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Hoffmann Sign

The Hoffmann sign or reflex is commonly taught as part of the physical examination to detect abstract upper motor neuron pathology. We present a case of a patient with congenital spinal stenosis and a fall who had a positive Hoffmann sign as the result of a central cord syndrome. The materials contain a video of this physical exam finding and briefly review its history, reliability and clinical utility

Effectiveness of iterative interventions to increase research productivity in one residency program.

BACKGROUND: The Accreditation Council for Graduate Medical Education requires residency programs to expose residents to research opportunities. OBJECTIVE: The purpose of this study was to assess the impact of a series of iterative interventions to increase scholarly activity in one internal medicine residency. METHODS: Retrospective analysis of the effectiveness of a series of interventions to increase resident and faculty scholarly productivity over a 14-year period was performed using quality improvement methodology. Outcomes measured were accepted regional and national abstracts and PubMed indexed manuscripts of residents and faculty. RESULTS: Initially, regional meeting abstracts increased and then were supplanted by national meeting abstracts. Sustained gains in manuscript productivity occurred in the eighth year of interventions, increasing from a baseline of 0.01 publications/FTE/year to 1.57 publications/FTE/year in the final year measured. Run chart analysis indicated special cause variation associated with the interventions performed. CONCLUSIONS: Programs attempting to stimulate research production among faculty and residents can choose among many interventions cited in the literature. Since success of any group of interventions is likely additive and may take years to show benefit, measuring outcomes using quality improvement methodology may be an effective way to determine success

Design of a clinical competency committee to maximize formative feedback.

BACKGROUND: As the next phase in the roll-out of Next Accreditation System, US residency programs are to develop Clinical Competency Committees (CCCs) to formally implement outcome-based medical education objectives in the resident assessment process. However, any changes to an assessment system must consider balancing formative and summative tensions, flexibility and standardization tensions, fairness and transparency to learners, and administrative burden for faculty. OBJECTIVES/METHODS: In this article, one program discusses the approach one internal medicine residency took to create a developmental model CCC. In this model, a learner\u27s mentor presents the argument for competence to the CCC, while a second reviewer presents challenges to that argument to the rest of the committee members. The CCC members provide other insights and make recommendations. The mentor presents the final committee recommendations to that resident, who then works with the mentor to develop a plan for future action. RESULTS: CCC second reviewers spent an average of 30.4 min (SD: 11.4) preparing for each resident\u27s discussion, a duty performed 5-7 times every 6 months. Faculty development was associated with an increase in the number of action-oriented comments in the meeting minutes (3.2-4.1 comments per resident, CONCLUSION: Developmental model CCCs may be feasible for residency programs, but faculty development may be necessary

Rater Perceptions of Bias Using the Multiple Mini-interview Format: a Qualitative Study

Introduction The Multiple Mini-Interview (MMI) format appears to mitigate individual rater biases. However, the format itself may introduce structural systematic bias, favoring extroverted personality types.  This study aimed to gain a better understanding of these biases from the perspective of the interviewer. Methods A sample of MMI interviewers participated in a series of primary and follow-up one-on-one semi-structured interviews.   Interviews pursued subjects of perception of biases (including norming; applicant personality, appearance and behavior; and interviewer personality) associated with the MMI process.  Emergent qualitative data analysis was performed using the constant-comparative method. Results A number of perceived biases were identified by subjects, sub-grouped into cultural factors, personality factors, perception of prior preparation, concerns with norming, and biases associated with specific applicant characteristics. Discussion While the MMI appears to help mitigate individual rater biases, our analysis suggests that raters perceive structural systematic biases may be introduced by the question type and format of the MMI itself.  Whether rater awareness of these biases mitigates them, and whether these herald other unconscious biases is unknown

The Epidemiology of College Alcohol and Gambling Policies

Background: This article reports the first national assessment of patterns of drinking and gambling-related rulemaking on college campuses (e.g., punitive versus recovery oriented). Analyses relating school policies to known school rates of drinking or gambling identified potentially influential policies. These results can inform and encourage the development of guidelines, or "best practices," upon which schools can base future policy. Methods: The college policy information was collected from handbooks, Web sites and supplemental materials of 119 scientifically selected colleges included in the fourth (2001) Harvard School of Public Health College Alcohol Study (CAS). A coding instrument of 40 items measured the scope and focus of school alcohol and gambling policies. This instrument included items to measure the presence of specific policies and establish whether the policies were punitive or rehabilitative. A total of 11 coders followed a process of information extraction, coding and arbitration used successfully in other published studies to codify policy information. Results: Although all schools had a student alcohol use policy, only 26 schools (22%) had a gambling policy. Punitive and restrictive alcohol policies were most prevalent; recovery-oriented policies were present at fewer than 30% of schools. Certain alcohol and gambling policies had significant relationships with student binge drinking rates. Conclusions: The relative lack of college recovery-oriented policies suggests that schools might be overlooking the value of rehabilitative measures in reducing addictive behaviors among students. Since there are few college gambling-related policies, schools might be missing an opportunity to inform students about the dangers of excessive gambling

Interventions to increase research publications in graduate medical education trainees: a systematic review.

Introduction: Competency-based educational models recommend trainee exposure to research, but the best methods for Graduate Medical Education (GME) programs to accomplish this have not been clarified. The objective of this study was to quantify published interventions to generate resident research and compare effectiveness among those interventions. Material and methods: A systematic review of English-language articles of studies of GME programs was performed, describing resident research interventions and quantifying the number of publications as an outcome. Results: The search produced 13,688 potentially relevant articles, and included 47 articles in the final synthesis. Publication effectiveness was calculated as publications per year. The top ten programs for publication effectiveness were compared to others for interventions chosen. Interventions were characterized as research director, protected time, research requirement, research mentor, curricula, research assistant, biostatistician, information technology support, research fund, pay-for-performance plans, and celebration of accomplishments. Total number of different interventions was not significantly associated with primary outcome ( Conclusions: Leadership interventions (directors, curricula) are associated with successful GME research efforts

Sphingolipid changes in Parkinson L444P GBA mutation fibroblasts promote α-synuclein aggregation

Intraneuronal accumulation of aggregated α-synuclein is a pathological hallmark of Parkinson's disease. Therefore, mechanisms capable of promoting α-synuclein deposition bear important pathogenetic implications. Mutations of the glucocerebrosidase 1 (GBA) gene represent a prevalent Parkinson's disease risk factor. They are associated with loss of activity of a key enzyme involved in lipid metabolism, glucocerebrosidase, supporting a mechanistic relationship between abnormal α-synuclein-lipid interactions and the development of Parkinson pathology. In this study, the lipid membrane composition of fibroblasts isolated from control subjects, patients with idiopathic Parkinson's disease and Parkinson's disease patients carrying the L444P GBA mutation (PD-GBA) was assayed using shotgun lipidomics. The lipid profile of PD-GBA fibroblasts differed significantly from that of control and idiopathic Parkinson's disease cells. It was characterized by an overall increase in sphingolipid levels. It also featured a significant increase in the proportion of ceramide, sphingomyelin and hexosylceramide molecules with shorter chain length and a decrease in the percentage of longer-chain sphingolipids. The extent of this shift was correlated to the degree of reduction of fibroblast glucocerebrosidase activity. Lipid extracts from control and PD-GBA fibroblasts were added to recombinant α-synuclein solutions. The kinetics of α-synuclein aggregation were significantly accelerated after addition of PD-GBA extracts as compared to control samples. Amyloid fibrils collected at the end of these incubations contained lipids, indicating α-synuclein-lipid co-assembly. Lipids extracted from α-synuclein fibrils were also analysed by shotgun lipidomics. Data revealed that the lipid content of these fibrils was significantly enriched by shorter-chain sphingolipids. In a final set of experiments, control and PD-GBA fibroblasts were incubated in the presence of the small molecule chaperone ambroxol. This treatment restored glucocerebrosidase activity and sphingolipid levels and composition of PD-GBA cells. It also reversed the pro-aggregation effect that lipid extracts from PD-GBA fibroblasts had on α-synuclein. Taken together, the findings of this study indicate that the L444P GBA mutation and consequent enzymatic loss are associated with a distinctly altered membrane lipid profile that provides a biological fingerprint of this mutation in Parkinson fibroblasts. This altered lipid profile could also be an indicator of increased risk for α-synuclein aggregate pathology

A Systematic Review of the Efficacy and Safety of Fecal Microbiota Transplant for Clostridium Difficile Infection in Immunocompromised Patients

Background: Fecal microbiota transplantation (FMT) has been shown to be effective in recurrent Methods: We searched MEDLINE and EMBASE for English language articles published on FMT for treatment of CD infection in immunocompromised patients (including patients on immunosuppressant medications, patients with human immunodeficiency virus (HIV), inherited or primary immunodeficiency syndromes, cancer undergoing chemotherapy, or organ transplant, including-bone marrow transplant) of all ages. We excluded inflammatory bowel disease patients that were not on immunosuppressant medications. Resolution and adverse event rates (including secondary infection, rehospitalization, and death) were calculated. Results: Forty-four studies were included, none of which were randomized designs. A total of 303 immunocompromised patients were studied. Mean patient age was 57.3 years. Immunosuppressant medication use was the reason for the immunocompromised state in the majority (77.2%), and 19.2% had greater than one immunocompromising condition. Seventy-six percent were given FMT via colonoscopy. Of the 234 patients with reported follow-up outcomes, 207/234 (87%) reported resolution after first treatment, with 93% noting success after multiple treatments. There were 2 reported deaths, 2 colectomies, 5 treatment-related infections, and 10 subsequent hospitalizations. Conclusion: We found evidence that supports the use of FMT for treatment of CD infection in immunocompromised patients, with similar rates of serious adverse events to immunocompetent patients