Requirements for effective academic leadership in Iran: A Nominal Group Technique exercise

Background

United States academic medical centers are increasingly incorporating electronic health records (EHR) into teaching settings. We report third year medical students' attitudes towards clinical learning using the electronic health record in ambulatory primary care clinics.

Methods

In academic year 2005–06, 60 third year students were invited to complete a questionnaire after finishing the required Ambulatory Medicine/Family Medicine clerkship. The authors elicited themes for the questionnaire by asking a focus group of third year students how using the EHR had impacted their learning. Five themes emerged: organization of information, access to online resources, prompts from the EHR, personal performance (charting and presenting), and communication with patients and preceptors. The authors added a sixth theme: impact on student and patient follow-up. The authors created a 21-item questionnaire, based on these themes that used a 5-point Likert scale from "Strongly Agree" to "Strongly Disagree". The authors emailed an electronic survey link to each consenting student immediately following their clerkship experience in Ambulatory Medicine/Family Medicine.

Results

33 of 53 consenting students (62%) returned completed questionnaires. Most students liked the EHR's ability to organize information, with 70% of students responding that essential information was easier to find electronically. Only 36% and 33% of students reported accessing online patient information or clinical guidelines more often when using the EHR than when using paper charts. Most students (72%) reported asking more history questions due to EHR prompts, and 39% ordered more clinical preventive services. Most students (69%) reported that the EHR improved their documentation. 39% of students responded that they received more feedback on their EHR notes compared to paper chart notes. Only 64% of students were satisfied with the doctor-patient communication with the EHR, and 48% stated they spent less time looking at the patient.

Conclusion

Third year medical students reported generally positive attitudes towards using the EHR in the ambulatory setting. They reported receiving more feedback on their electronic charts than on paper charts. However, students reported significant concerns about the potential impact of the EHR on their ability to conduct the doctor-patient encounter.     

Liver Transplant Recipients Quality of Life Instrument: Development and Psychometric Testing

Background

Liver transplantation is a life-saving intervention for many patients with end-stage liver disease. In the past, evaluation of successful liver transplantation was based on patients’ survival rate. However, in recent years this evaluation has been based on patients’ quality of life. Various instruments have been developed to evaluate patients’ quality of life. Nonetheless, scholars still believe that it is crucial to develop a standardized and disease specific instrument for evaluating the quality of life in liver transplant recipients.

Objectives

The aim of this paper was to describe the development and psychometric testing process of a quality of life instrument specific to liver transplant recipients.

Materials and Methods

Initial items of this instrument were extracted from a conventional content analysis study, and then were completed with findings of related international literature. The face validity was assessed by interviewing with four liver transplant recipients, and the content validity was evaluated by eleven experts in the field of transplantation. The construct validity was achieved by involving 250 liver transplant recipients through exploratory factor analysis method, and reliability was calculated by Cronbach''s alpha.

Results

Three main factors with 40 items were extracted from the exploratory factor analysis: Health Satisfaction, Concerns, and Complications. Reliability of the instrument was confirmed (alpha = 0.922).

Conclusions

Given the special considerations regarding liver transplant recipients, this questionnaire is more accurate in evaluating the success of liver transplantation.     

Coping with breast cancer in newly diagnosed Iranian women

AIM: This paper reports a study exploring how Iranian women coped with newly diagnosed breast cancer and provides a foundation for cultural-based care. BACKGROUND: Although research has indicated that coping strategies are associated with adaptation to breast cancer, and despite the number of women with newly diagnosed breast cancer increasing each year, there is no information on how Iranian women cope with breast cancer when compared with women of other cultures. METHOD: In this qualitative study, 19 women with newly diagnosed breast cancer were interviewed during the period May-September 2004 about coping with their disease. Interviews were analysed using a content analysis method. FINDINGS: The main themes emerging from this qualitative study included coping using a religious approach (acceptance of disease as God's will; spiritual fighting), thinking about the disease (positive thinking: positive suggestion, hope, intentional forgetfulness; negative thinking: hopelessness, fear, impaired body image), accepting the fact of the disease (active acceptance; passive acceptance), social and cultural factors and finally finding support from significant others. CONCLUSION: Understanding how Iranian women cope with diagnosis of breast cancer is important to nurses involved in the process of healing. The majority of strategies used by Iranian women were positive, and religious faith played a major role in this. The findings of the study can be used to design a nursing approach to improve successful coping in Iranian women suffering from breast cancer, and can provide nurses and other healthcare professionals with deeper understanding of these women as they face this diagnosis.     

Hyperhomocysteinemia and cobalamin deficiency in young Asian Indians in the United States

Hyperhomocysteinemia, a risk factor for vascular disease, may be a particular problem in Asian Indians, but information is limited, especially in the U.S., despite its growing Asian population. Moreover, suggestions have been made that folate deficiency is responsible for the hyperhomocysteinemia in Indians. Therefore, we studied homocysteine status in healthy Asian Indians in the U.S. prospectively, determined the frequency of cobalamin and folate deficiency as contributors to it, and examined whether food-cobalamin absorption contributed to cobalamin deficiency. Homocysteine levels were higher in Asian Indian men than in 4 other ethnic groups (P < 0.0001); 10/39 Indian men (25.6%) were hyperhomocysteinemic. Cobalamin levels were lower in Indian men (P = 0.000005) and women (P = 0.03) than in non-Indians; low levels were found more frequently in both Indian men (23/39; 59.0%) and women (5/21; 23.8%) than in others. Measuring methylmalonic acid in 10 selected subjects showed that the low cobalamin levels reflected cobalamin deficiency, and high methylmalonic acid levels were found in some subjects without hyperhomocysteinemia. Evidence of folate deficiency was not found in any subjects. Food-cobalamin absorption was normal in all 13 Indian subjects tested, including those with Helicobacter pylori infection. The results show that hyperhomocysteinemia is strikingly common in apparently healthy, young Asian Indian men. The cause appears to be cobalamin deficiency, which affected more than half of the Indian men, may be largely subclinical, is underestimated by homocysteine levels alone which were not always abnormal, and is probably largely dietary in origin. Folate deficiency is rare. This public health problem is amenable to prevention and treatment in this growing segment of the U.S. population. It was, parenthetically, noteworthy that many of the affected subjects were young physician trainees.     

Beneficial Effect of Cyproheptadine on Body Mass Index in Undernourished Children: A Randomized Controlled Trial

Objective:

Cyproheptadine hydrochloride (CH) is a first-generation antihistamine which is used as an appetite stimulant. This study was designed to identify the role of CH therapy on weight gain, linear growth and body mass index in children with mild to moderate undernutrition.

Methods:

Eighty-nine patients were enrolled. The present randomized, double-blinded controlled trial included 77 evaluable patients, aged 24–64 months with undernutrition. The patients were randomized to receive cyproheptadine with multivitamin, or multivitamin over a period of four weeks. The weight, height and body mass index were measured at the baseline, four weeks after intervention and four weeks after discontinuation.

Findings:

A significant higher body mass index was observed among CH-treated patients after 8 weeks intervention with cyproheptadine compared with the control group (P<0.041). Mean weight gain after eight weeks was 0.11 kg in the control group and 0.60 kg in the CH group. There were no significant differences in changes of weight and height velocity across the study between CH-treated and control group at the end of study.

Conclusion:

In our study, cyproheptadine promotes increase in body mass index in children with mild to moderate undernutrition after four weeks treatment.     

Serum butyrylcholinesterase activity and phenotype associations with lipid profile in stroke patients

Background

Butyrylcholinesterase (BuChE) catalyzes the hydrolysis of acetylcholine and other choline esters and is also involved in lipid metabolism. The purpose of this study was to investigate any association between BuChE serum phenotype and activity and lipid profile of ischemic stroke patients.

Methods

We determined serum BuChE activities and phenotypes, and levels of total cholesterol (TC), LDL-C, HDL-C and triacylglyerol (TG) in 33 patients with acute ischemic stroke within 12 h of the onset of the attack and 29 controls.

Results

The mean (± SD) serum BuChE activity and the BuChE of U/A phenotype in the stroke individuals were significantly lower and higher than that of the control (315 (± 124) IU/L. vs. 384 (± 99) IU/L, p = 0.02, t = − 2.4 and 21.2% vs.3.4%, p = 0.026 respectively).

Conclusions

Our results showed that a negative correlation between BuChE activity with TC level, in addition the frequency of BuChE phenotypes with low activity is high in stroke patients, who have high levels of cholesterol, may have increased susceptibility to stroke.     

In vitro evaluation of cell-mediated immunity to Epstein Barr virus

This study was conducted to measure cell-mediated immune response in healthy Epstein Barr virus (EBV)-seropositive individuals using a tissue culture "growth inhibition" assay (regression assay) where peripheral blood lymphocytes (PBLs) were tested for their ability to inhibit the outgrowth of the autologous lymphoblastoid cell lines (LCLs). Inhibition of the outgrowth of the autologous LCLs was seen after 4 weeks by the addition of PBLs from healthy EBV seropositive donors. The regression phenomenon was never seen when the donors of peripheral blood lymphocytes were EBV- seronegative. Regression assay showed that EBV- specific memory T cells were stable in healthy EBV seropositive over many years, which indicates the persistent nature of EBV infection.     

Identification of Hitherto Undefined B-Cell Epitopes by Antibodies in the Sera of Vitiligo Patients Using Phage-Display Peptide Library

A random 12 mers phage library was used to screen a pool of immunoglobulin fractions obtained from vitiligo patients. Subsequent to panning experiments, a panel of affinity selected phage from vitiligo patients were obtained. This panel was tested using an ELISA for their reactivity with pooled sera from patients and normal controls. Among the 16 randomly selected clones, two of clones showed distinct positive reactivity with the patient's sera compared with controls. The peptides displayed by these phages expressed the following amino acid sequences: SHMPLANQYQWA and NHVQAWEQFWDS. Thus, screening with phagedisplayed random peptide library of vitiligo sera can reveal peptide sequences that mimic vitiligo-related self-antigen.     

Expression of IP-10 chemokine is regulated by pro-inflammatory cytokines in cultured hepatocytes

Chemokines are classified in four distinct groups as CXC, CC, CX3C and C, depending on the presence or absence of a motif called ELR (Arg-Leu-Glu) before the first cysteine residue in their structure. CXC chemokines are also subdivided into ELR+ and ELR-. Increasing evidence has indicated the existence of a chemokine network in the liver which is involved in both physiological responses and, under certain circumstances, pathological and repair processes following hepatic injury. The CXC chemokines play a major role in both these processes, and much attention has been focused on their therapeutic applications to liver disease. The aim of this study was to examine the response of cultured hepatocytes to exogenous inflammatory cytokines (TNF-alpha and IFN-gamma) regarding expression of IP-10 and growth regulatory oncogen (Gro) chemokines. In this study we employed western and northern analysis to measure chemokines at the level of protein and mRNA by hepatocytes in response to pro-inflammatory cytokines. We found that, the pro-inflammatory cytokines, TNF-alpha and IFN-gamma, selectively stimulated expression of IP-10 but were without effect on Gro. This confirms a potential direct involvement of these cytokines in chemokine production by hepatocytes. Thus, IFN-gamma and TNF-alpha may play a role in hepatic injury and inflammation and produce some of their biological effects by localized induction of chemokines by hepatocytes. Given the similarity to an acute phase response, we were able to show that IFN-gamma and TNF-alpha mimicked the effects of cell isolation and culture on induction of IP-10 expression. Further, evidence for linkages between IFN- gamma and TNF- alpha and liver injuries is seen in hepatitis C and hepatitis B in which increased levels of TNF- alpha and its soluble receptor were reported.