An educational international partnership responding to local needs: process evaluation of the Brazil FAIMER Regional Institute

INTRODUCTION

The Brazilian public health system requires competent professionals sensitive to the needs of the population. The Foundation for Advancement of International Medical Education and Research (FAIMER) provides a two-year faculty development programme for health professions educators, aiming to build leadership in education to improve health. A partnership with governmental initiatives and FAIMER was established for meeting these needs. This paper describes the initial process evaluation results of the Brazilian FAIMER Institute Fellowship (FAIMER BR).

METHODS

Data were analysed for the classes 2007-2010 regarding: application processes; innovation project themes; retrospective post-pre self-ratings of knowledge acquisition; and professional development portfolios.

RESULTS

Seventeen of 26 Brazilian states were represented among 98 Fellows, predominantly from public medical schools (75.5%) and schools awarded Ministry of Health grants to align education with public health services (89.8%). One-third (n = 32) of Fellows' innovation projects were related to these grants. Significant increases occurred in all topic subscales on self-report of knowledge acquisition (effect sizes, 1.21-2.77). In the follow up questionnaire, 63% of Fellows reported that their projects were incorporated into the curriculum or institutional policies. The majority reported that the programme deepened their knowledge (98%), provided new ideas about medical education (90%) and provided skills for conflict management (63%). One-half of the Fellows reported sustained benefits from the programme listserv and other communications, including breadth of expertise, establishment of research collaboration and receiving emotional support.

CONCLUSION

Contributors to initial programme success included alignment of curriculum with governmental initiatives, curriculum design merging educational technology, leadership and management skills and central role of an innovation educational project responding to local needs.

Congenital cytomegalovirus infection - An update

Cytomegalovirus is estimated to be the leading infectious cause of nonheriditary sensorneural loss and a significant cause of mental retardation. Approximately 1% of newborn infants are congenitally infected with the virus. This review summarizes recent developments concerning this infection, including clinical outcome, risk factors for aquisition diagnosis and therapy.

An Inhibitor of ADAMs (a Distintegrin and Metalloproteinase) Overcomes HER3-Mediated Resistance to Trastuzumab and Lapatinib

Background: Inhibitors of HER-2/neu and EGF receptors such as trastuzumab, lapatinib, and erlotinib have demonstrated clinical efficacy but not all HER-2/neu or EGFR positive tumors respond and many that initially respond develop resistance. Ligand mediated HER-3 signaling results in tumor growth and survival and is a proposed mechanism of resistance to trastuzumab and lapatinib. Proteolytic cleavage of both ErbB ligands and receptors has been shown to be a critical event that results in ErbB pathway activation. Cleavage is necessary for the generation of soluble, functionally active forms of ErbB ligands and in the case of HER-2/neu, cleavage results in a shed extracellular domain (ECD) and a membrane bound fragment (p95) that contains a kinase domain with significant constitutive activity. In addition, it has been shown that the preferential association between HER3 and p95 can further activate the pathway. Both ErbB ligand and HER-2/neu cleavage are mediated by the ADAM family of proteases. Further, we have previously shown that the ADAM protease inhibitor, INCB7839, provides synergistic inhibition of HER2+ breast cancer cell line growth when combined with either trastuzumab or lapatinib. Materials and Methods: The HER-2 overexpressing BT-474 human breast cancer cell line was treated with either lapatinib or trastuzumab in the presence or absence of the HER-3 ligand, heregulin, and the effects on cell growth measured. The effects of the ADAM protease inhibitor INCB7839 in this system were also examined. Results: The addition of heregulin overcame the anti-proliferative effects of both lapatinib and trastuzumab on the growth of the BT-474 cell line in vitro. Addition of INCB7839 synergized with lapatinib or trastuzumab and importantly, restored the anti-proliferative effects of these agents in the presence of heregulin. Further, pretreatment of BT-474 cells with INCB7839 for 6 days, which we have previously shown completely eliminates the presence of the p95 form of HER2, amplified these effects, presumably by eliminating p95 before stimulating the cells with heregulin. Discussion: Together, these results confirm that heregulin can overcome the anti-proliferative effects of both trastuzumab and lapatinib as previously reported. Prevention of p95 formation by ADAM protease inhibitors appears to restore the anti-proliferative effects of both trastuzumab and lapatinib when heregulin/HER3 signaling occurs, negating a proposed mechanism of resistance to these agents in the clinic. These results suggest that combining an ADAM inhibitor with targeted inhibitors of the ErbB family can overcome HER-3-mediated resistance and enhance the clinical efficacy of approved HER2-targeted agents in the clinical setting. INCB7839 is currently under clinical investigation in combination with trastuzumab for women with metastatic breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3138.

Clinical correlates of atypical depression and validation of the French version of the Scale for Atypical Symptoms (SAS)

BACKGROUND

The 8-item "Scale for Atypical Symptoms" (SAS) and its structured interview, the SIGH-SAD, have been developed to assess atypical symptoms of depression in winter depression. Although they are commonly used, no validation study has yet been conducted.

METHODS

270 consecutive depressed inpatients were assessed prospectively. Pearson's correlation coefficients between fulfilment of Liebowitz criteria for atypical depression and both the SAS score and the atypical balance [ratio of the AS score to the total score on the Hamilton Depression Rating Scale 29-item (HDRS-29)] were calculated. The SAS was evaluated against Liebowitz criteria using binary logistic regression. A ROC curve was performed with the atypical balance against the fulfilment of Liebowitz criteria.

RESULTS

18.5% of patients met the criteria for atypical depression. The presence of an atypical depression was significantly correlated with both the atypical score (r=0.42) and the atypical balance (r=0.51). The logistic regression showed that a higher score on the SAS, the absence of a somatic syndrome (ICD-10) and a lower HDRS-21 score were independent predictors of an atypical depression while age, gender and bipolarity were not. The ROC curve showed that an atypical balance of 29% was the optimal threshold for the diagnosis of atypical depression (sensitivity=0.86, specificity=0.79).

LIMITATION

Patients with bipolar I and II were not distinguished.

CONCLUSION

Atypical depression is relatively frequent in hospitalised patients. The concurrent validity of the French version of the SAS and its structured interview, the SIGH-SAD is satisfactory.

Decisions and ethical issues among BRCA carriers and the use of preimplantation genetic diagnosis

The lifetime risks for both breast and ovarian cancer for BRCA mutation carriers far exceeds the general population risk of 13% for breast cancer and 1.4% for ovarian cancer. BRCA carriers have unique and medically complicated decisions to make regarding their cancer treatment or risk reduction. As BRCA testing becomes increasingly common among unaffected individuals in families with a previously documented BRCA mutation, there are a growing number of individuals with unique psychosocial needs and concerns. This review paper describes the BRCA 1/2 population, discusses preimplantation genetic diagnosis (PGD), and describes the decisions and ethical issues related to PGD among the BRCA 1/ 2 population.

Indomethacin tocolysis and white matter injury in preterm infants

OBJECTIVE

This study aims to clarify the relationship between indomethacin tocolysis and neonatal white matter injury (WMI) in preterm infants.

METHODS

We conducted a retrospective review of preterm infants born at 24-32 weeks who had sufficient cranial ultrasound examinations (CUS) to determine the incidence and severity of abnormalities. Infants with normal CUS were compared on univariate and multivariate analyses with infants with the different forms of WMI.

RESULTS

On multivariate logistic regression analysis, indomethacin tocolysis was significantly correlated with periventricular echogenicity (PVE; OR 2.84 95% CI 1.41-5.7, p = 0.003), but not with periventricular leucomalacia (PVL; OR 1.83 95% CI0.6-5.6, p = 0.29). Indomethacin was not related to increased risk for periventricular-intraventricular hemorrhage or periventricular hemorrhagic infarction.

CONCLUSION

These findings suggest caution in the use of indomethacin as a tocolytic therapy.

Association of adolescent and young adult cancer treatment trial activity with a national mortality reduction benefit in the United States

6605

Background: Adolescent and young adult (AYA) cancer patients in the U.S. have had less mortality and survival improvement than have children or older adults with cancer. Because <3% of 20–35 year-olds are entered onto national cancer treatment trials (NCTT), in contrast to ∼50% of children, initiatives were undertaken during the past 6 years to increase NCTT AYA participation. Methods: NCTT accrual data were obtained from the Cancer Treatment Evaluation Program, NCI. Survival, mortality, and incidence data were obtained from the NCI Surveillance, Epidemiology, and End Results (SEER) program. Results: In comparison of 2002–2006 with 1996–2001, the average annual NCCT accruals of patients 15–39 years of age increased from 1,032 to 1,792, the estimated proportion of patients in this age group on NCTT increased from an average of 4.2% to 6.5%, and the proportion of all NCCT accruals (of all ages) that were in the 15–39 year age group increased from an average of 5.2% to 8.2%. Of the 11 national NCTT groups, the pediatric group (Children's Oncology Group [COG]) had the largest AYA accrual number and increase, enrolling more than twice the number of 15–39 year-olds than any other cooperative group and 1/3 of all of them. Among 15–29 year-olds nearly all of the increased accrual occurred in patients with leukemia or lymphoma, in whom the ratio of the national death rate to SEER incidence fell below the projected linear regression for this ratio in each year during 2002–2005. Conclusions: In the U.S., COG is now contributing more AYA patients to NCTT than any adult cooperative group, suggesting that the adult-treating groups and cancer centers have increased capability to increase AYA accrual and should complement the pediatric effort. That the disease group that accounted for nearly all of the increase also had a concomitant reduction in deaths relative to incidence may be cause and effect. These favorable trends should encourage implementation of the clinical trial recommendations of the NCI Program Review Group in AYA Oncology ( http://planning.cancer.gov/disease/AYAO_PRG_Report_2006_FINAL.pdf ) that are being implemented in part by the LIVESTRONG Young Adult Alliance (Closing the Gap: A Strategic Plan).

[Table: see text]

[Injecting without getting infected: injectors' strategies to prevent HIV and HCV.]

OBJETIVO: Desde principios de los noventa, en la ciudad de Nueva York se han implementado con éxito programas para reducir la incidencia del virus de la inmunodeficiencia humana (VIH) y, en menor medida, del virus de la hepatitis C (VHC). A pesar de ello, aproximadamente el 70% de los usuario de drogas inyectables (UDI) están infectados por el VHC. Queremos investigar cómo el 30% restante se las ha arreglado para no infectarse. El Staying safe (nombre original del estudio) explora los comportamientos y mecanismos que ayudan a evitar la infección por el VHC y el VIH a largo plazo. MATERIAL Y M#ENTITYSTARTX000E9;TODOS: Hemos utilizado el concepto de «desviación positiva» aplicado en otros campos de salud pública. Estudiamos las estrategias, prácticas y tácticas de prevención de aquellos UDI que, viviendo en contextos de alta prevalencia, se mantienen sin infectar por VIH y el VHC, a pesar de haberse inyectado heroína durante años. Los resultados preliminares presentados en este artículo incluyen el análisis de las entrevistas realizadas a 25 UDI (17 doble negativos, 3 doble positivos y 5 con infección por el VHC y sin infección por el VIH). Se usaron entrevistas semiestructuradas que exploraban con detalle la historia de vida de los sujetos, incluyendo su consumo de drogas, redes sociales, contacto con instituciones, relaciones sexuales y estrategias de protección y vigilancia. RESULTADOS: La intencionalidad es importante para no infectarse, especialmente durante períodos de involución (períodos donde hay un deterioro económico y/o social que llevan al que se inyecta a situaciones de mayor riesgo). Presentamos tres dimensiones independientes de intencionalidad que conllevan comportamientos que pueden ayudar a prevenir la infección: a) evitar «el mono» (síntomas de abstención) asegurando el acceso a la droga; b) «llevarlo bien» para no convertirse en un junkie y así evitar la «muerte social» y la falta de acceso a los recursos, y c) seguir sin infectarse por el VIH (sólo un doble negativo tuvo un amplio conocimiento sobre la hepatitis C). Estas intencionalidades no son mutuamente excluyentes. La presencia de varias refuerza la puesta en práctica a diario de comportamientos que pueden ayudar al que se inyecta a mantenerse libre de infecciones durante años. Algunas prácticas que hemos identificado se implementan en grupo y se comunican de UDI a UDI, de esta manera se extienden entre algunas redes sociales de UDI. CONCLUSIONES: Los UDI que permanecen sin infectarse planean e implementan estrategias de prevención en circunstancias donde otros UDI aplican prácticas de riesgo. El mantenimiento de la no infección no es, por lo tanto, un resultado del azar, sino más bien el resultado del esfuerzo (agencia) de los UDI. Investigar y extender estas estrategias y tácticas a través de programas de prevención podría contribuir a la prevención del VIH y el VHC.

Retreatment efficacy of the Epiphany soft resin obturation system

AIM

To assess the efficacy of retreatment of canals filled with the Epiphany System with and without solvent, with particular reference to the extent of canal enlargement during retreatment.

METHODOLOGY

Sixty roots with canals prepared to apical size 45 were embedded in resin blocks and sectioned vertically. Digital micrographs of canal walls were captured. Roots were re-assembled and filled with Epiphany/Resilon (experimental) or gutta-percha/AH Plus (control). After 8 weeks, canals were retreated to size 45 with or without chloroform, and the time recorded. Roots were split, imaged, re-assembled, retreated to size 55, split and imaged. Root-filling residue, traced at three canal levels, was expressed as percentage of canal surface.

RESULTS

Residue percentage was greater (t-test, P < 0.01) in the experimental group than in the control. Most residue in all specimens was in the apical third (ANOVA, P < 0.01). Chloroform and enlargement to size 55 decreased residue in both groups (t-test, P < 0.01). Retreatment time was longer in the experimental group (P < 0.05), and reduced by chloroform in both groups (P < 0.05).

CONCLUSIONS

The Epiphany System was retreatable with and without chloroform, with lesser efficacy than gutta-percha and AH Plus sealer.

Randomized trial of peribulbar triamcinolone acetonide with and without focal photocoagulation for mild diabetic macular edema: a pilot study

OBJECTIVE

To provide pilot data on the safety and efficacy of anterior and posterior sub-Tenon injections of triamcinolone either alone or in combination with focal photocoagulation in the treatment of mild diabetic macular edema (DME).

DESIGN

Prospective, phase II, multicenter, randomized clinical trial.

PARTICIPANTS

One hundred nine patients (129 eyes) with mild DME and visual acuity 20/40 or better.

METHODS

The participants were assigned randomly to receive either focal photocoagulation (n = 38), a 20-mg anterior sub-Tenon injection of triamcinolone (n = 23), a 20-mg anterior sub-Tenon injection followed by focal photocoagulation after 4 weeks (n = 25), a 40-mg posterior sub-Tenon injection of triamcinolone (n = 21), or a 40-mg posterior sub-Tenon injection followed by focal photocoagulation after 4 weeks (n = 22). Follow-up visits were performed at 4, 8, 17, and 34 weeks.

MAIN OUTCOME MEASURES

Change in visual acuity and retinal thickness measured with optical coherence tomography (OCT).

RESULTS

At baseline, mean visual acuity in the study eyes was 20/25 and mean OCT central subfield thickness was 328 mum. Changes in retinal thickening and in visual acuity were not significantly different among the 5 groups at 34 weeks (P = 0.46 and P = 0.94, respectively). There was a suggestion of a greater proportion of eyes having a central subfield thickness less than 250 mum at 17 weeks when the peribulbar triamcinolone was combined with focal photocoagulation. Elevated intraocular pressure and ptosis were adverse effects attributable to the injections.

CONCLUSIONS

In cases of DME with good visual acuity, peribulbar triamcinolone, with or without focal photocoagulation, is unlikely to be of substantial benefit. Based on these results, a phase III trial to evaluate the benefit of these treatments for mild DME is not warranted.