Attitudes towards intramural continuing medical education: a European perspective

Continuing medical education (CME) is now one of the key areas of development in medical education. This paper describes the development of an intramural continuing medical education programme de novo in a newly opened cancer institute in Italy, which provided a unique opportunity to study attitudes towards the concepts and goals of continuing medical education as most of the individuals involved in this programme were exposed to continuing medical education for the first time. The continuing medical education programme was overseen by a CME committee for 1 year. Three 1-hour sessions were delivered each week and one credit point was awarded for each session. The sessions included grand rounds, clinical-based teaching and a 3-weekly rotating schedule of pathology, radiology and research. Participants were all the medical doctors attending the European Institute of Oncology. Attendance at greater than 50% of the total sessions available yearly qualified the individual for certification by the CME committee of the Institute. A questionnaire was circulated to all medical doctors at the Institute at the end of the academic year to assess attitudes to CME in general. Forty-six out of 84 questionnaires were returned. The majority of those involved in this CME intramural programme undertook self-directed CME activities and at least 50% had not previously attended either grand rounds or research seminars. Most felt that CME should not be mandatory but that its activities should be monitored. The greatest difficulty with CME was in its timing.     

Hyperfunctioning Thyroid Nodules in Children and Adolescents

ABSTRACT. Eight children and adolescents, seven female and one male, aged 7.1 to 15.0 years, referred over a 12-year period for a solitary mass in an otherwise normal thyroid gland, exhibited a hyperfunctioning nodule on thyroid scintiscan. Tracer uptake in the surrounding thyroid tissue was reduced or completely suppressed, but could be restored after TSH stimulation. Only one patient had mild clinical hyperthyroidism with normal T4 but increased T3 serum levels and blunted TSH responsiveness to TRH. A similar hormonal pattern suggestive of subclinical hyperthyroidism was found in three other subjects who were clinically euthyroid. One patient initially euthyroid progressed to subclinical hyperthyroidism two years later. In the whole group a significant negative relationship was found between serum T3 level and TRH-stimulated TSH peak (r= -0.829, p<0.02). All the patients underwent selective surgery after a 3-month to 2-year period of follow-up. Microscopic examination was consistent with adenoma in seven patients, while in one case a well-encapsulated papillary adenocarcinoma was found. Though hyperfunctioning nodules are seldom malignant, their surgical removal must be recommended when they become thyrotoxic, exceed 3 cm or show progressive enlargement.     

Cardiac Rehabilitation in Patients with Rate Responsive Pacemakers

This study investigated the suitability of our oxygen pulse reserve (OPR) method for tailoring parameters of rate responsive pacemakers and planning aerobic rehabilitation programs. We selected 11 patients, NYHA Classes I-III (7 males and 4 females; mean age 60 years, range 18–83), with rate responsive pacemakers implanted for high degree AV block and chronotropic incompetence. Five pacemakers had activity sensors, 4 had temperature sensors, and 2 had dual sensors. All patients underwent a cardiopulmonary stress test (CPX). We determined anaerobic threshold time (ATT), VO₂/AT, total exercise time (TET), VO₂ Max, and VO₂AT/VO₂ Max. OPR (mL-O₂/beat) was calculated for each patient using the formula OPR = (VO₂Max - VO₂ resting)/(HR Max - HR resting). During CPX, this slope was used as the rate response tailoring guideline by comparing the mL-O₂/beat equation and the pacing rate. Rate response settings were modified until the optimal relationship between theoretical and paced rate was obtained. The work protocol yielded rate response settings capable of providing pacing rates within ± 10 beats of the theoretical values. Data relating to theoretical and measured rates have been analyzed statistically. Patients underwent an aerobic rehabilitation program that followed the American College of Sports Medicine guidelines. Pacing rate at the anaerobic threshold was considered the border for an aerobic workload. After 2–7 months, all patients showed an evident improvement in ATT (92%), VO₂/AT(48%), TET(49%), VO-,Max (23%), and VO₂ AT/VO₂ (21%). Particularly, two patients improved from Weber Class C to A, and three improved from C to B. At each CPX step, the mean values of pacing rate and theoretical rate almost overlap, and the relevant coefficients suggest an excellent correlation (P < 0.001). Our OPR method for tailoring rate response provides the basis for an effective rehabilitation program with functional advantages for patients.     

Skin Angiosarcoma Arising in an Irradiated Breast: Case-Report and Literature Review

BACKGROUND: Angiosarcoma (AS) is a rare, invasive malignancy originating from endothelial cells caused by many different clinical situations. AS following radiotherapy for breast cancer after conservative surgery is a rare but well-known association. OBJECTIVE: The aim of this article is to describe a case of AS after breast conserving surgery and to review the literature to date. RESULTS: We report the case of an 84-year-old woman who developed AS four years after she was subjected to quadrantectomy for invasive ductal cancer, followed by 30 tangent field radiotherapy sessions. She presented with a one-month history or red papular skin eruptions on the operated breast. Skin lesions were submitted for biopsy, and they were positive for AS. The patients was subjected to surgical excision of the remaining breast including all AS lesions. She is alive with no evidence of disease after 10 months follow-up. CONCLUSION: Post-radiotherapy AS is rare neoplasm, but it should be considered in the case of patients with red lesions after breast conserving surgery and adjuvant radiotherapy.     

Paraphenylenediamine, a contact allergen, induces oxidative stress and ICAM-1 expression in human keratinocytes

In an investigation of the role of keratinocytes in the pre-immunological phase of contact allergy, we have studied the effect of paraphenylenediamine (PPD) on cell proliferation, membrane lipid peroxidation and the expression of the intercellular adhesion molecule 1 (ICAM-1). Because PPD undergoes rapid autoxidation in the culture medium, the effect of PPD-modified medium on keratinocyte proliferation and ICAM-1 expression was also examined. PPD at low concentrations (up to 10 micrograms/ml) and with low exposure times (0.5 h) enhanced keratinocyte proliferation, but at high concentrations and with longer exposure times resulted in cell stasis and toxicity. These effects and the enhanced membrane lipid peroxidation that was also observed can be ascribed to the production of superoxide and hydrogen peroxide by the autoxidation of PPD in the medium. At non-cytotoxic concentrations, PPD induced ICAM-1 expression on the keratinocytes. PPD-modified medium was also cytotoxic to the keratinocytes and induced ICAM-1 expression in non-cytotoxic concentrations. It appeared that superoxide and hydrogen peroxide were not responsible for the cytotoxicity. These results are consistent with the view that oxidative stress may be an essential part of the pre-immunological phase in the induction of allergic contact dermatitis.     

Relationship between Amplitude and Timing of Heart Sounds and Endocardial Acceleration

Objective: To study the correlation between heart sounds and peak endocardial acceleration (PEA) amplitudes and timings, by modulation of paced atrioventricular (AV) delay in recipients of dual chamber pacemakers.
Methods: Ten recipients of dual chamber pacemakers implanted for high-degree AV block were studied. Endocardial acceleration (EA) and phonocardiographic and electrocardiographic signals were recorded during performance of an AV delay scan in VDD and DDD modes.
Results: First PEA (PEA I) and first heart sound (S1) changed similarly with the AV delay. A close intrapatient correlation was observed between S1 and PEA I amplitudes in all patients (P < 0.0001). The interpatient normalized PEA I to S1 amplitudes correlation was r = 0.89 (P < 0.0001) in DDD mode, and r = 0.81 (P < 0.0001) in VDD mode. The mean cycle-by-cycle PEA I to S1 delay was −4.3 ± 22 ms and second PEA (PEA II) to second heart sound (S2) delay was −7.7 ± 15 ms.
Conclusions: A close correlation was observed between PEA I and S1 amplitudes and timings, and between PEA II and S2 timings. These observations support the hypothesis that PEA and heart sounds are manifestations of the same phenomena. EA might be a useful tool to monitor cardiac function.     

Transvenous Extraction Performance of Expanded Polytetrafluoroethylene Covered ICD Leads in Comparison to Traditional ICD Leads in Humans

Background: In the Endotak Reliance G defibrillating leads (Guidant Corporation, St. Paul, MN, USA), coils are covered with expanded polytetrafluoroethylene (ePTFE) to prevent tissue ingrowth. The aim of the study was to evaluate transvenous extraction performance, outcomes, and fibrotic adherences rate of ePTFE defibrillating leads in comparison to traditional non‐ePTFE cardiac defibrillator (ICD) leads. Methods: Seventeen consecutive ICD recipients (ePTFE Group A, 16 men, mean age 66 ± 12 years) with 17 Endotak Reliance G dual‐coil ICD leads (mean implantation time 23 ± 26 months) underwent a transvenous removal procedure. They were compared with two control groups, including 20 Sprint Quattro 6944 (non‐ePTFE Group B; Medtronic Inc., Minneapolis, MN, USA) and 36 Riata 1570 ICD leads (non‐ePTFE Group C; St. Jude Medical, St. Paul, USA). The indication for lead extraction was local infection in 35 patients (48%), sepsis in 24 patients (33%), and lead malfunction in 14 patients (19%). Results: In all groups, all leads were successfully and completely removed without major complications. Overall manual traction was effective in six patients (8%) and more effective in the ePTFE Group (29%) compared to Group B (0%) and Group C (3%) (P = 0.001). Sixty‐seven leads (92%) required mechanical dilatation by the venous entry site approach, with a shorter extraction time in the ePTFE Group (5 ± 11 min) compared to Group B (21 ± 22 min) and Group C (16 ± 22 min) (P = 0.003). ePTFE leads showed a lower rate of fibrotic adherences at the superior vena cava level (P = 0.01) without statistically significant differences in the other sites. Conclusions: ePTFE‐covered leads may be removed more easily and quickly than non‐ePTFE leads, requiring less frequently mechanical dilatation. (PACE 2010; 1376–1381)     

Incomplete Endothelialization of Left Atrial Appendage Occlusion Device 10 Months After Implantation

Incomplete Endothelialization of Left Atrial Appendage . We describe the case of a 74‐year‐old man with Rendu Osler Weber syndrome affected by permanent atrial fibrillation, who underwent percutaneous placement of a 24‐mm Watchman left atrial appendage system. After anticoagulation therapy dismissal, he had a transient ischemic attack (TIA). Therefore he underwent surgical removal of the device, ablation of atrial fibrillation with Maze IV procedure and biatrial reduction. Very interestingly, no significant endothelialization of the device was observed 10 months after implantation. In conclusion, this case is important because, to our knowledge, it is the first finding of Watchman device with lack of endothelialization. (J Cardiovasc Electrophysiol, Vol. 23, pp. 1384‐1385, December 2012)     

Maternal and paternal moderate daily alcohol consumption and unexplained miscarriages

Summary. The relation between parental moderate alcohol consumption and the risk of miscarriage was analysed using data from a casecontrol study in Milan between January 1987 and June 1988. Cases were 94 women who had two or more 'unexplained' miscarriages (after exclusion of genetic, endocrine and Miillerian factors) and without full-term pregnancies, admitted or referred to the First Obstetric and Gynecologic Clinic of the University of Milan. A total of 176 women admitted for normal delivery on selected days to the same university clinic and without previous miscarriages were chosen as controls. Compared with non-drinkers the risk of recurrent miscarriage was 0·9 for regular drinkers. The point estimates were 0·9 for women reporting one drink per day and 0·8 for those reporting two or more. Compared with non-drinkers, the relative risk estimates for drinking by fathers were slightly above unity, being 1·7 for less than three drinks and 1·4 for three or more drinks per day, but the trend in risk was not statistically significant.