Recent Publications by CFE Educators

BACKGROUND

This study describes comprehensive standardized patient examinations in medical schools nationally.

METHOD

We surveyed 121 medical school curriculum deans regarding their use of standardized patient assessments. Questions addressed examination characteristics, funding sources, and collaborations.

RESULTS

A total of 91 of 121 curriculum deans responded (75% response rate). The majority (84%) of respondents report conducting a comprehensive clinical skills assessment during the third or fourth year of medical school. Most programs are funded with dean's office monies. Although many collaborate with other institutions for examination development, the majority of schools score and remediate students independently. Two-thirds of all respondents (61/91) report that the new standardized patient licensing requirement elevates the importance of in-house clinical skills examinations.

CONCLUSIONS

Most medical schools now conduct comprehensive clinical skills assessments after the core clerkships, and collaboration is common. These results suggest increasing emphasis on clinical and communication skills competency and opportunities for collaborative research.

A major unanswered question concerning "pain" circuitry is the extent to which different populations of primary afferent nociceptor engage the same or different ascending pathways. In the present study, we followed the transneuronal transport of a genetically expressed lectin tracer, wheat germ agglutinin, in Na(V)1.8-expressing nociceptors of the nonpeptide class. We found that interneurons of lamina II are at the origin of the major ascending circuits targeted by the nonpeptide nociceptors. These interneurons contact lamina V projection neurons, which in turn predominantly target fourth-order neurons in the amygdala, hypothalamus, bed nucleus of the stria terminalis, and to a remarkable extent, the globus pallidus. These circuits differ greatly from the lamina I-based projection that is targeted by the peptide class of nociceptors. Our results indicate that parallel, perhaps independent pain pathways arise from different nociceptor classes and that motor as well as limbic targets predominate in the circuits that originate from the nonpeptide population.

BACKGROUND

National Cholesterol Education Program Adult Treatment Panel III (ATP III) guidelines recommend the use of Framingham risk scores (FRS) for cardiovascular assessment of asymptomatic individuals. We hypothesized that risk prediction could be improved with 2 non-ECG exercise test measures, exercise capacity (metabolic equivalents, or METs) and heart rate recovery (HRR).

METHODS AND RESULTS

An asymptomatic cohort with baseline treadmill tests (n=6126; 46% women, FRS 20%) was followed up prospectively for 20 years. Individuals with low (median or less) HRR or METs experienced 91% of all cardiovascular disease (CVD) deaths (225/246). After FRS adjustment, low HRR and METs individually were highly significant predictors of CVD death, but low HRR and METs together were associated with substantially higher risk (adjusted hazard ratio compared with high HRR/high METs for women 8.51, 95% CI 3.65 to 19.84; for men, 3.53, 95% CI 2.03 to 6.15; P0.001 for both). At 10-year follow-up, FRS-adjusted CVD death risk associated with low HRR/low METs was less than at 20 years but remained significant (women 3.83, 95% CI 1.09 to 13.47, and men 2.70, 95% CI 1.11 to 6.55). The application of HRR/METs information to FRS assessment identified those at high risk (>0.5% annual CVD mortality) in half of women with FRS 6% to 9% and 10% to 19% and just under half of men with FRS 10% to 19%. Low HRR/low METs was also associated with an increased relative risk of CVD death in individuals with low-risk FRS (FRS 6% in women and 10% in men), but absolute CVD mortality rates were low in this subgroup.

CONCLUSIONS

Exercise testing may be a useful adjunct for clinical risk assessment in asymptomatic women with FRS 6% to 19% and men with FRS 10% to 19%.

OBJECTIVE

The purpose of this study was (1) to assess maxillary development in cleft individuals with Van der Woude syndrome (VWS) and (2) to compare hypodontia in VWS and nonsyndromic cleft matched controls.

DESIGN AND SETTING

Retrospective case-control study from the Center for Craniofacial Anomalies, University of California, San Francisco, California.

PATIENTS AND PARTICIPANTS

The sample consisted of 15 individuals with Van der Woude syndrome and 15 nonsyndromic cleft lip and/or palate controls paired for age, gender, and cleft type in the age range of 5 to 13 years.

MAIN OUTCOME MEASURES

Cephalograms were digitized, and 31 linear and angular measurements were made. Serial panoramic radiographs were used to assess the presence or absence of permanent teeth.

RESULTS

The maxillary sagittal position represented by midface length (Co-A) was significantly shorter in the Van der Woude syndrome subjects than in the matched controls (p = .031), suggesting a trend towards greater maxillary hypoplasia, particularly in Van der Woude syndrome with bilateral cleft lip and/ or palate. Measurements indicating sagittal jaw relationship (ANB angle and the Wits) were significantly smaller in the children with Van der Woude syndrome than in matched controls (p = .008 and p = .006). A significantly larger number of individuals with Van der Woude syndrome than matched controls had missing teeth (p = .014). The mandibular second premolar was missing more frequently in children with Van der Woude syndrome than in the matched controls (p = .031). The differences concerning both maxillary hypoplasia and hypodontia were most marked in the more severe cleft type, represented by bilateral cleft lip and/or palate.

CONCLUSIONS

Based on these findings, the expectation is that there will be maxillary hypoplasia and hypodontia of greater severity in Van der Woude syndrome than in nonsyndromic clefts.

Time-varying elastance models have been used extensively in the past to simulate the pulsatile nature of cardiovascular waveforms. Frequently, however, one is interested in dynamics that occur over longer time scales, in which case a detailed simulation of each cardiac contraction becomes computationally burdensome. In this paper, we apply circuit-averaging techniques to a periodically driven, closed-loop, three-compartment recirculation model. The resultant cycle-averaged model is linear and time invariant, and greatly reduces the computational burden. It is also amenable to systematic order reduction methods that lead to further efficiencies. Despite its simplicity, the averaged model captures the dynamics relevant to the representation of a range of cardiovascular reflex mechanisms.

OBJECTIVE

To determine factors that influence medical student selection of internal medicine residency programs by ethnicity and gender.

DESIGN/SETTING

A cross-sectional mailed survey of graduating medical students applying to four residency programs in 1999.

MEASUREMENTS

A five-point (5=most important) Likert scale was used to evaluate factors and included 14 items on location characteristics, 20 on program features, six on recruitment, three on future plans and three on advising.

RESULTS

Of 2,820 surveys, 1,005 were completed (36%). The most important factors to applicants were house staff morale (mean +/- SD, 4.5 +/- 0.7), academic reputation (4.5 +/-0.8), and positive interview experience (4.1 +/- 1.0). Women rated gender diversity of faculty (3.3 vs. 2.3, p=0.0001) and house staff (3.3 vs. 2.5, p=0.0001), location of residency program near spouse (4.2 vs. 3.9, p=0.0001) or spouse's job (3.8 vs. 3.5, p=0.0002) and emphasis on primary care (2.9 vs. 2.4, p=0.0001) more highly than men. Minority applicants were more likely than whites to identify the following factors as more important: ethnic diversity of patients (3.8 vs. 3.4, p=0.008), house staff (3.3 vs. 2.4, p0.0001) and faculty (3.1 vs. 2.3, p0.0001); service to the medically indigent (3.8 vs. 3.3, p=0.004); feeling of being wanted (3.8 vs. 3.4, p=0.002); and an academic environment supportive of ethnic minorities (3.5 vs. 2.3, p0.0001).

CONCLUSIONS

Location and program factors are most important in influencing decisions to choose a residency program. However, women and minority applicants also place significant importance on family and diversity factors. Programs need to consider differential factors in recruitment of diverse students.