Marc J. Kahn

Factor V Leiden is not responsible for stroke in patients with sickling disorders and is uncommon in African Americans with sickle cell disease

Cerebrovascular accidents in patients with sickle cell anemia are among the most devastating complications of the disease. It has recently been demonstrated that some patients have a hypercoagulable state on the basis of the presence of an abnormal factor V molecule, factor V Leiden. We undertook this study to evaluate the presence of factor V Leiden in sickle cell patients with stroke. Eighty‐two patients with either Hgb SS, Hgb SC, or Hgb Sβ+‐thalassemia comprised the study population. Of the 82 patients in the study, 19 of them had a history of stroke. In our study population, none of the stroke patients possessed the factor V Leiden mutation. One of the non‐stroke patients was a heterozygote for the mutation (P = 1.00). The overall frequency of the factor V Leiden allele in our population is 0.6%. The estimated prevalence for this mutation is reportedly between 3 and 7% in Caucasian populations. We conclude that the gene frequency for factor V Leiden is less common in Africa Americans with sickle cell disease. Furthermore, factor V Leiden does not appear to be responsible for the development of stroke in sickle cell patients. Am. J. Hematol. 54:12–15, 1997.

Residency Program Director Evaluations Do Not Correlate With Performance on a Required 4th-Year Objective Structured Clinical Examination

Background: Assessment of resident performance is a complex task. Purpose: To correlate performance on a 4th-year objective structured clinical examination (OSCE) with residency program director assessment, class rank, and U.S. Medical Licensing Examination (USMLE) scores. Methods: We surveyed program directors about the performance of 50 graduates from our medical school chosen to represent the highest (OSCEHI) and lowest (OSCELO) 25 performers on our required 4th-year OSCE. Program directors were unaware of the OSCE scores of the graduates. Results: OSCE scores did not correlate with Likert scores for any survey parameter studied (r <. 23, p >. 13 for all comparisons). Similarly, program director evaluations did not correlate with class rank or USMLE scores (r <. 26, p >. 09 for all comparisons). Conclusions: We concluded that program director evaluations of resident performance do not appear to correlate with objective tests of either clinical skills or knowledge taken during medical school. These findings suggest that more structured and objective evaluative tools might improve postgraduate training program assessment of trainees.

Using standardized patients to teach end‐of life Skills to Clinical Clerks

BACKGROUND This study examines the use of standardized patients to teach end-of-life skills to clinical clerks. METHODS Forty-four third-year clinical medical students participated in a half-day standardized patient workshop that was precepted by faculty members. The students were asked to report on their perceived abilities prior to the workshop and these were compared with post-workshop responses. The students were also asked to provide an overall evaluation of the standardized patient workshop as a learning experience. RESULTS The students uniformly found the workshop to be realistic, found the faculty facilitators to be helpful, and found the workshop effective in enhancing their end-of-life skills. Following participation in the workshop, students reported significant improvements in their perceived abilities to deal with pain, to appreciate cultural differences in the dying process, to deliver bad news, and to understand the legalities of do-not-resuscitate orders. CONCLUSIONS Standardized patient workshops are useful for teaching end-of-life skills.

Allowing Patients to Die: Practical, Ethical, and Religious Concerns

HERE’S THE CASE R.L. was a 58-year-old woman with a history of metastatic rectal carcinoma to lymph nodes and sacrum. Despite several attempts to control her disease with combination chemotherapy, she continued to have progressive disease and pain. Despite attempts to manage her pain as an outpatient, she was admitted to the hospital with extreme sacral bone pain for a continuous intravenous morphine infusion, titrated for pain relief. PAIN CONTROL There is a large and growing body of experience and consensus that good end-of-life care, including attention to physical, psychological, emotional, and spiritual needs, should be widely available in the United States. Indeed, this is the impetus behind the hospice concept, started in the United Kingdom by Dame Cicely Sanders in the 1950s. The United States Supreme Court, although they did not endorse physician-assisted suicide (PAS), upheld the right of all Americans to have good palliative care at the end of life, as stated in the landmark June 1997 decision (Vacco v Quill). 1 A major focus of end-of-life care is pain control. Long-acting opiates have the benefit of providing continuous pain relief throughout their duration of action. For patients with severe pain (that has not been relieved in the outpatient setting) or for patients with acute pain syndromes, admission to the inpatient setting for titration of a continuous infusion of opiates may be necessary. R.L. had been treated with oral long-acting morphine, at a dose of 1,000 mg by mouth every 8 hours as an outpatient. She also had been receiving immediate-relief oral morphine tablets for breakthrough pain. Because the highest dose available in a single long-acting morphine tablet is 200 mg, she was thus taking 15 tablets daily. Given her current morphine dose and her severe pain, her initial infusion was set at 60 mg/h. She was also allowed additional intravenous morphine boluses of 10% of her total 24-hour maintenance dose every 15 minutes as needed. R.L. had good pain control with the intravenous morphine and other supportive medications. However, 2 days into her hospitalization, she began to feel quite anxious. Her anxiety was believed, in part, to be due to the high dose of intravenous morphine that she was receiving, but it also appeared to have a psychologic component. Specifically, she was concerned about being a burden for her family and concerned about her family’s burden of finalizing her affairs after her death. She had difficulty sleeping. ANXIETY CONTROL

Therapy-induced leukemias and myelodysplastic syndromes after breast cancer treatment: an underemphasized clinical problem.

With the advent of multidisciplinary oncologic therapeutic regimens, cancers are being treated with greater effectiveness, as measured by increases in both diseasefree and actuarial survival rates. The application of all of these treatment arms into a single, focused therapeutic attack has allowed patients to live far longer than was thought possible 30 years ago. However, for some patients, oncologic treatment (and resultant success) has come with a price, namely, therapy-induced malignancies.1 3 Although this is an important clinical problem, it is an underemphasized and underreported phenomenon in the literature. By using a typical case report to put this problem in perspective, this article reviews the frequency and mechanism of secondary malignancies after therapy for breast cancer.

Formal Public Health Education and Career Outcomes of Medical School Graduates

Background Few data are available evaluating the associations of formal public health education with long-term career choice and professional outcomes among medical school graduates. The objective of this study was to determine if formal public health education via completion of a masters of public health (MPH) degree among US medical school graduates was associated with early and long-term career choice, professional satisfaction, or research productivity. Methods We conducted a retrospective cohort study in 1108 physicians (17.1% completed a MPH degree) who had 10–20 years of follow-up post medical school graduation. Multivariable logistic regression analyses were conducted. Results Compared to their counterparts with no MPH, medical school graduates with a MPH were more likely to have completed a generalist primary care residency only [relative risk (RR) 1.79, 95% confidence interval (CI) 1.35–2.29], obtain employment in an academic institution (RR 1.81; 95% CI 1.33–2.37) or government agency (RR 3.26; 95% CI 1.89–5.38), and practice public health (RR 39.84; 95% CI 12.13–107.38) or primary care (RR 1.59; 95% CI 1.18–2.05). Furthermore, medical school graduates with a MPH were more likely to conduct public health research (RR 8.79; 95% CI: 5.20–13.82), receive NIH or other federal funding (RR 3.11, 95% CI 1.74–5.33), have four or more peer-reviewed publications (RR 2.07; 95% CI 1.56–2.60), and have five or more scientific presentations (RR 2.31, 95% CI 1.70–2.98). Conclusion Formal public health education via a MPH was associated with career choice and professional outcomes among physicians.

Estimating the Value of Medical Education: A Net Present Value Approach

Background: Estimating the value of a medical education is a difficult undertaking. Purpose: As student debt levels rise and the role of managed care in price-setting increases, the financial benefit of an MD degree comes into question. Methods: We developed a model using net present value (NPV) analysis for a range of annual costs of medical school attendance. Using this model, we determined the point at which pursuing a medical education is a “break-even” proposition from a financial perspective. Results: The NPV of a medical education was positive for all annual costs of attendance from

Updated role of nitric oxide in disorders of erythrocyte function.

10,000 to

Financial Implications of Increasing Medical School Class Size: Does Tuition Cover Cost?

100,000 and ranged from approximately

Successful Treatment of Hypereosinophilic Syndrome with Cyclosporine

39,000 to