Improvement In Composite Score Research Articles

Educating Our Future Medical Leaders: An Innovative Longitudinal Course Across Surgical and Medical Specialties in Graduate Education.

Increasing healthcare system complexity, multidisciplinary care delivery, and the need to deliver high-quality, cost-effective care drive a critical need for leadership development. Currently, few examples of multidisciplinary leadership development exist in the medical education literature. The Accreditation Council for Graduate Medical Education (ACGME) has identified leadership domains as essential milestones in residency education, encompassing areas such as interpersonal communication, quality improvement, and systems-based practice. Presently, published GME leadership curricula vary widely in content, delivery, and duration and rarely include multispecialty cohorts. The study authors designed and implemented a longitudinal leadership curriculum for a multispecialty cohort of senior residents and fellows from multiple hospitals within a large integrated GME program. Between July 2022-June 2023, authors delivered 12 monthly sessions on core leadership concepts. Sessions delivered relevant work-based content via large-group didactics with embedded opportunities for small-group interactive experiential and reflective practice, critical thinking, and application. Thirty GME trainees participated in the longitudinal curriculum. Interval pre-/post-session assessments demonstrated significant improvement in composite scores for 6 of 9 sessions assessed. Participants rated each module's overall importance, applicability, and acceptability highly on a summative program evaluation. This longitudinal leadership curriculum adheres to best leadership development practices, demonstrates improvement in knowledge and self-reported attitudes and behaviors related to cognitive, character, and emotional leadership domains, and develops a psychologically safe community of practice for GME participants.

Simulation-based low-dose, high-frequency plus mobile mentoring versus traditional group-based trainings among health workers on day of birth care in Nigeria; a cluster randomized controlled trial

BackgroundThe aim of this study was to compare health workers knowledge and skills competencies between those trained using the onsite simulation-based, low-dose, high frequency training plus mobile mentoring (LDHF/m-mentoring) and the ones trained through traditional offsite, group-based training (TRAD) approach in Kogi and Ebonyi states, Nigeria, over a 12-month period.MethodsA prospective cluster randomized controlled trial was conducted by enrolling 299 health workers who provided healthcare to mothers and their babies on the day of birth in 60 health facilities in Kogi and Ebonyi states. These were randomized to either LDHF/m-mentoring (intervention, n = 30 facilities) or traditional group-based training (control, n = 30 facilities) control arm. They received Basic Emergency Obstetrics and Newborn Care (BEmONC) training with simulated practice using anatomic models and role-plays. The control arm was trained offsite while the intervention arm was trained onsite where they worked. Mentorship was done through telephone calls and reminder text messages. The multiple choice questions (MCQs) and objective structured clinical examinations (OSCEs) mean scores were compared; p-value < 0.05 was considered statistically significant. Qualitative data were also collected and content analysis was conducted.ResultsThe mean knowledge scores between the two arms at months 3 and 12 post-training were equally high; no statistically significant differences. Both arms showed improvements in composite scores for assessed BEmONC clinical skills from around 30% at baseline to 75% and above at end line (p < 0.05). Overall, the observed improvement and retention of skills was higher in intervention arm compared to the control arm at 12 months post-training, (p < 0.05). Some LDHF/m-mentoring approach trainees reported that mentors’ support improved their acquisition and maintenance of knowledge and skills, which may have led to reductions in maternal and newborn deaths in their facilities.ConclusionThe LDHF/m-mentoring intervention is more effective than TRAD approach in improving health workers’ skills acquisition and retention. Health care managers should have the option to select the LDHF/m-mentoring learning approach, depending on their country’s priorities or context, as it ensures health workers remain in their place of work during training events thus less disruption to service delivery.Trial registrationThe trial was retrospectively registered on August 24, 2017 at ClinicalTrials.Gov: NCT03269240.

1268-P: Associations between ß-Cell Function and Cognitive Measures following Treatment in Youth with Impaired Glucose Tolerance (IGT) or Recently Diagnosed Type 2 Diabetes (T2D)

In cross-sectional studies, adolescents with T2D show poorer cognition than normoglycemic youth. In the Restoring Insulin Secretion (RISE) Study, we assessed longitudinal relationships between insulin sensitivity, β-cell function and cognition in 72 youth (mean age 14.3±2.0, 10-18 y) with IGT or recently diagnosed T2D, randomized to 12 months of metformin (MET) or 3 months of glargine followed by 9 months of metformin (G/M). Hyperglycemic clamps were used to measure insulin sensitivity and β-cell responses: acute (0-10 min) C-peptide response to glucose, steady-state C-peptide (SSCP) at glucose of 11.1 mmol/L, and arginine-stimulated maximum C-peptide response (ACPRmax) at glucose &amp;gt;25 mmol/L. A cognitive battery (CogStateTM and story recall) assessed 1) reaction time; 2) visual discrimination; 3) attention and working memory; and 4) learning and episodic memory. A composite measure of cognition was constructed by scaling the sum of the four domain scores. Linear regression models were fit to assess relationships between cognition, treatment and β-cell function. Treatment group models were adjusted for baseline cognitive function, HbA1c and fasting glucose. β-cell models were adjusted for baseline cognitive and β-cell function. Cognitive composite scores improved over the 12-month treatment period (p&amp;lt;0.001), with no differences between treatment arms. Greater baseline ACPRmax predicted greater improvement in composite scores over 12 months in the G/M (p&amp;lt;0.05), but not MET group (p=0.61). Change in SSCP over the 12-month treatment was positively associated with increased composite scores in the G/M (p&amp;lt;0.05) but not MET group (p=0.35). Thus, improved cognition over the 12-month treatment with G/M in adolescents with IGT or early T2D may be related to practice effects with repeated testing, to changes in β-cell function or to other impacts of insulin treatment. Disclosure S. Craft: Advisory Panel; Self; vTv Therapeutics. M. Tripputi: None. S. Edelstein: None. M. Espeland: Other Relationship; Self; Boehringer Ingelheim International GmbH, Ironwood Pharmaceuticals. A. Claxton: Employee; Self; Alkermes plc. S.A. Arslanian: Research Support; Self; National Institutes of Health. Other Relationship; Self; AstraZeneca, Eli Lilly and Company, Novo Nordisk Inc. E. Barengolts: None. T.S. Hannon: None. S.E. Kahn: Advisory Panel; Self; Boehringer Ingelheim International GmbH, Eli Lilly and Company, Intarcia Therapeutics, Janssen Scientific Affairs, LLC., Merck &amp; Co., Inc., Novo Nordisk A/S, Pfizer Inc. K.J. Mather: Research Support; Self; Abbott, Merck &amp; Co., Inc., Novo Nordisk Inc., Sanofi. B. Mokhlesi: None. K.J. Nadeau: None. A. Sanderlin: None. K.A. Temple: None. P. Zeitler: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Daiichi Sankyo, Eli Lilly and Company, Merck &amp; Co., Inc. T. Consortium: None. Funding American Diabetes Association (1-14-RISE-01 to S.E.K.); National Institute of Diabetes and Digestive and Kidney Diseases

A randomized single-blinded trial of early rehabilitation versus immobilization after reverse total shoulder arthroplasty

Reverse total shoulder arthroplasty (RTSA) does not have a standard postoperative protocol. Although instability is a worrisome complication, prolonged immobilization may also be disabling in the elderly population. This study aimed to determine if early vs. delayed range of motion (ROM) after RTSA affected postoperative ROM, patient-reported outcomes, and the dislocation rate. A single-blinded, randomized controlled trial was performed enrolling patients from 2013 to 2017. Patients were randomly assigned to either a delayed-rehabilitation group (no ROM for 6 weeks) or early-rehabilitation group (immediate physical therapy for passive and active ROM) and followed up for a minimum of 1 year. Demographic characteristics, ROM, American Shoulder and Elbow Surgeons (ASES) scores, and complications were recorded. Of an initial enrollment of 107 shoulders, 80.3% completed 1-year follow-up: 44 shoulders in the delayed-therapy group and 42 shoulders in the immediate-therapy group. Both groups had significantly improved forward flexion (32° improvement) and abduction (22° improvement) by 3 months. Both groups showed significant improvements in ASES scores by 6 weeks (9.4-point improvement in composite score) with continued improvement through 6 months (35.1 points). No significant differences were found between groups for any postoperative measure, with the exception of the ASES functional score favoring the delayed-therapy group at 6 months (26.3-point improvement vs. 16.7-point improvement). No differences in complications, notching, or narcotic use were noted between groups. Both early- and delayed-ROM protocols after RTSA demonstrated significant, similar improvements in ROM and outcomes. Early initiation of postoperative rehabilitation may benefit the elderly population by avoiding the limitations of prolonged immobilization postoperatively.

P20 Parental understanding of concussion in youth rugby is significantly improved by viewing the RFU concussion education video

ObjectivesTo investigate the current understanding parents have of concussion in their rugby-playing children aged 9–17.DesignCross-sectional studySubjects86 parents from four clubs completed an online questionnaireMethodsAreas covered (1) Parental experience of concussion (2) Rate of viewing of the RFU concussion educational video (RFUCEV), (3) Identification of symptoms of concussion (4) Understanding of the risk of concussion. Each participant was given a composite score, out of 19, based on their performance in symptom identification and true/false questions. Independent-sample two-tailed t-tests were conducted to analyse scores, primarily controlling for viewing of the RFUCEVResultsThere was a significant difference in the scores between the group that had viewed the RFUCEV (n=32, M=14.75, SD=2.55) and those who had not (n=54, M=13.05, SD=2.87); t(84)=2.75, p=0.00721. Additionally, over 25% of parents reported that their child had suffered a concussion, and this was also found to significantly improve the awareness score (p=0.04678)ConclusionsStatistically significant improvement in composite scores after viewing the RFUCEV makes it reasonable to require compulsory parental education prior to signing up a child to play rugby. This would build on the protocol changes made by the RFU in 2014 and further progress the safety of the sport. We suggest the video be improved to emphasise the areas highlighted as inadequately understood, including the increased risk of concussion in under-18s compared to adults.

Restorative occupational therapy for adolescents with chronic kidney disease

Occupational therapy is demonstrated to improve quality of life and enable rehabilitation of patients with various chronic diseases. However, their role in managing children with chronic kidney disease (CKD) remains unclear. Twelve adolescents with CKD managed at a single center in Hong Kong participated in a 4-weeks occupational lifestyle redesign program (OLSRP) comprising 8 sessions of self-initiated individualized activity plans, led by two occupational therapists. Two surveys, the self-management inventory and Chinese version of General Self-efficacy Scale, administered at initiation and end of OLSRP, were used to examine its impact on competence, confidence and self-efficacy scores. Following OLSRP, 91.7% and 75% of 12 adolescents showed significant improvements in composite scores of both scales, with significant increments in self-management concerning disease, social and collaborative skills, diet, proper schedule, medication intake and acceptance of their disease, and problem solving and confidence.

Efficacy of a Virtual Arthroscopic Simulator for Orthopaedic Surgery Residents by Year in Training.

Background:Virtual reality arthroscopic simulators are an attractive option for resident training and are increasingly used across training programs. However, no study has analyzed the utility of simulators for trainees based on their level of training/postgraduate year (PGY).Purpose/Hypothesis:The primary aim of this study was to determine the utility of the ArthroS arthroscopic simulator for orthopaedic trainees based on their level of training. We hypothesized that residents at all levels would show similar improvements in performance after completion of the training modules.Study Design:Descriptive laboratory study.Methods:Eighteen orthopaedic surgery residents performed diagnostic knee and shoulder tasks on the ArthroS simulator. Participants completed a series of training modules and then repeated the diagnostic tasks. Correlation coefficients (r2) were calculated for improvements in the mean composite score (based on the Imperial Global Arthroscopy Rating Scale [IGARS]) as a function of PGY.Results:The mean improvement in the composite score for participants as a whole was 11.2 ± 10.0 points (P = .0003) for the knee simulator and 14.9 ± 10.9 points (P = .0352) for the shoulder simulator. When broken down by PGY, all groups showed improvement, with greater improvements seen for junior-level residents in the knee simulator and greater improvements seen for senior-level residents in the shoulder simulator. Analysis of variance for the score improvement variable among the different PGY groups yielded an f value of 1.640 (P = .2258) for the knee simulator data and an f value of 0.2292 (P = .917) for the shoulder simulator data. The correlation coefficient (r2) was –0.866 for the knee score improvement and 0.887 for the shoulder score improvement.Conclusion:Residents training on a virtual arthroscopic simulator made significant improvements in both knee and shoulder arthroscopic surgery skills.Clinical Relevance:The current study adds to mounting evidence supporting virtual arthroscopic simulator–based training for orthopaedic residents. Most significantly, this study also provides a baseline for evidence-based targeted use of arthroscopic simulators based on resident training level.

Efficacy of an Arthroscopic Virtual Based Simulator for Orthopedic Surgery Residents by Year in Training

Objectives:Arthroscopic virtual-reality stimulators are an attractive option for resident training and are increasing across training programs. However, no study has analyzed the utility of the simulator for trainees based on their post-graduate level of training (PGY-level). The primary aim of this study was to determine the utility of the ArthroSTM arthroscopic simulator for orthopedic trainees based on their level of training (to determine at what point in training the simulator offers the most benefit for trainees). We hypothesized that all levels would show similar improvements in performance following completion of the training modules.Methods:Eighteen orthopedic surgery residents performed pre-training diagnostic knee and shoulder tasks on the ArthoSTM simulator. Subjects completed a series of training modules, then repeated the diagnostic tasks. Mean composite scores were calculated. Group differences for discrete variables were evaluated using ANOVA (analysis of variance). Correlation coefficients (R2) were calculated for improvements in mean composite score as a function of subject year-in-training.Results:Average improvement in composite score for participants as a whole was 11.2 points [SD 10; p-value 0.0003] for the knee simulator and 14.9 points [SD 10.9; p-value 0.0352] for the shoulder simulator. When broken down by PGY-level, all groups showed improvement, with greater improvements seen for junior-level residents in the knee simulator and greater improvements seen for senior-level residents in the shoulder simulator. ANOVA for the score improvement variable in the knee simulator data amongst the different PGY-groups yielded an f-value of 1.640 (p-value 0.2258) and that for the shoulder simulator data amongst the different PGY-groups yielded an f-value of 0.2292 (p-value 0.917). The correlation coefficient (r2) was -0.866 for the knee score improvement and 0.887 for the shoulder score improvement (Image 1).Conclusion:We found that residents training on a virtual arthroscopic simulator made significant improvements in both knee and shoulder arthroscopic skills. Most importantly, we report for the first time that the knee simulator appears to be more beneficial for junior residents, while the shoulder simulator appears to be more beneficial for senior residents. Our study adds to the mounting evidence supporting virtual arthroscopic simulator-based training for orthopedic surgery residents.

Fundamentals of Arthroscopic Surgery Training Program Improves Knee Arthroscopy Simulator Performance in Arthroscopic Trainees

To determine the effectiveness of a nonanatomic simulator in developing basic arthroscopy motor skills transferable to an anatomic model. Forty-three arthroscopy novice individuals currently enrolled in medical school were recruited to perform a diagnostic knee arthroscopy using a high-fidelity virtual reality arthroscopic simulator providing haptic feedback after viewing a video of an expert performing an identical procedure. Students were then randomized into an experimental or control group. The experimental group then completed a series of self-guided training modules using the fundamentals of arthroscopy simulator training nonanatomic modules including camera centering, tracking, periscoping, palpation, and collecting stars in a three-dimensional space. Both groups completed another diagnostic knee arthroscopy between 1 and 2weeks later. Camera path length, time, tibia and femur cartilage damage, as well as a composite score were recorded by the simulator on each attempt. The experimental group (n= 22) showed superior performance in composite score (30.09 vs 24, P= .046) and camera path length (71.51cm vs 109.07cm, P= .0274) at the time of the second diagnostic knee arthroscope compared with the control group (n= 21). The experimental group also showed significantly greater improvement in composite score between the first and second arthroscopes compared with the control group (14.27 vs 4.95, P < .01). Femoral and tibial cartilage damage were not significantly improved between arthroscopy attempts (-0.86% vs-1.45%, P= .40) and (-1.10 vs-1.27%, P= .83), respectively. The virtual reality-based fundamentals of arthroscopy simulator training nonanatomic simulator is beneficial in developing basic motor skills in arthroscopy novice individuals resulting in significantly greater composite performance in an anatomic knee model. Based on the results of this study, it appears that there may be benefit from nonanatomic simulators in general as part of an arthroscopy training program. Level II, randomized trial.

High velocity circuit resistance training improves cognition, psychiatric symptoms and neuromuscular performance in overweight outpatients with severe mental illness

We developed a physical exercise intervention aimed at improving multiple determinants of physical performance in severe mental illness. A sample of 12 (9M, 3F) overweight or obese community-dwelling patients with schizophrenia (n=9) and bipolar disorder (n=3) completed an eight-week, high-velocity circuit resistance training, performed twice a week on the computerized Keiser pneumatic exercise machines, including extensive pre/post physical performance testing. Participants showed significant increases in strength and power in all major muscle groups. There were significant positive cognitive changes, objectively measured with the Brief Assessment of Cognition Scale: improvement in composite scores, processing speed and symbol coding. Calgary Depression Scale for Schizophrenia and Positive and Negative Syndrome Scale total scores improved significantly. There were large gains in neuromuscular performance that have functional implications. The cognitive domains that showed the greatest improvements (memory and processing speed) are most highly predictive of disability in schizophrenia. Moreover, the improvements seen in depression suggest this type of exercise intervention may be a valuable add-on therapy for bipolar depression.

Changes in vision related quality of life in patients with diabetic macular edema: Ranibizumab or laser treatment?

PurposeTo compare the changes in vision related quality of life (VR-QoL) in patients with diabetic macular edema (DME) undergoing intravitreal ranibizumab (IVR) injection or focal/grid laser. Material and methodsIn this prospective study, 70 patients with clinically significant macular edema (CSME) were randomized to undergo IVR injection (n=35) and focal/grid laser (n=35). If necessary, the laser or ranibizumab injections were repeated. Distance and near visual acuities, central retinal thickness (CRT) and The 25-item Visual Function Questionnaire (VFQ-25) were used to measure the effectiveness of treatments and VR-QoL before and after 6 months following IVR or laser treatment. ResultsThe demographic and clinical findings before the treatments were similar in both main groups. The improvements in distance and near visual acuities were higher in IVR group than the laser group (p<0.01). The reduction in CRT in IVR group was higher than that in laser treatment group (p<0.01). In both groups, the VFQ-25 composite score tended to improve from baseline to 6 months. And at 6th month, the changes in composite score were significantly higher in IVR group than in laser group (p<0.05). The improvements in overall composite scores were 6.3 points for the IVR group compared with 3.0 points in the laser group. Patients treated with IVR and laser had large improvements in composite scores, general vision, near and distance visual acuities in VFQ-25 at 6 months, in comparison with baseline scores, and also mental health subscale in IVR group. ConclusionOur study revealed that IVR improved not only visual acuity or CRT, but also vision related quality of life more than laser treatment in DME. And these patient-reported outcomes may play an important role in the treatment choice in DME for clinicians.

Preoperative warm-up the key to improved resident technique: a randomized study.

The ACGME has required that a skills lab be incorporated into the surgical residency curriculum. While the value of warm-up is generally accepted in other areas requiring complex motor skills, there is little evidence to support the benefits of warm-up prior to performing surgery. We are conducting this study in an attempt to identify whether a warm-up period prior to operating impacts operative technique. All general surgery residents and MIS fellows were included in this IRB-approved randomized study. Participants were randomized to either warm-up or no warm-up groups. Participants randomized to the warm-up group completed a 10 min practice session in the simulation lab within 1 h of starting the case, using an FLS training box. At the conclusion of the operation, the participant was evaluated by the attending surgeon using the validated global rating scales of Reznick and Vassiliou. The attending surgeons were blinded to the use of pre-procedure warm-up. The results of the questionnaire were analyzed using student's t test with p < 0.05 for significance. Pilot data were obtained after completing 40 cases that were randomized to warm-up (19) or no warm-up (21). There was a statistically significant improvement in depth perception (p = 0.02), bimanual dexterity (p = 0.01), and efficiency of movements (p = 0.03) for those randomized to warm-up. There was statistical improvement when we preformed a composite scoring of the attending evaluations for each of the Reznick (p = 0.008) and the Vassiliou (p = 0.01) global rating scales. Preoperative warm-up significantly improves depth perception, bimanual dexterity, and efficiency of movements, as well as improvement in composite scores as judged by the attending surgeon. The lack of self-perceived improvement by the residents may be a reflection of the high standards and intense self-critique that is common among surgical trainees. We believe that our findings, while preliminary, reflect that surgical performance can be enhanced through structured warm-up activities.

Practice improves performance on a coronary anastomosis simulator, attending surgeon supervision does not

Enthusiasm for simulation early in cardiothoracic surgery training is growing, yet evidence demonstrating its utility is limited. We examined the effect of supervised and unsupervised training on coronary anastomosis performance in a randomized trial among medical students. Forty-five medical students were recruited for this single-blinded, randomized controlled trial using a low-fidelity simulator. After viewing an instructional video, all participants attempted an anastomosis. Subsequently, the participants were randomized to 1 of 3 groups: control (n=15), unsupervised training (n=15), or supervised training with a cardiothoracic surgeon or fellow (n=15). Both the supervised and unsupervised groups practiced for 1 hour per week. After 4 weeks, the participants repeated the anastomosis. All pre- and posttraining performances were videotaped and rated independently by 3 cardiothoracic surgeons blinded to the randomization. All raters scored 13 assessment items on a 1 to 5 (low-high) scale along with an overall pass/fail rating. After the training period, all 3 groups showed significant improvements in composite scores (control: +0.52 ± 0.69 [P=.014], unsupervised: +1.05 ± 0.48 [P<.001], and supervised: +1.10 ± 0.84 [P<.001]). Compared with control group, both supervised (P=.005) and unsupervised trainees (P=.005) demonstrated a significant improvement. Between the supervised and unsupervised groups there were no statistically significant differences in composite scores. Practice on low-fidelity simulators enabled trainees to improve on a broad range of skills; however, the additional effect of attending-level supervision is limited. In an era of increasing staff surgeon responsibilities, unsupervised practice may be sufficient for inexperienced trainees.

A Simplified Pathway for Total Knee Arthroplasty Improves Outcomes

Care pathways for total knee arthroplasty (TKA) demonstrate improved quality and utilization outcomes. Standardizing these processes over large systems is difficult due to the variability of practice patterns and the complexity of multistep pathways. A simplified approach to this process focusing on early activity and avoidance of continuous urinary catheters was performed to overcome these perceived barriers for implementing a system-wide care pathway. Data were collected from a total of 6,154 consecutive patients during the time period of 1 year before and 1 year after implementation of a pathway focusing on two key drivers: early activity and continuous urinary catheter avoidance. Patients included were adults admitted for elective primary TKA. A composite score was calculated based on the successful completion of the two key drivers. Outcome measures were tracked before and after implementation. Following implementation of a simplified TKA care pathway, there was a significant increase in the composite score with increases attributable to both increased early activity (p < 0.0001) and continuous urinary catheter avoidance (p < 0.0001). This improvement in composite score was associated with a significant decrease in hospital length of stay (HLOS) (p < 0.0001), costs (p < 0.0001), complications (p < 0.0001), and 30-day readmissions (p < 0.0106). A fixed-effect model analysis demonstrated early activity was associated with improvements in HLOS (p < 0.0001), complications (p = 0.0240), and 30-day readmissions (p = 0.0046). Avoidance of a continuous urinary catheter was associated with improvements in HLOS (p = 0.0001), costs (p < 0.0001), complications (p = 0.0006), and 30-day readmissions (p = 0.0008). A simplified care pathway for TKA focusing on early activity and continuous urinary catheter avoidance is associated with improved complications, costs, HLOS, and 30-day readmissions.

Hydralazine and Isosorbide Dinitrate in Heart Failure

Until the 1970s, treatment options for heart failure were limited to digitalis and diuretics.1 Although effective for symptoms, there was no evidence of mortality benefit with this combination, and it was an inadequate option for many patients with advanced symptoms. The search for more effective options led to strategies that modulated hemodynamics.1 Numerous physiological studies showed the dependence of ventricular function on vascular resistance, and drugs that reduced systemic vascular resistance improved cardiac performance.2,–,5 A pivotal study by Franciosa et al6 showed that sodium nitroprusside in patients with heart failure in the setting of acute myocardial infarction reduced left ventricular filling pressures from 22.7±2.0 to 11.3±1.6 mm Hg and led to a modest increase in cardiac output. A subsequent study revealed more striking improvements in patients with refractory heart failure, in whom nitroprusside reduced systemic vascular resistance by 50%, increased cardiac output by 56%, and reduced left ventricular filling pressure by 47%.7 These hemodynamic benefits with nitroprusside led to studies with oral agents, including hydralazine, isosorbide dinitrate (ISDN), prazosin, phentolamine, and minoxidil. Although these drugs did affect hemodynamics, none was as effective as nitroprusside individually.8,–,12 In 1977, Massie et al13 studied the combination of 2 oral agents, hydralazine and ISDN (H-ISDN) in class III to IV heart failure patients, proposing that simultaneously reducing preload with ISDN and afterload with hydralazine would result in a better response than with either drug individually. They found that H-ISDN reduced left ventricular filling pressure by 36%, increased cardiac index by 58%, and reduced systemic vascular resistance by 34%. Later, Pierpont et al14 compared H-ISDN with nitroprusside and showed that the 2 therapies had similar effects on wedge pressure reduction and cardiac index increase. Considering these hemodynamic benefits with …

Efficacy of Low-Dose Estradiol Vaginal Tablets in the Treatment of Atrophic Vaginitis

To evaluate the efficacy of two vaginal doses of estradiol (E2) compared with placebo in the treatment of atrophic vaginitis. In a multi-center, randomized, double-blind, parallel-group study, 230 postmenopausal women received treatment with 25 mcg or 10 mcg E2 or placebo for 12 weeks. Efficacy was measured through composite score of three vaginal symptoms and grading of vaginal health. Additional analyses included maturation of vaginal and urethral mucosa. Safety assessments included endometrial biopsy, adverse events, changes in laboratory tests, and physical examinations. After 12 weeks of treatment, all patients were switched to the open-label extension and received treatment with 25 mcg E2 up to week 52. Vaginal tablets with 25 mcg and 10 mcg E2 showed significant (P<.001) improvement in composite score of vaginal health. Other results with 10 mcg E2 were not entirely consistent with those for 25 mcg E2. Over 12 weeks, both active treatments resulted in greater decreases in vaginal pH than placebo. There were no significant differences between the 25 mcg and 10 mcg E2 groups in terms of improvements in maturation value or composite score of three vaginal symptoms. The efficacy was maintained to week 52 with 25 mcg E2. Vaginal tablets with 25 mcg and 10 mcg E2 provided relief of vaginal symptoms, improved urogenital atrophy, decreased vaginal pH, and increased maturation of the vaginal and urethral epithelium. Those improvements were greater with 25 mcg than with 10 mcg E2. Both doses were effective in the treatment of atrophic vaginitis. ClinicalTrials.gov, www.clinicaltrials.gov, NCT00465192 and NCT00464971 I.

Subcutaneous depot medroxyprogesterone acetate versus leuprolide acetate in the treatment of endometriosis-associated pain

A clinical study compared efficacy and safety of depot medroxyprogesterone acetate (DMPA) with leuprolide for endometriosis-associated pain. This multicentre, 18 month, evaluator-blinded, comparator-controlled trial randomized 300 women with laparoscopically diagnosed endometriosis to 6 month treatment with subcutaneous injection of 104 mg/0.65 ml DMPA (DMPA-SC 104) every 3 months or leuprolide (3.75 mg monthly or 11.25 mg every 3 months), with 12 months post-treatment follow-up. Endpoints included patient response to treatment in five signs/symptoms (dysmenorrhoea, dyspareunia, pelvic pain, pelvic tenderness, induration) and changes in bone mineral density (BMD) and productivity at 6 and 18 months. DMPA-SC 104 and leuprolide produced equivalent (P < 0.02) reductions in at least four pain categories and significant (P < 0.001) improvements in composite score at months 6 and 18. At month 6, reductions in total hip and lumbar spine BMD were significantly less (P < 0.001) with DMPA-SC 104 versus leuprolide. BMD returned to pre-treatment levels 12 months post-treatment in the DMPA-SC 104 but not the leuprolide group. Total productivity also significantly (P < or = 0.05) improved in both groups at 6 and 18 months. DMPA-SC 104 reduces endometriosis-associated pain as effectively as leuprolide and improves productivity with significantly less BMD decline.

Microteaching: A model for employee counseling education

An instructional model for the implementation and use of videotape simulation to improve dietetic students' skills in employee counseling was explored in the coordinated undergraduate program at the University of Tennessee, Knoxville. A five-day intensive workshop was conducted for senior students in the program, utilizing the microteaching technique. Students and actors simulated an employee counseling session on videotape; then, a small group and a clinical instructor evaluated the session. Suggestions from these evaluations were used in a repeat of the situation on videotape. A team of experts randomly viewed all the situations, judging a significant improvement in composite scores for the workshop participants. The students indicated on a Self-Perception of Confidence (SPOC) scale that they felt a higher degree of comfort in handling potential employee counseling after completing the workshop. They were pleased with the workshop and suggested expansion of the technique to other phases of their dietetic education.