Comparison of performance on the American Osteopathic Board of Internal Medicine certifying examination 1986 to 1996 by type of residency.

The purpose of this study was to determine if internal medicine residency type or location was associated with differences in performance of candidates as measured by the internal medicine certifying examination. Included in the study were all first-time taker candidates for the 1986 to 1996 American Osteopathic Board of Internal Medicine certifying examinations in internal medicine. Group analysis was performed based on the type of residency track leading to board eligibility: (1) traditional internship plus 3 years of internal medicine residency; (2) traditional internship plus 2 years of internal medicine residency and 1 year of subspecialty training; (3) specialty track internship plus 2 years of internal medicine residency; and (4) traditional internship plus 3 years of allopathic internal medicine residency. Subgroup analysis of the subspecialty track group was performed to determine if any particular subspecialty-trained subgroup performed better than the others. Results indicate that all groups had similar scores and pass rates except for the allopathic-trained residents, whose scores and pass rates were lower. Subgroup analysis of the subspecialty-trained candidates revealed that procedure-oriented subspecialty candidates performed similar to non-procedure-oriented candidates. No gender differences were noted in scores or pass rates. It is concluded that the overall performance of candidates is equivalent for each of the residency training tracks developed by the American College of Osteopathic Internists. Future performance on the recertification examination will need to be tracked to determine if these trends continue for practicing internists.

Performance of osteopathic medical school graduates on the American Osteopathic Board of Internal Medicine certifying examinations 1985 to 1994.

This study examined the trends in the medical knowledge of osteopathic internal medicine residents in American Osteopathic Association-approved residency programs during a recent 10-year period and compared these trends with the declining medical knowledge observed for internal medicine residents graduated from allopathic medical schools and trained in allopathic residency programs. These results demonstrate a similar pattern of declining medical knowledge that appears to have leveled off during the past few years of the study. These trends occurred among candidates from both large and smaller training institutions. Various factors may have contributed to these observations.

Performances of candidates with osteopathic compared with allopathic subspecialty training on the American Osteopathic Board of Internal Medicine subspecialty certifying examinations 1984 to 1992.

The American Osteopathic Board of Internal Medicine has been examining various factors that may affect candidate performance on subspecialty certifying examinations. To see whether taking subspecialty training in an osteopathic compared with an allopathic institution could predict better performance on the certifying examinations, the authors analyzed examination performance for all candidates from 1984 through 1992. There was no significant difference between the mean scores for the two groups for any of the nine subspecialty certifying examinations. When the results from all nine examinations were pooled, the mean first-time examination takers' score for candidates in allopathic subspecialty programs (n = 201) was 78.3 and for those in osteopathic subspecialty programs (n = 153), 77.4 (P > 0.2). On the basis of these results, we cannot conclude that osteopathic subspecialty training is a factor that predicts better performance on the subspecialty certifying examination.

Performance of candidates on the American Osteopathic Board of Internal Medicine subspecialty certifying examinations 1984-1992.

In 1973, the Board of Trustees of the American Osteopathic Association approved the Rules and Regulations of the American Osteopathic Board of Internal Medicine for the subspecialty certification program in internal medicine. The written objective examination process was finalized and implemented in 1984. Since 1984, 354 candidates have entered the examination process, with the largest number in the subspecialty field of cardiology. Through 1992, 91% of the candidates entering the examination process have passed the certifying examination and become certified. The number of first-time certifying-examination takers moderately increased in the last 2 years studied. The pass rate for first-time takers has averaged 75%, whereas the pass rate for repeaters has been 72%.

Nephrology/hypertension/fluid and electrolyte disorders.

The following annotated bibliography has been developed for the purpose of providing to primary care physicians a handy source of review articles and major studies in the field of nephrology, hypertension, and fluid and electrolyte disorders. Almost all of the articles are review articles of clinical topics that would be of interest to the practicing physician. JAOA will be publishing additional annotated bibliographies in various fields of internal medicine over the next several months. This is the second in the series. Part 1 appeared in the January 1993 issue (93:50-65). Others will appear in forthcoming issues of THE JOURNAL.

Nephrology/hypertension/fluid and electrolyte disorders.

The following annotated bibliography has been developed for the purpose of providing to primary care physicians a handy source of review articles and major studies in the field of nephrology, hypertension, and fluid and electrolyte disorders. Almost all of the articles are review articles of clinical topics that would be of interest to the practicing physician. JAOA will be publishing additional annotated bibliographies in various fields of internal medicine over the next several months. The second in this series will appear in a forthcoming issue of THE JOURNAL.

Familial glomerular disease with asymptomatic proteinuria and nephrotic syndrome: a new clinical entity.

Seventy-three members of a 100-member kindred with asymptomatic proteinuria, nephrotic syndrome, and progressive renal failure were studied. Of those studied, 11 members had progressed to end-stage renal disease and seven had significant proteinuria (greater than 1 g/24 hours) with normal renal function. The genetic mode of inheritance was autosomal dominant with variable penetrance and expressivity. Histopathologic changes were variable but included focal segmental glomerulosclerosis and diffuse glomerulosclerosis. Renal failure usually occurred in the fifth decade of life. The most consistent clinical finding was proteinuria without microscopic hematuria or other significant urinary sediment elements. This disease differed from Alport's hereditary nephritis and congenital nephrotic syndrome in age of onset, urinary findings, and associated conditions, that is, nerve deafness. The hereditary proteinuria and nephrotic syndrome described in this kindred represents another facet in the spectrum of hereditary renal disease.

Recruiting interns and residents to an osteopathic medical training program.

As more graduates of colleges of osteopathic medicine enroll in allopathic training programs and specialty programs, medical directors of osteopathic medical institutions are faced with the challenge of maintaining a well-trained housestaff. More important, perhaps, this exodus threatens the very core of osteopathic medicine, namely, its ability to produce well-trained primary care physicians. A recruitment plan used at the Chicago College of Osteopathic Medicine and its affiliates is presented here. The plan emphasizes the importance of trainee involvement in their own education as well as the use of residents in recruiting interns and specialty residents.

Phenytoin, renal function and renin release.

Phenytoin (DPH), a widely used anticonvulsant, has been shown to effect membrane transport in a wide variety of tissues. After injection, DPH is known to accumulate in high concentration in the kidney, however the renal effects of this drug have not been investigated. Therefore, these studies were designed to elucidate the effect of DPH on renal function and renin release. Dogs were anesthetized and had renal venous, aortic, brachial and ureteral catheters placed. During each of three successive experimental clearance periods, either saline, propylene glycol vehicle (V) or V + DPH (0.18 mg/kg/min) was infused via a 23-gauge needle in the left renal artery. In five dogs (Group I), the sequences of infusion was saline, (V) and (V). Five animals (Group II) differed only in that V was infused during all three periods. Seven animals (Group III) underwent sequential infusions of V, V + DPH, and V. Infusion of V alone resulted in a significant increase in systemic blood pressure from 120 to 135 mm Hg (P < .05). Significant increases after V infusion were found in urine volume (0.45 to 0.87 ml/min) (P < .05) and osmolar clearance (1.23 to 1.83 ml/min). Infusion of DPH produced a 22% increase in renal blood flow from 238 to 291 ml/min (P < .05) and a fall in renal vascular resistance from 0.51 to 0.41 mm Hg/ml/min (P < .05). Significant increases were also seen in urine volume from 0.87 to 1.58 ml/min (P < .05), urine sodium excretion (157 to 269 microEq/min) (P < .05) and osmolar clearance (1.54 to 2.62 ml/min) (P < .05). Renal renin secretion rate was unchanged in Group I and II animals but DPH infusion resulted in a 7-fold increase in renin secretion from 21 to 151 ng A-I/hr x min (P < .05). We conclude that intrarenal arterial infusion of DPH results in renal vasodilation, diuresis and natriuresis. Furthermore, this agent also stimulates renin release which may be the result of its effect on membrane transport.

Renal blockade to angiotensin II in acute and chronic sodium-retaining states.

Acute thoracic inferior vena cava constriction results in alterations in renal hemodynamics which may explain the characteristic antinatriuretic response. Since adrenalvein-aldosterone secretion is increased within 30 minutes of acute caval constriction and elevated plasma-renin activity is found in the chronic caval dog, we sought to determine whether the renal hemodynamic alterations observed in acute caval constriction are due to the intrarenal action of angiotensin II. The renal response to acute caval constriction in dogs receiving unilateral renal arterial infusion of a specific competitive antagonist of angiotensin II, 1-sarcosine-8-alanine-agiotensin II, was studied. Effective blockade did not alter the renal hemodynamic or antinatriuretic response to acute caval constriction. As a model of chronic sodium retention, dogs with chronic congestive heart failure produced by tricuspid insufficiency and pulmonary stenosis were similarly studied. Effective renal blockade to antiotensin II did not affect renal hemodynamics or urinary sodium excretion. The renal hemodynamic and antinatriuretic responses to acute caval constriction and chronic congestive heart failure are not dependent on the intrarenal action of angiotensin II.

Renal neuroadrenergic transmission.

To study the role of the renal sympathetic nerves in the regulation of sodium excretion, we examined the renal functional response to left renal nerve stimulation before (group I) and after (group II) left renal adrenergic blockade with guanethidine. In group I dogs, absolute sodium excretion from the left kidney fell markedly after left renal nerve stimulation; the decreases in glomerular filtration rate and renal blood flow were of a similar magnitude. Using the radiolabeled microsphere technique, distribution of renal blood flow to the outer cortex was diminished after left renal nerve stimulation. In group II dogs, guanethidine blocked all of these effects of left renal nerve stimulation. In group iii studies, a low level of left renal nerve stimulation was used which resulted in a decrease in sodium excretion in the absence of changes in glomerular filtration rate, renal blood flow, or intrarenal distribution of blood flow; this effect was blocked by renal adrenergic blockade with guanethidine in group iv studies. These data support a role for the renal sympathetic nerves to directly influence renal tubular sodium transport in the absence of alterations in renal hemodynamics.

Hypertension, renal vein thrombosis and renal failure (occurring in a patient on an oral contraceptive agent).

A case of accelerated hypertension leading to renal failure in a young woman taking an oral contraceptive agent is described. During the course of her disease the left kidney was documented to decrease in size. Renal vein plasma renin activity was found to be elevated on the left in the absence of renal artery stenosis. Left nephrectomy, prompted by continuing poor blood pressure control, resulted in amelioration of the hypertension. Left renal vein thrombosis was found at surgery. It is suggested that renal vein thrombosis was a contributing factor to this patient's accelerated hypertension and may represent an unusual thrombotic complication of oral contraceptives.