Skilled task teaching and assessment

Teaching and OSCE assessment of core clinical skills requires large resources in time and staff. Therefore, ensuring efficient and effective teaching that produces quantifiably competent students is important. This study compared the content of an 'Advanced Life Support (ALS) Course' with the medical undergraduate curriculum at this institution; it examined the OSCE resuscitation station for medical students to identify common errors where teaching could be improved; and finally it compared the resuscitation station with other skilled task stations. The written curriculum for the 'ALS' course and undergraduates was scrutinized for content and duration. Performance in the resuscitation station was analysed by dividing it into 20 separate skilled tasks marked individually. This station was compared with stations on chest and abdominal examination, and fundoscopy. Undergraduate resuscitation teaching exceeded the 'ALS' course in duration, including theoretical and practical teaching, and in depth of knowledge. During the practical resuscitation OSCE several skilled tasks were identified as deficient. The results of the resuscitation OSCE were better than those from the other skilled task stations. Students perform to a higher standard in OSCE stations that assess ability to deal with stressful situations. Their performance in the simulated environment of the OSCE is of a high standard and may in part be due to the fact that the station is omnipresent, without cross-compensation of marks. Formal 'ALS' courses are expensive and, as this study demonstrates, unnecessary given the high standards attained.     

Paclitaxel added to the cisplatin/etoposide regimen in extensive-stage small cell lung cancer -- the use of complete response rate as the primary endpoint in phase II trials

Obtaining a complete response (CR) is the most powerful predictor of survival in extensive-stage small cell lung cancer (SCLC). Improvements in long-term survival in extensive-stage SCLC can be made if the proportion of complete responders to induction therapy can be increased. We performed a phase II trial of the feasibility of adding paclitaxel to standard cisplatin/etoposide (EP regimen) in extensive-stage SCLC. The primary endpoint for this trial is the proportion of patients (pts) obtaining a CR rather than overall response. The null hypothesis for this trial consists of the absence of a CR rate >20%. Paclitaxel was given at doses of 135 (3 pts) or 170 mg/m(2) i.v. over 3 h on day 1. Cisplatin 60 mg/m(2) was given on day 1. On days 1-3 etoposide 80 mg/m(2) per day i.v. was given. G-CSF was used from days 5 to 14 of each cycle. Cycles were repeated q21 days. A two-stage design was used for patient accrual, based on the occurrence of complete responses. Initially, 16 patients were to be accrued. If more than three complete responses were to occur, a further 20 patients would be accrued to the study (Simon's optimal two stage design). Sixteen patients were enrolled. Two patients had a CR (13%) and nine patients had a partial response (56%) for an overall response rate of 69%. The trial was suspended due to the low CR rate. Review of the literature for paclitaxel based front-line treatment combined with EP therapy, in extensive stage SCLC, consistently shows a CR rate <20% but high overall response rate is maintained (thus most responses are partial). As virtually all long-term survivors in extensive-disease SCLC have had a CR to induction therapy and CR remains the strongest predictor of survival for this disease, this may suggest that paclitaxel added to standard EP may improve progression-free survival (and possibly median survival) but is unlikely to significantly improve long-term survival. Initial randomized phase III data confirm the absence of impact on survival for this triple-drug regimen compared to EP therapy alone. Furthermore, other regimens comparing favorably to the EP regimen have all shown consistent CR rates >20% in the phase II setting. In conclusion, consideration should be given to the use of CR rate as a phase II endpoint to determine if a particular regimen should be compared to the standard in a phase III setting for extensive-stage SCLC. A two-stage phase II design based on a minimum required completed responses for further patient accrual is recommended.     

Homozygosity at chromosome 8qter in individuals affected by mal de Meleda (Meleda disease) originating from the island of Meleda

BACKGROUND: The inherited palmoplantar keratodermas (PPKs) are a clinically heterogeneous group of disorders characterized by thickening of the skin of the palms and the soles. These diseases also exhibit genetic heterogeneity and many autosomal dominant and recessive forms have been described. Mal de Meleda (Meleda disease, MD) is an autosomal recessive form of PPK first described on the Dalmatian island of Meleda. A gene for MD has recently been assigned to the most telomeric portion of chromosome 8q using two large Algerian families. OBJECTIVES: To determine whether the same gene underlies the skin disease in Meleda islanders. METHODS: We have examined five affected individuals originating from the Dalmatian island itself for 8qter homozygosity. RESULTS: This region was found to be homozygous in all five affected individuals but in none of the 20 other unaffected family members examined. CONCLUSIONS: The current study confirms the localization of a gene for MD to 8qter using samples from the island of Meleda, highlighting the clinical and genetic homogeneity of this condition.     

Anesthesia,the aging brain,and the surgical patient

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Obstetric and nonmalignant gynecologic bleeding: treatment with angiographic embolization

Eight patients (seven post partum, one post abortion) with massive pelvic hemorrhage related to pregnancy and one patient with uncontrollable bleeding following a cervical biopsy underwent angiography to facilitate the identification and treatment of bleeding sites. In all nine patients pelvic hemorrhage was successfully controlled with embolization under angiographic guidance. Angiographic embolization allowed preservation of the uterus in six patients referred prior to hysterectomy, and one patient subsequently became pregnant. When conservative measures and minor surgical repairs have failed, embolization should be the next step in the treatment of postpartum hemorrhage to avoid major surgery in an unstable patient and to maintain reproductive function.     

Three novel spastin (SPG4) mutations in families with autosomal dominant hereditary spastic paraplegia

Hereditary spastic paraplegia (HSP) is a clinically and genetically heterogeneous condition, characterised principally by progressive spasticity of the lower limbs. Forty percent of autosomal dominant (AD) pedigrees show linkage to the SPG4 locus on chromosome 2, which encodes spastin, an ATPase associated with diverse cellular activities (AAA) protein. We have performed a clinical and genetic study of three AD-HSP families linked to SPG4. Sequencing revealed three novel causative mutations. Two of the mutations were located in exon 5 (a 1-base pair (bp) insertion and a 5-bp deletion), resulting in frameshift and premature termination of translation, with the predicted protein lacking the entire AAA functional domain. The 5-bp deletion was associated with a later onset and mild cerebellar features. The third mutation was a 3-bp deletion in exon 9, resulting in the loss of a highly conserved phenylalanine residue within the AAA cassette and an apparently milder phenotype. This is the first example of a deletion of an amino acid in spastin.     

Pulmonary lymphangitic spread of carcinoma: appearance on CT scans

Chest computed tomography (CT), including high-resolution CT with thin (1.5-mm) sections was used to evaluate proved (pathologically or clinically) lymphangitic spread (LS) of tumor in 12 patients. These appearances were compared with thin-section scans obtained in 11 healthy subjects. Thin-section CT demonstrated findings consistent with thickening of the normal lung interstitium. In all patients, thin sections showed an increase in the number of peripheral lines (1-2 cm in length) that were diffuse in generalized disease and localized in focal disease. Normal peripheral arcades were not increased in number, but the limbs forming the arcades were thickened in all patients. A diffuse increase in linear and curvilinear structures (reticular pattern) was seen toward the center of the lung. Polygonal structures 1-2 cm in diameter were seen in seven patients with LS but not in healthy subjects. Fissures were thickened in nine patients. Selected 1.5-mm-thick CT sections are recommended through abnormal areas (seen at CT or on chest radiographs) or if these are normal at three levels (midapex, hilus, and 3 cm above the diaphragm) when scanning patients with tumors known to cause LS.     

Multi-level Factors Associated with Pregnancy among Urban Adolescent Women Seeking Psychological Services

The purpose of this study was to examine the prevalence of pregnancy as well as multi-level factors (i.e., individual, family, and environment) associated with history of pregnancy among a sample of urban adolescent women seeking psychological services. Data were collected from a total of 264 sexually active, 13–18-year-old, adolescent women who participated in a larger HIV prevention study. Adolescents and one participating parent completed an audio computer-assisted self-interviewing survey. A total of 17.4 % of participants reported a history of pregnancy. A multivariable logistic regression model suggests that after controlling for empirically derived sociodemographic and behavioral covariates, absence of father in the home, family support and cohesion, and neighborhood risk were positively related to pregnancy. This study is among the first to examine multi-level factors associated with pregnancy among adolescent women diagnosed with psychological disorders. Consideration of such factors is crucial both in terms of clinical practice and in the design of pregnancy prevention programs. Collaboration between physicians and mental health providers working with adolescent women is crucial and represents an ideal opportunity to promote parental involvement and access to supportive community resources, including pregnancy prevention programs for this vulnerable population of adolescents.