Stephen D. Sisson

Oral antibiotic treatment of right-sided staphylococcal endocarditis in injection drug users: Prospective randomized comparison with parenteral therapy

PURPOSE To compare the efficacy and safety of inpatient oral antibiotic treatment (oral) versus standard parenteral antibiotic treatment (intravenous) for right-sided staphylococcal endocarditis in injection drug users. PATIENTS AND METHODS In a prospective, randomized, non-blinded trial, febrile injection drug users were assigned to begin oral or intravenous (IV) treatment on admission, before blood culture results were available. Oral therapy consisted of ciprofloxacin and rifampin. Parenteral therapy was oxacillin or vancomycin, plus gentamicin for the first 5 days. Antibiotic dosing was adjusted for renal dysfunction. Administration of other antibacterial drugs was not permitted during the treatment or follow-up periods. Bacteremic subjects having right-sided staphylococcal endocarditis received 28 days of inpatient therapy with the assigned antibiotics. Test-of-cure blood cultures were obtained during inpatient observation 6 and 7 days after the completion of antibiotic therapy, and again at outpatient follow-up 1 month later. Criteria for treatment failure and for drug toxicity were prospectively defined. RESULTS Of 573 injection drug users who were hospitalized because of a febrile illness and suspected right-sided staphylococcal endocarditis, 93 subjects (16.2%) had two or more sets of blood cultures positive for staphylococci; 85 of these bacteremic subjects (14.8%) satisfied diagnostic criteria for at least possible right-sided staphylococcal endocarditis (no other source of bacteremia was apparent) and entered the trial. Forty-four (oral, 19; IV, 25) of these 85 subjects completed inpatient treatment and evaluation including test-of-cure blood cultures. There were four treatment failures (oral, 1 [5.2%]; IV, 3 [12.0%]; not significant, Fishers exact test). Drug toxicity was significantly more common in the parenterally treated group (oral, 3%; IV, 62%; P < 0.0001), consisting largely of oxacillin-associated increases in liver enzymes. CONCLUSIONS For selected patients with right-sided staphylococcal endocarditis, oral ciprofloxacin plus rifampin is effective and is associated with less drug toxicity than is intravenous therapy.

Residents' perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements.

BACKGROUND: The Accreditation Council for Graduate Medical Education duty hour requirements may affect residents’ understanding and practice of professionalism.OBJECTIVE: We explored residents’ perceptions about the current teaching and practice of professionalism in residency and the impact of duty hour requirements.DESIGN: Anonymous cross-sectional survey.PARTICIPANTS: Internal medicine, neurology, and family practice residents at 3 teaching hospitals (n=312).MEASUREMENTS: Using Likert scales and open-ended questions, the questionnaire explored the following: residents’ attitudes about the principles of professionalism, the current and their preferred methods for teaching professionalism, barriers or promoters of professionalism, and how implementation of duty hours has affected professionalism.RESULTS: One hundred and sixty-nine residents (54%) responded. Residents rated most principles of professionalism as highly important to daily practice (91.4%, 95% confidence interval [CI] 90.0 to 92.7) and training (84.7%, 95% CI 83.0 to 86.4), but fewer rated them as highly easy to incorporate into daily practice (62.1%, 95% CI 59.9 to 64.3), particularly conflicts of interest (35.3%, 95% CI 28.0 to 42.7) and self-awareness (32.0%, 95% CI 24.9 to 39.1). Role-modeling was the teaching method most residents preferred. Barriers to practicing profession-alism included time constraints, workload, and difficulties interacting with challenging patients. Promoters included role-modeling by faculty and colleagues and a culture of professionalism. Regarding duty hour limits, residents perceived less time to communicate with patients, continuity of care, and accountability toward their colleagues, but felt that limits improved professionalism by promoting resident well-being and teamwork.CONCLUSIONS: Residents perceive challenges to incorporating professionalism into their daily practice. The duty hour implementation offers new challenges and opportunities for negotiating the principles of professionalism.

Effect of an Internet-based Curriculum on Postgraduate Education: A Multicenter Intervention

We hypothesized that the Internet could be used to disseminate and evaluate a curriculum in ambulatory care, and that internal medicine residency program directors would value features made possible by online dissemination. An Internet-based ambulatory care curriculum was developed and marketed to internal medicine residency program directors. Utilization and knowledge outcomes were tracked by the website; opinions of program directors were measured by paper surveys. Twenty-four programs enrolled with the online curriculum. The curriculum was rated favorably by all programs, test scores on curricular content improved significantly, and program directors rated highly features made possible by an Internet-based curriculum.

Mentorship and pursuit of academic medicine careers: a mixed methods study of residents from diverse backgrounds

BackgroundMentorship influences career planning, academic productivity, professional satisfaction, and most notably, the pursuit of academic medicine careers. Little is known about the role of mentoring in recruiting Black/African American and Hispanic/Latino residents into academia. The objective of this study was to assess the influence of mentoring on academic medicine career choice among a cohort of racially and ethnically diverse residents.MethodsA strategic convenience sample of U.S. residents attending national professional conferences between March and July 2010; residents completed a quantitative survey and a subset participated in focus groups.ResultsOf the 250 residents, 183 (73%) completed surveys and 48 participated in focus groups. Thirty-eight percent of residents were white, 31% Black/African American, 17% Asian/other, and 14% Hispanic/Latino. Most respondents (93%) reported that mentorship was important for entering academia, and 70% reported having sufficient mentorship to pursue academic careers. Three themes about mentorship emerged from focus groups: (1) qualities of successful mentorship models; (2) perceived benefits of mentorship; and (3) the value of racial/ethnic and gender concordance. Residents preferred mentors they selected rather than ones assigned to them, and expressed concern about faculty using checklists. Black/African American, Hispanic/Latino, and female residents described actively seeking out mentors of the same race/ethnicity and gender, but expressed difficulty finding such mentors. Lack of racial/ethnic concordance was perceived as an obstacle for minority mentees, requiring explanation of the context and nuances of their perspectives and situations to non-minority mentors.ConclusionsThe majority of residents in this study reported having access to mentors. However, data show that the lack of diverse faculty mentors may impede diverse residents’ satisfaction and benefit from mentorship relationships compared to white residents. These findings are important for residency programs striving to enhance resident mentorship and for institutions working to diversify their faculty and staff to achieve institutional excellence.

A ten-month program in curriculum development for medical educators: 16 years of experience.

BACKGROUNDDespite increased demand for new curricula in medical education, most academic medical centers have few faculty with training in curriculum development.OBJECTIVETo describe and evaluate a longitudinal mentored faculty development program in curriculum development.DESIGNA 10-month curriculum development program operating one half-day per week of each academic year from 1987 through 2003. The program was designed to provide participants with the knowledge, attitudes, skills, and experience to design, implement, evaluate, and disseminate curricula in medical education using a 6-step model.PARTICIPANTSOne-hundred thirty-eight faculty and fellows from Johns Hopkins and other institutions and 63 matched nonparticipants.MEASUREMENTSPre- and post-surveys from participants and nonparticipants assessed skills in curriculum development, implementation, and evaluation, as well as enjoyment in curriculum development and evaluation. Participants rated program quality, educational methods, and facilitation in a post-program survey.RESULTSSixty-four curricula were produced addressing gaps in undergraduate, graduate, or postgraduate medical education. At least 54 curricula (84%) were implemented. Participant self-reported skills in curricular development, implementation, and evaluation improved from baseline (p < .0001), whereas no improvement occurred in the comparison group. In multivariable analyses, participants rated their skills and enjoyment at the end of the program significantly higher than nonparticipants (all p < .05). Eighty percent of participants felt that they would use the 6-step model again, and 80% would recommend the program highly to others.CONCLUSIONSThis model for training in curriculum development has long-term sustainability and is associated with participant satisfaction, improvement in self-rated skills, and implementation of curricula on important topics.

Disseminated cryptococcosis with meningitis, peritonitis, and cryptococcemia in a HIV-negative patient with cirrhosis: a case report

IntroductionCryptococcus neoformans is an encapsulated yeast that causes serious infections in immunocompromised populations. The majority of cases occur in HIV-infected individuals. Disseminated disease is uncommon, and very rarely includes peritonitis.Case presentationWe report a case of a 41-year-old, HIV-negative, Caucasian man with alcoholic liver cirrhosis who presented with fever and seizure. Disseminated cryptococcosis with meningitis, peritonitis, and cryptococcemia was diagnosed, and despite adequate treatment the patient developed multi-system organ failure and eventually expired.ConclusionDisseminated cryptococcosis, particularly with peritonitis, is an uncommon manifestation of Cryptococcus neoformans infection. Liver cirrhosis serves as a risk factor for disseminated disease in HIV-negative patients. A high clinical suspicion and early initiation of therapy is needed to recognize and treat patients effectively.

Physician Familiarity With Diagnosis and Management of Hypertension According to JNC 7 Guidelines

Physician knowledge of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines is unknown and may contribute to the prevalence of uncontrolled hypertension. Our objective was to determine physician knowledge of JNC 7 guidelines and whether online instruction could improve knowledge. A pretest served as baseline knowledge, and comparison with a post‐test after completing an online didactic demonstrated improvement in knowledge. Participants included 1280 physicians at 45 internal medicine residency training programs. Average baseline knowledge of six concepts of hypertension was 51.2%. Attending physicians performed better than trainees on some but not all concepts (p<0.05). Third‐year post‐graduate trainees performed better than first‐year trainees on some but not all concepts (p<0.05). Knowledge increased significantly on all concepts after completing the curriculum (p<0.05). The authors demonstrated that physician knowledge of JNC 7 guidelines is poor but can be improved by an online curriculum. Further study is needed to determine the impact of physician education on clinical outcomes in individuals with hypertension.

Medical Residents' Knowledge of Dietary Supplements

Introduction: The widespread use of complementary and alternative medicine modalities such as dietary supplements has prompted many medical schools to offer courses covering such topics. To date, little is known about the impact of these courses on medical graduates’ knowledge. This study was designed to evaluate resident physicians’ level of understanding of popular dietary supplement regulation and to determine whether an interactive online curriculum could aid in improving such knowledge. Methods: A multicenter online educational intervention was developed and administered to physicians at 15 internal medicine residency programs throughout the United States, between March 1, 2006 and June 30, 2006. Pretest performance was used to measure baseline knowledge of commonly used dietary supplements. Posttest performance compared with pretest performance measured the effectiveness of the educational intervention. Results: A total of 335 physicians completed the module. Baseline knowledge of dietary supplements was low (average pretest score 59.7%). More than one-third of respondents were unaware of the reasons for use of saw palmetto and black cohosh. Results for questions on safety and drug-supplement interactions were similarly low. Only 57% of physicians knew that kava kava has been associated with hepatitis. Only 15% were aware that St. John’s Wort can lower cyclosporine levels. With regards to knowledge of efficacy, only 36% were aware that fish oil has been shown to lower triglyceride levels. After completion of the curriculum, scores improved significantly (P < 0.001) in all question/content areas. Conclusions: Residents’ knowledge of dietary supplements is poor. An online didactic module may improve knowledge and potentially enhance patient-physician communication regarding the use of such products.

Long‐term follow‐up of a 10‐month programme in curriculum development for medical educators: a cohort study

Context  There is an ongoing need for curriculum development (CD) in medical education. However, only a minority of medical teaching institutions provide faculty development in CD. This study evaluates the long‐term impact of a longitudinal programme in curriculum development.

Caring for patients with limited English proficiency: are residents prepared to use medical interpreters?

Purpose To evaluate whether educational sessions on interpreter use and experience with interpreters are associated with resident self-efficacy in the use of professional interpreters. Method In 2010, the authors surveyed residents from seven pediatric residency programs. Their 29-item survey collected data on training and experience with interpreters and self-efficacy in (1) determining when an interpreter is needed and (2) using a professional interpreter. The authors conducted bivariate and multivariate regression analyses. Results Among the 271 respondents, 82% reported that ≥ 10% of their patients had limited English proficiency (LEP), 53% indicated they had “a lot” of experience with interpreters, and 54% reported never receiving any educational sessions on interpreter use. The majority reported high self-efficacy in knowing when an interpreter is needed (69%) and in using an interpreter (68%). Residents reporting a high experience level with interpreters were more likely to report high self-efficacy in knowing when an interpreter is needed (odds ratio [OR] = 1.85; 95% confidence interval[CI] = 1.03–3.32) and in using an interpreter (OR = 3.97; 95% CI = 1.19–13.31). Formal training on using interpreters was also associated with high self-efficacy in interpreter use(OR = 1.62; 95% CI = 1.22–2.14). Conclusions Many residents who care for patients with LEP have never received educational sessions on interpreter use. Such training is associated with high self-efficacy and may enhance patient–provider communication. Incorporating this training into residency programs is necessary to equip providers with skills to communicate with patients and families with LEP.