Compression-only CPR saves more lives

Chest compressions alone may be more effective than standard cardiopulmonary resuscitation (CPR) for cardiac arrest patients in out-of-hospital setting, according to a Japanese study.

In the study, 46 percent of patients who received compression-only CPR were alive a month after cardiac arrest compared with 39.9 percent of those who received standard CPR with rescue breathing. Moreover, those who received compression-only CPR were 40.7 percent more likely to preserve brain function (as measured on a 5-point cerebral performance scale) compared with 32.9 percent in those receiving conventional CPR. [Circulation 2012;126:2844-2851]

“The data suggest that compression-only CPR should be the standard and conventional CPR with rescue breathing the option,” said lead investigator Dr. Taku Iwami from the department of preventive services in Kyoto University School of Public Health, Japan.

Iwami and colleagues reviewed the records of 1,376 individuals who had sudden cardiac arrests of presumed cardiac origin over a 5-year period. Each of them received CPR from bystanders followed by shocks using publicly-accessed defibrillators.

Among the study cohort, 37 percent received compression-only CPR while 63 percent received standard CPR. Prior to hospital admission, spontaneous circulation returned in 50.2 percent of patients receiving compression-only CPR and in 40.5 percent of those receiving standard CPR (p<0.001).

“This goes to show that the combination of early defibrillation and compression-only CPR by bystanders is the best way to save lives after sudden cardiac arrests,” the authors said.

Chest compressions alternating with rescue breathing remains the standard for trained rescuers. However, recommendation for untrained rescuers switched to only chest compressions regardless of emergency dispatch assistance in 2010. This was because rescue breathing is difficult to perform and can interrupt chest compressions, said Iwami.

Despite this, many people are still hesitant to perform CPR with rescue ventilation for fear they may do more harm to the patient. What they are not aware of is that chest compressions, even by those who are not trained in conventional CPR, can help a patient maintain blood flow to the heart and brain until a defibrillator gets the heart pumping again.

“We need to encourage chest compression-only CPR and public access defibrillation programs,” Iwami said. “Doing something is better than nothing.”

Dr. Michael Sayre of the University of Washington in Seattle, US, and spokesperson for the American Heart Association, said many people are dying from cardiac arrest because family members and friends are unsure how to help. The findings confirm that hands-on CPR is highly effective and is easy to do, he added.http://www.mims.com/Indonesia/pub/topic/Medical%20Tribune/2013-03/Compression-only%20CPR%20saves%20more%20lives?token=rnp4v0BfyQa5o3iSS1Uv5Ry6TWCP4H8SXzFN8QDJQWvspgHFYCA8hAPu41olpOmW3vr%2fgB8gvkMKWl5SuULZGmQWwSayeXpIXCS0PgyyJYA37UHiZeai7pULdfk67aMbyr4GUpBdzlxkw4CvmSbxxQBuSqfkGE%2bgDS3Mp3ngH19ooURzIC3fBUmjr9T%2fF8KG7W6FpzNyjIGc%2fz8vGlQyPD9%2fZLCzJJGnJNg844f%2b2GA%3d

Selenium supplementation for the primary prevention of cardiovascular disease

Background: Selenium is a key component of a number of selenoproteins which protect against oxidative stress and have the potential to prevent chronic diseases including cardiovascular disease (CVD). However, observational studies have shown inconsistent associations between selenium intake and CVD risk; in addition, there is concern around a possible increased risk of type 2 diabetes with high selenium exposure.

Objectives:To determine the effectiveness of selenium only supplementation for the primary prevention of CVD and examine the potential adverse effect of type 2 diabetes. 

Search methods: The following electronic databases were searched: the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 10 of 12, October 2012) onThe Cochrane Library; MEDLINE (Ovid) (1946 to week 2 October 2012); EMBASE Classic + EMBASE (Ovid) (1947 to 2012 Week 42); CINAHL (EBSCO) (to 24 October 2012); ISI Web of Science (1970 to 24 October 2012); PsycINFO (Ovid) (1806 to week 3 October 2012); Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database and Health Economics Evaluations Database (Issue 4 of 4, October 2012) on The Cochrane Library. Trial registers and reference lists of reviews and articles were searched and experts in the field were approached. No language restrictions were applied.

Selection Criteria: Randomised controlled trials on the effects of selenium only supplementation on major CVD end-points, mortality, changes in CVD risk factors, and type 2 diabetes were included both in adults of all ages from the general population and in those at high risk of CVD. Trials were only considered where the comparison group was placebo or no intervention. Only studies with at least three months follow-up were included in the meta-analyses, shorter term studies were dealt with descriptively.

Data collection and analysis: Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information.

Main results: Twelve trials (seven with duration of at least three months) met the inclusion criteria, with 19,715 participants randomised. The two largest trials that were conducted in the USA (SELECT and NPC) reported clinical events. There were no statistically significant effects of selenium supplementation on all cause mortality (RR 0.97, 95% CI 0.88 to 1.08), CVD mortality (RR 0.97, 95% CI 0.79 to 1.2), non-fatal CVD events (RR 0.96, 95% CI 0.89 to 1.04) or all CVD events (fatal and non-fatal) (RR 1.03, 95% CI 0.95 to 1.11). There was a small increased risk of type 2 diabetes with selenium supplementation but this did not reach statistical significance (RR 1.06, 95% CI 0.97 to 1.15). Other adverse effects that increased with selenium supplementation, as reported in the SELECT trial, included alopecia (RR 1.28, 95% CI 1.01 to 1.62) and dermatitis grade 1 to 2 (RR 1.17, 95% CI 1.0 to 1.35). Selenium supplementation reduced total cholesterol but this did not reach statistical significance (WMD - 0.11 mmol/L, 95% CI - 0.3 to 0.07). Mean high density lipoprotein (HDL) levels were unchanged. There was a statistically significant reduction in non-HDL cholesterol (WMD - 0.2 mmol/L, 95% CI - 0.41 to 0.00) in one trial of varying selenium dosage. None of the longer term trials examined effects on blood pressure. Overall, the included studies were regarded as at low risk of bias.

Authors' conclusions: The limited trial evidence that is available to date does not support the use of selenium supplements in the primary prevention of CVD.

Clinical Summary

Diet is a key factor in a person’s risk of cardiovascular disease and selenium is one of the dietary elements that might play a role in reducing this risk. It is a key component of a number of selenoproteins, which protect against oxidative stress and have the potential to prevent chronic diseases, including cardiovascular disease. However, observational studies have shown inconsistent associations between selenium intake and cardiovascular disease, and concerns have been raised about a possible increased risk of type 2 diabetes with high selenium exposure.

Use of selenium enriched foods, supplements and fertilizers has increased in recent years in many countries because of the perception that selenium may reduce the risk of cardiovascular disease and other chronic conditions. Therefore, it is important to understand the effects of a nutrient that is so frequently supplemented, and this needs to be done for both the potential benefits on cardiovascular disease and the potential harms on diabetes. This Cochrane Review received funding from the National Institute for Health Research’s systematic review programme in the UK in order to examine the effects of providing selenium supplements to healthy adults as a means of preventing the occurrence of cardiovascular disease. This was a primary aim of the review but it also included an assessment of whether selenium supplements would reduce risk factors associated with cardiovascular disease, but found that the evidence was too limited to look at this properly.

The review found 12 trials in which nearly 20,000 healthy adults were randomly assigned to receive either selenium supplements or a placebo. Overall, the included studies were regarded as at low risk of bias. The vast majority of participants were men living in the USA, where people are already well nourished and obtain large amounts of selenium from natural foods. Furthermore, most of these men were in just two of the trials: SELECT and NPC, with SELECT having been set up as a trial of the effects of selenium supplementation on cancer.

Considering the main results selenium supplements did not lead to any statistically significant difference in the risk of death due to cardiovascular disease or any other cause when compared to taking a placebo. There was also no effect detected on the occurrence of non-fatal cardiovascular disease events

The possibility of an adverse effect of increasing the risk of type 2 diabetes, which has been suggested in some previous studies, could not be ruled out by the analyses that were possible in the review. Supplements were associated with a small increase in risk, but this was not statistically significant. Minor side effects reported in the largest trial included hair loss and skin problems.

In summary, the authors conclude that the limited evidence available at this time does not support the use of selenium supplements as a means of preventing cardiovascular disease in healthy people. They suggest that taking selenium supplements is probably neither beneficial nor harmful, but would like to see more evidence before being confident that there is not a small increased risk of type 2 diabetes.

They also emphasise how most of the current evidence on selenium and cardiovascular disease comes from American adults, who are already getting adequate levels of selenium in their daily diets. This means that the trials they reviewed involved healthy people rather than those who might be predisposed to selenium deficiency and they call for research into the effects of selenium supplements in less well nourished populations, where dietary intake of the element is lower. However, based on the current evidence, their bottom line is that the indiscriminate and widespread use of selenium supplements for the prevention of cardiovascular disease in people with adequate or high selenium status is not justified and should not be encouraged.

http://www.cochranejournalclub.com/selenium-for-cardiovascular-disease-clinical/

Human Papillomavirus Vaccination History Among Women With Precancerous Cervical Lesions: Disparities and Barriers

Human Papillomavirus Vaccination History Among Women With Precancerous Cervical Lesions: Disparities and Barriers

Mehta, Niti R. MPH; Julian, Pamela J. MPH; Meek, James I. MPH; Sosa, Lynn E. MD; Bilinski, Alyssa; Hariri, Susan PhD; Markowitz, Lauri E. MD; Hadler, James L. MD, MPH; Niccolai, Linda M. PhD

Abstract

OBJECTIVE: To estimate racial, ethnic, and socioeconomic differences in human papillomavirus (HPV) vaccination history among women aged 18–27 years with precancerous cervical lesions diagnosed, barriers to vaccination, and timing of vaccination in relation to the abnormal cytology result that preceded the diagnosis of the cervical lesion.

METHODS: High-grade cervical lesions are reportable conditions in Connecticut for public health surveillance. Telephone interviews and medical record reviews were conducted during 2008–2010 for women (n=269) identified through the surveillance registry.

RESULTS: Overall, 43% of women reported history of one or more doses of HPV vaccine. The mean age at vaccination was 22 years. Publicly insured (77%) and uninsured (85%) women were more likely than privately insured women (48%) to report no history of vaccination (P<.05). Among unvaccinated women, being unaware of HPV vaccine was reported significantly more often among Hispanics than non-Hispanics (31% compared with 13%,P=.02) and among those with public or no insurance compared with those with private insurance (26% and 36% compared with 6%, P<.05 for both). The most commonly reported barrier was lack of provider recommendation (25%). Not having talked to a provider about vaccine was reported significantly more often among those with public compared with private insurance (41% compared with 18%, P<.001). Approximately 35% of women received vaccine after an abnormal cytology result; this occurred more frequently among African American women compared with white women (80% compared with 30%, P<.01).

CONCLUSION: Catch-up vaccination strategies should focus on provider efforts to increase timely coverage among low-income and minority women.

LEVEL OF EVIDENCE: III

Obstetrics & Gynecology:

March 2012 - Volume 119 - Issue 3 - p 575–581

doi: 10.1097/AOG.0b013e3182460d9f

Original Research

Diet Rich in Antioxidants May Cut Stroke Risk

December 2, 2011 — Women who eat an antioxidant-rich diet may significantly cut their stroke risk, particularly those without a history of cardiovascular disease (CVD), new research suggests.

The prospective study found that women with no history of CVD who consumed the highest amount of antioxidants in foods such as fruit, vegetables, tea, whole grains, and chocolate had a 17% lower risk for strokes than those who ate the least amount. Among women with a history of CVD, those who consumed the most antioxidants had a 45% lower risk for hemorrhagic strokes.

"This study suggests that eating a diet rich in antioxidants, especially from fruits and vegetables, may be of importance for stroke prevention," lead author Susanne Rautiainen, MSc, a PhD student at Karolinska Institutet, Sweden, told Medscape Medical News.

The study was published online December 1 in Stroke: Journal of the American Heart Association.

Antioxidant Capacity

Researchers used the Swedish Mammography Cohort, a database that includes women born from 1914 to 1948 in the counties of Uppsala and Västmanland, Sweden. The cohort contained 36,715 women who were followed up from September 15, 1997, to December 31, 2009. A 1997 questionnaire on diet, education, weight, height, and potential risk factors for stroke served as a baseline for the analysis.

Investigators calculated the total antioxidant capacity (TAC) in the diet, using a database of the most common foods. "The TAC does not identify specific antioxidants, but rather, it measures the entire antioxidant network, including all present antioxidants, and takes into account the synergistic effects between compounds," explained Ms. Rautiainen.

The researchers analyzed the 31,035 women who were free of CVD at baseline separately from the 5680 women with a history of CVD. Members of the CVD-free cohort were categorized into quintiles, and those with a CVD history into quartiles, of dietary TAC.

From the Swedish Hospital Discharge Registry, researchers identified 1322 strokes among CVD-free women and 1007 strokes among those with a history of CVD. Risk was adjusted for age; education; smoking; body mass index; physical activity; hypertension; hypercholesterolemia; diabetes; family history of myocardial infarction; aspirin use; dietary supplement use; and intakes of total energy, alcohol, and coffee.

The researchers report that among the CVD-free women, those in the highest quintile of dietary TAC had a statistically significant 17% lower risk for total stroke compared with women in the lowest quintile (hazard ratio, 0.83; 95% confidence interval, 0.70 - 0.99; P = .04).

Dietary TAC was inversely associated with both cerebral infarction and hemorrhagic stroke, although these results were not statistically significant.

Fruits and vegetables contributed about 50% of TAC. Other contributors included whole grains (18%), tea (16%), and chocolate (5%).

CVD Subgroup

In the CVD subgroup, women in the highest quartile of dietary TAC had a significant 45% lower risk for hemorrhagic stroke compared with those in the lowest quartile (adjusted hazard ratio, 0.55; 95% confidence interval, 0.32 - 0.95; P = .03). However, there was no association with total stroke.

In this subgroup, women in the lowest TAC quartile might have been more likely to have a history of stroke, and therefore be more likely to get a hemorrhagic stroke, although the inverse association remained after adjusting for history of stroke, said Ms. Rautiainen.

"Women with a CVD history may control their blood pressure or change their lifestyles because of knowledge of their disease," she speculated. "This might have produced a spurious inverse association between TAC of diet and risk of hemorrhagic stroke."

The findings of this study seem to conflict with those of previous research that failed to show beneficial effects of antioxidant supplements on stroke risk. "The contradiction may be explained by the fact [that] these studies looked at high doses of single antioxidants, whereas we aimed to examine antioxidant intake by taking into account all antioxidants present in the diet, including thousands of compounds, in doses obtained from a usual diet," said Ms. Rautiainen.

Oxidative stress may be at the root of some strokes, as the body may be unable to neutralize cell-damaging free radicals, which can lead to inflammation and vascular damage, said Ms. Rautiainen.

How might antioxidant-rich foods reduce this stroke risk? According to Ms. Rautiainen, vitamins C and E, carotenoids, flavonoids, and other such compounds scavenge free radicals, thereby inhibiting oxidative stress. "Antioxidants, especially flavonoids, may also help improve endothelial function and reduce blood clotting, blood pressure, and inflammation," she said.

The next step for the research team is to see whether TAC intake is associated with CVDs other than stroke, she concluded.

Overall Strengths

Approached for comment, Louise D. McCullough, MD, PhD, from the Department of Neurology and the Department of Neuroscience, University of Connecticut Health Center, and the Stroke Center at Hartford Hospital, said the study's overall strengths were its size and the fact that the cohort was followed up for such a long time.

"This is by far the biggest and most complete trial that's been done," she said.

The results confirm what has been long suspected: "People have known from retrospective trials and correlative studies that antioxidants in fruits and vegetables, etc, reduce stroke risk," said Dr. McCullough. "This confirms it in a prospective trial."

She pointed out that eating a healthy, antioxidant-rich diet is associated with other healthy behaviors. "People who tend to eat healthier tend to also have healthier lifestyles as a whole, but even controlling for that, in this large population it does seem that the diet had an independent beneficial effect on stroke incidence."

Dr. McCullough noted that the reduced risk among healthy women "wasn't a huge change in risk" in terms of absolute numbers, but she emphasized that reducing stroke risk by incorporating more antioxidant-rich foods in the diet is relatively easy to do.

The study was supported by the Swedish Research Council for Infrastructure and the Swedish Council for Working Life and Social Research. The authors have disclosed no relevant financial relationships.http://www.medscape.com/viewarticle/754618

Spotlight on Specialties-Neurology

Spotlight on Specialties-Neurology

Nature of the Work
Neurologists focus on the diagnosis and treatment of diseases and/or impaired function of the brain, spinal cord, peripheral nerves, autonomic nervous system, and muscles. Therefore they may be involved in dealing with tumors of the PNS and CNS, degenerative disorders of the nervous system, strokes, as well as various multi-systemic disorders that affect the nervous system. Neurologists may sub-specialize in:

• Child Neurology
• Clinical Neurophysiology, using clinical evaluation and electrophysiology tests such as EEG, EMG and nerve conduction studies
• Pain Medicine, providing advanced care to patients suffering acute, chronic or cancer pain

Training
One year of internship with a minimum of eight months in Internal Medicine, plus 3 years of neurology residency. Sub-specialization requires an additional 1-3 years of fellowship training.

Demand/Salary
The Bureau of Labor Statistics indicates that supply and demand is currently in rough balance in this specialty and likely to remain so for at least the next few years. The annual salary for a neurologist ranges from $152,000 to $221,000.

For More Information
Visit any of the following organizational websites:

• American Academy of Neurology www.aan.com
• American Board of Psychiatry & Neurology www.abpn.com
• American Neurological Association www.aneuroa.org

Choosing Action Over Reaction

Steven R. Daugherty, Ph.D.
Director, Education and Testing
Kaplan Medical

We all like to know and feel confident that we know. We load our brains with facts and details to be sure that we have the ones we need when we need them. Learning begins with exposure to important details and sets before us the task of making these details our own. On exams, we prove to ourselves and others what we have learned by being able to state the relevant fact when it is called for. In short, we see; we respond. And having the right response gives us the feeling of competence and satisfaction of mastery.

But this kind of learning, this sort of knowing, has one strong limitation. We are only able to respond to what we have already seen. When confronted with something novel, we are unlikely to have the required response. In the face of uniqueness, we search our responses and find ourselves deficient. The sense of deficit leads to uncertainty, uncertainty to frustration, and frustration to paralysis. In this situation we see, but do not know how to respond, and our sense of mastery dissolves to leave us with a growing fear of incompetence.

At its best, the USMLE* confronts you with things you may have never encountered and asks you to look at things in ways you may not have anticipated. Even those students who have studied well and taken in a host of details often find themselves surprised, and consequently frustrated. Many students try to overcome this by seeking to find out as much as they can about what has been tested and how it have been presented on previous exams. But this strategy inevitably comes up short. New questions are constantly being developed and novel presentations are continually being invented. Students who focus on what has been tested in the past will find themselves behind what is being tested in the present.

Doing well on the USMLE, therefore, depends not so much on having the right responses memorized, but being able to reorganize those acquired responses and refashion them to solve a new, unanticipated problem. Knowledge is the springboard for answering USMLE questions. But being able to reconstitute and think with that knowledge is the actual leap that carries you to success. Success depends not so much on having a pre-programmed reaction, but on being able to stop, think, and select the right action to respond to the novel situation presented. Mastering the exam rests not on programming your reactions to the questions you encounter, but on learning the right mental actions you take to arrive at the best solution. Thinking, not knowing, is the key.

The mental processes here are far more complex than the simple stimulus-response of a reaction. USMLE requires us to make new responses on the spot to cope with fresh, unanticipated scenarios. This is not mere temporal lobe recall, but frontal lobe problem-solving. The central issue is not do you know the right facts, but can you do the thought processes required to find the best answer.

But, having the right cognitive processes is just half the battle. Optimal performance also requires the proper emotional state. The question is, can you maintain your confidence long enough to let this essential problem-solving cognitive processes happen before uncertainty opens the door to anxiety and emotional escalation? The virtue of a pre-wired response is that it fixes emotionality. A pre-wired reaction means that little time is available for self-doubt, and that emotions remain in contained. Thinking takes time and doing the thinking that action requires allows time for emotions to run free elevate to a level of performance interfering anxiety.

As always, the secret to mastering the thought processes required by the USMLE is practice. Not practice in memorizing content, but practice at using that content in exam-parallel problem-solving situations. Mastering these thought processes means that you will have the essential skill the exam requires, but also that you will have the confidence that you can handle whatever the exam may throw at you. In the end confidence comes not from a sense of knowing everything (something that is not humanly possible), but in a practiced ability to think on your feet and arrive at a best solution to a any presented problem. The solution comes from thinking, not from knowing. And self-confidence arises from the ability to act to solve any problem, not merely from having the right pre-programmed reaction.

Remember that the USMLE is not only testing to see is you have the knowledge required to be a physician, but whether or not you can make use of that knowledge the way a physician’s have to use it. Knowing facts, but not knowing how to solve the problems that patient’s present makes you smart, but ineffective. What separates physicians from simple technicians, what makes you a professional, is that you know more than how to react to set scenarios, but that you can think and derive the right course of action to whatever situations you encounter. Knowledge is the foundation, but being able to think and apply that knowledge is what truly makes you a physician.

Can You Name It?

Mechanism of Action:

• This is a synthetic version of a substance made and released by the thyroid gland
• It is converted intracellularly to a substance that enters the nucleus, and binds to a receptor protein, leading to increased production of mRNA and protein synthesis.

Indications:

• This agent is indicated as replacement or supplemental therapy in congenital or acquired hypothyroidism of any etiology, except transient hypothyroidism during the recovery phase of subacute thyroiditis.
  Specific indications: primary (thyroidal), secondary (pituitary), and tertiary (hypothalamic) hypothyroidism and subclinical hypothyroidism.
• This agent is also indicated in the treatment or prevention of various types of euthyroid goiters.

Route of Administration:

• Oral Tablets – Strength in mcg (25, 50 75, 88, 100, 112, 125, 137, 150, 175, 200, 300)
• Parenteral: 200, 500 mcg/vial

Selected Adverse Effects:

• Cardiac: Palpitations, tachycardia, cardiac arrhythmias, angina
• CNS: Tremors, headache, nervousness, insomnia
• GI: Nausea, vomiting, diarrhea
• Miscellaneous: Weight loss, fever, menstrual irregularities

Selected Drug-Drug Interactions (Drug + Other medication =):

• + Cholestyramine = Dramatic decrease in drug absorption
• + Estrogens = Increased estrogen levels
• + Anticoagulants = Increased anticoagulant effect
• + Beta-Blockers = Decreased beta-blocker effect
• + Digoxin = Decreased digoxin levels
• + Theophylline = Decreased theophylline clearance in hypothyroid patients
• + "Fasting" = Increased drug absorption
• + Food = Decreased drug absorption

Special Considerations:

• Contraindications: Hypersensitivity to this product; thyrotoxicosis uncomplicated by hypothyroidism and the presence of BOTH hypothyroidism & hypoadrenalism
• Warnings/Precautions:
  • Obesity: Use in euthyroid patients is ineffective and may cause serious life-threatening toxicity, especially when given with sympathomimetic amines (such as anorexiants).
  • Cardiovascular disease
  • Endocrine disorders (Diabetes mellitus or insipidus; adrenal insufficiency (Addison disease)
    • Exacerbation of the intensity of symptoms of these disorders may occur
  • Pregnancy category A
  • Decreased bone density
  • Tartrazine sensitivity
  • Monitoring: Periodic assessment of the patient’s thyroid status can be achieved by means of appropriate laboratory tests

Drug of the Month: Levothyroxine sodium (Synthroid ®)


Endocrine Enigma

A 34-year-old woman presents to her doctor with complaints of anxiety and general nervousness. She states that she had been in her usual state of health until 3 weeks ago when she caught a cold. On physical examination, she is a slender, anxious-appearing female. The only significant physical finding is slight tenderness during examination of the neck. This pain is made worse when she swallows. Thyroid function tests are drawn, revealing high serum T3 and T4, and low TSH. Antibody assays are pending. Which of the following is the most likely diagnosis?

(A) De Quervain thyroiditis
(B) Graves disease
(C) Hashimoto thyroiditis
(D) Lymphocytic thyroiditis
(E) Myxedema


The correct answer to the question above is: A.

1. CORRECT: Subacute granulomatous thyroiditis is a painful inflammation of the thyroid gland. It is thought to be secondary to a direct viral infection or a postviral inflammatory phenomenon. The inflammatory process leads to the release of the stored thyroid hormone from the follicles. The patient has increased levels of T3 and T4. TSH is down-regulated. This is usually a self-limited disorder that may or may not be followed by transient hypothyroidism. The classic clinical features are painful postviral hyperthyroidism. The pain is exacerbated by swallowing. Patients are anxious, emotionally labile, and have heat intolerance.
2. Graves disease is characterized by the gradual development of hyperparathyroidism and an ophthalmopathy.
3. In Hashimoto thyroiditis, patients are hypothyroid.
4. Lymphocytic thyroiditis is painless.
5. Myxedema results from long standing hypothyroidism.

One Tool to Use in Assessing the Quality of Internal Medicine Residency Programs

One Tool to Use in Assessing the Quality of Internal Medicine Residency Programs

If you plan to apply for training in Internal Medicine, there is a website that you should know about. The American Board of Internal Medicine (ABIM) site publishes the passing rates for all accredited Internal Medicine training programs, and the information is searchable by state. Because passing rates on the specialty certifying board examination is one measure of the quality of the training provided to residents by programs, this is very useful in researching specific programs in order to determine if the residents trained by that program were properly prepared to pass their IM specialty boards. While factors outside of the control of a program can sometimes affect passing rates, prospective applicants to programs should investigate the success of programs in preparing their residents to become board certified, and this online searchable database provides an important tool for doing exactly that. Once you have identified Internal Medicine programs that you are interested in and are considering applying to, visit the following website to locate the IM Board pass rates for each program.

http://www.abim.org/resources/states/

The ABIM database contains information about the internal medicine certifying examination performance of programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). For each residency program listed, the American Board of Internal Medicine (ABIM) reports the cumulative pass rate for the 2002 to 2004 certifying examinations in internal medicine.

What data are reported?
For each program, the number of candidates that took the examination, the number who passed, the percent that passed, and the 95% confidence interval is given.

Which residents are included in the calculation of a program's pass rate?
Candidates are included in the computation of a program's passing rate if they meet the following four conditions:

1. They are first takers of the 2002, 2003, or 2004 certifying examinations in internal medicine (repeat takers are excluded)
2. They completed training in the year of or the year before the first attempt (i.e., a candidate who took the 2004 certifying examination for the first time must have completed training in 2003 or 2004)
3. The final year of training is in internal medicine or a combined training program such as pediatrics and medicine
4. Candidates must have received their satisfactory final evaluation of clinical competence from the training program