Affective disorders and cognitive performance. A clinical report

A study of 27 manic-depressives (some with histories of up to 65 years' duration and 100 attacks) showed that it is a disorder from which the patient can make a complete recovery without any cognitive deterioration. Many of these patients have had courses of the traditional drug and physical treatments (including ECT) used in mental hospitals over the last half century. This indicates that such treatments themselves need not produce deterioration.     

A repeat polymorphism in interleukin-4 gene is highly associated with specific clinical phenotypes of asthma.

BACKGROUND: IL-4 is a determining factor in immunologic mechanisms to allergy and inflammation. The authors designed a case-controlled study to investigate the potential association of a repeat polymorphism in IL-4 gene with specific clinical phenotypes of asthma. METHODS: The authors used the polymerase chain reaction to characterize the variation of the IL-4 intron 2 region in 145 unrelated Tunisian patients with asthma and 160 healthy control subjects. In order to strengthen the case-controlled study, analysis of IL-4 polymorphism was performed in families of several asthmatic patients. Asthma scores were determined and correlated with this polymorphism. RESULTS: Analysis of IL-4 polymorphism in patients with allergic asthma and in control subjects demonstrated a significant association between the IL-4 A1 allele and asthma. Further evidence of the strong association found between IL-4 intron 2 polymorphism and asthma was provided by the finding that asthma is transmitted in association with the inheritance of the IL-4 A1 marker. When patients were stratified into two groups according to the degree of the severity of asthma, the IL-4 A1 allele was specifically not associated with mild asthma, but highly associated with the moderate and severe forms of the disease. The relative risk (RR) of severe asthma is especially high in patients carrying the A1/A3 genotype (RR = 3.94, p = 0.0001). Conversely, a major decrease in the frequency of the IL-4 A3/A3 genotype was observed in patients with severe asthma, resulting in a significantly negative RR of this clinical phenotype of asthma (RR = 0.165, p = 0.0001). CONCLUSIONS: Tunisian persons carrying the IL-4 A1/A3 genotype may have an increased risk of severe asthma.     

A clinical performance exercise for medicine--pediatrics residents emphasizing complex psychosocial skills.

PURPOSE: To assess the skills of internal medicine-pediatrics (med-peds) residents in evaluating and counseling patients with complex psychosocial problems using a clinical performance exercise (CPE). METHOD: The authors designed a 13-station CPE [nine standardized-patient (SP) stations and four non-SP stations]. Eight of the SP stations focused on counseling or assessing complex psychosocial needs, and three were videotaped and analyzed for specific verbal and nonverbal communication skills. Residents completed a written task for each station and SPs completed a checklist on interviewing and communication skills and a 52-item patient's-satisfaction survey. All first- and third-year residents (n = 25) from two academic years participated. RESULTS: The range of the average scores on the nine SP stations was 43-75%. The residents performed better with common problems (newborn hospital discharge instructions and cardiac risk-factor counseling) than with more complex problems that are less often encountered in the institution (HIV counseling), or problems less often recognized (adult survivor of childhood sexual abuse). As expected, third-year residents scored better than did first-year residents on the written "plan" part of the SP stations and on the non-SP stations. Third-year and first-year residents had similar scores, however, on measures of verbal and nonverbal communication and patient's satisfaction, and for gathering data and providing information. CONCLUSION: This is the first performance-based evaluation of residents in a combined med-peds residency program. The stations addressed more complex clinical skills than those reported for objective structured clinical evaluations of residents.     

The uniform anatomical gift act: What every clinical anatomist should know

Although many are aware of the existence of a document called the Uniform Anatomical Gift Act (UAGA), few are aware that there are actually two such Acts (1968 and 1987), and even fewer have read the Acts themselves. Consequently, there are many different and frequently false impressions about their purpose and content. This paper is an attempt to acquaint readers with the two UAGAs. The historical background leading to the unprecedented rapid, uniform and unanimous adoption of the 1968 Act is presented. The content, rationale, and significance of that Act are outlined. The perceived shortcomings of the first Act resulting in the much less successful and less widely-adopted 1987 Act is explained and the major changes incorporated in the second Act are outlined. Specific features of the Acts of concern to anatomists involved in willed-body programs, and clinicians who may become involved in body/body part donation or utilization are addressed. Finally, the relationship of the UAGA to other lines of regulation and the need to be aware of them is indicated. © 1993 Wiley-Liss, Inc.     

Early clinical experience enhances third-year pediatrics clerkship performance.

PURPOSE: To determine whether clinical experiences in the preclinical years improve medical students' performances in a third-year clerkship. METHOD: A cohort study reviewed the pediatrics clerkship performances of 400 Eastern Virginia Medical School students in the graduating classes of 1996 through 1999. The first two classes completed a traditional preclinical curriculum with limited clinical experience. The final two classes participated in a mentorship program that provided 18 months of early clinical experience, consisting of one-on-one half-day sessions every other week with a generalist community faculty. The authors compared the clinical clerkship performances of the groups using clinical skills (CS) scores, history and physical examination (H&P) scores, and scores on the NBME pediatrics shelf examination. They also looked at the mean MCAT and USMLE scores for each group. The authors also looked at the scores within each class, comparing students who completed one of the first two pediatrics clerkship rotations with their classmates who completed clerkships later in the academic year. RESULTS: The students' NBME scores rose significantly (p < .05, r2 = 0.95) over the four-year study, paralleling a significant rise in MCAT scores (p < .03, r2 = 0.73). The CS and H&P scores did not rise. Students who had the traditional preclinical curriculum and who completed their clerkships early in the year had significantly lower CS and H&P scores than did their classmates. In contrast, the scores of students who had the early clinical experiences did not differ significantly according to the timing of their rotation. CONCLUSION: Students who had participated in a mentorship program that provided early clinical experience demonstrated significantly improved clinical skills in the pediatrics clerkship early in the academic year.     

Vital indication for erythropoietin in a chronic haemodialysis patient. A case report

A markedly anaemic, haemodialysis patient with a mixed deficiency of erythropoietin (EPO) and iron developed a life-threatening worsening of anaemia during an episode of severe rectal bleeding. Despite frequently recurring episodes of considerable ischaemic cardiac pain, the patient's religious conviction did not permit blood transfusion. Consequently, combination therapy with both recombinant human EPO (rhEPO) and oral iron was instituted. In this haemodialysis patient, the vitally significant replacement therapy of rhEPO and iron was followed by a steady and uncomplicated restoration of subnormal hematocrit and complete disappearance of cardiac ischaemia.     

Neuropsychological test performance among major clinical subtypes of depression.

Thirty-six patients with diagnoses of major depression were administered the Luria-Nebraska Neuropsychological Battery. Comparisons were made on six dichotomous subtypes of depression: agitated-nonagitated, endogenous-nonendogenous, primary-secondary, psychotic-nonpsychotic, retarded-nonretarded, and unipolar-bipolar. The psychotic depressives were more impaired than the nonpsychotics on the Profile Elevation and Impairment scales. No differences were found for other subtype comparisons on these global measures of neuropsychological dysfunction. Analysis of age effects indicated that older depressives performed more slowly on timed performance items and significant subtype differences on these items occurred for subtype diagnoses of psychotic, primary, and retarded depression. Localization and Lateralization scales revealed significant impairment for the psychotic and retarded patients, with less impairment for other subtypes. The relevance of these findings for neuropsychological evaluation are discussed, particularly with regard to the potentially confounding effects of depression on test performance.     

A.C. Cardiac defibrillator performance

An adequate expression of the desired characteristics is necessary for the assessment of commercially-available and privately-made defibrillators., The wide range of electrical performance of such units demands simple methods for measurement and possible modification. Observed performance characteristics are compared and subsidiary points of design mentioned. A simple instantaneous-electrode-current monitor is shown to be clinically useful and capable of giving rapid estimates of tissue resistance. It is also useful for assessment of defibrillator design and operation.     

Endocrinology: A 'sweet' indication for ovulation induction

In diabetic patients, euglycaemia at the thne of conceptionis crucial for the success of the pregnancy. In considerationof the difficulty in achieving and maintaining tight glycaemiccontrol for long periods, we administered clomiphene citrate,which is usually indicated in cases of absent or infrequentovulation, to enhance fecundability in 10 pregestational diabeticpatients. All conceived within one to three cydes of the drug,and nine delivered healthy term babies after uneventful pregnancies;one aborted spontaneously in the eighth gestatlonal week. Noeffect of the drug on the diabetes was noted as based on measurementsof glycosylated haemoglobin and fructosainine con centrationsand the absence of changes in the patients' insulin requirements.In the light of these successful results, and in view the importanceof euglycaemia at the beginning of diabetic pregnancies, wesuggest a new ‘sweet’ indication for the use ofclomiphene citrate.     

The influence of testing context and clinical rotation order on students' OSCE performance.

PURPOSE: To investigate the influence of testing context and rotation order on third-year medical student performance on a common objective structured clinical examination (OSCE) station in both obstetrics-gynecology (ob-gyn) and psychiatry rotations. METHOD: Archival OSCE performance data (in the form of a 25-item binary content checklist) from one class of third-year medical students (n = 141) at Saint Louis University (2002-03) were aggregated and analyzed. RESULTS: Despite the fact that the station was identical in both OSCEs, students were, in general, less likely to inquire about ob-gyn issues on the psychiatry OSCE and less likely to inquire about psychiatric issues on the ob-gyn OSCE, regardless of order of rotation. Order did have a positive effect on some results, such that students were more likely to mention menopause and vaginal dryness on the psychiatry OSCE if they had already had the ob-gyn rotation. CONCLUSION: The testing context may influence student approaches to patients in ways that bias their collection and interpretation of information. OSCE evaluations may better approximate true clinical context and complexity by presenting case scenarios that reflect a broader range of diagnostic possibilities than those limited to the recently completed rotation.     

Validation of a global measure of faculty's clinical teaching performance.

PURPOSE: To validate the University of Michigan Global Rating Scale (GRS), a single-item, five-point global measure of faculty members' clinical teaching performances previously shown to be reliable. METHOD: In June 1998, 98 senior medical residents (98% of seniors) from four academic institutions completed the GRS for all teaching faculty at their institutions. Each resident also completed the 26-item Stanford Faculty Development questionnaire (SFDP26) for ten faculty with whom he or she had had teaching contact during residency. The SFDP26 is a validated instrument that measures seven specific aspects of clinical teaching (e.g., communication of goals, feedback). RESULTS: The mean GRS score (SE) was 3.83 (.07). There was no difference in mean GRS or SFDP26 subscale scores across institutions. In a random-effects model that controlled for interrater reliability, correlation coefficients comparing the mean GRS scores and the mean scores for the individual SFDP26 subscales ranged from.86 to.98. CONCLUSIONS: The GRS correlates highly with measures of seven specific aspects of teaching effectiveness among senior medical residents. The GRS is a simple, readily administered measure of faculty's teaching performances that can be used by residency programs as part of an incentive or reward program, to identify teachers as potential candidates for faculty development, or for consideration in promotion decisions.     

Comparison of CTG repeat length expansion and clinical progression of myotonic dystrophy over a five year period.

Myotonic dystrophy (DM) is associated with an underlying CTG trinucleotide repeat expansion at a locus on chromosome 19q13.3. We have determined the repeat length in 23 DM patients with varying clinical severity of symptoms and various sizes of repeat amplification. We confirm that as in previous studies there is no strong correlation between repeat length and clinical symptoms but find that the repeat length in peripheral blood cells of patients increases over a time span of five years indicating continuing mitotic instability of the repeat throughout life. Repeat length progression does not appear to be indicative of clinical progression but age probably is. The degree of expansion correlates with the initial repeat size and 50% of the patients with continuing expansions showed clinical progression of their disease symptoms over the five year study period.