Ronald C. Silvestri

Spiral CT With Multiplanar and Three-Dimensional Reconstructions Accurately Predicts Tracheobronchial Pathology

BACKGROUND This study was designed to evaluate the clinical accuracy of multiplanar reconstructions and three-dimensional shaded surface displays compared with conventional transaxial computed tomography, bronchoscopy, and surgical pathologic findings. METHODS Transaxial computed tomographic images, two-dimensional nonstandard multiplanar reconstruction images, and three-dimensional images obtained from patients with tracheobronchial disease were prospectively evaluated for the relationship to adjacent structures, lesion characterization, and surgical anatomic correlation before invasive procedures. RESULTS Compared with conventional transaxial computed tomographic images, multiplanar reconstructions and three-dimensional shaded surface displays provided a correlative map of bronchoscopic and surgical anatomy in patients with benign and malignant tracheobronchial pathology. The longitudinal extent of abnormalities are better demonstrated on the multiplanar reconstruction and three-dimensional images, whereas the transverse extent of disease and relationships to adjacent structures were better shown on axial computed tomographic sections. CONCLUSIONS Three-dimensional and multiplanar two-dimensional images are additive to transaxial computed tomography for evaluation of diseases involving the central airways. They are beneficial for planning invasive procedures. More importantly, they provide consistent, highly accurate measurements for routine follow-up and for future clinical trials.

How well do second-year students learn physical diagnosis? Observational study of an objective structured clinical examination (OSCE)

BackgroundLittle is known about using the Objective Structured Clinical Examination (OSCE) in physical diagnosis courses. The purpose of this study was to describe student performance on an OSCE in a physical diagnosis course.MethodsCross-sectional study at Harvard Medical School, 1997–1999, for 489 second-year students.ResultsAverage total OSCE score was 57% (range 39–75%). Among clinical skills, students scored highest on patient interaction (72%), followed by examination technique (65%), abnormality identification (62%), history-taking (60%), patient presentation (60%), physical examination knowledge (47%), and differential diagnosis (40%) (p < .0001). Among 16 OSCE stations, scores ranged from 70% for arthritis to 29% for calf pain (p < .0001). Teaching sites accounted for larger adjusted differences in station scores, up to 28%, than in skill scores (9%) (p < .0001).ConclusionsStudents scored higher on interpersonal and technical skills than on interpretive or integrative skills. Station scores identified specific content that needs improved teaching.

Lung abcess complicating Legionella micdadei pneumonia in an adult liver transplant recipient : Case report and review

Legionella micdadei (Pittsburgh pneumonia agent) is the second most common cause of Legionella pneumonia, and occurs predominantly in immunocompromised hosts. L micdadei is the cause of nosocomial pneumonia in renal transplant recipients, but has not been described in other adult solid organ transplant recipients. This report describes the first case of L micdadei pneumonia in an adult liver transplant recipient on immunosuppressive therapy. Importantly, this case highlights the difficulties in establishing the diagnosis, as the Legionella urinary antigen is negative, and special culture conditions are required. Furthermore, this case illustrates several atypical clinical features of L micdadei pneumonia in a transplant recipient, including a community acquired mode of transmission, occurrence several years after organ transplantation, and lung abcess formation. The patient was successfully treated with limited surgical resection and quinolone antimicrobial monotherapy.

A core physical exam for medical students: results of a national survey.

Purpose Medical students are traditionally taught the physical exam as a comprehensive battery of maneuvers, yet they express uncertainty about which maneuvers are “core” and should be performed routinely on patients and which ones should be performed only when clinically indicated. The authors sought to determine whether educator consensus existed on the concept and the specifics of a core physical exam for students. Method The authors developed a 45-maneuver core physical exam to be performed by a medicine clerkship student on every newly admitted patient, with the expectation that it would be supplemented by clinically indicated additional maneuvers. From 2011 to 2012 they sent surveys to physical diagnosis course directors (PDCDs) and internal medicine clerkship directors (IMCDs) from all 132 U.S. allopathic medical schools to determine the extent of their agreement with the proposed 45 maneuvers and their opinions about the concept of a core exam. Results Seventy-one percent (94/132) of PDCDs and 63% (83/132) of IMCDs responded to the survey. In total, 84% (111/132) of all schools surveyed were represented by either their PDCD or IMCD. Of the 45 proposed maneuvers, 37 were deemed “core” by a majority of respondents. The majority of IMCDs preferred a slightly leaner 37-maneuver core exam than the majority of PDCDs, who voted for 41 maneuvers. Conclusions Among PDCDs and IMCDs, there was openness to teaching medical students a streamlined core physical exam to which other maneuvers are added as clinically indicated. These educators closely agreed on the maneuvers this core exam should include.

Addressing concerns about a "core + clusters" physical exam.

Academic Medicine, Vol. 89, No. 6 / June 2014 834 To the Editor: Gowda and colleagues suggest replacing the traditional head-to-toe (HTT) physical exam (PE) with teaching a core PE plus clusters of maneuvers appropriate for specific complaints (Core + Clusters). In the accompanying commentary, Uchida and colleagues suggest a longitudinal curriculum in which students begin by learning the HTT to gain basic PE skills, followed by learning the Core + Clusters to incorporate the clinical reasoning component of the PE. However, the concern with the HTT is that students are introduced to the PE through decontexualized rote learning and practice—a habit that may be hard to break.

In reply to Yudkowsky.

Academic Medicine, Vol. 89, No. 6 / June 2014 835 While We Advocate for Integrated Electronic Medical Records, Continue to Empower Patients and Families To the Editor: Medical students everywhere sympathize with, and likely can unanimously relate to, Mr. Ehrmann’s account of his recent futile attempts to obtain a transfer patient’s medical records that were critical to ongoing treatment. Disjointed systems and unavailable archives regularly drive frustration and delay patient care. With each failed attempt to obtain records, the cycle of redundant diagnostic medicine repeats, as it is currently the only way to serve our patients in real time. I into an HTT exam. However, it is our impression that if the Core + Clusters curriculum is learned, there would be no need for students to perform the HTT in clinical settings. The Core + Clusters curriculum is designed to allow students to identify and perform maneuvers relevant to their particular patient, without the rote learning that the HTT perpetuates. We agree with Dr. Yudkowsky that determining which of these approaches to learning the PE is most effective is testable, and we look forward to further contributions to this area of research.