An approach to meeting the needs of medical students with learning disabilities

The Cognitive Skills Program at the Albert Einstein College of Medicine has identified 1% to 2% of students from several classes whose learning disabilities were previously undiagnosed. In three case studies, the importance of early identification and support during the preclinical years—and the impact of diagnosis, evaluation, and intervention—are illustrated. In each case, there was a dramatic improvement in performance when the student was made aware of his or her learning disability and when appropriate intervention was provided.     

Associative conditioning analog selectively increases cAMP levels of tail sensory neurons in Aplysia.

Bilateral clusters of sensory neurons in the pleural ganglia of Aplysia contain cells involved in a defensive tail withdrawal reflex. These cells exhibit heterosynaptic facilitation in response to noxious skin stimulation that can be mimicked by the application of serotonin. Recently it has been shown that this facilitation can be selectively amplified by the application of a classical conditioning procedure to individual sensory neurons. We now report that an analog of this classical conditioning paradigm produces a selective amplification of the cAMP content of isolated sensory neuron clusters. The enhancement is achieved within a single trial and appears to be localized to the sensory neurons. These results indicate that a pairing-specific enhancement of cAMP levels may be a biochemical mechanism for associative neuronal modifications and perhaps learning.     

Laparoscopic Surgery for Genuine Stress Incontinence

Laparoscopic Burch colposuspension has rapidly become one of the primary surgical treatment options for genuine stress incontinence. The procedure has been modified by some investigators because of technical difficulty with laparoscopic suturing, but should be identical to the conventional open Burch procedure. This article reviews the indications, operative technique, clinical results, complications and learning curve for laparoscopic retropubic surgical procedures.     

Innate immunity alone is not sufficient for chronic rejection but predisposes healed allografts to T cell-mediated pathology

BackgroundAcute allograft rejection is dependent on adaptive immunity, but it is unclear whether the same is true for chronic rejection. Here we asked whether innate immunity alone is sufficient for causing chronic rejection of mouse cardiac allografts.MethodsWe transplanted primarily vascularized cardiac grafts to recombinase activating gene-knockout (RAG^?/?) mice that lack T and B cells but have an intact innate immune system. Recipients were left unmanipulated, received adjuvants that stimulate innate immunity, or were reconstituted with B-1 lymphocytes to generate natural IgM antibodies. In a second model, we transplanted cardiac allografts to mice that lack secondary lymphoid tissues (splenectomized aly/aly recipients) and studied the effect of NK cell inactivation on T cell-mediated chronic rejection.ResultsAcute cardiac allograft rejection was not observed in any of the recipients. Histological analysis of allografts harvested 50 to 90 days after transplantation to RAG^?/? mice failed to identify chronic vascular or parenchymal changes beyond those observed in control syngeneic grafts. Chronic rejection of cardiac allografts parked in splenectomized aly/aly mice was observed only after the transfer of exogenously activated T cells. NK inactivation throughout the experiment, or during the parking period alone, reduced the severity of T cell-dependent chronic rejection.ConclusionsThe innate immune system alone is not sufficient for causing chronic rejection. NK cells predispose healed allografts to T cell-dependent chronic rejection and may contribute to chronic allograft pathology.     

Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 16: bone graft extenders and substitutes

Despite the large volume of animal data regarding the use of synthetic bone graft substitutes or extenders, there are very few data regarding the use of these substances for fusion in lumbar degenerative disease. The best available data indicate that rhBMP-2 is a viable alternative to autograft bone for interbody fusion procedures. This same substance may also be a viable alternative to autograft for PLF; however, definitive medical evidence is not yet available. There is little, if any, medical evidence to support the use of other biological agents at the present time. As promising new compounds are brought to market, well-designed cohort studies and randomized trials will be required to determine the actual usefulness of these compounds in clinical practice. It is important not to generalize the results obtained with one preparation or application to different preparations or applications. The use of synthetic calcium phosphate ceramics as graft extenders appears to be reasonable in certain situations. The medical evidence available regarding their use is limited and of poor quality. Further study will be required to establish their utility for use in spinal fusion.     

Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 6: magnetic resonance imaging and discography for patient selection for lumbar fusion

Discography is an exquisitely sensitive but not specific diagnostic test for the diagnosis of discogenic low-back pain. The restriction of the definition of a positive discographic study to one that elicits concordant pain from a morphologically abnormal disc improves the definition's accuracy. Fusion surgery based on discography alone, however, is not reliably associated with clinical success. Therefore, discography is not recommended as a standalone test for treatment decisions in patients with low-back pain. Magnetic resonance imaging is a sensitive and noninvasive test for the presence of degenerative disc disease. Discography should not be attempted in patients with normal lumbar MR images. Discography appears to have a role in the evaluation of patients with low-back pain, but it is best limited to the evaluation of abnormal interspaces identified on MR imaging, the investigation of adjacent-level disc disease, and as a means to rule out cases of nonorganic pain from surgical consideration.     

Biological dust exposure in the workplace is a risk factor for chronic obstructive pulmonary disease

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. Although the main risk factor is smoking, 15-19% of COPD even in smokers has been attributed to occupational exposures. The aim of this study was to investigate the association between occupational exposure and risk of COPD. METHODS: Participants were part of a cross sectional study of risk factors for COPD. A total of 1232 completed a detailed respiratory questionnaire, spirometric testing and measurement of gas transfer. Job histories were coded according to the International Standard Classification of Occupations. These codes were then used to establish occupational exposures using the ALOHA job exposure matrix. RESULTS: The prevalence of emphysema was 2.4%, chronic obstructive bronchitis 1.8%, and COPD 3.4%. Subjects ever exposed to biological dusts had an increased risk of chronic obstructive bronchitis (OR 3.19; 95% CI 1.27 to 7.97), emphysema (OR 3.18; 95% CI 1.41 to 7.13), and COPD (OR 2.70, 95% CI 1.39 to 5.23). These risks were higher in women than in men. For biological dust, the risk of emphysema and COPD was also significantly increased in both the duration of exposure categories, again in women but not in men. No significant increased risks for COPD were found for mineral dust (OR 1.13; 95% CI 0.57 to 2.27) or gases/fumes (OR 1.63; 95% CI 0.83 to 3.22). CONCLUSION: In this general population sample of adults, occupational exposures to biological dusts were associated with an increased risk of COPD which was higher in women. Preventive strategies should be aimed at reducing exposure to these agents in the workplace.     

Improved outcomes for laparoscopic appendectomy compared with open appendectomy in the pediatric population

INTRODUCTION: The appendectomy is a common emergent surgical procedure in the pediatric population. The aim of this study was to examine our institution's experience and outcomes in the appendectomy in the pediatric population early in our transition from open surgery to a predominantly laparoscopic approach. METHODS: We retrospectively studied all pediatric patients (age 20 years) that underwent an appendectomy at a tertiary care center over 2 years. The data collected included patient demographics, comorbidities, operative details, outcomes, and complications. RESULTS: Two hundred twenty-three consecutive patients, with a mean age of 9.5 (3.9) years, were included in the study. Forty-four laparoscopic and 179 open appendectomies were performed. Two of the laparoscopic cases were converted to open appendectomies. Significant differences were seen between the two groups, with longer operative times (P < 0.0001) and lower estimated blood loss (P = 0.007) in the laparoscopic group. Operative times improved significantly for the laparoscopic group as the surgeons became more experienced (P = 0.03). The laparoscopic group used intravenous pain medication for a shorter time (0.8 vs. 1.9 days; P = 0.0003) and had a shorter postoperative hospital length of stay (2.2 vs. 3.4 days; P = 0.004). The laparoscopic group had fewer wound infections (2.3% vs. 6.2%; P = 0.3), intra-abdominal abscesses (4.5% vs. 5.6%; P = 0.8), and postoperative ileus (0% vs. 2.2%; P = 0.3), although these differences did not reach statistical significance. CONCLUSION: The laparoscopic appendectomy procedure is a safe alternative to open appendectomy in pediatric patients and results in shorter hospital stays with less postoperative pain.