Viewpoint: suggestions for a shift in teaching clinical skills to medical students: the reflective clinical examination.

How medical students are taught physical examination (PE) skills appears to have changed little since the 1950s. Textbooks are organized according to organ systems and describe methods of eliciting and recording history and PE data using a routine format. In many medical schools, the preclinical teaching programs for clinical examination skills similarly emphasize an orderly collection of data. Teaching students to use diagnostic reasoning is postponed until students have learned history-taking and PE skills. The authors propose three modifications to this educational approach. First, rather than performing the clinical examination using a routine format, students should be encouraged to form diagnostic hypotheses early on while listening to the patient's narrative, and conduct the subsequent search for history and PE data in a reflective way in order to confirm or refute these hypotheses. Second, the authors propose that interviewing patients and conducting the PE be taught by one-on-one tutoring until students achieve mastery. Last, they suggest that the PE be guided not only by students' diagnostic hypotheses, but also by patients' expectations. These modifications are consistent with current trends in medical education that encourage a reflective practice and problem-based learning (PBL), and they also introduce medical students to the precepts of clinical reasoning. The authors suggest that challenging students to seek specific physical findings may increase the likelihood of detecting findings when they are present, and may transform patient interviewing and conducting the PE from routine activities into intellectually exciting experiences.     

A cytogenetic survey of an institution for the mentally retarded: I. Chromosome abnormalities

A cytogenetic survey of 475 patients in an institution for the mentally retarded is reported. The chromosomes of all patients were studied using both a non-banding and a G-banding technique in order to estimate the relative efficiency of the two technique in detecting structural rearrangements of the chromosomes. A total of 57 patients was found to have a chromosome abnormality, including five with a balanced structural rearrangement. The contribution of chromosome aberrations to the etiology of mental retardation is discussed with special emphasis on the contribution of balanced structural rearrangements.     

Rates in vitro changes of gonococcal colony opacity phenotypes.

The rate of change of colony opacity phenotype was determined for 12 strains of Neisseria gonorrhoeae. The average rate of change was about 2 X 10(-3) per colony-forming unit per generation with a range of 0.2 X 10(-3) to 4 X 10(-3) per colony-forming unit per generation. Transition from opaque to transparent occurred at the same rate as transition from transparent to opaque. The following factors were shown to have no effect on the transition rate: (i) the state of piliation; (ii) the number of passages as a particular phenotype; (iii) alteration in the temperature, pH, or amount of oxygen in the atmosphere during growth; (iv) the addition of any of 194 compounds or mixtures to the growth media; (v) the addition of DNase or of DNA from opaque or transparent gonococci; and (vi) incubation between the opacity-transparency transition and the change resulting in the loss of piliation was seen. Some implications of the high transition rate are discussed.     

Infliximab for the treatment of fistulas in patients with Crohn's disease

BACKGROUND: Enterocutaneous fistulas are a serious complication of Crohn's disease and are difficult to treat. Infliximab, a chimeric monoclonal antibody to tumor necrosis factor alpha, has recently been developed as a treatment for Crohn's disease. We conducted a randomized, multicenter, double-blind, placebo-controlled trial of infliximab for the treatment of fistulas in patients with Crohn's disease. METHODS: The study included 94 adult patients who had draining abdominal or perianal fistulas of at least three months' duration as a complication of Crohn's disease. Patients were randomly assigned to receive one of three treatments: placebo (31 patients), 5 mg of infliximab per kilogram of body weight (31 patients), or 10 mg of infliximab per kilogram (32 patients); all three were to be administered intravenously at weeks 0, 2, and 6. The primary end point was a reduction of 50 percent or more from base line in the number of draining fistulas observed at two or more consecutive study visits. A secondary end point was the closure of all fistulas. RESULTS: Sixty-eight percent of the patients who received 5 mg of infliximab per kilogram and 56 percent of those who received 10 mg per kilogram achieved the primary end point, as compared with 26 percent of the patients in the placebo group (P=0.002 and P=0.02, respectively). In addition, 55 percent of the patients assigned to receive 5 mg of infliximab per kilogram and 38 percent of those assigned to 10 mg per kilogram had closure of all fistulas, as compared with 13 percent of the patients assigned to placebo (P=0.001 and P=0.04, respectively). The median length of time during which the fistulas remained closed was three months. More than 60 percent of patients in all the groups had adverse events. For patients treated with infliximab, the most common were headache, abscess, upper respiratory tract infection, and fatigue. CONCLUSIONS: Infliximab is an efficacious treatment for fistulas in patients with Crohn's disease.     

Hairline aesthetics and styling in hair replacement surgery

Punch grafting and flap surgery are proven methods of correcting baldness. Using either method, the location and shape of a new hairline on the frontal and temporal scalp is one of the most important aspects of hair replacement surgery. If the hairline is not aesthetic, the results can be unacceptable or even devastating for the patient and surgeon alike. The principles of planning the frontal and temporal hairline are presented using punch grafts as well as flaps. Postoperative styling of the "new" hair will vary depending upon the method used to transfer the hair (flaps or grafts), the local factors involved (texture, direction, density, tufting, etc.), as well as the patient's preference. The various advantages and disadvantages of styling possibilities with each method are presented. These factors should be discussed with the patient preoperatively.