Recent Publications by CFE Educators

Gender differences exist in outcomes, particularly early mortality, for percutaneous interventions (PCI) and coronary artery bypass graft surgery (CABG). Better understanding of this issue may target areas for improvement for all patients undergoing revascularization. Therefore, we summarized the evidence on gender differences in PCI and CABG outcomes, particularly early mortality, and mediators of this difference. Using the key terms "women" or "gender," "revascularization," "coronary artery bypass," "angioplasty," "stent," and "coronary intervention," we searched MEDLINE from 1985 to 2005 for all randomized controlled trials (RCTs) and registries reporting outcomes by gender. Bibliographies and the Web sites of cardiology conferences were also reviewed. The literature was examined to identify gender differences in outcomes and mediators of these differences. We identified 23 studies reporting outcomes by gender for CABG and 48 studies reporting outcomes by gender for PCI. The majority of studies noted greater in-hospital mortality in women than in men, with mortality differences resolving with longer follow-up. Early mortality differences were reduced but not consistently eliminated after adjustment for comorbidities, procedural characteristics, and body habitus. Power to detect gender differences after multivariate adjustment was limited by declining mortality rates and small sample size. Gender was an independent risk factor for complications after both CABG and PCI. Women experience greater complications and early mortality after revascularization. Future exploration is needed of gender differences in quality of care and benefit from combinations of stenting and antiplatelet, and anticoagulant medications in order to optimize treatment.

BACKGROUND

Though most medical schools administer comprehensive clinical skills assessments to identify students who have not achieved competence, the types of problems uncovered by these exams have not been characterized.

METHOD

The authors interviewed 33 individuals responsible for remediation after their schools' comprehensive assessments, to explore their experience with the problems students demonstrate and strategies for and success with remediation.

RESULTS

Respondents perceived that technique problems in history taking and physical examination were readily correctable, but that poor performance resulting from inadequate knowledge or poor clinical reasoning ability was more difficult to ameliorate. Interpersonal skill deficiencies, which often manifested as detachment from the patient, and professionalism problems attributed to lack of insight, were most refractory to remediation.

CONCLUSIONS

Poor performance in comprehensive assessments often indicates underlying deficiencies in cognitive ability, communication skills, or professionalism. The challenge of remediating these deficiencies late in medical school calls for earlier identification and intervention.

PURPOSE

To explore the congruence between students' and clerkship directors' perceptions and attributions of students' struggles during the transition to clerkships.

METHOD

Focus groups and interviews were conducted with third- and fourth-year medical students and clerkship directors at 10 U.S. medical schools in 2005 and 2006. Schools were selected to represent diverse locations, sizes, and missions. Interviews and focus groups were recorded, transcribed, and analyzed thematically.

RESULTS

Students' struggles included understanding roles and responsibilities, adjusting to clinical cultures, performing clinical skills, learning the logistics of clinical settings, and encountering frequent changes in staff, settings, and content. Clerkship directors recognized students' struggles with roles and responsibilities, performing clinical skills, and adjusting to clinical cultures, but they also focused on students' difficulties applying knowledge to clinical reasoning and engaging in self-directed learning.

CONCLUSIONS

Clerkship directors and students recognize many challenges associated with learning and performing in the clerkships. Students' perspectives suggest that these challenges may be more complex than clerkship directors and clinical teachers realize and/or are capable of addressing. The areas in which clerkship directors' and students' perspectives are not congruent point to directions for future research that can guide curricula and teaching strategies.

BACKGROUND

The use of combination therapies is needed to treat dyslipidemia in patients with both elevated low-density lipoprotein cholesterol (LDL-C) and low high-density lipoprotein cholesterol (HDL-C). We conducted a study to assess the efficacy and safety of combination therapy with statin plus extended-release (ER) niacin and colesevelam, aimed at lowering LDL-C and raising HDL-C, in subjects with atherosclerotic disease.

METHODS

This 1-year study randomized 123 subjects with atherosclerotic disease to atorvastatin alone, double therapy with atorvastatin plus ER niacin, or triple therapy with atorvastatin, plus ER niacin and colesevelam. Target LDL-C was ≤80 mg/dL for single and double therapy, and ≤60 mg/dL for triple therapy. Target HDL-C was an increase of ≥10 mg/dL for double and triple therapy.

RESULTS

Single therapy, with mean atorvastatin dose 30 mg/day, had a 47% reduction in LDL-C (P 0.001) from 148 ± 29 mg/dL to 77 ± 15 mg/dL. With the addition of ER niacin, the double therapy had a 25% increase in HDL-C, from 42 ± 11 mg/dL to 53 ± 16 mg/dL (P 0.001). The triple therapy decreased LDL-C by 57%, from 157 ± 29 mg/dL to 66 ± 18 mg/dL (P 0.001), and increased HDL-C by 29%, from 40 ± 9 mg/dL to 50 ± 14 mg/dL (P 0.001). Double and triple therapy required a lower atorvastatin dose of 20 mg/day to reach the target LDL-C levels. On average, 75% and 67% of subjects reached the predefined LDL-C and HDL-C treatment targets. No related myopathy or hepatotoxicity required stopping the therapy.

CONCLUSION

This study demonstrated that combination therapy with atorvastatin plus ER niacin and colesevelam can safely and effectively treat dyslipidemia in subjects with atherosclerotic disease.

OBJECTIVE

This study aimed to establish documentation standards for medical education activities, beyond educational research, for academic promotion consistent with principles of excellence and scholarship.

METHODS

In 2006 a Consensus Conference on Educational Scholarship was convened by the Association of American Medical Colleges (AAMC) Group on Education Affairs (GEA) to outline a set of documentation standards for use by educators and academic promotion committees. Conference participants' work was informed by more than 15 years of literature on scholarship, educator portfolios and academic promotion standards.

RESULTS

The 110 conference participants, including medical school deans, academic promotion committee members, department chairs, faculty and AAMC leaders, re-affirmed the 5 education activity categories (teaching, curriculum, advising and/or mentoring, education leadership and/or administration, and learner assessment), the contents of each category, and cross-category documentation standards. Educational excellence requires documentation of the quantity and quality of education activities. Documenting a scholarly approach requires demonstrating evidence of drawing from and building on the work of others, and documenting scholarship requires contributing work through public display, peer review and dissemination; both involve engagement with the community of educators. Implementation of these standards - quantity, quality and engagement with the education community - should occur in parallel with the development of an infrastructure to support educators, including sustained faculty development for educators, access to educational resources and journals, peer review mechanisms and consultation and support specific to each activity category.

CONCLUSIONS

Educators' contributions to their institutions must be visible to be valued. The establishment of documentation standards for education activities provides the foundation for academic recognition of educators.

To date, the US FDA has approved three tumor necrosis factor (TNF)-a inhibitors for use in dermatology. Etanercept (Enbrel, Amgen-Wyeth), a fully human fusion protein of TNF receptor II bound to the Fc component of human IgG1, is approved for use in psoriasis (2004) and psoriatic arthritis (2002). Infliximab (Remicade, Centocor) is a chimeric monoclonal antibody that is approved for use in psoriasis (2006) and psoriatic arthritis (2005), and adalimumab (Humira, Abbott Laboratories), a fully human monoclonal antibody, is approved for use in psoriatic arthritis (2005). While data regarding the efficacy and safety of these therapies is abundant, it proves nearly impossible to objectively compare and contrast agents as there are no head-to-head trials. Clinical experience and post-marketing reporting has allowed dermatologists to identify the relative strengths and limitations of each agent. The well-founded enthusiasm for these agents, because of their excellent initial efficacy and safety profile, is reasonably tempered by concerns about declining efficacy over time, the risk of infection, lymphoma and demyelinating disorders, and cost. The distinct and targeted mechanism of action of the TNF inhibitors allows dermatologists to customize therapy to match the individual needs and characteristics of patients who are candidates for systemic or phototherapy.

Using a large consortium of undergraduate students in an organized program at the University of California, Los Angeles (UCLA), we have undertaken a functional genomic screen in the Drosophila eye. In addition to the educational value of discovery-based learning, this article presents the first comprehensive genomewide analysis of essential genes involved in eye development. The data reveal the surprising result that the X chromosome has almost twice the frequency of essential genes involved in eye development as that found on the autosomes.

TRPA1 is an excitatory ion channel expressed by a subpopulation of primary afferent somatosensory neurons that contain substance P and calcitonin gene-related peptide. Environmental irritants such as mustard oil, allicin, and acrolein activate TRPA1, causing acute pain, neuropeptide release, and neurogenic inflammation. Genetic studies indicate that TRPA1 is also activated downstream of one or more proalgesic agents that stimulate phospholipase C signaling pathways, thereby implicating this channel in peripheral mechanisms controlling pain hypersensitivity. However, it is not known whether tissue injury also produces endogenous proalgesic factors that activate TRPA1 directly to augment inflammatory pain. Here, we report that recombinant or native TRPA1 channels are activated by 4-hydroxy-2-nonenal (HNE), an endogenous alpha,beta-unsaturated aldehyde that is produced when reactive oxygen species peroxidate membrane phospholipids in response to tissue injury, inflammation, and oxidative stress. HNE provokes release of substance P and calcitonin gene-related peptide from central (spinal cord) and peripheral (esophagus) nerve endings, resulting in neurogenic plasma protein extravasation in peripheral tissues. Moreover, injection of HNE into the rodent hind paw elicits pain-related behaviors that are inhibited by TRPA1 antagonists and absent in animals lacking functional TRPA1 channels. These findings demonstrate that HNE activates TRPA1 on nociceptive neurons to promote acute pain, neuropeptide release, and neurogenic inflammation. Our results also provide a mechanism-based rationale for developing novel analgesic or anti-inflammatory agents that target HNE production or TRPA1 activation.