Chilblain lupus erythematosus mimicking acrofacial vitiligo

Chilblain lupus erythematosus with depigmentation is a rare presentation of lupus erythematosus that may simulate vitiligo. A 52-year-old lady with such a manifestation is being reported.     

Does Residency Selection Criteria Predict Performance in Orthopaedic Surgery Residency?

Background

More than 1000 candidates applied for orthopaedic residency positions in 2014, and the competition is intense; approximately one-third of the candidates failed to secure a position in the match. However, the criteria used in the selection process often are subjective and studies have differed in terms of which criteria predict either objective measures or subjective ratings of resident performance by faculty.

Questions/purposes

Do preresidency selection factors serve as predictors of success in residency? Specifically, we asked which preresidency selection factors are associated or correlated with (1) objective measures of resident knowledge and performance; and (2) subjective ratings by faculty.

Methods

Charts of 60 orthopaedic residents from our institution were reviewed. Preresidency selection criteria examined included United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores, Medical College Admission Test (MCAT) scores, number of clinical clerkship honors, number of letters of recommendation, number of away rotations, Alpha Omega Alpha (AOA) honor medical society membership, fourth-year subinternship at our institution, and number of publications. Resident performance was assessed using objective measures including American Board of Orthopaedic Surgery (ABOS) Part I scores and Orthopaedics In-Training Exam (OITE) scores and subjective ratings by faculty including global evaluation scores and faculty rankings of residents. We tested associations between preresidency criteria and the subsequent objective and subjective metrics using linear correlation analysis and Mann-Whitney tests when appropriate.

Results

Objective measures of resident performance namely, ABOS Part I scores, had a moderate linear correlation with the USMLE Step 2 scores (r = 0.55, p < 0.001) and number of clinical honors received in medical school (r = 0.45, p < 0.001). OITE scores had a weak linear correlation with the number of clinical honors (r = 0.35, p = 0.009) and USMLE Step 2 scores (r = 0.29, p = 0.02). With regards to subjective outcomes, AOA membership was associated with higher scores on the global evaluation (p = 0.005). AOA membership also correlated with higher global evaluation scores (r = 0.60, p = 0.005) with the strongest correlation existing between AOA membership and the “interpersonal and communication skills” subsection of the global evaluations.

Conclusions

We found that USMLE Step 2, number of honors in medical school clerkships, and AOA membership demonstrated the strongest correlations with resident performance. Our goal in analyzing these data was to provide residency programs at large a sense of which criteria may be “high yield” in ranking applicants by analyzing data from within our own pool of residents. Similar studies across a broader scope of programs are warranted to confirm applicability of our findings. The continually emerging complexities of the field of orthopaedic surgery lend increasing importance to future work on the appropriate selection and training of orthopaedic residents.     

Effect of intensive glycemic lowering on health-related quality of life in type 2 diabetes: ACCORD trial

OBJECTIVE

To compare the effect of intensive versus standard glycemic control strategies on health-related quality of life (HRQL) in a substudy of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial.

RESEARCH DESIGN AND METHODS

A randomly selected subsample of 2,053 ACCORD participants enrolled in the HRQL substudy was assessed at baseline and 12-, 36-, and 48-month visits. HRQL assessment included general health status (the 36-Item Short Form Health Survey [SF-36]), diabetes symptoms (the Diabetes Symptom Distress Checklist), depression (Patient Health Questionnaire [PHQ]-9), and treatment satisfaction (Diabetes Treatment Satisfaction Questionnaire [DTSQ]). Repeated-measures ANOVA models were used to estimate change in HRQL outcomes by treatment group over 48 months adjusting for model covariates. The effects of early discontinuation of the ACCORD intensive glycemic control arm on study results were explored.

RESULTS

A total of 1,956 (95%) completed the self-report HRQL instrument(s) at baseline. The intensive arm had a larger decrease in SF-36 physical health component score than the standard arm (−1.6 vs. −1.1, P = 0.0345). Treatment satisfaction (DTSQ) showed larger improvement with intensive than standard (P = 0.0004). There were no differences in mean scores of the Diabetes Symptom Checklist and PHQ-9. Effects of participant transition following discontinuation of the intensive arm on HRQL were not significant.

CONCLUSIONS

The ACCORD trial strategy of intensive glycemic control did not lead to benefits in HRQL and was associated with modest improvement in diabetes treatment satisfaction. Thus patient acceptability was apparently not compromised with intensive and complex interventions such as those used in ACCORD.The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study was a multicenter randomized controlled treatment trial testing independent effects of two strategies of control of blood glucose, blood pressure, and lipids on cardiovascular disease (CVD) in patients with type 2 diabetes (1). The glycemia trial randomized 10,251 participants with type 2 diabetes to intensive (goal HbA_1c <6%) or standard therapies (goal HbA_1c 7.0–7.9%). All participants were also randomized to the blood pressure or lipid trial arms. An ACCORD substudy focused on health-related quality of life (HRQL) outcomes associated with intensive versus standard glycemic control strategies (2). The rationale for the HRQL substudy was the need to consider the impact or potential benefit of intensive glycemia management from the participants’ point of view. Diabetes is known to be associated with decrements in HRQL from functional limitations, restrictions in normal activities, work limitations, poor general health, and depression (3–6) and from symptom distress such as excessive thirst, frequent urination, fatigue, and neuropathies (7–11). Patients with diabetes commonly suffer from psychological disturbances such as depression, anxiety, and social withdrawal (12,13). Thus potential treatment benefits of improved diabetes control and reduced risk for vascular diseases could have broad HRQL benefit. Short-term effects of HbA_1c level on HRQL have been reliably shown (3); however, few longitudinal studies have examined HRQL in the context of intensive glycemic control. The potential impact of treatment complexity on daily life with diabetes is also important to consider (5,14,15). In ACCORD the intensive glycemia target of HbA_1c <6% places a greater burden on the patient in terms of self-management, pharmacologic intensification, and office visits. Additionally the potential for side effects must be weighed. Thus this report addresses a secondary objective of the ACCORD trial to investigate the effects of glycemic control strategy on patient appraisal of general health, symptoms, depression, and treatment satisfaction.