Mark C. Henderson

Risk factors for venous thromboembolism after total hip and knee replacement surgery.

Elective total hip and total knee arthroplasty surgeries are associated with an extraordinarily high incidence of asymptomatic venous thromboembolism (VTE). Symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE) is diagnosed in only 2%–4% of these patients. A number of studies have defined the incidence and time course of symptomatic thromboembolism after these procedures. Knee arthroplasty is associated with a very high incidence of asymptomatic calf vein thrombosis, with almost all symptomatic VTE events diagnosed in the first 21 days after surgery. Hip arthroplasty, however, is associated with a higher incidence of asymptomatic proximal thrombi and a modestly higher incidence of symptomatic VTE events, many diagnosed up to 6 or 8 weeks after hospital discharge. Extended medical thromboprophylaxis has been shown to reduce the incidence of symptomatic and asymptomatic VTE among hip arthroplasty patients but not among knee arthroplasty patients. Risk factors for VTE after knee arthroplasty are not well defined. Important risk factors that have been shown to be associated with the development of VTE after hip surgery include (1) a history of prior VTE, (2) obesity (body mass index > 25), (3) delay in ambulation after surgery, and (4) female sex. Factors associated with lower risk include (1) Asian/Pacific Islander ethnicity, (2) use of pneumatic compression among non-obese patients after surgery, and (3) extended thromboprophylaxis after hospital discharge.

Factors affecting resident performance: development of a theoretical model and a focused literature review.

Purpose The clinical performances of physicians have come under scrutiny as greater public attention is paid to the quality of health care. However, determinants of physician performance have not been well elucidated. The authors sought to develop a theoretical model of physician performance, and explored the literature about factors affecting resident performance. Method Using expert consensus panel, in 2002–03 the authors developed a hypothesis-generating model of resident performance. The developed model had three input factors (individual resident factors, health care infrastructure, and medical education infrastructure), intermediate process measures (knowledge, skills, attitudes, habits), and final health outcomes (affecting patient, community and population). The authors used factors from the model to focus a PubMed search (1967–2002) for all original articles related to the factors of individual resident performance. Results The authors found 52 original studies that examined factors of an individual residents performance. They describe each studys measurement instrument, study design, major findings, and limitations. Studies were categorized into five domains: learning styles/personality, social/financial factors, practice preferences, personal health, and response to job environment. Few studies examined intermediate or final performance outcomes. Most were single-institution, cross-sectional, and survey-based studies. Conclusions Attempting to understand resident performance without understanding factors that influence performance is analogous to examining patient adherence to medication regimens without understanding the individual patient and his or her environment. Based on a systematic review of the literature, the authors found few discrete associations between the factors of individual resident and the residents actual job performance. Additionally, they identify and discuss major gaps in the educational literature.

DVT prophylaxis and anticoagulation in the surgical patient

One of the most common postoperative complications is venous thromboembolism, a term encompassing deep vein thrombosis and pulmonary embolism. This article reviews the epidemiology, natural history, difficulties in diagnosis, and strategies for the prevention of postoperative venous thromboembolism. We thoroughly review the currently available methods for thromboprophylaxis including: early ambulation, elastic compression stockings, pneumatic compression devices, inferior vena cava filters, and a variety of pharmacologic agents such as unfractionated heparin, warfarin, aspirin, low molecular weight heparin, and pentasaccharides. Finally, we review the perioperative management of patients on long-term oral anticoagulation.

Does Applicant Personality Influence Multiple Mini-Interview Performance and Medical School Acceptance Offers?

Purpose To examine relationships among applicant personality, Multiple Mini-Interview (MMI) performance, and medical school acceptance offers. Method The authors conducted an observational study of applicants who participated in the MMI at the University of California, Davis, School of Medicine during the 2010–2011 admissions cycle and responded to the Big Five Inventory measuring their personality factors (agreeableness, conscientiousness, extraversion, neuroticism, openness). Individuals’ MMI performance at 10 stations was summarized as a total score. Regression analyses examined associations of personality factors with MMI score, and associations of personality factors and MMI score with acceptance offers. Covariates included sociodemographic and academic performance measures. Results Among the 444 respondents, those with extraversion scores in the top (versus bottom) quartile had significantly higher MMI scores (adjusted parameter estimate = 5.93 higher, 95% CI: 4.27–7.59; P < .01). In a model excluding MMI score, top (versus bottom) quartile agreeableness (AOR = 3.22; 95% CI 1.57–6.58; P < .01) and extraversion (AOR = 3.61; 95% CI 1.91–6.82; P < .01) were associated with acceptance offers. After adding MMI score to the model, high agreeableness (AOR = 4.77; 95% CI 1.95–11.65; P < .01) and MMI score (AOR 1.33; 95% CI 1.26–1.42; P < .01) were associated with acceptance offers. Conclusions Extraversion was associated with MMI performance, whereas both extraversion and agreeableness were associated with acceptance offers. Adoption of the MMI may affect diversity in medical student personalities, with potential implications for students’ professional growth, specialty distribution, and patient care.

Anticoagulation in the elderly.

Oral anticoagulation therapy has demonstrated benefit in the treatment and prevention of a variety of thromboembolic disorders. Most individuals who receive oral anticoagulant therapy are elderly patients with nonvalvular atrial fibrillation and acute or recurrent venous thromboembolism. Anticoagulation in elderly patients poses unique challenges for the practicing clinician because they are simultaneously at higher risk for recurrent thromboembolism and major bleeding, including catastrophic intracranial hemorrhage. The pharmacology of warfarin in the elderly is reviewed, including important drug interactions and current dosing recommendations for elderly patients. Evidence of the benefits and risks of oral anticoagulation therapy are reviewed for patients with atrial fibrillation and venous thromboembolism. This information should enable practitioners to better assess the relative risks and benefit of oral anticoagulation therapy to guide treatment decisions in the elderly.

An academic-community partnership to improve care for the underserved.

Despite the need for a robust primary care workforce, the number of students and residents choosing general internal medicine careers continues to decline. In this article, the authors describe their efforts at the University of California, Davis School of Medicine to bolster interest in internal medicine careers and improve the quality of care for medically underserved populations through a tailored third-year residency track developed in partnership with the Sacramento County Department of Health and Human Services. The Transforming Education and Community Health (TEACH) Program improves continuity of care between inpatient and outpatient settings, creates a new multidisciplinary teaching clinic in the Sacramento County health system, and prepares residents to provide coordinated care for vulnerable populations. Since its inception in 2005, 25 residents have graduated from the TEACH Program. Compared with national rates, TEACH graduates are more likely to practice general internal medicine and to practice in medically underserved settings. TEACH residents report high job satisfaction and provide equal or higher-quality diabetes care than that indicated by national benchmarks. The authors provide an overview of the TEACH Program, including curriculum details, preliminary outcomes, barriers to continued and expanded implementation, and thoughts about the future of the program.

How Medical School Applicant Race, Ethnicity, and Socioeconomic Status Relate to Multiple Mini-Interview-Based Admissions Outcomes: Findings From One Medical School.

Purpose To examine associations of medical school applicant underrepresented minority (URM) status and socioeconomic status (SES) with Multiple Mini-Interview (MMI) invitation and performance and acceptance recommendation. Method The authors conducted a correlational study of applicants submitting secondary applications to the University of California, Davis, School of Medicine, 2011–2013. URM applicants were black, Southeast Asian, Native American, Pacific Islander, and/or Hispanic. SES from eight application variables was modeled (0–1 score, higher score = lower SES). Regression analyses examined associations of URM status and SES with MMI invitation (yes/no), MMI score (mean of 10 station ratings, range 0–3), and admission committee recommendation (accept versus not), adjusting for age, sex, and academic performance. Results Of 7,964 secondary-application applicants, 19.7% were URM and 15.1% self-designated disadvantaged; 1,420 (17.8%) participated in the MMI and were evaluated for acceptance. URM status was not associated with MMI invitation (OR 1.14; 95% CI 0.98 to 1.33), MMI score (0.00-point difference, CI −0.08 to 0.08), or acceptance recommendation (OR 1.08; CI 0.69 to 1.68). Lower SES applicants were more likely to be invited to an MMI (OR 5.95; CI 4.76 to 7.44) and recommended for acceptance (OR 3.28; CI 1.79 to 6.00), but had lower MMI scores (−0.12 points, CI −0.23 to −0.01). Conclusions MMI-based admissions did not disfavor URM applicants. Lower SES applicants had lower MMI scores but were more likely to be invited to an MMI and recommended for acceptance. Multischool collaborations should examine how MMI-based admissions affect URM and lower SES applicants.

Drug reaction with eosinophilia and systemic symptoms syndrome (DRESS) syndrome associated with azithromycin presenting like septic shock: a case report

IntroductionDrug reaction with eosinophilia and systemic symptoms syndrome is a potentially life-threatening cutaneous hypersensitivity reaction characterized by extensive mucocutaneous eruption, fever, hematologic abnormalities including eosinophilia and/or atypical lymphocytosis, and extensive organ involvement. The drugs most often responsible for causing drug reaction with eosinophilia and systemic symptoms syndrome are anticonvulsants, antimicrobial agents and antipyretic or anti-inflammatory analgesics. Although azithromycin is widely prescribed in clinical practice, serious cutaneous reactions from this agent have been rarely described. We report the first adult case of drug reaction with eosinophilia and systemic symptoms syndrome associated with azithromycin.Case presentationA 44-year-old previously healthy Caucasian man with history of tobacco use presented to his primary care physician with fever and productive cough. He was prescribed azithromycin, promethazine hydrochloride and dextromethorphan hydrobromide syrup. One week later, he developed a blistering erythematous rash over both hands, which over the next two weeks spread to involve nearly his entire body surface, sparing only his face. He was admitted to an outside hospital with signs of systemic inflammatory response syndrome and severe sepsis, presumably from a skin infection. Despite aggressive therapy he deteriorated, with worsening diffuse erythema, and was transferred to our institution. He developed multiple organ failure requiring ventilatory and hemodynamic support. Pertinent laboratory studies included a leukocytosis with a white blood cell count of 17.6×109/L and 47% eosinophils. A skin biopsy showed evidence of spongiotic lichenoid dermatitis with eosinophils and neutrophils, compatible with a systemic drug-induced hypersensitivity reaction. Our patient was started on high-dose steroids and showed dramatic improvement within 48 hours.ConclusionsWe report the first adult case of drug reaction with eosinophilia and systemic symptoms syndrome associated with azithromycin exposure. Clinicians should be aware of this potentially devastating complication from this commonly prescribed medication.

Doing What Comes Naturally

In this series, a clinician extemporaneously discusses the diagnostic approach (regular text) to sequentially presented clinical information (bold). Additional commentary on the diagnostic reasoning process (italic) is interspersed throughout the discussion.

Reducing Medical School Admissions Disparities in an Era of Legal Restrictions: Adjusting for Applicant Socioeconomic Disadvantage

A diverse physician workforce is needed to increase access to care for underserved populations, particularly as the Affordable Care Act expands insurance coverage. Yet legal restrictions constrain the extent to which medical schools may use race/ethnicity in admissions decisions. We conducted simulations using academic metrics and socioeconomic data from applicants to a California public medical school from 2011 to 2013. The simulations systematically adjusted medical school applicants’ academic metrics for socioeconomic disadvantage. We found that socioeconomic and under-represented minority disparities in admissions could be eliminated while maintaining academic readiness. Adjusting applicant academic metrics using socioeconomic information on medical school applications may be a race-neutral means of increasing the socioeconomic and racial/ethnic diversity of the physician workforce.