An educational game for teaching clinical practice guidelines to Internal Medicine residents: development,feasibility and acceptability

Background  

Adherence to Clinical Practice Guidelines (CPGs) remains suboptimal among internal medicine trainees. Educational games are of growing interest and have the potential to improve adherence to CPGs. The objectives of this study were to develop an educational game to teach CPGs in Internal Medicine residency programs and to evaluate its feasibility and acceptability.     

Petrous metastasis of a lung small cell carcinoma

Malignant tumors of the temporal bone are rare. They include a wide histological variety. They are mostly primary tumors with an estimated incidence of 0.8-1.0 per 1,000,000 inhabitants per year 1. Metastases form an uncommon subgroup. The clinical features of these temporal bone metastases are nonspecific and predominantly consist of hearing loss, vertigo, facial palsy, tinnitus, headache, otalgia or otorrhoea 2. The aim of our publication is to report a rare case of metastasis in the temporal bone as initial manifestation of lung cancer.Our patient was a 44-year-old man who presented for a right mastoid swelling with a grade VI right facial nerve palsy. Imaging and biopsy confirmed the diagnosis of small cell lung carcinoma petrous metastasis. The treatment was palliative. An osteolytic lesion of the temporal bone in an elderly patient may fit with a primary tumor of the temporal bone. It must, also, suggest the diagnosis of metastasis. The malignant tumor most frequently responsible is breast cancer, but lung cancer must also be considered in smoking patients.     

Myeloid sarcoma of the vulva as the presenting symptom in a patient with acute myeloid leukemia

BACKGROUND: Myeloid sarcoma is a tumor of myeloblasts or immature myeloid cells occurring in an extramedullary site. Myeloid sarcoma of female genital tract is very rare with no cases of vulvar location reported in English-language literature. CASE: A 73-year-old female presented with an indurated mass encompassing her left labia majora and vulva. The mass was diagnosed as vulvar myeloid sarcoma. The patient's peripheral blood smear revealed Auer rods and other findings consistent with a diagnosis of acute myeloid leukemia (M-2 type, FAB classification). CONCLUSION: To the best of our knowledge this case is the first report in the English-language literature of the myeloid sarcoma of the vulva. Correct diagnosis of myeloid sarcoma in an otherwise asymptomatic patient is crucial for early administration of antileukemic chemotherapy.     

Prognostic value of adenosine single-photon emission computed tomographic thallium imaging in medically treated patients with angiographic evidence of coronary artery disease

Background  

This study examined the prognostic value of adenosine single-photon emission computed tomographic thallium imaging in medically treated patients with angiographic evidence of coronary artery disease (CAD).     

Determinants of women's choice of their obstetrician and gynecologist provider in the UAE

BACKGROUND: The objective of this study is to evaluate women's priorities and preferences in selecting their obstetrician and gynecologist in a non-Western society. METHODS: Consecutive sample of 508 patients attending the obstetric and gynecologic services of AL-Ain Hospital; AL-Ain; United Arab Emirates during 4 months was recruited. Participants were interviewed by using a structured 26-item questionnaire administered by means of face-to-face interview within 24 h of admission in the ward or before consultation in the outpatient clinic. Respondents were asked about their preferences, priorities, determinants of choice of their obstetrician and gynecologist, their view of his/her role as a medical provider, and their perception of importance of each of provider's characteristics and roles on a five-point Likert scale. RESULTS: Four hundred thirty-nine (86.4%) participants preferred female physicians. Sixty-one (12%) had no preference and eight (1.6%) preferred male physicians. Reasons for female selection were privacy during intimate examination (89.1%) or counseling (68.8%), religious beliefs (74.3%), and cultural traditions (45.3%). Female preference was significantly associated with higher parity (P = 0.002), religion (P = 0.005), nationality (P = 0.01), occupation (P = 0.02), education (P = 0.04), and poor recognition of physician's role as professional/expert (P < 0.00001). Male preference was significantly associated with experience at previous encounter (P = 0.03), obstetric consultation (P = 0.04), and perceiving physician's role as skilled communicator (P = 0.01) or health educator (P = 0.04). Other physician characteristics affecting choice were professionalism, bedside manners, empathy, communication, competence, availability, and religion. CONCLUSIONS: Physician's attitude, professional profile, sex, and religious faith determine women's choice of obstetricians and gynecologists. Most women prefer female providers because of embarrassment during pelvic examination and reproductive counseling, religious beliefs, and sociocultural values.     

Urocortin in the central nervous system of a primate (Cebus apella): sequencing,immunohistochemical, and hybridization histochemical characterization

The urocortin (UCN)-like immunoreactivity and UCN mRNA distribution in various regions of the nonprimate mammalian brain have been reported. However, the Edinger-Westphal nucleus (EW) appears to be the only brain site where UCN expression is conserved across species. Although UCN peptides are present throughout vertebrate phylogeny, the functional roles of both UCN and EW remain poorly understood. Therefore, a study focused on UCN system organization in the primate brain is warranted. By using immunohistochemistry (single and double labeling) and in situ hybridization, we have characterized the organization of UCN-expressing cells and fibers in the central nervous system and pituitary of the capuchin monkey (Cebus apella). In addition, the sequence of the prepro-UCN was determined to establish the level of structural conservation relative to the human sequence. To understand the relationship of acetylcholine cells in the EW, a colocalization study comparing choline acetyltransferase (ChAT) and UCN was also performed. The cloned monkey prepro-UCN is 95% identical to the human preprohormone across the matched sequences. By using an antiserum raised against rat UCN and a probe generated from human cDNA, we found that the EW is the dominant site for UCN expression, although UCN mRNA is also expressed in spinal cord lamina IX. Labeled axons and terminals were distributed diffusely throughout many brain regions and along the length of the spinal cord. Of particular interest were UCN-immunoreactive inputs to the medial preoptic area, the paraventricular nucleus of the hypothalamus, the oral part of the spinal trigeminal nucleus, the flocculus of the cerebellum, and the spinal cord laminae VII and X. We found no UCN hybridization signal in the pituitary. In addition, we observed no colocalization between ChAT and UCN in EW neurons. Our results support the hypothesis that the UCN system might participate in the control of autonomic, endocrine, and sensorimotor functions in primates.     

Controlled release of lipopolysaccharide in the subarachnoid space of rabbits induces chronic vasospasm in the absence of blood

OBJECTIVE: Leukocyte-endothelial cell interactions appear to play a role in the development of vasospasm after SAH. Using a purely inflammatory protein, LPS, we evaluated the effect of inflammation on the development of chronic vasospasm in the absence of blood and compared it to SAH-induced vasospasm in rabbits. METHODS: Lipopolysaccharide was incorporated into EVAc polymers to produce 20% LPS/EVAc polymers (wt/wt). Rabbits (n = 23) were randomized to 4 experimental groups: (1) empty polymer (n = 6), (2) SAH (n = 5), (3) 0.7 mg/kg polymeric LPS dose (n = 6), and (4) 1.4 mg/kg polymeric LPS dose (n = 6). Blood and polymers were inserted into the cisterna magna. The rabbits were killed 3 days postoperatively, and the basilar arteries were harvested for morphometric analysis. Clinical response and lumen patencies were analyzed using ANOVA and a post hoc Newman-Keuls Multiple Comparisons test. RESULTS: Significant narrowing of the basilar artery was observed by insertion of 20% LPS/EVAc polymers into the subarachnoid space at a polymeric dose of 1.4 mg/kg (actual dose, 66 microg kg(-1) d(-1)) (75.4% +/- 4.2%; P < .01) and by SAH (80.3% +/- 8.1%; P < .01) as compared with the empty polymer group. A trend toward narrowing was observed in the 0.7 mg/kg polymeric LPS dose group (actual dose, 33 microg kg(-1) d(-1)) (85.2% +/- 2.6%; P > .05). Symptoms associated with SAH were noted in 50% of the rabbits in the 0.7 mg/kg LPS group and in 100% of rabbits in the 1.4 mg/kg LPS group. CONCLUSION: Controlled release of LPS into the subarachnoid space of rabbits produced chronic vasospasm in a dose-dependent manner. At a polymeric dose of 1.4 mg/kg, LPS-induced vasospasm was equivalent to that induced by SAH. This suggests that LPS and SAH may induce vasospasm through similar mechanisms and provides further evidence that inflammation plays a central role in the etiology of chronic vasospasm.