Faculty Bibliography

OVERVIEW: This study reviews the first decade of critical care medicine (CCM) certification by the American Board of Internal Medicine (1987-1996). Included are the characteristics of examinee and certificate-holder groups; examination performances from different underlying disciplines of internal medicine, with or without formal CCM training; and the influence of background and a training program as correlates of examination performance. DATA SOURCES: The CCM certification examination has been offered biennially since November 1987. Performance data on the American Board of Internal Medicine examinations in internal medicine and its subspecialties and added qualifications were available for candidates taking the CCM examinations. For examinees with formal CCM training, residency program director ratings, and information regarding the program characteristics of size and percentage of United States and Canadian medical graduates were also available. STUDY SELECTION: All examinees who ever attempted certification were included in this study. The study cohort for each of the five examination administrations consists of all first-time takers. CONCLUSIONS: Cohort sizes have decreased since formal training became an admission requirement in 1993. Percentages of International Medical Graduates and women attempting and achieving certification have increased steadily. Examination performance was positively associated with formal training, internal medicine examination performance, recent medical training, and pulmonary disease certification. For those with formal training, performance was also positively associated with training program director ratings of overall clinical competence and completion of a training program with a higher proportion of United States and Canadian medical graduates

Anti-inflammatory substances are released during septic shock that modulate monocyte function. Decreased monocyte responsiveness to bacterial toxins and decreased expression of human-leukocyte-associated antigen-DR (HLA-DR) have been reported during septic shock and critical illness. Impaired antigen presentation has been inferred from these observations but has not been demonstrated. We assessed antigen presentation and costimulatory molecule expression in 12 age-matched control subjects, 10 noninfected critically ill patients (CINS), and 17 critically ill patients with sepsis (CIS). Antigen presentation was assessed by using in vitro lymphocyte 5-bromo-2-deoxyuridine (BrdU) incorporation in response to tetanus toxoid. The expression of HLA-DR and the costimulatory molecules CD28, CD86, and CTLA-4 was assessed by flow cytometry. Serum interleukin-10 (IL-10) was also measured by enzyme-linked immunosorbent assay. Serum IL-10 levels were significantly elevated in CIS patients (91 +/- 38 pg/mL) as compared with levels in control subjects (5 +/- 4 pg/mL)(P < .05). Lymphocyte BrdU incorporation increased by 710% +/- 243% in control subjects but by only 144% +/- 62% in CIS patients and 76% +/- 31% in CINS patients (P < .01 vs control). Monocyte HLA-DR expression, monocyte CD86 expression, and lymphocyte CD28 expression were significantly decreased in CIS patients (P < .01) as compared with control subjects. Conversely, lymphocyte CTLA-4 expression was significantly increased in CIS patients (P < .05 vs control). Monocyte CD86 expression was also significantly decreased in CINS patients as compared with control subjects. These data indicate that antigen presentation is decreased in critically ill patients with sepsis. This appears in part related to decreased expression of HLA-DR and the costimulatory molecules CD86 and CD28. Increased expression of the negative signal receptor CTLA-4 may also impair antigen presentation in patients with sepsis