Counseling Fathers (2010) by C.Z. Oren and D.C. Oren

No abstract available for this article.     

Unstable stenocardia: the results of the intracoronary administration of fibrinolytic agents

Intracoronary thrombolytic infusions were used in 10 patients with unstable angina and high risk of myocardial infarction (MI). Streptokinase (500,000 units per hour) was used in 9 patients, and urokinase, in one. Vascular recanalization was achieved in 4 cases where angiography showed coronary arterial occlusion by a thrombus. Myocardial infarction developed in 8 patients (large-focal in 6 and small-focal in 2) within 1 to 16 days after the thrombolytic infusion. Therefore, short-term local thrombolytic infusion fails to prevent myocardial infarction in patients with unstable angina.     

Recent angina pectoris: the first experience using programmed stimulation of the heart for the detection of the electrical instability of the heart ventricles

Programmed ventricular stimulation was performed in 41 patients with recent angina pectoris (RAP, defined as less than 3 months old), 14 patients after large focal myocardial infarction (MI) and 9 patients without organic heart disease (WHD). The prevalence and number of repetitive ventricular responses (RVR) after programmed stimulation with one to three extra stimuli (2 ms, 2 MDS) from 2 right-ventricular sites at sinus rhythm and three basic pacing cycle lengths (600, 500 and 400 ms) were compared in RAP, MI and WHD patients. In 56% of WHD patients, 32% of RAP patients, and 22% of MI patients, RVRs were absent. Five or more RVR were provoked in MI patients only (43%). The incidence of ventricular fibrillation during programmed stimulation was 2.5% in RAP patients and 22% in MI patients. Differences in incidence are not significant, but show the influence of the severity or organic coronary arterial and left-ventricular damage on the prevalence of RVRs. Programmed stimulation seems to have no diagnostic value for the detection of electrical instability in RAP patients without a history of MI.     

Characterization of novel Mycobacterium tuberculosis pncA gene mutations in clinical isolates from the Ukraine

Multidrug-resistant (MDR) and extensively drug-resistant (XDR) Mycobacterium tuberculosis cases in the Ukraine are increasing. Pyrazinamide (PZA) is critically important for first- and second-line tuberculosis (TB) treatment regimes. However, PZA drug susceptibility testing is time consuming and technically challenging. The present study utilized Next-generation sequencing (NGS) to identify mutations in the pncA gene from clinical isolates and to assess the prevalence of pncA gene mutations in MDR/XDR-TB patients. Clinical isolates were inactivated in molecular transport media and shipped from Kharkiv, Ukraine, to San Antonio, TX. Whole-genome and targeted pncA gene sequencing was carried out using Illumina MiSeq instrumentation. Mutations were noted in 67 of 91 (74%) clinical isolates comprising substitutions, insertions, and deletions in the pncA coding and upstream promoter region. Of 45 mutation types, there were 11 novel, i.e., to date unknown, pncA mutations identified of which 3 were confirmed PZA resistant. Seven isolates contained mixed base mutations, whereas 4 harbored doubled mutations. Data reported here further support use of NGS for pncA gene characterization and may contribute in significant fashion to PZA therapy, especially in MDR- and XDR-TB patients.     

Induction of high-affinity IgE receptor on lung dendritic cells during viral infection leads to mucous cell metaplasia

Respiratory viral infections are associated with an increased risk of asthma, but how acute Th1 antiviral immune responses lead to chronic inflammatory Th2 disease remains undefined. We define a novel pathway that links transient viral infection to chronic lung disease with dendritic cell (DC) expression of the high-affinity IgE receptor (FcεRIα). In a mouse model of virus-induced chronic lung disease, in which Sendai virus triggered a switch to persistent mucous cell metaplasia and airway hyperreactivity after clearance of replicating virus, we found that FceRIa^−/− mice no longer developed mucous cell metaplasia. Viral infection induced IgE-independent, type I IFN receptor–dependent expression of FcεRIα on mouse lung DCs. Cross-linking DC FcεRIα resulted in the production of the T cell chemoattractant CCL28. FceRIa^−/− mice had decreased CCL28 and recruitment of IL-13–producing CD4⁺ T cells to the lung after viral infection. Transfer of wild-type DCs to FceRIa^−/− mice restored these events, whereas blockade of CCL28 inhibited mucous cell metaplasia. Therefore, lung DC expression of FcεRIα is part of the antiviral response that recruits CD4⁺ T cells and drives mucous cell metaplasia, thus linking antiviral responses to allergic/asthmatic Th2 responses.     

National Survey of Clerkship Directors in Internal Medicine on the Competencies That Should Be Addressed in the Medicine Core Clerkship

PURPOSE: To prioritize competencies that should be addressed in the medicine core clerkship, assess factors influencing this prioritization, and estimate the percentage of clerkship time that should be devoted to inpatient versus outpatient care.METHODS: A national survey of the Clerkship Directors in Internal Medicine (CDIM) was used. Using explicit criteria, respondents assigned priority scores, on a 1 to 5 scale, to 17 general competencies and 60 disease-specific clinical competencies pertinent to care of adult patients in inpatient. ambulatory, intensive care, and emergency settings.RESULTS: Ninety-three (75%) of 124 CDIM members responded. The highest mean priority scores were assigned to 6 general competencies: case presentation skills (4.65), diagnostic decision-making (4.64), history and physical diagnosis (4.61), test interpretation (4.47), communication with patients (4.35), and therapeutic decision-making (4.12). Disease-specific clinical competency areas receiving the highest mean priority scores were: hypertension (4.57), coronary disease (4.53), diabetes mellitus (4.45), heart failure (4.42), pneumonia (4.39), chronic obstructive pulmonary disease (4.26), acid-base/electrolyte disorders (4.19), and acute chest pain (4.08). Priorities for general competencies were moderately correlated with importance to the practice of general internists (mean Spearman rho 0.49) and with importance to students pursuing careers outside internal medicine (mean Spearman rho 0.45), but only weakly correlated with the adequacy with which a competency was addressed in other parts of the curriculum. Respondents' mean recommended allocation of clerkship time was: 52% inpatient, 33% ambulatory care, 8% intensive care, and 7% emergency medicine. This time allocation did not differ by any characteristics of respondents.CONCLUSION: There is consensus among medicine clerkship directors that the medicine core clerkship should emphasize fundamental competencies and devote at least one third of the time to clinical competencies pertinent to ambulatory care.