrasound guided punctures. The accuracy of needle tip placement was ascertained with the help of computed axial tomography. Six variables: puncture depth and needle angle, procedure time, number of attempts per space, steps in needle advances, number of bony contacts and number of spaces attempted, were studied and compared among the groups. RESULTS: The accuracy of epidural needle placement and quality of the procedure in study group were superior to the control group. CONCLUSIONS: The pre-procedure ultrasound imaging enhances the accuracy and quality of epidural needle placement.

Ultrasound-guided regional anesthesia: learning with an optimized cadaver model.

PURPOSE: To date, there have been few studies of the simulation of ultrasound-guided regional anesthesia for teaching purposes. The present study aimed to evaluate the visibility of nerves and their adjacent structures, and the feasibility of the use of ultrasound-guided blocks in specially prepared cadavers to develop a new teaching model. METHODS: Nerves of the brachial, lumbar, and sacral plexus were examined, and their visibility evaluated in 12 specially embalmed cadavers. Thereafter a needle was advanced under direct ultrasound guidance to target nerves, and selected blocks were imitated using saline. The model was evaluated with standardized questionnaires in two international workshops with 124 participants. RESULTS: The selected nerves were successfully identified in all cadavers. The typical ultrasound appearance of nerves and their adjacent structures was very similar to the echotexture of the living, and the spread of injected saline around nerves was comparable to that of local anesthetics used in live patients. 79 % of the participants completed the questionnaire and confirmed the value of this optimized teaching model. CONCLUSIONS: This cadaver model is a promising teaching tool for practicing both the visualization of nerves and the needle manipulation. Moreover, it is possible to simulate the interventional application and the spread of local anesthetics using saline. With the aim of maximizing the effectiveness of teaching, it is hoped that we, and others, may be able to establish the use of this kind of tool as a valuable adjunct to other models of teaching regional anesthesia.

What/Why/When/Where/How Framework and Faculty Development Workshop to Improve the Utility of Narrative Evaluations for Assessing Internal Medicine Residents.

Introduction: Clinical competency committees (CCCs) rely on narrative evaluations to assess resident competency. Despite the emphasis on these evaluations, their utility is frequently hindered by lack of sufficient detail for use by CCCs. Prior resources have sought to improve specificity of comments and use of evaluations by residents but not their utility for CCCs in assessing trainee performance. Methods: We developed a 1-hour faculty development workshop focused on a newly devised framework for Department of Medicine faculty supervising internal medicine residents. The what/why/when/where/how framework highlighted key features of useful narrative evaluations: behaviors of strength and growth, contextualized observations, improvement over time, and actionable next steps. Workshop sessions were implemented at a large multisite internal medicine residency program. We assessed the workshop by measuring attendee confidence and skill in writing narrative evaluations useful for CCCs. Skill was assessed through a rubric adapted from literature on the utility of narrative evaluations. Results: Fifty-four participants started the presurvey, and 33 completed the workshop, for a response rate of 61%. Participant confidence improved pre-, post-, and 3 months postworkshop. Total utility scores improved in mock evaluations from 12.4 to 15.5 and in real evaluations from 13.7 to 15.0, but only some subcomponent scores improved, with fewer improving in the real evaluations. Discussion: A short workshop focusing on our framework improves confidence and utility of narrative evaluations of internal medicine residents for use by CCCs. Next steps should include developing more challenging components of narrative evaluations for continued improvement in trainee performance and faculty assessment.

Functional analyses of mycobacterial lipoprotein diacylglyceryl transferase and comparative secretome analysis of a mycobacterial lgt mutant.

Preprolipopoprotein diacylglyceryl transferase (Lgt) is the gating enzyme of lipoprotein biosynthesis, and it attaches a lipid structure to the N-terminal part of preprolipoproteins. Using Lgt from Escherichia coli in a BLASTp search, we identified the corresponding Lgt homologue in Mycobacterium tuberculosis and two homologous (MSMEG_3222 and MSMEG_5408) Lgt in Mycobacterium smegmatis. M. tuberculosis lgt was shown to be essential, but an M. smegmatis ΔMSMEG_3222 mutant could be generated. Using Triton X-114 phase separation and [(14)C]palmitic acid incorporation, we demonstrate that MSMEG_3222 is the major Lgt in M. smegmatis. Recombinant M. tuberculosis lipoproteins Mpt83 and LppX are shown to be localized in the cell envelope of parental M. smegmatis but were absent from the cell membrane and cell wall in the M. smegmatis ΔMSMEG_3222 strain. In a proteomic study, 106 proteins were identified and quantified in the secretome of wild-type M. smegmatis, including 20 lipoproteins. All lipoproteins were secreted at higher levels in the ΔMSMEG_3222 mutant. We identify the major Lgt in M. smegmatis, show that lipoproteins lacking the lipid anchor are secreted into the culture filtrate, and demonstrate that M. tuberculosis lgt is essential and thus a validated drug target.

Phenylethyl butyrate enhances the potency of second-line drugs against clinical isolates of Mycobacterium tuberculosis.

Ethionamide (ETH) is a second-line drug for the treatment of tuberculosis. As a prodrug, ETH has to be activated by EthA. ethA is controlled by its repressor EthR. 2-Phenylethyl-butyrate (2-PEB) inhibits EthR binding, enhances expression of EthA, and thereby enhances the growth-inhibitory effects of ethionamide, isoxyl, and thiacetazone in Mycobacterium tuberculosis strains with resistance to ETH due to inhA promoter mutations but not ethA mutations.

Postinterview communication between military residency applicants and training programs.

PURPOSE: Each year military medical students participate in a separate, military match culminating with the Joint Services Graduate Medical Education Selection Board (JSGMESB). Prior studies have explored postinterview communication that occurs during the National Resident Matching Program (NRMP), but not during the JSGMESB. We examined the frequency and nature of communication during the JSGMESB and compared it with the NRMP. METHODS: Cross-sectional survey study of senior students conducted at Uniformed Services University of the Health Sciences (USU) and seven civilian U.S. medical schools during March to May 2010. Respondents answered questions regarding communication with residency programs during the match. RESULTS: Significantly fewer USU respondents communicated with programs compared with the civilian cohort (54.1% vs. 86.4%, p < 0.01). Specific inquiries regarding rank order were more commonly experienced by USU respondents compared with civilians (17.5% vs. 4.8%, p = 0.02). USU respondents found postinterview communication both helpful (41.3%) and stressful (41.3%). 11.1% of USU respondents indicated that they moved a program higher on their final rank lists because of further communication with these programs. CONCLUSIONS: Postinterview communication during the JSGMESB process is less common and less stressful than that reported in the NRMP. USU respondents are more likely to be asked directly about their rank list and occasionally do change their lists. Uniform guidance mirroring the NRMP's dealing with direct inquiries about rank lists could potentially improve the process.

A synthetic mammalian gene circuit reveals antituberculosis compounds.

Synthetic biology provides insight into natural gene-network dynamics and enables assembly of engineered transcription circuitries for production of difficult-to-access therapeutic molecules. In Mycobacterium tuberculosis EthR binds to a specific operator (O(ethR)) thereby repressing ethA and preventing EthA-catalyzed conversion of the prodrug ethionamide, which increases the resistance of the pathogen to this last-line-of-defense treatment. We have designed a synthetic mammalian gene circuit that senses the EthR-O(ethR) interaction in human cells and produces a quantitative reporter gene expression readout. Challenging of the synthetic network with compounds of a rationally designed chemical library revealed 2-phenylethyl-butyrate as a nontoxic substance that abolished EthR's repressor function inside human cells, in mice, and within M. tuberculosis where it triggered derepression of ethA and increased the sensitivity of this pathogen to ethionamide. The discovery of antituberculosis compounds by using synthetic mammalian gene circuits may establish a new line of defense against multidrug-resistant M. tuberculosis.

Relationship of the internal jugular vein to the common carotid artery: implications for ultrasound-guided vascular access.

BACKGROUND AND OBJECTIVE: For cannulation of the internal jugular vein (IJV), ultrasound increases the number of first pass successes and reduces the rate of mechanical complications. A frequent complication of IJV access is the accidental injury of the common carotid artery (CCA), which can be dangerous in some circumstances. Landmarks and palpation of the CCA are used when ultrasound is not available. These conventional methods are based on the lateral position of the IJV to the CCA, and physicians traditionally employ head rotation to increase the success rates of IJV cannulation. Ultrasound scanning strictly from the anterior to posterior is not possible for this process because the probe must be adequately coupled to compensate for the curvature of the neck. Scans have been performed from different angles lateral to the neck, but misleadingly depict the relationship of the IJV to the CCA. In this study, the authors examined the effect of scanning at a 45° angle at the level of the cricoid on the depiction of the IJV in relation to the CCA. Furthermore, the influence of 30° head rotation to the contralateral side was also investigated. METHOD: The relationship of the IJV to the CCA was recorded using ultrasound in 600 patients. Patients were placed in a supine position and the probe was coupled at the level of the cricoid, scanning at an angle of 45° from the lateral side of the neck. Based on the ultrasound images, the position of the IJV in relation to the CCA was recorded using a segmented grid. The centre of the vein (cross-section of the vertical and longitudinal diameter) determined the segment classification, in which the top of the ultrasound image was defined as the anterior. Additionally, in 300 patients, the head was rotated to the contralateral side at 30° to examine the impact of head rotation on the position of the IJV. RESULTS: The IJV was found in the lateral segment in only 3.0-3.3% of the patients. It was found in the anteromedial segment more frequently on the left side compared to the right side (P < 0.005). On the right side, the IJV was shown more frequently in the anterolateral position (P < 0.0001). Head rotation at 30° in 300 of the 600 patients caused a significant change of the IJV position in the left anteromedial segment, in that it frequently placed the IJV towards the anterior and anterolateral segment (P < 0.05). There was no significant impact of head rotation on the IJV representation on the right side. Atypical positions of the IJV (posterior, medial or thrombosis) were found in some cases. CONCLUSION: Ultrasound images used for IJV access usually depict the vein as being anterior to the CCA and only to a minor extent in the lateral position. This positioning is important for needle processing in order to avoid accidental arterial puncture and to identify atypical positions of the IJV. To determine the ideal puncture site, images of the neck vessels along their entire pathway should be obtained when using ultrasound for vascular access.

Identification of apolipoprotein N-acyltransferase (Lnt) in mycobacteria.

Lipoproteins of Gram-negative and Gram-positive bacteria carry a thioether-bound diacylglycerol but differ by a fatty acid amide bound to the alpha-amino group of the universally conserved cysteine. In Escherichia coli the N-terminal acylation is catalyzed by the N-acyltransferase Lnt. Using E. coli Lnt as a query in a BLASTp search, we identified putative lnt genes also in Gram-positive mycobacteria. The Mycobacterium tuberculosis lipoprotein LppX, heterologously expressed in Mycobacterium smegmatis, was N-acylated at the N-terminal cysteine, whereas LppX expressed in a M. smegmatis lnt::aph knock-out mutant was accessible for N-terminal sequencing. Western blot analyses of a truncated and tagged form of LppX indicated a smaller size of about 0.3 kDa in the lnt::aph mutant compared with the parental strain. Matrix-assisted laser desorption ionization time-of-flight/time-of-flight analyses of a trypsin digest of LppX proved the presence of the diacylglycerol modification in both strains, the parental strain and lnt::aph mutant. N-Acylation was found exclusively in the M. smegmatis parental strain. Complementation of the lnt::aph mutant with M. tuberculosis ppm1 restored N-acylation. The substrate for N-acylation is a C16 fatty acid, whereas the two fatty acids of the diacylglycerol residue were identified as C16 and C19:0 fatty acid, the latter most likely tuberculostearic acid. We demonstrate that mycobacterial lipoproteins are triacylated. For the first time to our knowledge, we identify Lnt activity in Gram-positive bacteria and assigned the responsible genes. In M. smegmatis and M. tuberculosis the open reading frames are annotated as MSMEG_3860 and M. tuberculosis ppm1, respectively.

Cloning, expression and characterization of Mycobacterium tuberculosis lipoprotein LprF.

Lipoproteins are well known virulence factors of bacterial pathogens in general and of Mycobacterium tuberculosis (Mtb), the causative agent of tuberculosis, in particular. Lipoprotein lipidation between Gram-positive and Gram-negative bacteria differs significantly as these are di- and triacylated, respectively. Little is known about the lipid anchor of mycobacterial lipoproteins. We reported recently that mycobacterial LppX, a lipoprotein involved in synthesis of cell wall components is triacylated, although mycobacteria are classified as GC-rich Gram-positive bacteria. We here exploited the model organism Mycobacterium smegmatis for the expression of Mtb LprF and characterized N-terminal modifications at the molecular level. LprF is a putative lipoprotein of Mtb involved in signaling of potassium-dependent osmotic stress. LprF is extensively modified in a mycobacterium-specific manner by a thioether-linked diacylglyceryl residue with one ester-bound tuberculostearic- and one C16:0 fatty acid and additionally by a third N-linked C16:0 fatty acid, and a hexose.

Ultrasound characteristics of needles for regional anesthesia.

BACKGROUND AND OBJECTIVES: Needle visibility is a crucial requirement for successful and safe ultrasound-guided peripheral nerve blocks. We performed a prospective study on the ultrasonic imaging quality of various commercially available needles. We tested the hypothesis that different nerve block needles would have different ultrasonic appearances. Furthermore, we examined the influence of needle angle with regard to the ultrasound plane, 2 types of media surrounding the needle, and the impact of 3 different ultrasound machines. METHODS: Twelve needles were prospectively tested for 3 ultrasound planes (longitudinal, axial tip, and axial shaft) at 2 different angles (0 degrees and 45 degrees). Quality of needle visibility and ultrasound scans were described by using 6 criteria (visibility score range 0-10): (1) visibility of needle; (2) visibility of surrounding media; (3) consistency of needle surface; (4) formation of artifacts; (5) degree of shadowing; and (6) detection and distinction of the needle from the surrounding media. Additionally, every ultrasound scan was performed in 2 media (water bath and animal model) with 3 ultrasound devices and evaluated by 2 investigators. Evaluation of the ultrasound scans was blinded with regard to needle but not to the ultrasound machine and media. RESULTS: In the animal model, visibility was good at 0 degrees (visibility score greater than 6) but was decreased for all needles at a 45 degree angle (criterion 6). In this setting, 2 needles were difficult to identify (score less than 3; criterion 6) and only 3 of 12 reached a score of 7 or more (criterion 6). Depiction quality for all 3 planes was significantly lower in the animal model when compared with the water bath (P < .001) and at an angle of 45 degrees when compared with 0 degrees (P < .001). There was no significant impact of the ultrasound machine on image quality. CONCLUSIONS: In a tissue-equivalent model we found significant differences among different types of needles at a 45 degree angle. In clinical use, angles between 30 degrees and 60 degrees are required. Because visibility of the needle is a keystone of ultrasound-guided peripheral nerve blocks, our results suggest the need to optimize the echogenicity of needles used for ultrasound-guided nerve blocks.

Induction of antibodies against murine full-length prion protein in wild-type mice.

The causative and infectious agent of the transmissible spongiform encephalopathies, e.g. bovine spongiform encephalopathy in cattle or variant Creutzfeldt-Jakob disease in humans, is a pathogenic form of the scrapie prion protein (PrP(Sc)) generated by a conformational rearrangement in the normal cellular prion protein (PrP(C)). Anti-PrP antibodies have been shown to exert a protective effect against infection with PrP(Sc). However, the generation of anti-PrP antibodies has proven quite difficult in wild-type animals, PrP being a notoriously poor immunogen. We developed a vaccine against PrP by mixing recombinant murine PrP 23-231 with DnaK, an Hsp70 homolog in Escherichia coli, and cross-linking the two proteins by means of glutaraldehyde. After three injections of the vaccine into BALB/c mice at 6, 8 and 9 weeks of age, a low-titer immune response was detected with ELISA in all animals. The specificity of the antibodies for PrP was confirmed with Western blotting. The straightforward procedure might render active immunization against prion infection feasible.

Intersite consistency as a measurement of programmatic evaluation in a medicine clerkship with multiple, geographically separated sites.

PURPOSE: This study introduces "intersite consistency" as a measurement of programmatic evaluation and demonstrates its feasibility and construct validity. METHOD: Student data in our multisite, geographically separated clerkship were collected prospectively over a ten-year period (1990-2000). We calculated mean scores for each clerkship measurement and analyzed these data on both a yearly and a 10-year cumulative basis. Analyses of variance (ANOVA) and linear regression were used for statistical analysis. RESULTS: Data for 1,632 (98%) students were included in our study. During this ten-year study period, we had 22 different on-site clerkship directors at seven clerkship sites. ANOVA and linear regression of year-to-year and cumulative data did not demonstrate an effect of site on student outcomes. CONCLUSIONS: Intersite consistency can be used as one measure of programmatic evaluation for multisite clerkships.

Assessing the effectiveness of combining evaluation methods for the early identification of students with inadequate knowledge during a clerkship.

This study examined the predictive validity of in-clerkship evaluation methods to identify medical students who have insufficient knowledge. Study subjects were 124 third-year medical students at the Uniformed Services University. Insufficient knowledge was defined by: (1) a clerkship 'pre-test' score one standard deviation below the mean or lower; or (2) any teacher verbally rating a student's general knowledge as 'marginal' or less; or (3) a student did not pass Step One of the United States Medical Licensing Examination (USMLE). We determined sensitivity and specificity using a standard score of 90%. Using USMLE Step One pass-fail performance did not improve sensitivity. Combining a 'pre-test' and instructors' formal evaluation session comments improves the early identification of students with insufficient knowledge, allowing for formative feedback and remediation during the clerkship.

Efficacy of ultrasound imaging in obstetric epidural anesthesia.

STUDY OBJECTIVE: To assess the clinical use of ultrasonographic localization of the epidural space, and to evaluate the clinical efficacy of ultrasound diagnostics in obstetric anesthesia. DESIGN: Randomized prospective study. SETTING: University Clinic of Obstetrics and Gynecology. PATIENTS: 300 parturients, 85 of whom had conventional delivery and 65 who underwent cesarean section. INTERVENTIONS: Patients underwent ultrasonography for the identification of the intervertebral structures. Puncture depth and angle were measured to improve the placement of the Tuohy needle. MEASUREMENTS: In the ultrasound group, additional puncture data, optimized puncture point, expected puncture depth, and angle were used to optimize the puncture technique. To control for side effects, we compiled data on the number of puncture attempts and the number of necessary puncture levels, visual analog scale (VAS) scores, the rate of side effects, and the patient acceptance of the technique. MAIN RESULTS: The two groups were similar regarding demographic data. Using ultrasound for structure detection, the rate of puncture attempts were significantly (p < 0.013) reduced from 2.18 +/- 1.07 to 1.35 +/- 0.61. The mean rate of necessary puncture levels was 1.30 +/- 0.55 and with ultrasound detection 1.136 +/- 0.36 (p < 0.029). Complete analgesia was achieved in 147 patients with ultrasound detection versus 138 patients in the Control group (p < 0,03). The maximum VAS pain score in the control group was 1.3 +/- 2.1 versus 0.8 +/- 1.5 in the Ultrasound group (p < 0.006). The rate of side effects were reduced significantly: 99 patients in the Control group had no side effects compared with 120 patients from the Ultrasound group who were free of side effects. Patient acceptance of the technique in the Ultrasound group was significantly higher than in the Control group. CONCLUSION: The clinical use of ultrasound for epidural catheter placement may improve regional anesthesia. The use of ultrasound resulted in superior quality in all measured endpoints.