Medical students' experience of vaginal examinations of anaesthetised women

Medical students usually initially learn vaginal examination (VE) by examining consenting anaesthetised women. To assess their experience of this practice, a questionnaire was distributed to all 66 fifth-year students at the Wellington School of Medicine in 2005—53 students responded. Although 184 women were available to approach for consent, only 141 were approached—students claimed insufficient time as their major difficulty. All male students discussed consent with women only in the 2 hours preoperatively, whereas nine (28%) of the female students sought consent earlier on the day or the day before. Of the 114 women asked, 97 gave written consent, but the VE was conducted in only 76 women mostly because the supervising gynaecologist claimed time constraints or was uninterested. Four other women were examined when consent was uncertain and two without consent. All but one of the students considered the experience educationally valuable. Eleven responding students did not perform a VE, and if the 13 nonresponders also did not, more than one-third of students lack this educational opportunity prior to their final year. In conclusion, some students require more commitment to seeking consent, and some gynaecologists may need to better facilitate this learning opportunity so that the consent agreed with the woman and student is more often respected.     

Identification and characterization of novel uroporphyrinogen decarboxylase gene mutations in a large series of porphyria cutanea tarda patients and relatives

Porphyria cutanea tarda (PCT) arises from decreased hepatic activity of uroporphyrinogen decarboxylase (UROD). Both genetic and environmental factors interplay in the precipitation of clinically overt PCT, but these factors may vary between different geographic areas. Decreased activity of UROD in erythrocytes was used to identify patients with UROD mutations among a group of 130 Spanish PCT patients. Nineteen patients (14.6%) were found to harbor a mutation in the UROD gene. Eight mutations were novel: M1I, 5del10, A22V, D79N, F84I, Q116X, T141I and Y182C. Five others were previously described: F46L, V134Q, R142Q, P150L and E218G. The new missense mutations and P150L were expressed in Escherichia coli. D79N and P150L resulted in proteins that were localized to inclusion bodies. The other mutations produced recombinant proteins that were purified and showed reduced activity (range: 2.3–73.2% of wild type). These single amino acid changes were predicted to produce complex structural alterations and/or reduced stability of the enzyme. Screening of relatives of the probands showed that 37.5% of mutation carriers demonstrated increased urinary porphyrins. This study emphasizes the role of UROD mutations as a strong risk factor for PCT even in areas where environmental factors (hepatitis C virus) have been shown to be highly associated with the disease.     

Anteroinferior plating of midshaft clavicular nonunions

Many different techniques have been reported for the treatment of clavicular nonunions. Those techniques involving screws and plate generally position the plate on the superior (subcutaneous) surface of the clavicle. To decrease the risk of screw pull-out and prominence of the instrumentation, we currently perform anteroinferior plating using a 3.5-millimeter pelvic reconstruction plate with a lag screw and bone graft. A consecutive group of twelve patients with midshaft clavicular nonunions was treated with this technique. All nonunions united after an average of 3.6 months (range 2 to 8 months). All patients regained full function and mobility of the shoulder. The technique as described in this article illustrates a successful modification of the traditional plating technique of midshaft clavicular nonunions. We conclude that anteroinferior plating is a reliable and safe technique that leads to high rates of bony union in midshaft clavicular nonunions.     

Reduced thrombomodulin in human peripheral nerve microvasculature

Thrombomodulin (TM), a vascular endothelial receptor, terminates the actions of thrombin and accelerates activated protein C formation. TM is ubiquitous throughout the systemic microcirculation but is reduced in brain regions predisposed to lacunar infarction. We investigated whether TM is present within human nerve and differentially expressed according to vessel caliber and proximity to the blood-nerve barrier. Vascular endothelial TM was detected on sural nerve biopsies with immunohistochemistry. The proportion of TM-positive microvessels was expressed relative to total von Willebrand factor (vWF)-positive vessels. Although vWF was detectable in all microvessels, TM expression was absent from the perineurial vessels. TM was detected in 47% (15-80%, 95% confidence level) of larger epineurial arterioles, in 43% (30-61%) of smaller epineurial vessels, and in 30% (19-47%) of endoneurial vessels. These findings demonstrate that TM is present in human nerve microvasculature but is regionally deficient in proximity to the blood-nerve barrier, which may predispose nerve to microvascular ischemia in inflammatory/prothrombotic conditions.     

Spirituality, Coping, and HIV Risk and Prevention in a Sample of Severely Mentally Ill Puerto Rican Women

Hispanics have been disproportionately impacted by HIV/AIDS. Although HIV risk is significantly elevated among severely mentally ill persons (SMI), the risk of infection appears to be even greater among those SMI who are Hispanic, reflecting the increased risk of HIV among Hispanics. We report on findings from the first 41 participants in a qualitative study examining the context of HIV risk and risk reduction strategies among severely mentally ill Puerto Rican women residents in northeastern Ohio. Individuals participated in a baseline interview, two follow-up interviews, and up to 100 hours of shadowing. Interviews and shadowing activities were recorded and analyzed using a grounded theory. The majority of individuals reported using identification with a religious faith. A large proportion of the participants reported that their religious or spiritual beliefs were critical to their coping, had influenced them to reduce risk, and/or provided them with needed social support. Several participants also reported having experienced rejection from their faith communities. The emphasis on spirituality among Puerto Rican SMI is consistent with previous research demonstrating the importance of spirituality in the Hispanic culture and reliance on spiritual beliefs as a mean of coping among SMI. Our results support the incorporation of spiritual beliefs into secular HIV prevention efforts. Loue is with the Department of Epidemiology and Biostatistics, Center for Minority Public Health, School of Medicine, Case Western Reserve University, Cleveland, OH, USA; Sajatovic is with the Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, OH, USA.