Preliminary validation of muscle ultrasound in juvenile dermatomyositis (JDM).

OBJECTIVE: To compare muscle ultrasound (MUS) parameters in patients with juvenile JDM and healthy controls, and examine their association with JDM disease activity measures and MRI. METHODS: MUS of the right mid-rectus femoris was performed in 21 patients with JDM meeting probable or definite Bohan and Peter criteria and 28 demographically matched healthy control subjects. MUS parameters were quantitated by digital image processing and correlated with JDM disease activity measures and semi-quantitative thigh MRI short tau inversion recovery (STIR) and T1 scores. RESULTS: Rectus femoris MUS echogenicity was increased (median 47.8 vs 38.5, P = 0.002) in patients with JDM compared with controls. Rectus femoris MUS echogenicity correlated with Physician Global Activity (PGA), Manual Muscle Testing (MMT), and Childhood Myositis Assessment Scale (CMAS) (rs 0.4-0.54). Some MUS parameters correlated with functional quantitative measures of muscle strength: resting RF area on MUS strongly correlated with knee extension quantitative muscle testing (rs 0.76), and contracted area correlated with proximal MMT, knee extension quantitative muscle testing, and CMAS (rs 0.71-0.80). MUS echogenicity correlated with both STIR and T1 MRI (rs 0.43), and T1 MRI correlated inversely with RF contracted area (rs -0.49) on MUS. There were differences in pre- and post-exercise vascular power and colour Doppler on MUS in patients with JDM vs controls, with the percentage change of post-exercise vascular power Doppler lower in JDM compared with controls (7.1% vs 100.0%). CONCLUSIONS: These data suggest MUS may be a valuable imaging modality to assess JDM disease activity and damage.

Competency champions in the clinical competency committee: a successful strategy to implement milestone evaluations and competency coaching.

OBJECTIVES: To create a clinical competency committee (CCC) that (1) centers on the competency-based milestones, (2) is simple to implement, (3) creates competency expertise, and (4) guides remediation and coaching of residents who are not progressing in milestone performance evaluations. DESIGN: We created a CCC that meets monthly and at each meeting reviews a resident class for milestone performance, a competency (by a faculty competency champion), a resident rotation service, and any other resident or issue of concern. SETTING: University surgical residency program. PARTICIPANTS: The CCC members include the program director, associate program directors, director of surgical curriculum, competency champions, departmental chair, 2 at-large faculty members, and the administrative chief residents. RESULTS: Seven residents were placed on remediation (later renamed as coaching) during the academic year after falling behind on milestone progression in one or more competencies. An additional 4 residents voluntarily placed themselves on remediation for medical knowledge after receiving in-training examination scores that the residents (not the CCC membership) considered substandard. All but 2 of the remediated/coached residents successfully completed all area milestone performance but some chose to stay on the medical knowledge competency strategy. CONCLUSIONS: Monthly meetings of the CCC make milestone evaluation less burdensome. In addition, the expectations of the residents are clearer and more tangible. "Competency champions" who are familiar with the milestones allow effective coaching strategies and documentation of clear performance improvements in competencies for successful completion of residency training. Residents who do not reach appropriate milestone performance can then be placed in remediation for more formal performance evaluation. The function of our CCC has also allowed us opportunity to evaluate the required rotations to ensure that they offer experiences that help residents achieve competency performance necessary to be safe and effective surgeons upon completion of training.

Long-term follow-up of endovascular abdominal aortic aneurysm repair in a rural veteran patient population.

BACKGROUND: The endovascular repair of abdominal aortic aneurysms (EVARs) requires follow-up to detect and treat late complications. METHODS: Two hundred eleven patients underwent EVAR for infrarenal, nonruptured abdominal aortic aneurysms from 1999 to 2010 at the Raymond G. Murphy VA Medical Center, Albuquerque, NM. A retrospective review examined patient demographics, comorbidities, the distance the patient lived from the facility, early and late complications, and the device implanted. Statistical analysis included the chi-square test for independence, the Fisher exact test, and the 2-sample Mann-Whitney U test for means. RESULTS: The mean time from the operation to the first complication was 21 months (standard deviation = 20 months) with a mean follow-up of 48 months (standard deviation = 36 months). The late complication rate was 22.8% (54 patients). Sixteen percent did not require any reinterventions, 57% were treated with percutaneous interventions, and 27% required an open surgical procedure. No single comorbidity, combination of comorbidities, distance the patient lived from the facility, or device implanted was predictive of complications. CONCLUSIONS: EVAR follow-up is essential to detect complications. When complications occur, the majority occur well after the initial treatment, and most can be treated with minimally invasive percutaneous techniques.