The effect of a rolling admission policy on a medical school's selection of applicants

PURPOSE

As the University of Kentucky College of Medicine (UKCM) employs a rolling admission policy, this study was designed to determine (1) whether the month during which applicants were considered by the UKCM admission committee was associated with admission status, (2) whether applicants considered early in the process differed in selected academic and noncognitive pre-admission characteristics in comparison with later applicants, and (3) what the importance of the month of the applicant's consideration was relative to other predictors of admission to UKCM.

METHOD

The application files and admission committee's minutes regarding 302 applicants who received interviews during the 1993-94 application cycle were examined. Data reviewed included each applicant's gender, age, geographic origin, undergraduate science and non-science grade-point averages, and Medical College Admission Test scores; the date of consideration by the committee; interviewers' ratings; the initial motion on the applicant; and the final admission status.

RESULTS

The findings indicate that the applicants considered earlier were significantly more likely to gain admission. However, upon assigning the applicants to three groups according to the month of consideration, no difference in academic qualifications was found. Regression analyses revealed that despite the effect of time of consideration, noncognitive characteristics related to UKCM's mission also predicted admission decisions.

CONCLUSION

This study provides useful information to admission committees reviewing the effect of a rolling admission policy, as well as to applicants and premedical advisors, who should be aware of the potential importance of submitting applications in a timely manner.

A comparison of specialty choices, residency training, and practice locations of early-decision and regular-admission graduates

PURPOSE

Early-decision (ED) medical school applicants express a clear preference for attending a particular medical school. The present study assessed whether ED graduates would demonstrate similar geographic preferences in their choices of undergraduate institutions and selections of in-state residency sites and practice locations.

METHOD

The study was conducted at the University of Kentucky College of Medicine. Uniform academic and nonacademic criteria were used to evaluate the applications of ED and regular-admission students who matriculated from 1974-75 to 1984-85. The student variables assessed were class year, gender, age, county of residence, and undergraduate college, as well as undergraduate science and cumulative grade-point averages (GPAs) and Medical College Admission Test (MCAT) scores. Specialty choice and locations of residency programs were obtained from the medical school's commencement programs. Specialty types and practice locations were obtained from practicing physician records maintained by the alumni office.

RESULTS

Of the 1,243 matriculants, 193 (15.5%) gained admission to the school through the ED plan. The ED graduates were significantly more likely to have completed their undergraduate studies at the University of Kentucky than at other public or private schools, in state or out of state, and had significantly higher GPAs and MCAT scores. As a group, the ED graduates were somewhat (though not significantly) more likely than the regular-admission graduates to remain in state for their residencies and practice in state.

CONCLUSION

The authors suggest that medical schools should work closely with their undergraduate admission offices to attract academically outstanding high school students. Such students are likely to stay in state for the eight-year span of their undergraduate and medical educations and may have a greater tendency to practice in state.

Individual differences in the voluntary use of a memory aid during decision making

To characterize selective uses of external memory aids, 42 younger and 38 older adults made decisions and then completed individual difference measures. Experimental manipulation of the availability of a memory aid allowed examination of the effects of having a memory aid available as opposed to the spontaneous use of that aid. Use of the memory aid resulted in longer decision times, more requests for information, and less rechecking of already viewed information. Younger and older adults with high abstraction scores and older adults with high vocabulary scores were more likely to use the aid. Patterns of use differed in that younger adults used the aid in the middle of their information gathering and older adults used the aid toward the end. Making a memory aid available for use during decision making affected decision-making processes of older adults; use of the aid was associated with greater crystallized and fluid intelligence.

Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously

BACKGROUND

Prompt recognition of the reversal of respiratory failure may permit earlier discontinuation of mechanical ventilation, without harm to the patient.

METHODS

We conducted a randomized, controlled trial in 300 adult patients receiving mechanical ventilation in medical and coronary intensive care units. In the intervention group, patients underwent daily screening of respiratory function by physicians, respiratory therapists, and nurses to identify those possibly capable of breathing spontaneously; successful tests were followed by two-hour trials of spontaneous breathing in those who met the criteria. Physicians were notified when their patients successfully completed the trials of spontaneous breathing. The control subjects had daily screening but no other interventions. In both groups, all clinical decisions, including the decision to discontinue mechanical ventilation, were made by the attending physicians.

RESULTS

Although the 149 patients randomly assigned to the intervention group had more severe disease, they received mechanical ventilation for a median of 4.5 days, as compared with 6 days in the 151 patients in the control group (P=0.003). The median interval between the time a patient met the screening criteria and the discontinuation of mechanical ventilation was one day in the intervention group and three days in the control group (P<0.001). Complications -- removal of the breathing tube by the patient, reintubation, tracheostomy, and mechanical ventilation for more than 21 days -- occurred in 20 percent of the intervention group and 41 percent of the control group (P=0.001). The number of days of intensive care and hospital care was similar in the two groups. Total costs for the intensive care unit were lower in the intervention group (median, $15,740, vs. $20,890 in the controls, P=0.03); hospital costs were lower, though not significantly so (median, $26,229 and $29,048, respectively; P=0.3).

CONCLUSIONS

Daily screening of the respiratory function of adults receiving mechanical ventilation, followed by trials of spontaneous breathing in appropriate patients and notification of their physicians when the trials were successful, can reduce the duration of mechanical ventilation and the cost of intensive care and is associated with fewer complications than usual care.

Chest X-ray changes in air space disease are associated with parameters of mechanical ventilation in ICU patients

To assess relationships between parameters of mechanical ventilation (MV) and portable chest X-ray (CXR) measurements of lung length (LL) and severity of air space disease, a prospective, randomized, blinded comparison of 102 adults in a university hospital was performed. Each patient received two portable, supine CXRs on different MV breaths within 5 min of one another. Ventilator parameters were recorded. All 204 CXRs were randomly assorted and read independently by three radiologists. Air space disease was considered more severe with pressure support ventilation (PSV) breaths than with intermittent mandatory ventilation (IMV) breaths (p = 0.0003), and its extent correlated inversely with static compliance (p = 0.0001, r = -0.40). Among patients having CXRs on both IMV and PSV breaths, 15 of 67 (22%) had their overall degree of air space disease read differently by one category (mild, moderate, or severe). Increases in LL between the two CXRs were associated with increasing peak (p = 0.0038) or mean (p = 0.0065) airway pressure, tidal volume (VT) (p = 0.022), and VT per kilogram (p = 0.006). We conclude that lung volume changes during MV, typically not noted nor controlled for during portable chest radiography, may substantially alter the interpretation of air space disease and LL. Physicians monitoring intensive care unit (ICU) patients with daily CXRs should be aware of the variables influencing interpretation of portable CXRs of ICU patients.

Geographic origin and its impact on practice location in Kentucky

This study examined which medical students from the University of Kentucky College of Medicine are most likely to return to their geographic origins to practice medicine and the frequency with which this occurs. This study is based on statistical analysis of longitudinal data (1974-1985). The database includes 1243 matriculants for whom residency data were available. Follow-up data were available for 1093 physicians-in-practice. Results indicate that a significant percentage of matriculants return to their in-state district of origin to practice. Significant predictors of practice location included gender, undergraduate institution, and residence at admission. However, these factors explained only 8% of the variance in physician practice location. Expanding the model to include location of residency program and specialty choice contributed an additional 14% of the variance. Admissions officers seeking to improve the ratio of graduates practicing in rural areas should devise new measures to assess applicant's attraction to positive aspects of rural medical practice or small town life.

Compliance with the screening mammography program of British Columbia: will she return?

OBJECTIVE

To identify factors associated with compliance in the Screening Mammography Program of British Columbia (SMPBC).

METHOD

Factors associated with rescreening within 18 months (annual compliers) and between 18 to 36 months later (late compliers) were identified in a cohort of SMPBC screenees using a self-administered questionnaire.

RESULTS

Fewer than half of women initially screened within the SMPBC were annual compliers, nearly 40% not returning by 3 years. In women age 50+ years, annual compliers tended to have no prior mammography, no prior breast pain, a physician referral to SMPBC, and a normal initial SMPBC mammogram. Late compliers also tended to have no prior mammography, a physician referral, and a normal initial SMPBC mammogram.

CONCLUSIONS

Several modifiable factors associated with compliance were identified: a physician referral to the program and possibly subsequent referral back to the program after workup for an abnormal mammogram.

Metabolism of gammalinolenic acid in human neutrophils

Gammalinolenic acid (GLA), when provided as a dietary supplement, has been reported to improve clinical symptoms of several inflammatory disorders. The goal of the current study was to examine the metabolism of GLA and its relationship to arachidonic acid (AA) in the human neutrophil. Initial studies indicated that neutrophils provided GLA in vitro rapidly elongate it (by two carbons) to dihomogammalinolenic acid (DGLA). The bulk of this newly formed DGLA is incorporated into neutral lipids and specifically triacylglycerides. Neutrophils from volunteers supplemented with GLA as borage oil also had elevated quantities of DGLA but not GLA, when compared with neutrophils from volunteers not consuming the GLA supplement. To determine whether DGLA could be mobilized from cellular glycerolipids, neutrophils were stimulated with ionophore A23187 and fatty acid levels were determined. DGLA and AA were both released during stimulation, and the quantities of DGLA mobilized increased threefold after in vitro GLA supplementation. Exogenously provided DGLA was converted to one major metabolite during cell stimulation; this product migrated on reverse-phase HPLC with the 15-lipoxygenase product, 15-hydroxy-eicosa-trienoic acid (15-HETre). Both 15-HETre and DGLA (provided exogenously) inhibited the formation of leukotriene B4, (LTB4) and 20-hydroxy-leukotriene B4 (20-OH-LTB4). The IC50 for 15-HETre inhibition of both LTR, and 20-OH-LTB4 in A23187-stimulated neutrophils was 5 microM. This inhibition could be reversed by removing the compounds from the cells. Taken together, these data reveal that there are enzymes within the human neutrophil that metabolize GLA or its elongation product DGLA, and that the metabolism of GLA and AA may interact at a number of critical junctures.

Metabolism of gammalinolenic acid in human neutrophils

Gammalinolenic acid (GLA), when provided as a dietary supplement, has been reported to improve clinical symptoms of several inflammatory disorders. The goal of the current study was to examine the metabolism of GLA and its relationship to arachidonic acid (AA) in the human neutrophil. Initial studies indicated that neutrophils provided GLA in vitro rapidly elongate it (by two carbons) to dihomogammalinolenic acid (DGLA). The bulk of this newly formed DGLA is incorporated into neutral lipids and specifically triacylglycerides. Neutrophils from volunteers supplemented with GLA as borage oil also had elevated quantities of DGLA but not GLA, when compared with neutrophils from volunteers not consuming the GLA supplement. To determine whether DGLA could be mobilized from cellular glycerolipids, neutrophils were stimulated with ionophore A23187 and fatty acid levels were determined. DGLA and AA were both released during stimulation, and the quantities of DGLA mobilized increased threefold after in vitro GLA supplementation. Exogenously provided DGLA was converted to one major metabolite during cell stimulation; this product migrated on reverse-phase HPLC with the 15-lipoxygenase product, 15-hydroxy-eicosa-trienoic acid (15-HETre). Both 15-HETre and DGLA (provided exogenously) inhibited the formation of leukotriene B4, (LTB4) and 20-hydroxy-leukotriene B4 (20-OH-LTB4). The IC50 for 15-HETre inhibition of both LTR, and 20-OH-LTB4 in A23187-stimulated neutrophils was 5 microM. This inhibition could be reversed by removing the compounds from the cells. Taken together, these data reveal that there are enzymes within the human neutrophil that metabolize GLA or its elongation product DGLA, and that the metabolism of GLA and AA may interact at a number of critical junctures.

Thoracobiliary fistula

Thoracobiliary communications in the form of either pleurobiliary or bronchobiliary fistulas are reported complications of many diseases. A strong suspicion in the appropriate clinical setting is necessary to recognize this problem. Bilioptysis is the sine qua non of a bronchobiliary fistula. Diagnostic imaging studies are useful to identify the communication and to delineate its location. Although surgery is the optimal intervention, percutaneous drainage and intravenous antimicrobial therapy may offer the best therapeutic option in patients with metastatic cancer and limited physiologic reserve. We report a unique case of bronchobiliary fistula complicating a uterine leiomyosarcoma with hepatic metastases. Long-term palliation was achieved with percutaneous drainage and appropriate fluid and electrolyte replacement therapy.

Respiratory rehabilitation, exercise capacity and quality of life in chronic airways disease in old age

Respiratory rehabilitation improves exercise capacity and quality of life in younger patients but is untried in the aged. We aimed to: (a) assess repeatability of the 6-minute walk test, factors affecting it and its relation to quality of life in elderly patients with chronic obstructive airways disease (COAD); (b) assess compliance of such patients with an intensive respiratory rehabilitation protocol; (c) pilot the assessment of the effect of respiratory rehabilitation on the 6-minute walk test in these patients. Seventeen subjects with stable, symptomatic COAD were recruited, 15 (six men), 70-89 (mean 76) years, completed the study. Mean (standard deviation) 1-second forced expiratory volume (FEV1) = 49 (5)% predicted. Six-minute walk tests were repeated single-blind, 2-10 days apart. Quality of life was measured using Guyatt respiratory questionnaire. Patients underwent 12 weeks incremental respiratory rehabilitation (x4/day step-ups, unweighed arm raises, inflating balloons). Baseline 6-minute walk was repeatable and was correlated with the log Guyatt dyspnoea score (r = 0.65, p = 0.006). In multiple regression neither age nor FEV1 predicted walk distance: body mass index, maximal expiratory mouth pressure; calorie intake. Mean (SEM) 6-minute walk distance after-rehabilitation was greater than baseline (p = 0.003). Elderly patients with COAD tolerate intensive respiratory rehabilitation and a controlled, blinded study is needed.

Work hardening: evidence for success of a program

The effectiveness of a work hardening program in facilitating gains in physical strength and return to work in 40 chronic low back-pain clients was assessed. Statistically significant gains in physical strength were found. Also, 27 of the 32 clients reached by follow-up telephone calls returned to work full time.

In vivo study of indomethacin in bronchiectasis: effect on neutrophil function and lung secretion

Bronchiectasis is associated with sputum containing high levels of the proteolytic enzyme elastase, which is thought to be involved in the pathogenesis of the disease. Agents which inhibit neutrophil function and interfere with neutrophil elastase release may have a beneficial effect on the development and progression of such diseases. We have studied the effects of the nonsteroidal anti-inflammatory agent indomethacin on neutrophil function in nine patients with clinically stable bronchiectasis. All patients remained clinically stable during the study. We observed a significant reduction in peripheral neutrophil chemotaxis to 10 nmol.L-1 N-formyl-methionyl-leucyl-phenylalanine (FMLP) from a mean of 19.86 (SEM 1.35) to 8.46 (0.68) cells.field-1 after 4 weeks of therapy. There was also a significant reduction in fibronectin degradation both by resting and FMLP-stimulated neutrophils, from a mean of 1.90 (0.19) micrograms x 3 x 10(5) cells at the start of therapy to 0.87 (0.08) micrograms after 4 weeks, and from 3.17 (0.35) micrograms to 1.48 (0.05) micrograms, respectively. There was no effect on spontaneous or stimulated superoxide anion generation by neutrophils. Despite the marked changes in peripheral neutrophil function, no adverse effect was observed on viable bacterial load in the bronchial secretions. In addition, there was no difference in sputum albumin, elastase or myeloperoxidase levels, and only minor changes in the chemotactic activity of the sputum. These results suggest that nonsteroidal anti-inflammatory agents have a major effect on peripheral neutrophil function but do not appear to have an adverse effect on bacterial colonization of the airways.

In vivo study of indomethacin in bronchiectasis: effect on neutrophil function and lung secretion

Bronchiectasis is associated with sputum containing high levels of the proteolytic enzyme elastase, which is thought to be involved in the pathogenesis of the disease. Agents which inhibit neutrophil function and interfere with neutrophil elastase release may have a beneficial effect on the development and progression of such diseases. We have studied the effects of the nonsteroidal anti-inflammatory agent indomethacin on neutrophil function in nine patients with clinically stable bronchiectasis. All patients remained clinically stable during the study. We observed a significant reduction in peripheral neutrophil chemotaxis to 10 nmol.L-1 N-formyl-methionyl-leucyl-phenylalanine (FMLP) from a mean of 19.86 (SEM 1.35) to 8.46 (0.68) cells.field-1 after 4 weeks of therapy. There was also a significant reduction in fibronectin degradation both by resting and FMLP-stimulated neutrophils, from a mean of 1.90 (0.19) micrograms x 3 x 10(5) cells at the start of therapy to 0.87 (0.08) micrograms after 4 weeks, and from 3.17 (0.35) micrograms to 1.48 (0.05) micrograms, respectively. There was no effect on spontaneous or stimulated superoxide anion generation by neutrophils. Despite the marked changes in peripheral neutrophil function, no adverse effect was observed on viable bacterial load in the bronchial secretions. In addition, there was no difference in sputum albumin, elastase or myeloperoxidase levels, and only minor changes in the chemotactic activity of the sputum. These results suggest that nonsteroidal anti-inflammatory agents have a major effect on peripheral neutrophil function but do not appear to have an adverse effect on bacterial colonization of the airways.

The isolation and characterization of non-typeable Haemophilus influenzae from the sputum of adult cystic fibrosis patients

The role of non-typeable Haemophilus influenzae in cystic fibrosis (CF) remains unclear. We wanted, therefore, to determine the presence and characteristics of non-typeable H. influenzae in sputum samples from patients with CF. In order to do this, we have assessed sputum samples from 55 consecutive clinically stable patients seen routinely at an adult CF out-patient clinic. Quantitative bacterial culture was performed using a selective media containing cefsoludin, and isolates were characterized by biotyping and outer membrane protein profile analysis. In 17 (30%) of these samples, non-typeable H. influenzae was isolated and was present in similar viable numbers (mean 7.7 x 10(8) colony-forming units (cfu).mL-1; SEM 3.1) to Pseudomonas aeruginosa (mean 8 x 10(8) cfu.mL-1: SEM 2.4). All non-typeable H. influenzae isolates recovered were beta-lactamase negative and sensitive to a range of antibiotics. Several biotypes and outer membrane protein profiles were observed, with no apparent association between these two phenotypic characteristics. The study showed that large numbers of non-typeable H. influenzae are often present in sputum from adult patients with CF. Further longitudinal studies of outer-membrane protein profile analysis are required to determine the dynamics of non-typeable H. influenzae colonization in individual patients and the clinical significance.

The isolation and characterization of non-typeable Haemophilus influenzae from the sputum of adult cystic fibrosis patients

The role of non-typeable Haemophilus influenzae in cystic fibrosis (CF) remains unclear. We wanted, therefore, to determine the presence and characteristics of non-typeable H. influenzae in sputum samples from patients with CF. In order to do this, we have assessed sputum samples from 55 consecutive clinically stable patients seen routinely at an adult CF out-patient clinic. Quantitative bacterial culture was performed using a selective media containing cefsoludin, and isolates were characterized by biotyping and outer membrane protein profile analysis. In 17 (30%) of these samples, non-typeable H. influenzae was isolated and was present in similar viable numbers (mean 7.7 x 10(8) colony-forming units (cfu).mL-1; SEM 3.1) to Pseudomonas aeruginosa (mean 8 x 10(8) cfu.mL-1: SEM 2.4). All non-typeable H. influenzae isolates recovered were beta-lactamase negative and sensitive to a range of antibiotics. Several biotypes and outer membrane protein profiles were observed, with no apparent association between these two phenotypic characteristics. The study showed that large numbers of non-typeable H. influenzae are often present in sputum from adult patients with CF. Further longitudinal studies of outer-membrane protein profile analysis are required to determine the dynamics of non-typeable H. influenzae colonization in individual patients and the clinical significance.

Age and gender differences in students' preadmission qualifications and medical school performances

PURPOSE

To investigate the age- and gender-related differences in matriculants' preadmission performances and in their subsequent medical school performances.

METHOD

A longitudinal database was used to provide information on the 557 students in six entering classes (1984-1989) at the University of Kentucky College of Medicine. The preadmission variables were undergraduate science and cumulative grade-point averages (GPAs), Medical College Admission Test (MCAT) scores, and interview ratings. The medical school variables were GPAs for the four years of school and scores on the National Board of Medical Examiners Part I and Part II examinations. Age- and gender-related differences were analyzed by analyses of variance. To examine age differences, the students were grouped by age at matriculation: less than 23 years old, between 23 and 27, and 28 or older.

RESULTS

The younger matriculants had significantly higher undergraduate GPAs than did their older peers; however, their performances on the MCAT were nearly identical. The men had higher MCAT scores than the women in all age groups, but the older women had higher undergraduate GPAs than the older men. The younger students tended to have slightly higher medical school GPAs than the older students. No age differences were found for the NBME I and II, and no gender difference was found for the NBME II; however, a modest gender difference was found for the NBME I, with the men performing better than the women.

CONCLUSION

Dramatic age and gender differences were evident in the preadmission performances, while the differences in the medical school performances were much smaller.

A description of a new DR allele, DRB1*1113

We have discovered a previously unpublished HLA-DRB1 allele, observed in a patient (SB), his mother, and one sibling. The undefined allele gave sporadic positive reactions with sera in the DR52-associated group. SSOPH analysis utilizing both generic and group specific primers and probes also gave ambiguous results. SB typed clearly as a DRB1*0301 (paternal allele) but the DNA from SB also bound probes specific for DRB1*14 and DRB1*11. Sequencing revealed that the undefined allele was similar to a DRB1*14 allele with a segment of sequence found in DRB1*11 alleles. The patient was MLC reactive with donors who express DRB1*0301, *1401 and *0301, *11 and was nonreactive solely to DRB1*0301 (Dw3) homozygous typing cells.

Domestic violence in a primary care setting. Patterns and prevalence

OBJECTIVES

To determine the prevalence of domestic violence among women patients in a primary care setting, the types of violence experienced by each woman, and the reasons for their visit to the family physician.

DESIGN AND SAMPLE

Structured interviews with all consecutive, consenting women patients scheduled for morning appointments between July 26 and August 13, 1993.

SETTING

A community-based family practice residency outpatient clinic in a midwestern city with a population of 85,000.

RESULTS

Of the 42 women interviewed, 45% reported experiencing physical, social, and/or emotional violence in their relationships. Thirty-six percent reported being physically battered during their lifetimes; 12% reported being currently involved in a battering relationship. Relationships and patterns between various types of violence were evident. Sixty-two percent of the women who had experienced slapping and hitting (moderate abuse) also experienced punching and kicking (severe violence), some of which included sexual violence and weapon use. Women who were sexually abused were also likely to be emotionally abused (r = .66; P < .001), and women who were socially abused were also likely to be severely battered (r = .60; P < .005). None of the currently battered women was being seen for routine health maintenance reasons, but presented instead with specific complaints such as neck stiffness and migraine headache.

CONCLUSIONS

Domestic violence is very prevalent among women patients in primary care settings and involves predictable patterns of injury. Physicians should routinely assess for violence at all types of visits, educate patients about violence, and work to prevent the violence that occurs in abusive relationships.

Effects of family disruption on Southeast Asian refugee women

Identifying refugee women at a high risk of depression, anxiety and post-traumatic stress is an important role of the nurse, so that appropriate interventions--including family and community support--can be implemented. Below, an assessment of Southeast Asian refugee women experiencing emotional distress from the disruption of family ties that occurred during war, escape and resettlement.