An Evaluation of Cost and Appropriateness of Care as Recommended by Candidates on a National Clinical Skills Examination

Background: The National Board of Osteopathic Medical Examiners administers the COMLEX-USA Level 2-PE, an assessment of clinical skills of osteopathic medical students. This evaluation includes developing a patient care plan. Purpose: Based on one simulated case, we investigated the appropriateness and cost of care and quantified their relationship to performance. Methods: Four hundred sixty-seven postencounter notes were coded for appropriateness using expert physician judgments and for cost of care using Centers for Medicare and Medicaid Services data. Various outcome measures were correlated with physician scores. Results: In this case, candidates recommended an average of 5.6 interventions with an average cost of $227 and appropriateness rating of 2.4 on a 1 (indicated) to 4 (potentially dangerous) scale. Total cost and inappropriateness of actions were negatively correlated with candidate scores (r = ?.208, p < .0001 and r = ?.318, p < .0001, respectively). Conclusions: Results from this investigation provide some evidence to support the validity of physician note ratings of patient care plans and demonstrate the need to include these principles in medical education.     

Therapeutic leukocytapheresis for improvement in respiratory function in a woman with hyperleukocytosis and mantle cell lymphoma with a circulating small lymphocyte phenotype

Mantle cell lymphoma is an aggressive malignant B‐cell disorder that often presents with a leukemic picture. Circulating lymphoma cell morphology may vary from small round mature‐appearing lymphocytes resembling the lymphocytes of chronic lymphocytic leukemia to large prolymphocytoid or blastoid cells. Rare reports of hyperleukocytosis with leukostasis, treated with leukocytapheresis, are described in patients with prolymphocytoid or blastoid morphology. We report an 88 year old woman with mantle cell lymphoma, hyperleukocytosis (WBC > 400 × 10³/µL) with severe respiratory compromise but without interstitial or alveolar infiltrates on radiograph or computerized tomography of the chest. She was afebrile and had no central nervous system signs. Circulating lymphoma cell morphology was predominantly of the small lymphocyte type. A two‐whole‐blood‐volume leukocytapheresis reduced her WBC from 465 to 221 × 10³/µL in 150 min. Her respiratory rate decreased from 28/min to 18/min and her arterial oxygen saturation (SpO₂) rose from 91% to 97% on 6 L/min of oxygen by nasal cannula. Severe breathlessness before the procedure abated completely by the end of the procedure. Respiratory compromise may occur in mantle cell lymphoma with hyperleukocytosis with a mature lymphoma cell phenotype, even without a clear picture of leukostasis. Although the ultimate survival of the patient depends on treatment with chemotherapy, leukocytapheresis for alleviation of symptoms may be warranted and should be considered. Respiratory status and response to leukocytapheresis should be documented with physiological measurements. J. Clin. Apheresis 31:398–402, 2016. © 2015 Wiley Periodicals, Inc.     

Are anti-Chlamydia pneumoniae antibodies prognosis indicators for peripartum cardiomyopathy?

BACKGROUND: The authors recently pointed out an epidemiological relation between specific anti-Chlamydia pneumoniae antibodies and peripartum cardiomyopathy in Niamey (Republic of Niger). DESIGN: In this work, they studied the prognosis value of such specific antibodies. METHODS: The serological status for specific IgG, IgA and IgM anti-C. pneumoniae antibodies of 50 African women (age, mean+/-SD = 30.2 +/- 7 years) hospitalized in Niamey, with peripartum cardiomyopathy, was determined at the time of diagnosis. The diagnosis was categorized as 'complete remission' (13 patients, age = 29.3 +/- 6.5 years, observation delay = 27 months), 'incomplete remission' (27 patients, age = 30.7 +/- 7.6 years, observation delay = 14 months) and 'deceased' (10 patients, age = 30.3 +/- 6.2 years, observation delay = 13 months). The control group comprised 27 African women (age = 25.2 +/- 4.6 years), living in the same area. The Mann-Whitney and Fisher's exact tests were used for the statistical comparison. RESULTS: The dilution of IgG specific anti-C. pneumoniae antibodies was higher (P = 0.047) in the 'incomplete remission' compared with 'complete remission'. The dilution of IgA specific anti-C. pneumoniae antibodies was higher (P = 0.033) in the patients with a severe evolution ('deceased' + 'incomplete remission') compared with 'complete remission'. There was no significant difference between patients in 'complete remission' compared with 'controls'. CONCLUSIONS: At the time of peripartum cardiomyopathy diagnosis the specific IgG and IgA anti-C. pneumoniae antibodies are of prognosis value: a high dilution is more often associated with a poor prognosis. This is the first identified prognosis factor during the precocious evolution of peripartum cardiomyopathy.