Lee R. Berkowitz

Hemostasis in Renal Disease: Pathophysiology and Management

The hemostatic abnormalities commonly encountered in patients with renal disease can significantly threaten the well-being of the patient and pose difficult management issues for the clinician. In this review, we explore the pathophysiology underlying the bleeding diathesis and hypercoagulability that can occur. Current therapeutic interventions are also discussed.

Competency-Based Education and Training in Internal Medicine

Recent efforts to improve medical education include adopting a new framework based on 6 broad competencies defined by the Accreditation Council for Graduate Medical Education. In this article, the Alliance for Academic Internal Medicine Education Redesign Task Force II examines the advantages and challenges of a competency-based educational framework for medical residents. Efforts to refine specific competencies by developing detailed milestones are described, and examples of training program initiatives using a competency-based approach are presented. Meeting the challenges of a competency-based framework and supporting these educational innovations require a robust faculty development program. Challenges to competency-based education include teaching and evaluating the competencies related to practice-based learning and improvement and systems-based practice, as well as implementing a flexible time frame to achieve competencies. However, the Alliance for Academic Internal Medicine Education Redesign Task Force II does not favor reducing internal medicine training to less than 36 months as part of competency-based education. Rather, the 36-month time frame should allow for remediation to address deficiencies in achieving competencies and for diverse enrichment experiences in such areas as quality of care and practice improvement for residents who have demonstrated skills in all required competencies.

Validity of the in-training examination for predicting american board of internal medicine certifying examination scores

Objective:To determine whether the results of the Internal Medicine In-Training Examination (ITE) can predict subsequent performance on the American Board of Internal Medicine certifying examination (ABIMCE).Design:Retrospective data review.Setting:A mixture of six community hospital and university-based internal medicine training programs in the Eastern United States.Subjects:109 residents who first took the ABIMCE in 1988 or 1989, and who had also taken at least one ITE.Measurements:Scores for the composite and subspecialty sections of the ITE were compared with those for the ABIMCE. An R2was obtained to relate the scores on the two examinations. A cutoff score was derived to maximize the ability of the ITE to discriminate between residents who were likely to pass and those who were likely to fail the ABIMCE.Main results:ABIMCE scores were available for 109 residents who had also taken the ITE during PGY-2 (19), PGY-3 (50), or both years (40). Composite scores on the ABIMCE were highly correlated with those on the ITE-PGY-2 (R2=0.593) and the ITE-PGY-3 (R2=0.677) (p<0.0001 for each).Most of the subspecialty sections on the two examinations were significantly correlated, although less strongly (range of R2=0.041 to 0.32)than were the composite scores. An empirically derived cutoff score of the 35th percentile on the ITE-PGY-2 had a positive predictive value of 89% (probability of passing ABIMCE) and a negative predictive value of 83% (probability of failing ABIMCE).Conclusions:Performance on the ITE can accurately predict and is highly correlated with performance on the ABIMCE. ITE results may therefore be useful in counseling residents about their educational needs in preparation for the ABIMCE.

The development of entrustable professional activities for internal medicine residency training: A report from the Education Redesign Committee of the Alliance for Academic Internal Medicine

Purpose The Alliance for Academic Internal Medicine charged its Education Redesign Committee with the task of assisting internal medicine residency program directors in meeting the challenges of competency-based assessment that were part of the Accreditation Council for Graduate Medical Education’s (ACGME’s) Next Accreditation System. Method Recognizing the limitations of the ACGME general competencies as an organizing framework for assessment and the inability of the milestones to provide the needed context for faculty to assess residents’ competence, the Education Redesign Committee in 2011 adopted the work-based assessment framework of entrustable professional activities (EPAs). The committee selected the EPA framework after reviewing the literature on competency-based education and EPAs and consulting with experts in evaluation and assessment. The committee used an iterative approach with broad-based feedback from multiple sources, including program directors, training institutions, medical organizations, and specialty societies, to develop a set of EPAs that together define the core of the internal medicine profession. Results The resulting 16 EPAs are those activities expected of a resident who is ready to enter unsupervised practice, and they provide a starting point from which training programs could develop assessments and curricula. The committee also provided a strategy for the use of these EPAs in competency-based evaluation. Conclusions These EPAs are intended to serve as a starting point or guide for program directors to begin developing meaningful, work-based assessments that inform the evaluation of residents’ competence.

What do applicants look for when selecting internal medicine residency programs? - A comparison of rating scale and open-ended responses

Objective: To develop reliable scale measures of factors most important to applicants when they select internal medicine residencies and to assess their validity by comparing scores from these measures with responses to open-ended questions.Design: All 353 applicants ranked by the University of North Carolina at Chapel Hill (UNC-CH) for the 1988 National Residency Match Program received a questionnaire after submitting their match lists. First, they listed the three most important factors considered in ranking residency programs and starred the single most important factor out of the three. Then, they rated 41 items on a five-point Liken scale ranging from 1 (not important) to 5 (extremely important).Setting: Categorical internal medicine residency program at an academic medical center.Measurements and main results: 315 (8896) applicants responded to the survey. Three reliable scales, Interpersonal Issues (7 items, alpha=0.78), Reputation (5 items, alpha=0.77), and Work Issues (11 items, alpha=0.89), were developed using exploratory factor analysis of applicants’ responses to the 41 items. Applicants felt interpersonal issues were very important (mean score=4.2±0.5), academic reputation was important (3.3±0.8), and work issues were less important (2.8±0.7). The differences between these scores were significant (F=3.76, p<0.05). The ratings for the top five items not in these scales also indicated that education and location -were very important. These results were corroborated by applicants’ responses to the open-ended request to list the three most important factors in ranking residencies.Conclusion: These findings suggest that work issues are important, but greater emphasis is placed on interpersonal issues, education, location, and a program’s reputation when applicants select residency programs. Furthermore, this study provides evidence supporting the reliability and validity of the three scales.

Genetic Variants Affecting the Structure and Function of the Human Red Cell Membrane

Investigators interested in the plasma membrane have long appreciated the red cell as an object of study. Red cells can be obtained in abundance and easily freed of contamination by other cell types. Mammalian red cells have no membranes other than the plasmalemma, which is easily isolated and purified. The “extracellular space” problem that plagues studies of cell solute and water content is virtually nonexistent. The techniques of making “resealed ghosts” and “inside-out vesicles” have provided ingenious approaches to problems that involve asymmetrical membrane properties. Our understanding of the ultrastructure and organization of lipids and proteins in biological membranes derives largely from the study of human erythrocytes. Much of what we know about the state of water and solutes in cytoplasm, the Na+,K + pump, the Ca2+ pump, and some coupled, passive transport systems is based on work in red cell preparations.

AAIM Report on Master Teachers and Clinician Educators Part 2: faculty development and training.

AIM Report on Master Teachers and Clinician ducators Part 2: Faculty Development and Training tephen A. Geraci, MD, Regina A. Kovach, MD, Stewart F. Babbott, MD, Harry Hollander, MD, aquel Buranosky, MD, Donna R. Devine, BS, Lee Berkowitz, MD Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Mississippi School of edicine, Jackson; Division of General Internal Medicine, Department of Medicine, Southern Illinois University School of edicine, Springfield; Division of General and Geriatric Medicine, Department of Medicine, University of Kansas School of edicine, Kansas City; Division of Infectious Diseases, Department of Medicine, University of California, San Francisco; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pa; Department of Medicine, niversity of Washington, Seattle; Department of Medicine, University of North Carolina at Chapel Hill.

A Single‐dose pharmacokinetic study of the antisickling agent cetiedil

Cetiedil citrate is an antisickling agent shown to be effective in reducing the severity and duration of acute sickle cell crisis. With the use of a sensitive GC/MS assay, the pharmacokinetic profile of cetiedil was studied in normal men and in men with sickle cell anemia who were not in crisis at the time of study. A peak cetiedil concentration of 70 to 200 ng/ml was found immediately after a 30‐minute drug infusion. The plasma level then gradually declined to approximately 10 ng/ml during a 3‐hour distributive phase. Computer analysis of the data was most consistent with a three‐compartment model. No pharmacokinetic differences were found between the normal men and the subjects with sickle cell. Because the cetiedil plasma levels achieved during this in vivo study are well below concentrations that exhibit antisickling activity in vitro, additional clinical studies will be necessary before an optimal dosing regimen can be established.

AAIM Report on Master Teachers and Clinician Educators Part 4: Faculty Role and Scholarship

AIM Report on Master Teachers and Clinician ducators Part 4: Faculty Role and Scholarship tephen A. Geraci, MD, Harry Hollander, MD, Stewart F. Babbott, MD, Raquel Buranosky, MD, onna R. Devine, BS, Regina A. Kovach, MD, Lee Berkowitz, MD Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Mississippi School of edicine, Jackson; Division of Infectious Diseases, Department of Medicine, University of California, San Francisco; Division of General and Geriatric Medicine, Department of Medicine, University of Kansas School of Medicine, Kansas ity; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Penn; Department of edicine, University of Washington; Division of General Internal Medicine, Department of Medicine, Southern Illinois niversity School of Medicine, Springfield; Department of Medicine, University of North Carolina at Chapel Hill, Chapel ill.

Inhibition of Erythrocyte Calcium Transport by Cetiedil

The elevated calcium content found in red cells from patients with sickle cell anemia may be of pathophysiologic importance in the hemolysis and vasoocclusion which characterize this disorder. Cetiedil, an antisickling agent, has been reported to inhibit the activity of enzymes that are stimulated by the calcium regulatory protein calmodulin. To investigate the mechanism by which cetiedil modifies calcium-mediated erythrocyte function, the effect of the drug on the active transport of calcium into inside-out erythrocyte vesicles was examined and its influence on the activities of phosphodiesterase and Ca-ATPase studied. Cetiedil, in the presence of calmodulin, significantly inhibited calcium transport into inside-out vesicles that were prepared with erythrocytes from normal controls and from patients with sickle cell anemia. However, in the absence of calmodulin, no inhibition was observed. Likewise, cetiedil inhibited calmodulin-stimulated, but not basal, activities of phosphodiesterase and Ca-ATPase. These data, along with previous reports, suggest that cetiedil does not act by lowering the intracellular calcium content. It is, therefore, likely that the beneficial effect of cetiedil is due to its ability to protect the red cell from the deleterious consequences of an elevated concentration of intracellular calcium.