Lessons learned from developing a drug evidence base to support pharmacovigilance.

OBJECTIVE: This work identified challenges associated with extraction and representation of medication-related information from publicly available electronic sources. METHODS: We gained direct observational experience through creating and evaluating the Drug Evidence Base (DEB), a repository of drug indications and adverse effects (ADEs), and supplemented this through literature review. We extracted DEB content from the National Drug File Reference Terminology, from aggregated MEDLINE co-occurrence data, and from the National Library of Medicine's DailyMed. To understand better the similarities, differences and problems with the content of DEB and the SIDER Side Effect Resource, and Vanderbilt's MEDI Indication Resource, we carried out statistical evaluations and human expert reviews. RESULTS: While DEB, SIDER, and MEDI often agreed on medication indications and side effects, cross-system shortcomings limit their current utility. The drug information resources we evaluated frequently employed multiple, disparate vaguely related UMLS concepts to represent a single specific clinical drug indication or adverse effect. Thus, evaluations comparing drug-indication and drug-ADE coverage for such resources will encounter substantial numbers of false negative and false positive matches. Furthermore, our review found that many indication and ADE relationships are too complex - logically and temporally - to represent within existing systems. CONCLUSION: To enhance applicability and utility, future drug information systems deriving indications and ADEs from public resources must represent clinical concepts uniformly and as precisely as possible. Future systems must also better represent the inherent complexity of indications and ADEs.

The computer-based lecture.

Advancing computer technology, cost-containment pressures, and desire to make innovative improvements in medical education argue for moving learning resources to the computer. A reasonable target for such a strategy is the traditional clinical lecture. The purpose of the lecture, the advantages and disadvantages of "live" versus computer-based lectures, and the technical options in computerizing the lecture deserve attention in developing a cost-effective, complementary learning strategy that preserves the teacher-learner relationship. Based on a literature review of the traditional clinical lecture, we build on the strengths of the lecture format and discuss strategies for converting the lecture to a computer-based learning presentation.

Outpatient morning report: a new conference for internal medicine residency programs.

To clarify the use of outpatient morning report in internal medicine residency programs, we conducted a national survey of internal medicine residency directors and a local survey of a cohort of residents at a large teaching hospital. The program directors reported a 24% prevalence of outpatient morning report. The cohort of residents reported that the conference contributed much to their education by meeting specific learning needs and covering topics not covered elsewhere in their residency training.

Outpatient morning report: a new educational venue.

Increasingly, medical educators are looking for ways to train residents and medical students in outpatient medicine. One novel idea, outpatient morning report, draws upon the concept of inpatient morning report and applies a similar conference format to the outpatient setting. The authors describe outpatient morning report and comment on its successful use in their institution.

Prescribing controlled substances in Tennessee: progress, not perfection.

BACKGROUND: In the 1980s, Tennessee ranked among the top 10 states in per capita consumption of several controlled substances. We describe efforts designed to reduce non-criminally motivated misprescribing in Tennessee, present Tennessee's recent Drug Enforcement Administration (DEA) rankings, and suggest how physicians may reduce misprescribing. METHODS: Tennessee's Board of Medical Examiners (BME) consults with Tennessee Physician Health Program (PHP) and refers selected physicians to a continuing medical education (CME) program offered at Vanderbilt University School of Medicine. The BME has also published a clear set of prescribing guidelines. RESULTS: Of more than 160 CME participants, only two have reappeared before the BME for prescribing infractions. Tennessee's overall DEA ranking improved from 7th highest to 17th from 1994 to 1997. CONCLUSIONS: The reasons the rankings improved cannot be established, but the changes occurred at the same time as the BME, PHP, and Vanderbilt CME collaborations. We will continue to promote professional and patient health throughout the region.

Physician impairment by substance abuse.

Physician impairment by substance abuse represents a significant challenge to physicians, patients, and society as a whole. Although data is sparse, the prevalence of alcohol and illicit drug abuse among physicians is probably similar to that of the general population, while abuse of prescription drugs may be more prevalent. From a medicolegal standpoint, these issues are managed mostly at the state level and substance abuse is of increasing interest to credentialling organizations such as hospitals and managed care organizations. A variety of concrete steps can be taken to identify physicians with substance abuse problems and treatment approaches have been designed specifically for impaired physicians. With improved attention to the problem of physician impairment by substance abuse, the well-being of both physicians and their patients can be enhanced.

Improving residents' teaching skills and attitudes toward teaching.

OBJECTIVE: To determine whether a short, 3-hour teaching skills workshop could improve residents' teaching performances and attitudes toward teaching. DESIGN: Controlled study. PARTICIPANTS AND SETTING: Forty-four second- and third-year residents in a university-based internal medicine residency program. INTERVENTIONS: Twenty-two residents were assigned to a nonparticipant (control) group, and 22 residents were assigned to a 3-hour teaching skills workshop designed to help them establish a positive learning climate and provide effective feedback to medical students. MEASUREMENTS: Questionnaires completed by medical students and residents that measured the residents' abilities to establish a positive learning climate and provide feedback, their overall teaching skills, and their attitudes toward teaching. RESULTS: Four months after the workshop intervention, workshop participants improved their learning climate and feedback according to student evaluations (p = .02, p = .001, respectively) and resident self-assessments (p = .002, p = .01, respectively) compared with nonparticipants. Overall teaching skills were not significantly changed (p = .20 for student evaluation and p = .09 for self-assessments). Workshop participants also gained more confidence in their teaching (p = .001), and adopted more learner-centered approaches to teaching than did nonparticipants. CONCLUSIONS: A 3-hour instructional workshop is a feasible and effective method to help residents improve their teaching skills, their confidence in teaching, and the approaches they use to teach medical students on the wards.

The paradox of cytokine monitoring-predictor of immunologic activity as well as immunologic silence following cardiac transplantation.

The utility of cytokine monitoring to predict the onset of significant rejection was evaluated in 34 patients following heart transplantation. Serial blood levels of 5 cytokines involved in inflammation and immune activation(IL-1, IL-2, IL-6, IL-8, and TNF) were correlated with clinical outcome and endomyocardial biopsy scores. The majority of patients (68%) experienced a significant rejection during the study period. IL-6 and IL-8 levels were effective markers of significant rejection 2-4 days before diagnosis with EMBX. IL-6 and IL-8 levels of 15 and 1000 pg/ml predicted the onset of rejection with sensitivities of 75% and 66% and specificities of 86% and 76%, respectively. In contrast, IL-6 and IL-8 levels less than 15 and 400 pg/ml predicted a rejection-free course with sensitivities of 91% and 91% and specificities of 81% and 68%, respectively. The remaining cytokines differentiated patients experiencing a clinically unremarkable course from those experiencing mild-to-moderate rejection but did not discriminate rejection severity. IL-6 levels identified steroid and OKT3 resistance within 48 hr of antirejection therapy. IL-6 levels elevated to 197 +/- 20 pg/ml among steroid-resistant patients and normalized to 20 +/- 5 pg/ml among responders. IL-8 levels delineated OKT3 resistance. IL-8 levels rose to 3496 +/- 500 pg/ml among nonresponders, whereas levels fell to 152 +/- 50 pg/ml among responders. This study demonstrates that IL-6 and IL-8 are useful markers of rejection and therapeutic efficacy following heart transplation.

Exogenous lipoid pneumonia.

Exogenous lipoid pneumonia is an uncommon condition resulting from aspirating or inhaling fatlike material, such as mineral oil found in laxatives and various aerosolized industrial materials. These substances elicit a foreign body reaction and proliferative fibrosis in the lung. Because symptoms are absent or nonspecific and the roentgenographic findings simulate other diseases, exogenous lipoid pneumonia is often unrecognized. Yet, appropriate historical inquiries and simple laboratory tests can lead to the correct diagnosis, removal of the offending agent, and, potentially, improvement in lung function before serious complications develop.

Alcoholism: the missed diagnosis.

Physicians fail to recognize the early signs and symptoms of alcoholism in their patients. This results in delays in the proper diagnosis and treatment for alcoholism, the underlying cause for many common complaints. Reasons for missing the diagnosis include inadequate education opportunities for physicians in the field of chemical dependency, the physician's attitude toward alcoholics, and the alcoholic's own denial of his addiction. There are steps that physicians can take to increase their ability to identify alcoholism as the underlying cause of the patient's complaint.

Michigan Alcoholism Screening Test to diagnose early alcoholism in a general practice.

General medical patients can be easily screened for alcohol dependence on a routine basis. The Michigan Alcoholism Screening Test (MAST) is a 24-item yes-no questionnaire concerning alcohol-related behavior. When it was included in the history self-administered to new patients in an internal medicine faculty-resident outpatient practice, it uncovered unsuspected alcohol dependence. The combined questionnaire (health history plus MAST) was given to 351 consecutive new outpatients. Thirteen (4%) were found to have positive MAST scores (greater than 7), indicating alcohol dependence. Nine patients were in the mild dependence range (7 to 20), two in the moderate range (20 to 30), and two in the severe range (30 to 53). All patients with significant MAST scores had complaints related to active drinking. The MAST score directed the physicians' therapeutic efforts in nine of 13 patients; in four the significant MAST score was ignored. The MAST is useful to detect unsuspected alcohol dependence in office practice. When used by faculty and residents trained in recognizing alcohol-related behavior, the test will properly direct therapeutic and rehabilitative efforts for those patients with the primary diagnosis of alcohol dependence.