A follow-up study of the characteristics of dean's letters.

PURPOSE: To assess the content and quality of dean's letters since the publication of guidelines recommended by the Association of American Medical Colleges (AAMC) in 1989. METHOD: In 1998, the dean's letter writers at all 124 U.S. medical schools were surveyed. The questionnaire incorporated items from two previous surveys (1981 and 1992). In addition, samples of dean's letters (n = 451) from all U.S. medical schools for the graduating class of 1998 were rated based on the AAMC's guidelines. RESULTS: The response rate of the 1998 survey (66%) was lower than those of the two previous surveys (87% for 1992 and 85% for 1981). Schools that prepared letters that followed the AAMC's guidelines were somewhat more likely to have responded. According to the letter writers in 1998, close to 300,000 letters (approximately 1,050,000 pages total) were sent to residency directors, at an estimated cost of $26,000 per school. A total of 65% of schools produced adequate dean's letters based on the 1989 AAMC's guidelines, compared with 55% in 1992. Many schools were organizing the dean's letter in more readable formats, and more schools provided information that allowed for a comparison of students within the same school. CONCLUSION: The improvements in dean's letters are encouraging, but ten years after the AAMC's guidelines, 35% of U.S. schools still produce unacceptable letters. With the addition of the electronic submission of information, it is time to review further improvements to the dean's letter.

Does intrathecal morphine alter the stress response following coronary artery bypass grafting surgery?

PURPOSE: Intrathecal morphine administered prior to coronary artery revascularization (CABG) surgery was studied to determine its effects on the stress response. METHODS: In a single centre, open, randomized clinical trial, first time elective CABG surgery patients, < 75 yr, were studied. Control subjects (n=12) received a standardized anesthetic consisting of fentanyl (maximum cumulative dose of 35 microg x kg(-1)), propofol, and pancuronium. In addition, spinal subjects (n=13) received 1.0 mg (age > 60 yr) or 1.5 mg (age < or = 59 yr) intrathecal morphine prior to induction of anesthesia. Control subjects received continuous i.v. morphine at 2 mg x hr(-1) on arrival in the ICU with i.v. bolus morphine supplementation as required while spinal subjects received bolus i.v. morphine as required. Changes in plasma cortisol and catecholamine concentrations were measured preoperatively, poststernotomy, on admission to ICU, following tracheal extubation, at 0800 hr on the first postoperative day, and 24 and 48 hr after ICU admission. RESULTS: No differences between groups were detected for demographic variables. The percent change in cortisol concentration relative to preoperative values (control vs spinal; (38 (87) vs -41 (46)%: P < 0.05)) was lower in the spinal group on admission to ICU. The percent change in plasma epinephrine levels (control vs spinal) on admission to ICU (285 (337) vs -10 (37)%) and 0800 hr after surgery (314 (341) vs -4 (37)%) was also significantly different. CONCLUSION: Intrathecal morphine only partially attenuated the postsurgical stress response in CABG surgical patients.

Massive osteolytic bone metastases from a primary aortic sarcoma: a case report.

We present an unusual case of an aortic intimal sarcoma, which originally manifested itself by the presence of extensive radiologically osteolytic lesions in the long bones of the lower limbs. The histology of these was puzzling and was first considered to represent a low grade sarcoma of vasoformative tissue and subsequently skeletal angiomatosis. Despite a good initial clinical response to disodium etidronate, the patient ultimately developed small bowel infarction and the true diagnosis only came to light at autopsy. This revealed a tumour in the lower thoracic aorta which, unusually for aortic sarcoma, consisted of loosely packed bland spindle cells with no necrosis and infrequent mitoses. Immunocytochemistry was unhelpful but electron microscopy suggested myofibroblastic differentiation. The majority of previous reports of the tumour in the literature lack information on electron microscopy and immunocytochemistry and have suggested that these tumours are generally pleomorphic in appearance. Embolic phenomena and post mortem diagnosis are usual although occasional antemortem diagnosis has been made using computed tomography (CT) and magnetic resonance imaging (MRI) scanning with the latter being the investigation of choice.

Light versus heavy sedation after cardiac surgery: myocardial ischemia and the stress response. Maritime Heart Centre and Dalhousie University.

UNLABELLED: The influence of light versus heavy sedation after coronary artery bypass graft (CABG) surgery on the development of postoperative myocardial ischemia has not been described. After uncomplicated CABG surgery, 50 patients were randomly assigned to receive LOW (n = 24; target Ramsay Sedation Score [RSS] = 2) or HIGH (n = 26; target RSS = 4) sedation with propofol. Analgesia was provided to maintain a visual analog scale (VAS) pain score <7. Myocardial ischemia was identified perioperatively using continuous 3-lead Holter monitoring. By measuring creatine kinase (CK) MB levels preoperatively, at entry to the intensive care unit (ICU), and every 12 h for 48 h; and by obtaining serial 12-lead electrocardiograms (ECG) (preoperatively; 2, 4, 12, 24, and 48 h after ICU admission, 8:00 AM the morning after surgery; and 5 min pre- and postextubation), myocardial infarction was identified. Endocrine stress response was assessed by measuring serum cortisol levels preoperatively, on admission to the ICU, and 24 h postoperatively. In a subset of patients (LOW n = 10, HIGH n = 11), plasma and urinary catecholamine levels were also measured. There were no between-group differences in demographics, operative course, hemodynamic variables, or cortisol levels while in the ICU. The VAS pain score and target RSS were achieved and sustained, and they differed between groups. There were three myocardial infarctions in each group by CKMB criteria alone. No ECG-identifiable myocardial infarction occurred. The ST segment versus time curve (LOW 187 +/- 295 versus HIGH 1071 +/- 2137 mm/min) differed between groups. Urinary and plasma catecholamine levels were similar between groups over the observation period. We conclude that the use of a reduced sedation regimen in combination with adequate analgesia did not result in an increased endocrine stress response or risk of myocardial ischemia. IMPLICATIONS: This randomized study of patients after coronary artery bypass surgery examined whether light (versus heavy) sedation with propofol in the intensive care unit was associated with an increased degree of myocardial ischemia. Using techniques to detect myocardial ischemia, including Holter monitoring, electrocardiogram, and myocardial enzyme measurements, no differences were found. We conclude that light sedation does not increase the endocrine stress response or the risk of myocardial infarction.

Neurological complications of high tibial osteotomy--the fibular osteotomy as a causative factor: a clinical and anatomical study.

A clinical study of 105 upper tibial osteotomies was undertaken to investigate the incidence, pathology and outcome of perioperative neurological deficit. Motor weakness and/or sensory deficit occurred in 21 patients (20%) and in half of these the deficit was permanent. For descriptive purposes the fibula was divided into four zones. The occurrence of a neurological deficit was clearly related to the level of the fibular osteotomy. An anatomical explanation is proposed for this complication, based on cadaveric studies. Due to unacceptably high levels of complications it is recommended that the fibular osteotomy should not be performed in zones II and III (from just below the fibular head to 15 cm distal to this level).

Characteristics of dean's letters in 1981 and 1992.

PURPOSE: To compare results from 1981 and 1992 national surveys of the writers of medical school dean's letters, and to rate the 1992 letters based on the guidelines recommended by the Association of American Medical Colleges (AAMC). METHOD: In early 1992 a survey was administered to the dean's letter writers at all 125 U.S. medical schools with fully accredited four-year programs; the survey incorporated many items from a 1981 survey. In addition, 550 dean's letters from all U.S. medical schools for the graduating class of 1992 were collected and rated based on guidelines published by the AAMC in 1989. RESULTS: The response rate of the 1992 survey was comparable to that of the 1981 survey (85% and 87%, respectively). In both surveys, slightly more than half the schools used more than one letter writer; however, the 1992 letters were longer and there were more of them, in spite of the fact that there were approximately 700 fewer graduates. In 1992 the estimated total cost per school was $25,000 (comparable data were not collected in 1981). The ratings of the letters revealed that only 38% of the schools introduced their letters as letters of "evaluation," as recommended by the AAMC, and that 15% of the schools failed to use the AAMC guidelines for format. When the schools were rated for overall quality (i.e., format combined with information about the students' performance in comparison with that of peers), 55% of the schools passed and 45% failed. CONCLUSION: Several recommendations for improving dean's letters are discussed, including the following: (1) all dean's letters should be formatted according to the AAMC guidelines; (2) each school should have one person responsible for central overview of the school's letters; and (3) for comparative performance information, schools should at least give the percentages of grades given in the required clerkships, and it would be preferable for them to employ systems that group students into four to six groups and to indicate the percentage of students in each group.

Comparing assessments of medical students' potentials as residents made by the residency directors and deans at two schools.

The Association of American Medical Colleges' Committee on Dean's Letters advised in 1988 that the dean's letter should be a letter of evaluation rather than a letter of recommendation. The committee also recommended that the letter contain some form of comparative information to let the residency director know how individual students fared in comparison with their peers. This article reports the results of a 1989 study of the types of agreements between the letter writers and the residency directors of two schools. Three standard methods of providing comparative information were used in their ranking of 20 graduates from the class of 1987 at each school. Ordinal ranking from best to worst students revealed a surprisingly high degree of rank-order agreement, but only for 15 of the 16 participating residency directors. Clustering into fixed groups ("top third," etc.) gave high agreement for top students but weaker agreement for the middle and lower groupings. The advantages and disadvantages of these evaluation methods are discussed.

Hemodialysis-associated febrile episodes: surveillance before and after major alteration in the water treatment system.

Surveillance for bacteremic or pyrogenic episodes associated with hemodialysis was undertaken before and after the reconstruction of the water treatment system at our University medical center. The new water system included a holding tank with iodination treatment. The water delivered to individual dialysis stations had only occasional positive bacterial cultures (3 of 21 samples before completion of construction, 2 of 16 samples afterwards) and intermittent detection of endotoxin (6 of 21 samples before completion of construction, 9 of 16 samples afterwards) at monthly sampling. Among 51 individual dialysis treatments (25 patients) before reconstruction and 56 treatments (29 patients), after, only 2 and 3 febrile events were identified, respectively. All of these were associated with underlying infectious illness and not with the hemodialysis procedure itself. Overall, we conclude that pyrogenic episodes associated directly with hemodialysis treatment are infrequent, and that the addition of a water storage tank with iodination treatment does not appear to increase the risk of bacteremia or pyrogenic episodes.