On the Origins of Clinical Psychology Faculty: Who Is Training the Trainers?

There exists little published research regarding the comparative performance of graduate programs in clinical psychology on relevant measures of program achievement. The present report thus aims to provide information about one such measure—program proficiency in training graduates to assume clinical psychology faculty positions. Degree-granting institution and year of degree completion were obtained for 1,529 individuals listed as core faculty at 150 university-based clinical psychology Ph.D. programs accredited by the American Psychological Association. On this basis, leading programs (i.e., those having trained numerous clinical faculty members) are identified. Proficiency in placing graduates in clinical faculty positions was moderately positively correlated with program reputational strength; it was not significantly associated with program size. A set of recommendations for the systematic investigation of factors germane to such proficiency, as well as to program achievement in other important (and heretofore unstudied) domains, is proffered. It is argued that no single measure is adequate as an overall gauge of program excellence.     

Clinical effects of mutations to CD95 (Fas): relevance to autoimmunity?

Conclusion The Fas/FasL system has been recognized as a major player in apoptosis, not only in the immune system but in many other tissues of the organism. It is implicated in various biological processes such as physiological cellular turnover, killing by cytotoxic T lymphocytes, protection of tissular integrity, protection of fetus during pregnancy. Its mode of action seems to be rather simple and can be summarized in the equation: Fas + FasL = death. Many pathological processes in humans implying cell death are directly derived from this equation. We have covered different aspects of these pathological situations in humans starting with the lymphoproliferation caused by a defective Fas-dependent apoptosis pathway and responsible for the development of autoimmunity to the Fas-dependent tissue injury as a consequence of a secondary Fas system defect. The complexity of the Fas system in autoimmunity is best recapitulated in the nonobese diabetic (NOD)^lpr/lpr mouse model [9]. On the one hand the lpr mice develop accelerated autoimmunity as a consequence of their Fas defect, on the other hand the destruction of the pancreas in NOD mice is thought to be mediated in part by the interaction between Fas on -islet cells and FasL on diabetogenic infiltrating T lymphocytes. Moreover, these T cells are responsible for the expression of Fas on cells. The intercross of these two mice leads to the paradoxical situation of an autoimmune-prone mouse (lpr) protected from autoimmune diabetes (NOD). One can imagine that in the near future one will be able to modulate the Fas/FasL system for therapeutic purposes.     

Evidence-Based Medicine: What Is It and How Does It Apply to Athletic Training?

OBJECTIVE: To introduce the concept of evidence-based medicine (EBM) to athletic trainers. This overview provides information on how EBM can affect the clinical practice of athletic training and enhance the care given to patients. DATA SOURCES: We searched the MEDLINE and CINHAL bibliographic databases using the terms evidence-based medicine and best practice and the online Index to Abstracts of Cochrane Reviews by group (injury, musculoskeletal injuries, and musculoskeletal) to identify reviews on topics pertinent to athletic training. DATA SYNTHESIS: Evidence-based medical practice has 5 components: defining a clinically relevant question, searching for the best evidence, appraising the quality of the evidence, applying the evidence to clinical practice, and evaluating the process. Evidence-based medicine integrates the research evidence, clinician's expertise, and patient's preferences to guide clinical decision making. Critical to this effort is the availability of quality research on the effectiveness of sports medicine techniques. Athletic training outcomes research is lagging behind that of other health care professions. RECOMMENDATIONS: Athletic trainers need to embrace the critical-thinking skills to assess the medical literature and incorporate it into their clinical practice. The profession should encourage more clinically related research and enhance the scientific foundation of athletic training. Evidence-based medicine provides an important next step in the growth of the athletic training profession.     

Routine CD4 monitoring in HIV patients with viral suppression: Is it really necessary? A Portuguese cohort

Purpose

CD4 cell-count has been regarded as the key surrogate marker for prognostic staging and therapeutic monitoring of HIV-infected individuals. Our purpose was to assess the probability of maintaining a CD4 count >200 cells/μL in patients with continuous viral suppression and CD4 cell counts >200 cells/μL.

Reaching to recover balance in unpredictable circumstances: Is online visual control of the reach-to-grasp reaction necessary or sufficient?

Reaching to grasp an object for support is a common and functionally important response to sudden balance perturbation. The need to react very rapidly (to prevent falling) imposes temporal constraints on acquisition and processing of the visuospatial information (VSI) needed to guide the reaching movement. Previous results suggested that the CNS may deal with these constraints by using VSI stored in memory proactively, prior to perturbation onset; however, the extent to which online visual control is necessary or sufficient to guide these reactions has not been established. This study examined the speed, accuracy, and effectiveness of perturbation-evoked reach-to-grasp reactions when forced to rely entirely on either online- or stored-VSI by using liquid–crystal goggles to occlude vision either before or after perturbation onset. The reactions were evoked, in twelve healthy young adults, via sudden unpredictable antero-posterior platform translation (barriers deterred stepping reactions). Prior to perturbation onset, a small cylindrical handhold was positioned unpredictably (by a motor-driven device) at one of four locations in front of the subject. Results indicated that equilibrium could be recovered successfully by grasping the handhold using either online-VSI or stored-VSI to guide the arm reaction; however, both sources of VSI were required for optimal performance. Reach initiation and arm movement were slowed when dependent on online-VSI, whereas reach accuracy and grip formation were impaired when dependent on stored-VSI. Comparison with normal-VSI trials suggests that both sources of VSI are utilized when grasping a small handhold for support under normal visual conditions, with stored-VSI predominating during initiation/transport and online-VSI contributing primarily to final target acquisition/prehension.     

Category effects: Is top-down control alone sufficient to elicit the mismatch negativity (MMN) component?

This study investigated whether the mismatch negativity (MMN) event-related brain potential (ERP) could be evoked by purely top-down, attentional control. An infrequently occurring tone was designated as a target prior to presenting a randomized sequence of five equi-probably occurring tones. MMN elicitation to the tones categorized as “high”, “medium”, or “low” frequency, and designated as the target, would indicate that the change detection process can be driven solely by top-down control. However, MMNs were not elicited by the categorized tones. Only the N2b and P3b attention-driven target detection components were elicited. These results suggest that top-down factors alone cannot generate mismatch negativity. Standard formation by stimulus-driven factors is required.     

Gestational diabetes mellitus (class A): A human teratogen?

Between January 1, 1982 and December 31, 1992 we evaluated 200 children of mothers with pregestational or gestational diabetes mellitus through the University of South Florida Genetics/Dysmorphology Clinics. They were a portion of the 22,100 families seen during that period. Pregnant women with diabetes mellitus were not part of this study. One hundred and fifty-two of the 200 were offspring of mothers with gestational diabetes (classes A₁ and A₂). Class B₁ was not encountered as a subclass of gestational diabetes in this series. Twenty-four of the 152 did not have anomalies. Forty-one of the 152 had another primary diagnosis to account for their malformations. Eighty-seven of the 152 had a constellation of anomalies or solitary structural defects as seen in diabetic embryopathy. Chromosomal, monogenic, and other teratogenic causes were excluded. The observed phenotypes matched those seen in offspring of mothers with diabetes mellitus classes B₂ to T. They also corroborated the animal studies, indicating that the embryopathy of gestational diabetes has a pathogenesis similar to that in classes B₂ to T, and recent epidemiological studies showing a statistically significant increase of anomalies as in diabetic embryopathy in the offspring of gestational diabetes mothers. As per established obstetric practice the testing for gestational diabetes was after gestation 16 weeks. Thus, it was impossible to prove that the anomalies of the 87 propositi were due to gestational diabetes. However, the anomalies occurred during organogenesis as in the other diabetic classes, and inferred that gestational diabetes is a human teratogen. If so, common “idiopathic” malformations may be actually caused by undiagnosed maternal gestational diabetes. Am. J. Med. Genet. 83:402–408, 1999. © 1999 Wiley-Liss, Inc.     

Infectious atherosclerosis: Is the hypothesis still alive? A clinically based approach to the dilemma

Among the multiple factors involved in the pathophysiology of heart disease, infections have been proposed to play a role in atherosclerosis with most of the available evidence implicating Chlamydia pneumonia, influenza virus and Mycoplasma pneumoniae. Based on a model case presentation, we speculate that in the absence of traditional risk factors and in the context of an ongoing respiratory infection caused by a pro-inflammatory pathogen (M. pneumoniae) along with a past positive serologic history for potentially proven atherogenic microorganism (C. pneumoniae) and infection may elicit potentially pathogenic events on vascular wall cells and leukocytes of atheromatous lesions, supporting the hypothesis that such infections may potentiate atherosclerotic cardiovascular disease (CVD).     

Antibody to GBV-C second envelope glycoprotein (anti-GBV-C E2): Is it a marker for immunity?

The clinical significance of GB virus C (GBV-C E2) antibody is under investigation. The prevalence rates of GBV-C RNA and antibody to GBV-C E2 glycoprotein were determined in a population of 123 Egyptian anti-hepatitis C virus (HCV)-positive patients with chronic liver disease (CLD) who had not been treated previously with interferon. Sera were tested for GBV-C RNA by the LCx assay (Abbott Laboratories, North Chicago, IL), and for GBV-C E2 antibody by enzyme immunoassay. GBV-C RNA was present in 11.4% of patients. GBV-C E2 antibody was detected in 55.9% of GBV-C RNA-negative patients and in 2.2% of GBV-C RNA-positive patients (P = 0.006). GBV-C RNA was associated significantly with a history of schistosomiasis (relative risk [RR] = 5.83, 95% confidence interval [CI] 1.99–17.14, P < 0.005) but not with parenteral risk factors. The presence of GBV-C E2 antibody was not associated with age, gender, parenteral risk factors, schistosomal infection, or HCV viremia. The HCV genotype and level of viremia were similar in GBV-C anti-E2-positive and negative patients. There was a trend toward more severe histological disease with anti-E2 seropositivity (RR = 1.45, 95% CI 0.89–2.45, P = 0.11), an association which was independent of the evidence of schistosomiasis. It is concluded that GBV-C infection is common among HCV-infected Egyptian patients with CLD due to HCV infection. A significant negative correlation between the GBV-C viremia and GBV-C E2 antibody suggests that an antibody response is associated with viral clearance. This antibody response presumably occurs spontaneously, as none of the patients had received antiviral therapy. The unexpected association between GBV-C RNA and schistosomiasis suggests that nonparenteral or occult parenteral routes of GBV-C infection are likely to be important. J. Med. Virol. 53:354–360, 1997. © 1997 Wiley-Liss, Inc.     

Apparent cyclophosphamide (cytoxan) embryopathy: A distinct phenotype?

Cyclophosphamide (CP) is an alkylating agent widely used in treating cancer and autoimmune disease. CP is classified as a pregnancy risk factor D drug and is teratogenic in animals, but population studies have not conclusively demonstrated teratogenicity in humans. Six isolated reports of prenatally exposed infants with various congenital anomalies exist, but to date no specific phenotype has been delineated. The purpose of this report is to document a new case of in utero CP exposure with multiple congenital anomalies and to establish an apparent CP embryopathy phenotype. The mother had systemic lupus erythematosus and cyclophosphamide exposure in the first trimester. She also took nifedipine, atenolol, clonidine, prednisone, aspirin, and potassium chloride throughout pregnancy. The infant had growth retardation and multiple anomalies including microbrachycephaly, coronal craniosynostosis, hypotelorism, shallow orbits, proptosis, blepharophimosis, small, abnormal ears, unilateral preauricular pit, broad, flat nasal bridge, microstomia, high-arched palate, micrognathia, preaxial upper limb and postaxial lower limb defects consisting of hypoplastic thumbs, and bilateral absence of the 4th and 5th toes. Chromosomes were apparently normal. The reported cases of in utero exposure to cyclosposphamide shared the following manifestations with our patient: growth deficiency, developmental delay, craniosynostosis, blepharophimosis, flat nasal bridge, abnormal ears, and distal limb defects including hypoplastic thumbs and oligodactyly. We conclude that (a) cyclophosphamide is a human teratogen, (b) a distinct phenotype exists, and (c) the safety of CP in pregnancy is in serious question. Am. J. Med. Genet. 86:237–241, 1999. © 1999 Wiley-Liss, Inc.     

Response to a Supervised Structured Aerobic Exercise Training Program in Patients with Type 2 Diabetes Mellitus – Does Gender Make a Difference? A Randomized Controlled Clinical Trial

Objective

Because of the globally increasing occurrence of diabetes mellitus (DM) in the population, exercise is becoming vitally important for prevention and disease management, along with medical and dietary interventions. This study was designed to test the hypothesis that women with DM would respond similarly to men with DM following supervised structured aerobic exercise training (SSAET) program.

A novel approach to biliary tract pathology based on similarities to pancreatic counterparts: Is the biliary tract an incomplete pancreas?

There are peribiliary glands around the biliary tract, and these glands drain into the bile duct lumen. Interestingly, small amounts of pancreatic exocrine acini are intermingled with these glands. Experimental studies using animals suggest that the biliary tract shows some potential for pancreatic differentiation. It is noteworth that the biliary tract and pancreas have similar pathological features. IgG4‐related sclerosing cholangitis and autoimmune pancreatitis are representative inflammatory diseases with similar features. Intraductal papillary neoplasms are found in the biliary tract and also in the pancreas: intraductal papillary neoplasm of the bile duct (IPNB) and intraductal papillary mucinous neoplasm of the pancreas (IPMN). IPNB and IPMN share common histologic and phenotypic features and biological behaviors. Interestingly, mucinous cystic neoplasm (MCN) arises in both the pancreas and the heaptobiliary system. Intraductal tubular neoplasia is found in both the biliary tract and pancreas as well. Intraepithelial neoplasm is found in the biliary tract and pancreas: biliary intraepithelial neoplasm (BilIN) and pancreatic intraepithelial neoplasm (PanIN). BilIN and PanIN are followed by conventional invasive adenocarcinoma, while IPNB and IPMN are followed by tubular adenocarcinoma and mucinous carcinoma in both organs. Further study of the biliary tract's pathophysiology based on its similarity to pancreatic counterparts is warranted.     

Gestational diabetes mellitus (class A): a human teratogen?

Between January 1, 1982 and December 31, 1992 we evaluated 200 children of mothers with pregestational or gestational diabetes mellitus through the University of South Florida Genetics/Dysmorphology Clinics. They were a portion of the 22,100 families seen during that period. Pregnant women with diabetes mellitus were not part of this study. One hundred and fifty-two of the 200 were offspring of mothers with gestational diabetes (classes A1 and A2). Class B1 was not encountered as a subclass of gestational diabetes in this series. Twenty-four of the 152 did not have anomalies. Forty-one of the 152 had another primary diagnosis to account for their malformations. Eighty-seven of the 152 had a constellation of anomalies or solitary structural defects as seen in diabetic embryopathy. Chromosomal, monogenic, and other teratogenic causes were excluded. The observed phenotypes matched those seen in offspring of mothers with diabetes mellitus classes B2 to T. They also corroborated the animal studies, indicating that the embryopathy of gestational diabetes has a pathogenesis similar to that in classes B2 to T, and recent epidemiological studies showing a statistically significant increase of anomalies as in diabetic embryopathy in the offspring of gestational diabetes mothers. As per established obstetric practice the testing for gestational diabetes was after gestation 16 weeks. Thus, it was impossible to prove that the anomalies of the 87 propositi were due to gestational diabetes. However, the anomalies occurred during organogenesis as in the other diabetic classes, and inferred that gestational diabetes is a human teratogen. If so, common "idiopathic" malformations may be actually caused by undiagnosed maternal gestational diabetes.     

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis: where to go?

Enormous progress has been made during the last 25 years in our understanding of the aetiopathogenesis of the anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitides (AAV). This has led to improvements in early diagnosis, treatment and secondary prevention of these diseases. Nevertheless, there are still unmet needs in the AAV. With respect to diagnosis and follow-up, sensitive biomarkers that reflect disease activity, also during smouldering disease, are needed. In the field of aetiopathogenesis, genetic and epigenetic studies are being performed not only directed at the autoimmune response but also at the expression of, possibly modified, autoantigens. Environmental factors, in particular microbial factors, are also being explored. This will enable analysis of gene-environment interactions in the AAV, so elucidating further their aetiopathogenesis. Explaining the differences in clinical presentation between proteinase 3 (PR3)-associated AAV and myeloperoxidase (MPO)-associated AAV requires an adequate animal model for PR3-ANCA disease, which is currently lacking. Although many large randomized controlled trials have built a base for a rational therapeutic approach in the AAV, late morbidity and mortality is still significant. The availability of new biologicals and the development of sensitive biomarkers for disease activity could further improve prognosis for patients suffering from AAV.     

Is Leishmania (Viannia) braziliensis preferentially restricted to the cutaneous lesions of naturally infected dogs?

Previous studies have shown that proteasome inhibitors are novel agents for chemotherapy of human African trypanosomiasis or sleeping sickness. In this study, five peptide trileucine methyl vinyl sulfones with different N-terminal substituents were tested for their trypanocidal activities in vitro using culture-adapted bloodstream forms of Trypanosoma brucei. Two inhibitors displayed promising anti-trypanosomal activities with ED₅₀ values in the sub-micromolar range. Higher trypanocidal activity of the compounds generally corresponded to a higher k_obs/[I] value for inhibition of the trypsin-like activity but not for the inhibition of the chymotrypsin-like activity of the proteasome. These data suggest that inhibitors with strong activity against the trypsin-like activity of the proteasome are the rational choice for future anti-sleeping sickness drug development.     

Begin the BEGAN (The Brown Educational Guide to the Analysis of Narrative) – A framework for enhancing educational impact of faculty feedback to students’ reflective writing

Objective

The study aim was the development of a method to further enhance the educational benefit of medical students’ reflective writing. The setting is a Doctoring course at the Warren Alpert Medical School of Brown University, which includes reflective writing assignments, termed “field notes”, combining students’ reflective writing with ongoing individualized feedback from small group faculty.

Methods

Three-year (2005–2008) iterative process with three stages of immersion, analysis, and revision that resulted in the analysis framework. An interdisciplinary team composed of the four authors with backgrounds in narrative medicine, qualitative research, psychology, and medical education analyzed 12 first and second year students’ selected field notes in iterative cycles. In each cycle, consultations with small group faculty and content experts were conducted to further validate the emergent framework.

Results

This process culminated in the creation of the Brown Educational Guide to Analysis of Narrative (BEGAN) framework, a guide for crafting feedback to students’ reflective writing, and the integration of the BEGAN framework into the faculty and student manuals for the Doctoring Course in 2008–2009.

Conclusions

We propose the BEGAN framework as a useful innovative tool that can be incorporated in reflective writing curricula in the field of health professions education. It is tailored to support the educational impact of the course through additional scaffolding of student writing, and the robust process it delineates for crafting of faculty feedback.Providing systematic feedback to enhance reflective writing may represent the path forward in fostering professional development through reflection in health professions education.

Practice implications

The BEGAN can be incorporated in reflective writing curricula in the field of health professions education. It is a springboard for the necessary next steps of development and research into the acquisition of reflective and narrative competence in the emerging professional.