Assessment of clinical competencies by the foreign medical graduate examination in the medical sciences

A test to assess clinical competence requires the inclusion of a domain consisting of multiple clinical competencies. Although some can be tested in simulated clinical settings with standardized patients, others should not be tested in such integrated clinical encounters because of the limited amount of time that can be allotted in a case‐specific context. This is particularly true of diagnosis/management competencies, which include problem identification and differential diagnosis, interpretation of diagnostic and laboratory procedures, and patient management.

In this study, responses to all 139 multiple‐choice questions (MCQs) addressing diagnosis/management competencies in the July 1989 Day 2 component of the Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS) were compared with the entire Day 2 scores and with the other categories of MCQs in that component. The results show that FMGEMS Day 2 scores are reliable in measuring the ability of examinees to address diagnosis/management competencies.     

Supporting hemodynamics: what should we target? What treatments should we use?

Assessment and monitoring of hemodynamics is a cornerstone in critically ill patients as hemodynamic alteration may become life-threatening in a few minutes. Defining normal values in critically ill patients is not easy, because 'normality' is usually referred to healthy subjects at rest. Defining 'adequate' hemodynamics is easier, which embeds whatever pressure and flow set is sufficient to maintain the aerobic metabolism. We will refer to the unifying hypothesis proposed by Schrier several years ago. Accordingly, the alteration of three independent variables - heart (contractility and rate), vascular tone and intravascular volume - may lead to underfilling of the arterial tree, associated with reduced (as during myocardial infarction or hemorrhage) or expanded (sepsis or cirrhosis) plasma volume. The underfilling is sensed by the arterial baroreceptors, which activate primarily the sympathetic nervous system and renin-angiotensin-aldosterone system, as well as vasopressin, to restore the arterial filling by increasing the vascular tone and retaining sodium and water. Under 'normal' conditions, therefore, the homeostatic system is not activated and water/sodium excretion, heart rate and oxygen extraction are in the range found in normal subjects. When arterial underfilling occurs, the mechanisms are activated (sodium and water retention) - associated with low central venous oxygen saturation (ScvO₂) if underfilling is caused by low flow/hypovolemia, or with normal/high ScvO₂ if associated with high flow/hypervolemia. Although the correction of hemodynamics should be towards the correction of the independent determinants, the usual therapy performed is volume infusion. An accepted target is ScvO₂ >70%, although this ignores the arterial underfilling associated with volume expansion/high flow. For large-volume resuscitation the worst solution is normal saline solution (chloride load, strong ion difference = 0, acidosis). To avoid changes in acid-base equilibrium the strong ion difference of the infused solution should be equal to the baseline bicarbonate concentration.     

Rational fluid management in today's ICU practice

Intravenous fluid therapy has evolved significantly over time. From the initial report of the first intravenous administration of sodium-chloride-based solution to the development of goal-directed fluid therapy using novel dynamic indices, efforts have focused on improving patient outcomes. The goal of this review is to provide a brief overview of current concepts for intravenous fluid administration in the ICU. Results of recently published clinical trials suggesting harmful effects of starch-based solutions on critically ill patients are discussed. Concepts for goal-directed fluid therapy and new modalities for the assessment of fluid status as well as for the prediction of responsiveness to different interventions will continue to emerge. Advances in technology will have to be critically evaluated for their ability to improve outcomes in different clinical scenarios.