Adrenal Venous Sampling for Subtype Diagnosis of Primary Hyperaldosteronism

Adrenal venous sampling (AVS) is the key procedure for lateralization of primary hyperaldosteronism (PA) before surgery. Identification of the adrenal veins using computed tomography (CT) and intraoperative cortisol assay facilitates the success of catheterization. Although administration of adrenocorticotropic hormone (ACTH) has benefits such as improving the success rate, some unilateral cases could be falsely diagnosed as bilateral. Selectivity index of 5 with ACTH stimulation to assess the selectivity of catheterization and lateralization index (LI) >4 with ACTH stimulation for unilateral diagnosis is used in many centers. Co-secretion of cortisol from the tumor potentially affects the lateralization by the LI. Patients aged <35 years with hypokalemia, marked aldosterone excess, and unilateral adrenal nodule on CT have a higher probability of unilateral disease. Patients with normokalemia, mild aldosterone excess, and no adrenal tumor on CT have a higher probability of bilateral disease. Although no methods have 100% specificity for subtype diagnosis that would allow bypassing AVS, prediction of the subtype should be considered when recommending AVS to patients. Methodological standardization and strict indication improve diagnostic quality of AVS. Development of non-invasive imaging and biochemical markers will drive a paradigm shift in the clinical practice of PA.

Association between physical function and long-term care in community-dwelling older and oldest people: the SONIC study

BACKGROUND@#Preventing the need for long-term care (LTC) by identifying physical function risk factors are important to decrease the LTC burden. The objective of this study was to investigate whether grip strength and/or walking speed, which are components of the frailty definition, are associated with LTC in community-dwelling older and oldest people.@*METHODS@#The participants were 1098 community-dwelling older and oldest people who had not received LTC at the baseline. The endpoint was receiving LTC after the baseline survey. The independent variables were grip strength and walking speed, and participants were divided into two groups based on these variables. The confounding factors were age, sex, the Japanese version of the Montreal Cognitive Assessment (MoCA-J), hypertension, diabetes mellitus, stroke, joint diseases, living alone, body mass index, and serum albumin. We calculated the hazard ratio of receiving LTC using the Cox proportional hazard model.@*RESULTS@#Among the 1098 participants, 107 (9.7%) newly received LTC during the follow-up. Regarding the physical function, only slow walking speed was significantly correlated with LTC after adjusting for all confounding factors except the MoCA-J score (HR = 1.74, 95% CI = 1.10-2.75, P = .018). However, slow walking speed was still a risk factor for LTC after adjusting for the MoCA-J score and other confounding factors (HR = 1.64, 95% CI = 1.03-2.60, P = .037).@*CONCLUSIONS@#The findings from this study may contribute to a better understanding of slow walking speed as a factor related to LTC, which might be a criterion for disability prevention and could serve as an outcome measure for physical function in older people.

Analysis of a newly introduced comprehensive clinical competency examination at Osaka University / 医学教育

Background: Osaka University has introduced a new oral examination that evaluates comprehensive clinical competency. The purpose of this study was to clarify the characteristics of this examination.<br>Method: We compared the scores of this examination with those of other a&szlig;e&szlig;ments: basic medicine, clinical medicine, computer&ndash;based testing （CBT）, objective structured clinical examination （OSCE）, and clinical clerkships.<br>Results: The Pearson correlation coefficient between this examination and other examinations was relatively low: basic medicine, 0.32; clinical medicine, 0.36; CBT, 0.44; OSCE, 0.39; and clinical clerkships, 0.24. Principal component analysis revealed that this examination could be grouped with OSCE and clinical clerkships, whereas basic medicine, clinical medicine and CBT could be grouped.<br>Conclusions: This new oral examination evaluates aspects of the examinees distinct from aspects evaluated by other examinations and could be an indicator of ability to solve clinical problems.

Replacement of the paper–based graduation examination by a comprehensive clinical competency examination at Osaka University / 医学教育

Background: In 2011, Osaka University abolished the paper–based final examination at the end of 6th year of medical school and introduced a new examination that evaluates comprehensive clinical competency after clinical training.<br>Method: For this examination, sequential scenarios were developed that demonstrate the process of problem solving in patient care. The examiners administered an oral test to students using the scenarios in the same manner as ward rounds and evaluated the clinical competency of students according to their attitudes, knowledge, and thinking.<br>Results: The examination was administered smoothly. Eighty–nine percent of examiners and 59% of students affirmed the significance of the examination in a questionnaire.<br>Discussion: Our reform of the final examination was met with acceptance, especially by examiners. To assess clinical competency more accurately, our next goal is to integrate performance–based assessment into the sequential scenarios..