The discontinuation of the United States Medical Licensing Examination Step 2 Clinical Skills Examination emphasizes the need for other reliable standardized assessments of medical student clinical skills. For 30 years, the California Consortium for the Assessment of Clinical Competence (CCACC) has collaborated in the development of clinical skills assessments and has become a valuable resource for clinicians, standardized patient educators, psychometricians, and medical educators. There are many merits to strong multi-institutional partnerships, including the integration of data across multiple schools to provide feedback to both students and curricula, pooled test performance statistics for analysis and quality assurance, shared best practices and resources, individual professional development, and opportunities for research and scholarship. The infrastructure of the CCACC allows member schools to adapt to a changing medical landscape, from emerging trends in clinical medicine to the limitations imposed by a global pandemic. In the absence of a national examination, there is now a greater need for all medical schools to develop a comprehensive, dynamic, and psychometrically sound assessment that accurately evaluates clinical skills. Medical schools working together in regional consortia have the opportunity to create and implement innovative and robust assessments that evaluate a wide range of clinical skills, ensure that medical students have met an expected level of clinical competency before graduation, and provide a framework that contributes to ongoing efforts for the development of new national clinical skills standards.

BackgroundThere are limited data on structural heart disease among people living with HIV in southern Africa, where the success of antiretroviral therapy (ART) has drastically improved life expectancy and where risk factors for cardiovascular disease are prevalent.MethodsWe performed a cross-sectional study of screening echocardiography among adults (≥18 years) with HIV in Malawi presenting for routine ART care. We used univariable and multivariable logistic regression to evaluate correlates of abnormal echocardiogram.ResultsA total of 202 individuals were enrolled with a median age of 45 years (IQR 39–52); 52% were female, and 27.7% were on antihypertensive medication. The most common clinically significant abnormality was left ventricular hypertrophy (LVH) (12.9%, n=26), and other serious structural heart lesions were rare (<2% with ejection fraction less than 40%, moderate-severe valve lesions or moderate-severe pericardial effusion). Characteristics associated with abnormal echocardiogram included older age (OR 1.04, 95% CI 1.01 to 1.08), higher body mass index (OR 1.09, 95% CI 1.02 to 1.17), higher mean systolic blood pressure (OR 1.03, 95% CI 1.02 to 1.05) and higher mean diastolic blood pressure (OR 1.03, 95% CI 1.01 to 1.05). In a multivariable model including age, duration on ART, body mass index, and systolic and diastolic blood pressure, only mean body mass index (adjusted OR 1.10, 95% CI 1.02 to 1.19), systolic blood pressure (aOR 1.05, 95% CI 1.03 to 1.08) and diastolic blood pressure (aOR 0.96, 95% CI 0.92 to 1.00) remained associated with abnormal echocardiogram.ConclusionsLVH was common in this population of adults on ART presenting for routine care and was associated with elevated blood pressure. Further research is needed to characterise the relationship between chronic hypertension, LVH and downstream consequences, such as diastolic dysfunction and heart failure in people living with HIV.

Background The Ovarian-Adnexal Reporting and Data System (O-RADS) US risk stratification and management system (O-RADS US) was designed to improve risk assessment and management of ovarian and adnexal lesions. Validation studies including both surgical and nonsurgical treatment as the reference standard remain lacking. Purpose To externally validate O-RADS US in women who underwent either surgical or nonsurgical treatment and to determine if incorporating acoustic shadowing as a benign finding improves diagnostic performance. Materials and Methods This retrospective study included consecutive women who underwent pelvic US between August 2015 and April 2017 at a tertiary referral oncology center. Two independent readers blinded to clinical and histologic outcome assigned an O-RADS risk category and an International Ovarian Tumor Analysis (IOTA) Assessment of Different NEoplasias in the adneXa (ADNEX) model risk of malignancy score to assessable lesions. Reference standards were surgical histopathology or 2-year imaging follow-up. Receiver operating characteristic (ROC) curve analysis was used to evaluate performance of the O-RADS US, ADNEX, and modified O-RADS models incorporating acoustic shadowing. Results In total, 227 women (mean age, 52 years ± 16 [SD]) with 262 ovarian or adnexal lesions were evaluated. Of these lesions, 187 (71%) were benign and 75 (29%) were malignant. The proportion of malignancy was 0% (0 of 100) for O-RADS 2, 3% (one of 32) for O-RADS 3, 35% (22 of 63) for O-RADS 4, and 78% (52 of 67) for O-RADS 5. The area under the ROC curve (AUC) for O-RADS and ADNEX was 0.91 (95% CI: 0.88, 0.94) and 0.95 (95% CI: 0.92, 0.97; P = .01), respectively. The addition of acoustic shadowing as a benign finding improved O-RADS AUC to 0.94 (95% CI: 0.91, 0.96; P = .01). Use of O-RADS 4 as a threshold yielded a sensitivity of 99% (74 of 75; 95% CI: 96, 100) and a specificity of 70% (131 of 187; 95% CI: 64, 77). Conclusion In a tertiary referral oncology center, the Ovarian-Adnexal Reporting and Data System US risk stratification and management system enabled accurate distinction of benign from malignant ovarian and adnexal lesions. Adding acoustic shadowing as a benign finding improved its diagnostic performance. © RSNA, 2022 See also the editorial by Levine in this issue.

To assess the performance of O-RADS Ultrasound Risk Stratification to distinguish benign and malignant adnexal masses. 262 adnexal lesions were included in 227 patients who underwent pelvic transvaginal ultrasound at a single-site tertiary care referral centre between August 2015 and April 2017. Exclusions included O-RADS 1 normal ovary, bilateral oophorectomy, pregnancy, incomplete imaging and high genetic risk for ovarian cancer. Adnexal masses were assessed by two independent readers blinded to clinical and histologic outcome who assigned O-RADS score based on criteria. Additional descriptors and clinical indices for the IOTA ADNEX model were also assessed and used to determine the ADNEX overall risk of malignancy. The reference standard was histopathology or minimum 2-year follow-up imaging. ROC curve analysis was used to assess the performance of the O-RADS model and to compare the O-RADS and ADNEX models. Of the 262 adnexal lesions, 187 (71.3%) were benign and 75 (28.6%) were malignant. All O-RADS 2 category lesions had benign outcome. The frequency of malignant outcome was 3.1% (1/32) for O-RADS 3, 34.9% (22/63) for O-RADS 4 and 77.6% (52/67) for O-RADS 5. AUC for O-RADS was 0.91 (95% CI 0.88-0.94) and 0.95 for the ADNEX model (95% CI 0.92-0.97) with ADNEX showing statistically significant better performance (p < 0.05). Adding acoustic shadowing as an independent variable to the O-RADS model increased the AUC 0.94 (95% CI 0.91-0.96), with no statistically significant difference between the adjusted O-RADS and ADNEX models (p = 0.3). The optimal threshold for distinguishing benign and malignant masses was O-RADS 3 with sensitivity 1 and specificity 0.53 (95% CI 0.46-0.61). Using O-RADS 4 as a cut-off resulted in decrease in sensitivity to 0.99 (95% CI 0.96-1) with increase specificity to 0.70 (95% CI 0.64-0.77). The O-RADS Ultrasound Risk Stratification System can differentiate benign from malignant adnexal masses with high accuracy. The addition of acoustic shadowing to the ORADS model further improves diagnostic performance.

Background: Hypertension is among the most commonly diagnosed non-communicable diseases in Africa, and studies have demonstrated a high prevalence of hypertension among individuals with HIV. Despite high prevalence, there has been limited attention on the clinical outcomes of hypertension treatment in this population. Objective: We sought to characterize rates of and factors associated with blood pressure control over one year among individuals on antiretroviral therapy (ART) and antihypertensive medications. Methods: We performed a prospective observational cohort study at an HIV clinic in Malawi. We defined uncontrolled hypertension as a systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg at two or more follow-up visits during the year, while controlled hypertension was defined as <140 mm Hg systolic and <90 mm Hg diastolic at all visits, or at all but one visit. We calculated an antihypertensive non-adherence score based on self-report of missed doses at each visit (higher score = worse adherence) and used rank sum and chi-square tests to compare sociodemographic and clinical factors (including adherence) associated with blood pressure control over the year. Results: At study entry, 158 participants (23.5%) were on antihypertensive medication; participants had a median age of 51.0 years, were 66.5% female, and had a median of 6.9 years on ART. 19.0% (n = 30) achieved blood pressure control over the year of follow-up. Self-reported non-adherence to hypertension medications was the only factor significantly associated with uncontrolled blood pressure. The average non-adherence score for those with controlled blood pressure was 0.22, and for those with uncontrolled blood pressure was 0.61 (p = 0.009). Conclusions: Adults living with HIV and hypertension in our cohort had low rates of blood pressure control over one year associated with self-reported non-adherence to antihypertensive medications. Given the high prevalence and incidence of hypertension, interventions to improve blood pressure control are needed to prevent associated long-term cardio- and cerebrovascular morbidity and mortality.

Malawi has the highest incidence of and mortality rate due to cervical cancer in the world. This is largely because of inadequate screening and high rates of human immunodeficiency virus (HIV) infection, which greatly increases cervical cancer risk. We describe the implementation of a quality improvement program to increase use of cervical cancer screening at a non-government medical center in Lilongwe, Malawi. The intervention, developed and launched from March to August 2017, aimed to promote education among patients and clinicians about the importance of cervical cancer screening and improve accessibility of screening information within medical records. Visual inspection with acetic acid (VIA) was used to screen for cervical cancer. Women with a positive VIA were offered treatment using thermocoagulation. The number of VIA screenings conducted in 2016 (pre-intervention), 2017 (intervention), and 2018 (post-intervention) was 125, 234 and 456, respectively. Of the 815 women screened during this period, 36 (4.4%) had a VIA-positive result and 12 (1.5%) had suspect cancer. Of the VIA-positive women, 13 (36.1%) received same-day treatment with thermocoagulation. An interrupted time series regression revealed that there was a sustained increase in monthly screenings between the pre- and post-intervention period ( β = 30.84; p = 0.006; 95% CI 9.72–51.97), suggesting that the intervention likely was effective in increasing cervical cancer screening. Our results demonstrate that focusing on developing sustainable solutions and improving system processes, without additional equipment or funding, significantly increased the number of women screened and should be considered in other settings to enhance cervical cancer prevention services.

BACKGROUND:The focused assessment with sonography for HIV-associated tuberculosis (TB) (FASH) ultrasound protocol has been increasingly used to help clinicians diagnose TB. We sought to quantify the diagnostic utility of FASH for TB among individuals with HIV in Malawi. METHODS:Between March 2016 and August 2017, 210 adults with HIV who had 2 or more signs and symptoms that were concerning for TB (fever, cough, night sweats, weight loss) were enrolled from a public HIV clinic in Lilongwe, Malawi. The treating clinicians conducted a history, physical exam, FASH protocol, and additional TB evaluation (laboratory diagnostics and chest radiography) on all participants. The clinician made a final treatment decision based on all available information. At the 6-month follow-up visit, we categorized participants based on clinical outcomes and diagnostic tests as having probable/confirmed TB or unlikely TB; association of FASH with probable/confirmed TB was calculated using Fisher's exact tests. The impact of FASH on empiric TB treatment was determined by asking the clinicians prospectively about whether they would start treatment at 2 time points in the baseline visit: (1) after the initial history and physical exam; and (2) after history, physical exam, and FASH protocol. RESULTS:A total of 181 participants underwent final analysis, of whom 56 were categorized as probable/confirmed TB and 125 were categorized as unlikely TB. The FASH protocol was positive in 71% (40/56) of participants with probable/confirmed TB compared to 24% (30/125) of participants with unlikely TB (odds ratio=7.9, 95% confidence interval=3.9,16.1; P<.001). Among those classified as confirmed/probable TB, FASH increased the likelihood of empiric TB treatment before obtaining any other diagnostic studies from 9% (5/56) to 46% (26/56) at the point-of-care. For those classified as unlikely TB, FASH increased the likelihood of empiric treatment from 2% to 4%. CONCLUSION:In the setting of HIV coinfection in Malawi, FASH can be a helpful tool that augments the clinician's ability to make a timely diagnosis of TB.

ObjectivesAs HIV-positive individuals’ life expectancy extends, there is an urgent need to manage other chronic conditions during HIV care. We assessed the care-seeking experiences and costs of adults receiving treatment for both HIV and hypertension in Malawi.Design, setting and participantsA cross-sectional survey was conducted with HIV-positive adults with hypertension at a health facility in Lilongwe that offers free HIV care and free hypertension screening, with antihypertensives available for purchase (n=199). Questions included locations and costs of all medication refills and preferences for these refill locations. Respondents were classified as using ‘integrated care’ if they refilled HIV and antihypertensive medications simultaneously. Data were collected between June and December 2017.ResultsOnly half of respondents reported using the integrated care offered at the study site. Among individuals using different locations for antihypertensive medication refills, the most frequent locations were drug stores and public sector health facilities which were commonly selected due to greater convenience and lower medication costs. Although the number of antihypertensive medications was equivalent between the integrated and non-integrated care groups, the annual total cost of care differed substantially (approximately US$21 in integrated care vs US$90 for non-integrated care)—mainly attributable to differences in other visit costs for non-integrated care (transportation, lost wages, childcare). One-third of those in the non-integrated care group reported no expenditure for antihypertensive medication, and six people in each group reported no annual hypertension care-seeking costs at all.ConclusionsIndividuals using integrated care saw efficiencies because, although they were more likely to pay for antihypertensive medications, they did not incur additional costs. These results suggest that preferences and experiences must be better understood to design effective policies and programmes for integrated care among adults on antiretroviral therapy.

The purpose of our student-led project was to fulfill junior medical students’ demand for instructive, curriculum-specific practice questions while providing a learning experience and teaching opportunity for participating senior students. Eleven second-year students were taught how to write high-quality multiple-choice questions through an interactive workshop. Subsequently, they were instructed to write questions with detailed explanations for their assigned lecture topics. Thirty-four student-written and faculty-reviewed questions were combined with 16 purely faculty-written questions to create a 50-question exam. No significant difference was found in question difficulty between the student-written (79.5%) and faculty-written (84.0%) questions ( p = 0.37). The discrimination index and point biserial correlation were higher for student-written (0.29, 0.32) vs. faculty-written (0.17, 0.25) questions ( p < .01, < .05). The test-takers learned key course topics, while the test-writers reviewed key first-year objectives and refined their test-taking strategies. The project provided a model for feasibly developing comprehensive, high-quality, and curriculum-specific questions.

BACKGROUND:Point-of-care ultrasound is increasingly being used as a diagnostic tool in resource-limited settings. The majority of existing ultrasound protocols have been developed and implemented in high-resource settings. In sub-Saharan Africa (SSA), patients with heart failure of various etiologies commonly present late in the disease process, with a similar syndrome of dyspnea, edema and cardiomegaly on chest X-ray. The causes of heart failure in SSA differ from those in high-resource settings. Point-of-care ultrasound has the potential to identify the underlying etiology of heart failure, and lead to targeted therapy. Based on a literature review and weighted score of disease prevalence, diagnostic impact and difficulty in performing the ultrasound, we propose a context-specific cardiac ultrasound protocol to help differentiate patients presenting with heart failure in SSA.RESULTS:Pericardial effusion, dilated cardiomyopathy, cor pulmonale, mitral valve disease, and left ventricular hypertrophy were identified as target conditions for a focused ultrasound protocol in patients with cardiac failure and cardiomegaly in SSA. By utilizing a simplified 5-question approach with all images obtained from the subxiphoid view, the protocol is suitable for use by health care professionals with limited ultrasound experience.CONCLUSIONS:The "Cardiac ultrasound for resource-limited settings (CURLS)" protocol is a context-specific algorithm designed to aid the clinician in diagnosing the five most clinically relevant etiologies of heart failure and cardiomegaly in SSA. The protocol has the potential to influence treatment decisions in patients who present with clinical signs of heart failure in resource-limited settings outside of the traditional referral institutions.

In a prior study, we used flow cytometry to characterize lymphocytes from mother-infant pairs from healthy and preeclamptic pregnancies. Despite a relatively low number of study participants, we acquired a large, multidimensional dataset and felt limited in our capacity to fully explore it. Here we describe the use of Mathematica to create an interactive display tool that allows dynamic data exploration. The end result is a HIPAA compliant data library and code that can be exported, published, and explored by readers with the freely available MathReader application. Our database included flow cytometry data from 8 staining panels with up to 15 markers each, clinical, and obstetric data in MS Excel. By combining Mathematica’s Chart, Manipulate, and Tooltip functions, we incorporated the clinical variables including neonatal sex, birth weight, and prior obstetric history into each graph, while the Tooltip function displays the participant study ID. We have coded an interactive tool that allows the rapid display of data from multiple complex datasets in a single, interactive graph allowing the scientist to compare immunologic parameters between specific clinical conditions. This makes it possible to highlight, for example: activated NK-, NKT-, γδT -, naïve CD4 T, CD8 T-, memory CD4 T, and memory CD8 T cells from mothers with PE who gave birth to female neonates who were small for gestational age, and easily change all those graphs to highlight those patients who gave birth normal size fetuses. Interactive tools are ideal to display complex, multidimensional data such as human immune phenotyping. Ideally, they should also be publishable as interactive tools for the reader to explore on their own. Mathematica allows for this.

Non-communicable diseases like hypertension are increasingly common among individuals living with HIV in low-resource settings. The prevalence of hypertension among people with HIV in Malawi, e.g. has been estimated to be as high as 46%. However, few qualitative studies have explored the patient experience with comorbid chronic disease. Our study aimed to address this gap by using the health belief model (HBM) to examine how comparative perceptions of illness and treatment among participants with both HIV and hypertension may affect medication adherence behaviours. We conducted semi-structured interviews with 75 adults with HIV and hypertension at an urban clinic in Lilongwe, Malawi. Questions addressed participants' experiences with antiretroviral and antihypertensive medications, as well as their perspectives on HIV and hypertension as illnesses. Interviews were performed in Chichewa, transcribed, translated into English and analysed using ATLAS.ti. Deductive codes were drawn from the HBM and interview guide, with inductive codes added as they emerged from the data. Self-reported medication adherence was much poorer for hypertension than HIV, but participants saw hypertension as a disease at least as concerning as HIV-primarily due to the perceived severity of hypertension's consequences and participants' limited ability to anticipate them compared with HIV. Differences in medication adherence were attributed to the high costs of antihypertensive medications relative to the free availability of antiretroviral therapy, with other factors like lifestyle changes and self-efficacy also influencing adherence practices. These findings demonstrate how participants draw on past experiences with HIV to make sense of hypertension in the present, and suggest that although patients are motivated to control their hypertension, they face individual- and system-level obstacles in adhering to treatment. Thus, health policies and systems seeking to provide integrated care for HIV and hypertension should be attentive to the complex illness experiences of individuals living with these diseases.

BACKGROUND United States hospitals have widely adopted electronic health records (EHRs). Despite the potential for EHRs to increase efficiency, there is concern that documentation quality has suffered. OBJECTIVE To examine the impact of an educational session bundled with a progress note template on note quality, length, and timeliness. DESIGN A multicenter, nonrandomized prospective trial. SETTING Four academic hospitals across the United States. PARTICIPANTS Intern physicians on inpatient internal medicine rotations at participating hospitals. INTERVENTION A task force delivered a lecture on current issues with documentation and suggested that interns use a newly designed best practice progress note template when writing daily progress notes. MEASUREMENTS Note quality was rated using a tool designed by the task force comprising a general impression score, the validated Physician Documentation Quality Instrument, 9-item version (PDQI-9), and a competency questionnaire. Reviewers documented number of lines per note and time signed. RESULTS Two hundred preintervention and 199 postintervention notes were collected. Seventy percent of postintervention notes used the template. Significant improvements were seen in the general impression score, all domains of the PDQI-9, and multiple competency items, including documentation of only relevant data, discussion of a discharge plan, and being concise while adequately complete. Notes had approximately 25% fewer lines and were signed on average 1.3 hours earlier in the day. CONCLUSIONS The bundled intervention for progress notes significantly improved the quality, decreased the length, and resulted in earlier note completion across 4 academic medical centers.

The diagnosis of tuberculosis (TB) in patients infected with human immunodeficiency virus (HIV) can be challenging in resource-limited settings. Extrapulmonary TB is particularly underdiagnosed, with data suggesting that half of patients with disseminated TB are not diagnosed until autopsy [ 1 WHO Expert Group on Smear-Negative TBImproving the diagnosis and treatment of smear-negative pulmonary and extrapulmonary tuberculosis among adults and adolescents. World Health Organization, Geneva, Switzerland2007 Google Scholar ].

INTRODUCTION:Maternal-fetal chimerism is miniscule, a testament to the integrity of the uteroplacental interface. The soundness of this border region is potentially altered through cesarean delivery of prior babies with uncertain consequences for the following pregnancies. METHODS:Using multicolor flow cytometry and quantitative PCR of non-inherited maternal antigens we performed a retrospective case control pilot study and formulated the null hypothesis that placental implantation over a prior uterine scar does not result in the presence of memory Treg (CD45RO+) in the fetus. We then performed a power calculation and performed a blinded, appropriately powered prospective case control study to test the null hypothesis. RESULTS:Fetuses born to mothers with prior uterine scar have a roughly five times higher maternal to fetal microchimerism when the placenta directly interacts with the uterine scar. Unlike exposure to antigens in adult life, in utero antigenic exposure induces tolerogenic (Treg) responses in fetuses and we here report the presence of fetal Treg with a memory phenotype (CD45RO+). However, we only find such CD45RO+ fetal Tregs when the placenta abuts the uterine scar (Risk Ratio = 5 [p < 0.05 CI:(1.448 to 17.27)]). These memory fetal Tregs are functionally highly suppressive compared to CD45RA-expressing fetal Tregs, and have specificity for non-inherited maternal antigens. CONCLUSIONS:We found that uterine scars, in the case of our study these scars are from prior c-sections, fundamentally impair uterine integrity allowing for increased antigen exposure of the fetus; with our appropriately powered study we rejected the null hypothesis and accepted the alternative hypothesis that placental implantation over a prior uterine scar results in the presence of memory Treg (CD45RO+) in the fetus. Thus, our study demonstrates a previously unappreciated role for uterine integrity in limiting fetal antigenic exposure, a key element to avoid the formation of inappropriate tolerances by the fundamentally tolerogenic fetal immune system.

A 49-year-old man with a history of HIV-infection (CD4+ T-cell count: 45 cells/μl), presented to Partners in Hope Medical Center in Lilongwe, Malawi, with recurrent seizures, lethargy, reduced consciousness, and fevers. He was febrile, tachycardic, had elevated blood pressure, and was saturating 93% on room air. On examination, he was minimally responsive and had significant meningismus. A lumbar puncture revealed an increased opening pressure. Cerebrospinal fluid (CSF) analysis found 0 white blood cells, 0 red blood cells, 41 mg/dl of protein. CSF cryptococcal antigen lateral flow assay (CrAg LFA; IMMY, Norman, Oklahoma, USA) was negative. India ink stain showed densely packed encapsulated organisms leading to the diagnosis of cryptococcal meningitis (Fig. 1). For CSF, the IMMY CrAg LFA has 100% sensitivity (95% confidence interval = 96.0–100%) and 100% specificity (95% confidence interval = 97.0–100%), except in cases with high CrAg concentrations (>0.140 mg/ml), that is, the Postzone Phenomenon. A semi-quantitative procedure of the CSF yielded the following titers: 1 : 5, negative; 1 : 10, weakly positive; 1 : 20, positive; 1 : 40, weakly positive; and 1 : 80, negative (see Supplemental Figure 1, https://links.lww.com/QAD/B256). Amphotericin B and high-dose fluconazole were initiated.Fig. 1: India ink stain of cerebrospinal fluid for the described patient showing round, encapsulated organisms consistent with cryptococcal meningitis.The IMMY CrAg LFA is an antigen-capture assay that detects free capsular CrAg from serotypes A, B, C, and D (Cryptococcus neoformans, serotypes A and D; Cryptococcus gattii, serotypes B and C) [1,2]. The highly sensitive and specific assay uses two monoclonal antibodies, one for serotypes A, B, and C, and the other for serotypes A and D [1]. The test is a lateral flow immunochromatographic assay platform – a dipstick assay [3]. The Postzone Phenomenon is a false-negative test caused by excessive antigen, relative to antibodies, which prevents antibody-to-antigen crosslinking [4]. Crosslinking is necessary for immunochromatographic detection [4]. That effect is often mistakenly attributed to the Prozone Phenomenon (Hook Effect), which is a false-negative test caused by excessive antibodies relative to antigen [4]. When compared with a reference standard, the IMMY CrAg LFA had a sensitivity of 100% when samples suspected of having a high organism load were diluted; however, the assay had a sensitivity of 90.9% when samples were not diluted [3]. A prior case was reported of unencapsulated C. neoformans that was CrAg negative [5]; however, we observed competent capsules on microscopy. Our patient's CSF tested CrAg positive after dilution, confirming the Postzone Phenomenon. Among cases with a high suspicion of cryptococcal meningitis and a negative CSF CrAg LFA, serial dilutions must be performed to avoid false-negative test results and significant morbidity and mortality to the patient. Acknowledgements The authors would like to acknowledge Chifundo Soko and the staff at Partners in Hope in Lilongwe, Malawi. D.G.K. is supported by Department of Internal Medicine, which is a part of the University of California, Los Angeles. N.K. is supported by the Fogarty International Center of the National Institutes of Health (NIH) under award number D43TW009343 and the University of California Global Health Institute (UCGHI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or UCGHI. Conflicts of interest There are no conflicts of interest.

PURPOSE:Training medical providers of different backgrounds the "focused assessment with sonography for HIV-associated TB" (FASH) exam to expand the availability of ultrasound for TB diagnosis in resource poor settings in the central region of Malawi.METHODS AND MATERIALS:A survey was completed by the 19 eligible participants before and after a 4-day training course regarding the utility of the FASH exam. A six-question quiz was used to assess knowledge of the use of ultrasound in the FASH exam before and after the course.RESULTS:Participants' knowledge of the FASH technique significantly improved after the four-day course with a 32% increase in total quiz questions answered correctly (p<0.001).Ninety-five percent (n= 18) of participants answered that they would "likely" incorporate FASH in their clinical practice. Furthermore, 100% (n=19) of participants agreed that the FASH exam would improve their ability to diagnose TB and 95% (n=18) agreed that FASH would improve patient care in their clinic.CONCLUSIONS:After completing a 4-day training course, medical providers were more knowledgeable about the FASH exam and its findings, and felt more comfortable using ultrasound for the diagnosis of TB. Participants were also unanimous in opinion that the FASH ultrasound exam would improve their ability to diagnose TB.

Objective We study whether using an intra-aortic balloon (IAB) during cesarean hysterectomy decreases delivery morbidity in patients with suspected morbidly adherent placentation. Study Design This is a retrospective cohort study of deliveries complicated by suspected abnormal placentation between 2009 and 2016 comparing maternal and neonatal outcomes with an IAB placed prior to cesarean hysterectomy versus no IAB. The primary outcome included quantified blood loss (QBL). Results Thirty-five cases were reviewed, 16 with IAB and 19 without IAB. No difference was seen in median QBL between the two groups (1,351 vs. 1,397 mL; p = 0.90). There were no significant differences in overall surgical complications (19% IAB, 21% no IAB; p = 0.86), bladder complications (12 vs. 21%; p = 0.66), intensive care unit admissions (12 vs. 26%; p = 0.41), surgical duration (2.9 vs. 2.8 hour; p = 0.83), or blood transfusions (median 2 vs. 2; p = 0.27) between the two groups. There was one groin hematoma at the balloon site that was managed conservatively. There were no complications involving thrombosis or limb ischemia in the IAB group. Conclusion While we did not detect statistically significant differences, larger studies may be warranted given the potential for extreme morbidity in these cases. This study highlights the potential use of an IAB in the management of these cases.

Liver abscess is a rare but serious complication of Crohn’s disease. Patients with Crohn’s disease are at risk for pyogenic liver abscesses due to immunosuppressive therapy, fistulous disease, and intraabdominal abscesses. Inflammatory bowel disease patients are also known to have a greater prevalence of amebiasis compared to the rest of the population; however, a higher incidence of amebic liver abscess has not been reported. We describe a case of a liver abscess in a patient with Crohn’s disease that was initially presumed pyogenic but later determined to be amebic in origin. Epidemiology, clinical presentation, diagnosis, and treatment of amebic and pyogenic liver abscesses are discussed.

This article was migrated. The article was marked as recommended. IntroductionMedical educators need to demonstrate that their trainees meet expected competency levels when progressing through medical education. This study aimed to develop competency-based pass/fail cut-scores for a graduation required Objective Structured Clinical Examination (OSCE), and examine validity evidence for new standards.MethodsSix clinicians used the modified Angoff method to determine the cut-scores for an 8-station OSCE. The clinicians estimated the percentage of minimally competent students who would answer each checklist item correctly. Inter-rater reliability, differences in other academic achievements between pass/fail groups, educational impact, and response process were examined. ResultsOne hundred seventy-four rising 4th-year medical students participated in the OSCE. The cut-scores determined for the OSCE resulted in a substantially lower failure rate (5% vs. 29% of the previous year). The inter-rater reliability across domains and cases was .98 (95% CI = .97 - .99). The pass/fail groups significantly differed in six of the eight measures of academic achievements included in the study.DiscussionThe impact of the standards setting was substantial as it significantly reduced the failure rate and burdens of remediation for both students and faculty. The very high inter-rater reliability indicates that the modified Angoff method produced reliable cut-scores. The significant differences between the pass/fail groups in other measures support external validity of the standards and ensure no false passes. The study also supports response process validity by including discussion among judges and check of previous student performances, as well as recruiting and training multiple clinician educators experienced in medical student teaching.ConclusionFindings of the study provide strong evidence supporting validity of the new cut-scores from a wide spectrum of validity metrics, including response process, internal structure, relations to other variables, and consequences. The study also added to the literature the value of the modified Angoff method in determining competency-based standards for OSCEs.