Quality of care associated with number of cases seen and self-reports of clinical competence for Japanese physicians-in-training in internal medicine.

BACKGROUND: The extent of clinical exposure needed to ensure quality care has not been well determined during internal medicine training. We aimed to determine the association between clinical exposure (number of cases seen), self- reports of clinical competence, and type of institution (predictor variables) and quality of care (outcome variable) as measured by clinical vignettes. METHODS: Cross-sectional study using univariate and multivariate linear analyses in 11 teaching hospitals in Japan. Participants were physicians-in-training in internal medicine departments. Main outcome measure was standardized t-scores (quality of care) derived from responses to five clinical vignettes. RESULTS: Of the 375 eligible participants, 263 (70.1%) completed the vignettes. Most were in their first (57.8%) and second year (28.5%) of training; on average, the participants were 1.8 years (range = 1-8) after graduation. Two thirds of the participants (68.8%) worked in university-affiliated teaching hospitals. The median number of cases seen was 210 (range = 10-11400). Greater exposure to cases (p = 0.0005), higher self-reports of clinical competence (p = 0.0095), and type of institution (p < 0.0001) were significantly associated with higher quality of care, using a multivariate linear model and adjusting for the remaining factors. Quality of care rapidly increased for the first 100 to 200 cases seen and tapered thereafter. CONCLUSION: The amount of clinical exposure and levels of self-reports of clinical competence, not years after graduation, were positively associated with quality of care, adjusting for the remaining factors. The learning curve tapered after about 200 cases.

Guidewire-induced coronary artery perforation treated with transcatheter delivery of subcutaneous tissue.

In three cases of small coronary artery perforation by guidewires during percutaneous coronary intervention, coronary leakage continued despite prolonged balloon inflation and reversal of heparin. Subcutaneous tissue was selectively delivered to perforated vessels by means of microcatheters in a successful attempt to stop leakage. This method appears to be extremely effective for treating guidewire-induced perforations of distal coronary arteries.

Endovascular stent-grafting for recurrent aneurysm in Behcet's disease.

Arterial aneurysms represent a severe complication of Behcet's disease. A 42-year-old woman with Behcet's disease had a recurrence of an aneurysm after two surgical repair attempts using grafts. A covered stent-graft was implanted in her iliac external artery to occlude the neck of the aneurysm at the anastomosis of the bypass graft to her external iliac artery. The procedure reduced the size of the aneurysm by allowing the formation of a thrombus within its cavity. The implantation of an endovascular stent-graft may be a sound alternative to surgical repair for aneurysms associated with Behcet's disease.

Aortocoronary dissection resolved by coronary stenting guided by intracoronary ultrasound.

Percutaneous coronary intervention (PCI) was performed for chronic total occlusion of the proximal right coronary artery in a 70-year-old male with unstable angina. The forceful manipulation of the guide catheter led to an aortocoronary dissection involving the right Valsalva sinus and the ascending aorta. Intracoronary ultrasound (ICUS) showed the important characteristics of the dissection, enabling successful coronary stenting under ICUS guidance.

Obstinate thrombosis during percutaneous coronary intervention in a case with heparin-induced thrombocytopenia with thrombosis syndrome successfully treated by argatroban anticoagulant therapy.

We describe a case of massive coronary thrombus after the coronary stenting due to heparin-induced thrombocytopenia with thrombosis syndrome (HITTS). Only argatroban was able to resolve the thrombus. This is the first case in which argatroban successfully treated massive thrombus during percutaneous coronary intervention in a patient with HITTS.

Highly vascular pelvic tumor causing high-output heart failure because of massive arteriovenous shunting: a case report.

A 53-year-old Japanese woman underwent investigation of her heart murmur. A continuous abdominal bruit was heard. Blood gas analysis and chest X-ray showed congestive heart failure. Enhanced computed tomography of the pelvis showed a 10 x 4 cm hypervascular tumor in the retroperitoneal space. Cardiac catheterization disclosed a cardiac output of 13.2 L/min and a step-up of oxygen at the right common iliac vein. Abdominal aortic angiography showed an extremely vascular pelvic tumor and rapid filling of the inferior vena cava. This is a rare case of a highly vascular pelvic tumor causing high-output heart failure because of th massive arteriovenous shunting.