Strategies to Improve Teaching Point-of-Care Ultrasound at the Bedside

Point-of care-ultrasound (POCUS) is becoming a core clinical skill in many medical specialties. Teaching POCUS at the bedside allows for observation of learners during actual patient encounters, provides a medium for role modeling skills and behaviors, and incorporates all core POCUS competencies. Nonetheless, bedside teaching can be time consuming and intimidating for learners and teachers, and the full benefits of teaching at the bedside can be difficult to attain. We provide strategies for improving bedside POCUS teaching based on our collective experience as medical educators and POCUS instructors at both the undergraduate and graduate levels in medical education.

Improving diagnosis by feedback and deliberate practice: one-on-one coaching for diagnostic maturation

Reflective practice is essential for the ongoing maturation of clinicians and requires regular self-evaluation in association with ongoing mentoring and feedback. Currently, most resident physicians do not have access to educational experiences that fulfill these needs. We present a novel model for structured one-on-one longitudinal coaching using the principles of deliberate practice to improve diagnostic skills. This is an easily implementable educational model that can be replicated in residencies across the country to improve clinical reasoning. Skills learned through this program have the potential not only to bolster the academic approach to patients but to also directly improve the clinical assessment and care of patients under the trainee's care.

The mortality burden of chronic liver disease may be substantially underestimated in the United States

PURPOSE

The United States National Center for Health Statistics (NCHS) uses death certificate data to estimate the burden of serious disease. This study aimed to determine the accuracy of the NCHS method for estimating the burden of chronic liver disease (CLD).

METHOD

The authors identified death certificates of New Haven County residents who died from October 1999-September 2000 that were assigned one of 115 ICD-10 codes that might indicate CLD. They reviewed medical charts, medical examiner records and a certifier questionnaire to determine whether CLD was the cause of death.

RESULT

Using the authors' determination of CLD status as the gold standard, the specificity of the NCHS classification was high (86%), but the sensitivity was low (36%). The authors found that adding selected ICD-10 codes to those considered by the NCHS to be CLD (certain CLD malignancies and viral hepatitis) could improve sensitivity. Ensuring that deaths attributed by certifiers to "End Stage Liver Disease" were coded as CLD could also improve completeness. These modifications could increase sensitivity substantially with little effect on specificity.

CONCLUSION

The NCHS method may understate the CLD burden substantially which could have a detrimental effect on planning for and evaluating prevention and treatment. Modifications could improve completeness.

Quantifying the burden of chronic viral hepatitis-related cirrhosis hospitalizations in New Haven County, Connecticut

Chronic viral hepatitis can cause cirrhosis. Viral hepatitis-related cirrhosis may be causing an increasing health burden since exposure to hepatitis B virus and hepatitis C virus in the United States increased starting in the 1960s. Using hospital discharge data, we estimated the number of adult New Haven County residents hospitalized for cirrhosis and examined the proportion caused by chronic viral hepatitis. Data on etiology were obtained from hospital discharge records, death certificate information, and New Haven County Liver Study records. From 1 October 1999 to 30 September 2000, 269 adult New Haven County residents were hospitalized for cirrhosis in a New Haven County hospital, for an incidence of 43.2 per 100,000 population. The burden of viral hepatitis-related cirrhosis was 15.9 per 100,000. Hepatitis C virus was the most common viral etiology. Given the long period between initial infection and clinical decompensation, screening and treatment programs aimed at reducing viral hepatitis-related morbidity should reduce hospitalization rates.

Retrospective validation of a surveillance system for unexplained illness and death: New Haven County, Connecticut

OBJECTIVES

This study investigated retrospective validation of a prospective surveillance system for unexplained illness and death due to possibly infectious causes.

METHODS

A computerized search of hospital discharge data identified patients with potential unexplained illness and death due to possibly infectious causes. Medical records for such patients were reviewed for satisfaction of study criteria. Cases identified retrospectively were combined with prospectively identified cases to form a reference population against which sensitivity could be measured.

RESULTS

Retrospective validation was 41% sensitive, whereas prospective surveillance was 73% sensitive. The annual incidence of unexplained illness and death due to possibly infectious causes during 1995 and 1996 in the study county was conservatively estimated to range from 2.7 to 6.2 per 100,000 residents aged 1 to 49 years.

CONCLUSIONS

Active prospective surveillance for unexplained illness and death due to possibly infectious causes is more sensitive than retrospective surveillance conducted through a published list of indicator codes. However, retrospective surveillance can be a feasible and much less labor-intensive alternative to active prospective surveillance when the latter is not possible or desired.

Eugenic sterilization and a qualified Nazi analogy: the United States and Germany, 1930-1945

In the United States and Germany before World War II, physicians participated in state-authorized eugenic sterilization programs in an attempt to prevent persons deemed to possess undesirable heritable characteristics from propagating. A comparison of U.S. and German histories reveals similarities that argue against easy dismissal of a Nazi analogy. On the basis of a review of editorials in New England Journal of Medicine and Journal of the American Medical Association from 1930 to 1945 it is difficult to accept the suggestion that the alliance between the medical profession and the eugenics movement in the United States was short-lived. Comparison of the histories of the eugenic sterilization campaigns in the United States and Nazi Germany reveals important similarities of motivation, intent, and strategy and differences that explain why support for eugenic sterilization in the United States gradually weakened. The eugenics movement in Germany was influenced by economic crisis, radical nationalism, Hitler's totalitarianism, and the medical profession's willing participation and attraction to Nazism for financial and ideological reasons. In the United States, a combination of public unease, Roman Catholic opposition, federal democracy, judicial review, and critical scrutiny by the medical profession reversed the momentum of the eugenics movement and led to the conclusion that eugenic sterilization should be voluntary.

Candida dubliniensis fungemia: the first four cases in North America

We report the first four North American cases of Candida dubliniensis fungemia, including the first isolation of this organism from the bloodstream of an HIV-infected person. All isolates were susceptible in vitro to commonly used antifungal drugs. This report demonstrates that C. dubliniensis can cause bloodstream infection; however, the incidence of disease is not known.

Synthesis of insulin-like growth factor II (IGF-II) in fetal rat tissues: translation of IGF-II ribonucleic acid and processing of pre-pro-IGF-II

The single insulin-like growth factor II (IGF-II) gene is transcribed into multiple RNA species in most fetal and neonatal rat tissues. For IGF-II to serve as a local growth factor in fetal tissues, IGF-II RNA must be translated into pre-pro-rat (r) IGF-II, and the biosynthetic precursor processed to smaller biologically active forms. IGF-II RNA extracted from fetal rat liver, muscle, intestine, lung, and stomach, from rat placenta, and from fetal or neonatal mouse liver and lung directed the synthesis of 22,000 mol wt pre-pro-IGF-II in a reticulocyte lysate cell-free translation system. A biosynthetic precursor of this size had been observed previously in translation of RNA from BRL-3A rat liver cells and is predicted by the nucleotide sequence of cDNA clones encoding rIGF-II. Consistent with the developmental pattern of expression of IGF-II RNA observed in hybridization studies, RNA from adult rat liver, muscle, and intestine did not direct the synthesis of pre-pro-rIGF-II. To determine whether the IGF-II biosynthetic precursor was processed to smaller biologically active IGF-II, term fetal rat tissues were extracted with acid-ethanol, the extracts were fractionated by acid gel filtration, and the IGF pools were examined in a RIA specific for IGF-II. Levels of 1-2 micrograms/g were observed in liver, limb, lung, intestine, and brain; lower levels were observed in heart and kidney. In general, the levels of immunoreactive IGF-II corresponded to the levels of IGF-II mRNA. These results suggest that IGF-II mRNA is translated, and pre-pro-IGF-II processed to mature IGF-II in different fetal rat tissues. In contrast to IGF-I, in which alternative RNA splicing generates possible precursor molecules containing different COOH-terminal propeptide segments, we find no evidence for an IGF-II precursor in rat tissues other than 22,000 mol wt pre-pro-rIGF-II.