Pamela M. Williams

Henoch-Schönlein purpura.

Henoch-Schönlein purpura is an acute, systemic, immune complex-mediated, leukocytoclastic vasculitis. It is characterized by a triad of palpable purpura (without thrombocytopenia), abdominal pain, and arthritis. Most patients have an antecedent upper respiratory illness. More than 90 percent of Henoch-Schönlein purpura cases occur in children younger than 10 years; however, adults with this condition are more likely to experience complications than children. All patients with Henoch-Schönlein purpura develop a purpuric rash, 75 percent develop arthritis, 60 to 65 percent develop abdominal pain, and 40 to 50 percent develop renal disease. Because Henoch-Schönlein purpura spontaneously resolves in 94 percent of children and 89 percent of adults, supportive treatment is the primary intervention. Oral prednisone at 1 to 2 mg per kg daily for two weeks has been used to treat abdominal and joint symptoms. A meta-analysis found that corticosteroid use in children reduced the mean time to resolution of abdominal pain and decreased the odds of developing persistent renal disease. Early aggressive therapy with high-dose steroids plus immunosuppressants is recommended for patients with severe renal involvement. Long-term prognosis depends on the severity of renal involvement. End-stage renal disease occurs in 1 to 5 percent of patients.

Who will be the faculty of the future? Results of a 5-year study growing educators using an immersive third postgraduate year (PGY-3) faculty development mini-fellowship

Background: Residency education requires large numbers of skilled teaching faculty. Potential faculty can often be identified during residency training. Aims: Employ a 4-week immersive faculty development mini-fellowship to enhance the teaching skills of selected PGY-3 residents and study outcomes over 5 years. Methods: PGY-3 residents were competitively selected and completed the 4-week curriculum to increase skills in precepting, small group teaching, large group teaching, learner feedback/assessment, academic career development, and research. Results: Fifteen residents completed the mini-fellowship over the 5-year study period. The curriculum was rated highly by the residents with mean ratings of curriculum components ranging from 4.5 to 4.9 on a 5-point scale. Eight residents (53%) were selected for faculty positions compared to a usual selection rate of 11%. Compared to new faculty without mini-fellowship completion, program directors rated the residents completing the mini-fellowship as better prepared to perform learner feedback (4.1 vs. 3.0, p ≤ 0.01) and to understand the conduct of research (3.6 vs. 2.5 p ≤ 0.01). Conclusions: This study demonstrates short-term success at growing faculty with enhanced teaching skills during residency. While long-term retention in academic medicine cannot be predicted, this program represents one method to mitigate shortages of qualified junior residency faculty.

Institutional support for handheld computing: clinical and educational lessons learned.

Handheld computing devices, or personal digital assistants (PDAs), are used often in the health care setting. They provide a convenient way to store and carry either personal or reference information and can be used to accomplish other tasks associated with patient care. This article reports clinical and educational lessons learned from a longitudinal institutional initiative designed to provide medical students with PDAs to facilitate patient care and assist with clinical learning.

Prevention of Cardiovascular Disease

Cardiovascular disease remains the leading cause of death in the United States and worldwide. Prevention of cardiovascular disease is an achievable goal. A rigorous 2010 analysis by the World Health Organization suggests that reducing risk factors in young adults and maintaining an optimum risk profile through age 50 could prevent 90% of atherosclerotic cardiovascular disease events. Misinformation and poor implementation of proven preventive strategies, misplaced fears of medications, or incorrect understanding of ideal dietary and lifestyle choices all contribute to poor risk profiles. Every patient deserves an individualized prescription for cardiovascular disease prevention incorporating strategies to control modifiable cardiovascular risk factors.

The Train Wreck: Assessment and Management of a Complex Medical Patient

The difficult patient, like the illustrative train wreck about to be described, is a complex dilemma not infrequently confronted by physicians in the clinical setting. These patients come in many versions but typically involve complicated medical histories, extensive medication lists, and repeated medical visits without any apparent medical benefit. The patients do not always seem to want to get well and physicians are frequently unsure what to do to make them better, leading to ineffective care. Recurrent, vague complaints such as insomnia, back pain, dizziness, fatigue, or abdominal pain are superimposed on known medical conditions that are typically suboptimally treated. The pursuit of diagnoses to explain somatic complaints can distract from the care of other chronic conditions, adding frustration to the encounter. Clinical time constraints, productivity demands, and a desire to cure further result in conflicting expectations between the patient and the physician. In spite of a commitment to care, the physician working with a difficult patient may feel guilty when his or her efforts to treat a patient appear to be failing. Unsure of where to start or what to treat, the individual physician begins to experience a sense of helplessness, not so dissimilar from distress experienced by the patients themselves. A clinical health psychologist is a strong ally of the physician in caring for these challenging patients. Since unrecognized psychiatric problems often lead to high health care system utilization and vague medical complaints, health psychologists have added expertise in identifying these issues. Less confined by the time constraints of a 15-min encounter and separated from the pressures of treating concomitant health conditions, health psychologists may accomplish a more comprehensive assessment. Further, training in patient advocacy and collaboration make them a natural partner in ongoing treatment. With the layers of complexity identified, effective care may begin.