A cross-cultural study of students' approaches to professional dilemmas: sticks or ripples

Medical Education 2012: 46 : 245–256 Context Medical educators internationally are faced with the challenge of teaching and assessing professionalism in their students. Some studies have drawn attention to contextual factors that influence students’ responses to professional dilemmas. Although culture is a significant contextual factor, no research has examined student responses to professional dilemmas across different cultures. Methods Semi‐structured interviews inquiring into reactions towards, and reasoning about, five video clips depicting students facing professional dilemmas were conducted with 24 final‐year medical students in Taiwan. The interviews were transcribed and analysed according to the theoretical framework used in prior Canadian studies using the same videos and interview questions. Results The framework from previous Canadian research, including the components of principles, affect and implications, was generally applicable to the decision making of Taiwanese students, with some distinctions. Taiwanese students cited a few more avowed principles. Taiwanese students emphasised an additional unavowed principle that pertained to following the advice of more senior trainees. In addition to implications for patients, team members or themselves, Taiwanese students considered the impact of their responses on multiple relationships, including those with patients’ families and alumni residents. Cultural norms were also cited by Taiwanese students. Conclusions Medical educators must acknowledge students’ reasoning in professionally challenging situations and guide students to balance considerations of principles, implications, affects and cultural norms. The prominence of Confucian relationalism in this study, exhibited by students’ considerations of the rippling effects of their behaviours on all their social relationships, calls for further cross‐cultural studies on medical professionalism to move the field beyond a Western individualist focus.     

Polymorphism in endostatin,an angiogenesis inhibitor,and prostate cancer risk and survival: A prospective study

Endostatin inhibits endothelial cell proliferation and migration, prerequisites of angiogenesis. A functional missense mutation (D104N) in endostatin was associated with an increased prostate cancer risk in a small study. We undertook a larger, prospective study within the Physicians' Health Study to examine D104N and prostate cancer risk and progression among 544 incident prostate cancer cases (1982–1995) and 678 matched controls. The association between endostatin genotype and cancer risk was estimated using logistic regression models. Among cases, Cox models were used to assess D104N and lethal prostate cancer. Given the role of endostatin in neovascularization of adipose tissue, we cross classified individuals on D104N genotype and body mass index (BMI). The genotype frequency was 1.3% homozygous (NN), 14.5% heterozygous (DN) and 84.2% wildtype homozygous (DD). There was no overall association between carriage of the N allele and prostate cancer risk (RR = 1.2, 95% CI: 0.9–1.6) or cancer‐specific mortality (HR = 1.2, 0.7–1.8). Cases with the polymorphic allele were less likely to be overweight (BMI 25 kg/m² or greater, 26%) compared to men wildtype homozygous (48%), p < 0.0001. Being overweight was associated with a 60% greater prostate cancer risk among those who were wildtype homozygous. In contrast, being overweight was associated with a 50% lower risk of cancer among those with the N allele. We did not confirm an earlier observation between the D104N polymorphism and prostate cancer. However, our data indicate that prostate cancer cases who carry the variant N allele are more likely to be overweight, and may be more susceptible to the angiogenic influences of obesity in prostate cancer pathogenesis. © 2009 UICC     

Tensions in the field: teaching standards of practice in optometry case presentations.

PURPOSE: Professional identity formation and its relationship to case presentations were studied in an optometry school's onsite clinic. METHODS: Eight optometry students and six faculty optometrists were audio-recorded during 31 oral case presentations and the teaching exchanges related to them. Using convenience sampling, interviews were audio-recorded of four of the students and four of the optometrists from the field observations. After transcribing these audio-recordings, the research team members applied a grounded theory method to identify, test, and revise emergent themes. The theme reported herein pertains to communicating standards of practice. RESULTS: Faculty optometrists demonstrated three ways of communicating standards of practice to optometry students during case presentations: Official Way, Our Way, and My Way. Although there were differences between these standards, the rationale for the disparities was rarely explicitly articulated by the instructors to the students. Without this information, the incongruity among the standards was left to the students to interpret on their own. CONCLUSIONS: The risk created by faculty not articulating the rationale underlying standards of practice was that students misinterpreted the optometrists' ways as idiosyncratic. Thus, opportunities were missed in the educational setting to assist students in making responsible decisions, locating their position in practice, and shaping their professional identity. Competing responsibilities of patient care and student education left instructors with little time to articulate rationale for standards of practice. Therefore, educators must reflect on innovative ways to bring into relief the logic behind their actions when working with novices.     

Comparison of the prognostic effect of left versus right versus no bundle branch block on presenting electrocardiogram in acute myocardial infarction patients treated with primary angioplasty in the primary angioplasty in myocardial infarction trials

The presence of bundle branch block (BBB) has been associated with poor outcomes in patients who have acute myocardial infarction. Whether this is true in the angioplasty era is not known. We sought to evaluate the outcome of patients with acute myocardial infarction and BBB who were treated with primary angioplasty. We evaluated 3,053 patients who underwent emergency catheterization in the PAMI trials. Patients who had left BBB (n = 48, 1.6%) on presenting electrocardiogram were compared with patients who had right BBB (n = 95, 3.1%) or no BBB (n = 2,910, 95.3%). Patients who had BBB were older and more frequently had diabetes mellitus, peripheral vascular disease, and previous coronary artery bypass grafting. They had lower ejection fraction and more multivessel disease. There were no significant differences in door-to-balloon time, final Thrombolysis In Myocardial Infarction flow grade or stent use. In-hospital major adverse cardiac events (death, ischemic target vessel revascularization, and reinfarction) were higher in patients who had BBB due primarily to increased in-hospital death (left BBB 14.6%, right BBB 7.4%, no BBB 2.8%, p < 0.0001). In multivariate logistic regression analysis, left BBB was an independent predictor of in-hospital death (odds ratio 5.53, 95% confidence interval 1.89 to 16.1, p = 0.002). In conclusion, patients who have acute myocardial infarction and BBB have increased co-morbidities and higher mortality rates despite treatment with primary angioplasty. Despite early identification of multivessel disease with triage to angioplasty or coronary artery bypass grafting, if necessary, similar treatment times, and final Thrombolysis In Myocardial Infarction grade 3 flow, the presence of left BBB on admission electrocardiogram in patients who have acute myocardial infarction is an independent predictor of in-hospital mortality. Because 85% of deaths in patients who have left BBB occur within the first week, these patients should be recognized early and receive prompt and aggressive treatment.     

Computational Design and Biological Testing of Highly Cytotoxic Colchicine Ring A Modifications

Microtubules are the primary target for many anti-cancer drugs, the majority of which bind specifically to β-tubulin. The existence of several β-tubulin isotypes, coupled with their varied expression in normal and cancerous cells provides a platform upon which to construct selective chemotherapeutic agents. We have examined five prevalent human β-tubulin isotypes and identified the colchicine-binding site as the most promising for drug design based on specificity. Using this binding site as a template, we have designed several colchicine derivatives and computationally probed them for affinity to the β-tubulin isotypes. These compounds were synthesized and subjected to cytotoxicity assays to determine their effectiveness against several cancerous cell lines. We observed a correlation between computational-binding predictions and experimentally determined IC₅₀ values, demonstrating the utility of computational screening in the design of more effective colchicine derivatives. The most promising derivative exhibited an IC₅₀ approximately threefold lower than values previously reported for either colchicine or paclitaxel, demonstrating the utility of computational design and assessment of binding to tubulin.     

Alcohol influence on acrylamide to glycidamide metabolism assessed with hemoglobin-adducts and questionnaire data

Our purpose was to investigate whether alcohol (ethanol) consumption could have an influence on the metabolism of acrylamide to glycidamide in humans exposed to acrylamide through food. We studied a subsample from a population-based case–control study of prostate cancer in Sweden (CAPS). Questionnaire data for alcohol intake estimates was compared to the ratio of hemoglobin-adduct levels for acrylamide and glycidamide, used as a measure of individual differences in metabolism. Data from 161 non-smoking men were processed with regard to the influence of alcohol on the metabolism of acrylamide to glycidamide. A negative, linear trend of glycidamide-adduct to acrylamide-adduct-level ratios with increasing alcohol intake was observed and the strongest association (p-value for trend = 0.02) was obtained in the group of men with the lowest adduct levels (?47 pmol/g globin) when alcohol intake was stratified by acrylamide-adduct levels. The observed trend is likely due to a competitive effect between ethanol and acrylamide as both are substrates for cytochrome P450 2E1. Our results, strongly indicating that ethanol influence metabolism of acrylamide to glycidamide, partly explain earlier observations of only low to moderate associations between questionnaire data on dietary acrylamide intake and hemoglobin-adduct levels.