Clinical instructors' perception of a faculty development programme promoting postgraduate year-1 (PGY1) residents' ACGME six core competencies: a 2-year study

Objective The six core competencies designated by Accreditation Council for Graduate Medical Education (ACGME) are essential for establishing a patient centre holistic medical system. The authors developed a faculty programme to promote the postgraduate year 1 (PGY(1)) resident, ACGME six core competencies. The study aims to assess the clinical instructors' perception, attitudes and subjective impression towards the various sessions of the 'faculty development programme for teaching ACGME competencies.' Methods During 2009 and 2010, 134 clinical instructors participated in the programme to establish their ability to teach and assess PGY(1) residents about ACGME competencies. Results The participants in the faculty development programme reported that the skills most often used while teaching were learnt during circuit and itinerant bedside, physical examination teaching, mini-clinical evaluation exercise (mini-CEX) evaluation demonstration, training workshop and videotapes of 'how to teach ACGME competencies.' Participants reported that circuit bedside teaching and mini-CEX evaluation demonstrations helped them in the interpersonal and communication skills domain, and that the itinerant teaching demonstrations helped them in the professionalism domain, while physical examination teaching and mini-CEX evaluation demonstrations helped them in the patients' care domain. Both the training workshop and videotape session increase familiarity with teaching and assessing skills. Participants who applied the skills learnt from the faculty development programme the most in their teaching and assessment came from internal medicine departments, were young attending physician and had experience as PGY(1) clinical instructors. Conclusions According to the clinical instructors' response, our faculty development programme effectively increased their familiarity with various teaching and assessment skills needed to teach PGY(1) residents and ACGME competencies, and these clinical instructors also then subsequently apply these skills.

Assessment of clinical competence of medical students using the objective structured clinical examination: first 2 years' experience in Taipei Veterans General Hospital

BACKGROUND

Competence-oriented education is currently the mainstream method of teaching clinical medical education. The objective structured clinical examination (OSCE) is a widely employed and accepted tool to measure the clinical competence of medical students. We describe the first 2 years' experience of OSCE in Taipei Veterans General Hospital.

METHODS

At Taipei Veterans General Hospital, every 7(th)-year medical student has taken the OSCE since 2006. There were 15 stations in the first 2 years' OSCEs. In years 1 and 2, 133 and 132 students were assessed by the OSCE, respectively. The content of the OSCE included internal medicine, surgery, pediatrics, obstetrics and gynecology, communication, and emergency training. All categories and results of examinees' evaluation at each station were recorded inclusively and compared statistically.

RESULTS

The average scores of students from the 15 stations ranged from 47.7 ± 16.4 to 93.7 ± 8.5 in 2007. The score for communication skills was the lowest, whereas the score for Micro-Sim was the highest. Communication skills and electrocardiography interpretation were the 2 categories in which most of the students failed. A reliability analysis was conducted of the 2007 OSCE questions. The overall score and reliability (Cronbach's reliability) was 0.641. The difference between the impacts on reliability after deleting a test item ranged from 0.59 to 0.65 for all stations. This meant that every station had a similar impact on reliability after being deleted. The squared multiple correlation, R(2), of the reliability of each item was between 0.12 and 0.49, with chest X-ray interpretation being the lowest. The item-total correlation was between 0.10 and 0.41, with interactive case being the lowest.

CONCLUSION

The OSCE is an effective method for assessing the clinical competence of medical students. The OSCE could be improved further by modifying the examination questions and promoting effective training for standardized patients and examiners.

Surface and bulk uniaxial to biaxial smectic-A transition in a bent core liquid crystal

A null transmission ellipsometer was employed to study the uniaxial to biaxial smectic-A phase transition of a bent core liquid crystal material. Free-standing films of thicknesses ranging from 5 molecular layers to more than 300 were prepared and studied. Critical exponents for both the surface and interior biaxiality were obtained. The results were discussed in the general framework of phase transition in lower dimensions.

Evolution of a rare sequence of surface transitions with temperature and film thickness

In free-standing smectic films, layers near the surfaces of the film often contain molecules tilted away from the layer normal, while in the bulk of the film the magnitude of the tilt decays exponentially with distance from the surface. We have identified the detailed molecular tilt orientations in the surface layers of films for one antiferroelectric liquid crystal compound. A series of five surface structures exists with different nonplanar tilt arrangements for each structure. The molecular orientations in the surface layers evolve with temperature. The polarization of the film also evolves with temperature, corresponding to the tilt arrangements. Using ellipsometric data, we reconstruct the changes in the magnitude and azimuthal direction of the tilt as functions of temperature. We have also studied films of several different thicknesses. We present a phase diagram for the five surface structures showing the dependence on temperature and film thickness.

Discovery of a novel smectic-C{*} liquid-crystal phase with six-layer periodicity

We report the discovery of a new smectic-C{*} liquid-crystal phase with six-layer periodicity by resonant x-ray diffraction. Upon cooling, the new phase appears between the SmC{alpha}{*} phase having a helical structure and the SmC{d4}{*} phase with four-layer periodicity. This SmC{d6}{*} phase was identified in two mixtures which have an unusual reversed SmC{d4}{*}-SmC{*} phase sequence. The SmC{d6}{*} phase shows a distorted clock structure. Three theoretical models have predicted the existence of a six-layer phase. However, our experimental findings are not consistent with the theories.

Extracorporeal shockwave for hip necrosis in systemic lupus erythematosus

Patients with systemic lupus erythematosus (SLE) frequently received corticosteroid therapy, resulting in osteonecrosis of the femoral head (ONFH). Prior studies demonstrated the effectiveness of extracorporeal shockwave treatment (ESWT) for ONFH.. This study evaluated the effectiveness of ESWT for ONFH in patients with SLE. We studied 39 patients, including 15 patients with SLE (26 hips) and 24 controls (29 hips). To each affected hip we applied ESWT (6000 impulses at 28 kV in a single session). Patients were ambulated with partial weight bearing for 4-6 weeks. The primary endpoint was the need for hip replacement. The secondary endpoints were improvement in hip pain and function and image changes on X-ray and MRI. Patients received total hip replacement in 12% of patients with SLE and in 14% of controls (P = 0.802). There was no statistically significant difference in pain scores (0.86 vs. 0.89; P = 0.467) and function scores (89% vs. 91%; P = 0.194) between patients with SLE and controls. SLE response to ESWT for ONFH is comparable with ONFH in patients without SLE.

Experimental and simulation studies on the mechanisms of levetiracetam-mediated inhibition of delayed-rectifier potassium current (KV3.1): contribution to the firing of action potentials

Levetiracetam (LEV) is an S-enantiomer pyrrolidone derivative with established antiepileptic efficacy in generalized epilepsy and partial epilepsy. However, its effects on ion currents and membrane potential remain largely unclear. We investigated the effect of LEV on differentiated NG108-15 neurons. In these cells treated with dibutyryl cyclic AMP, the expression level of the K(V)3.1 mRNA was elevated. With the aid of patch clamp technology, we found that LEV could suppress the amplitude of delayed rectifier K(+) current (I(K(DR))) in a concentration-dependent manner with an IC(50) value of 37 microM. LEV (30 microM) shifted the steady-state activation of I(K(DR)) to a more positive potential by 10 mV, without shifting the steady-state inactivation of I(K(DR)). Neither Na(+), nor erg (ether-a-go-go-related)-mediated K(+) and ATP-sensitive K(+) currents were affected by LEV (100 microM). LEV increased the duration of action potentials in current clamp configuration. Simulation studies in a modified Hodgkin-Huxley neuron and network unraveled that the reduction of slowly inactivating I(K(DR)) resulted in membrane depolarization accompanied by termination of the firing of action potentials in a stochastic manner. Therefore, the inhibitory effects on slowly inactivating I(K(DR)) (K(V)3.1-encoded current) may constitute one of the underlying mechanisms through which LEV affect neuronal activity in vivo.

Thickness dependent phase behavior of antiferroelectric liquid crystal films

Free standing films of a liquid crystal compound with simple surface enhanced order were studied. The resultant phase diagram demonstrates that (1) the short helical pitch smectic-C(alpha)* phase disappears below a film thickness of 10 layers, and (2) the temperature window of a distorted 4 layer smectic-C(FI2)* phase increases dramatically upon decreasing film thickness. The experimental findings were attributed to the reduced dimensionality and enhanced surface effects in thin films. The results of the smectic-C(alpha)* phase are consistent with what have been reported for helically ordered magnetic thin films, with a noticeable difference due to the opposite effect of the surface on ordering in the two systems.

Relationship between age and serum thyrotropin among asymptomatic older people in Taiwan

Hypothyroidism is a common disorder in older people, and may be asymptomatic and hard to be diagnosed. The main purpose of this study was to evaluate the distribution of serum thyrotropin (thyroxin-stimulating hormone, TSH) among asymptomatic older people in Taiwan, and to evaluate the relationship between age and serum TSH. In 2007, all subjects participating in the annual elderly health examinations at Taipei Veterans General Hospital were invited for study and were enrolled when they were fully consented. In total, 1716 asymptomatic elderly people (mean age: 73.2+/-4.4 years, 56.3% males) participated in this study after careful exclusion of 38 subjects with past history of thyroid disorders. All participants were divided into two groups: (1) younger old (age 65-79) and (2) older old (age over 80) for further analysis. The mean serum levels of TSH were similar between younger old and older old groups (2.43+/-5.36 microIU/ml for younger old and 2.36+/-3.51 microIU/ml for older old, p=0.444). The overall prevalence of suspected hypothyroidism was 9.2% among asymptomatic older people in Taiwan, which was significantly lower than in Caucasians. The prevalence of suspected hypothyroidism may reach 25.9% if the TSH cutoff was lowered to 2.5 microIU/ml. Further study is needed to determine the normal reference range of serum TSH in older people.

Comparison between experiment and theory in the temperature variation of film tension above the bulk isotropic transition in free-standing liquid-crystal films

Using differential scanning calorimetry, the transition enthalpies and temperatures for the bulk smectic-isotropic phase transition have been measured for a series of liquid-crystal compounds. For five compounds, those values were used as parameters in a microscopic mean-field model to predict the temperature dependence of the difference in free-energy density between a sample of material in a free-standing smectic film and that in the bulk. The model predicts a weak temperature dependence below the bulk clearing point and a pronounced monotonic increase with temperature above the transition temperature. The compounds used in this study were chosen specifically because they were also the subject of a previous independent experimental study [M. Veum, Phys. Rev. E 74, 011703 (2006)] that demonstrated a sudden monotonic increase in the free-standing film tension with temperature, which is qualitatively consistent with the predictions of the above-mentioned mean-field model. This study presents a direct and quantitative comparison between the predictions of the mean-field model and the results from previous tension experiments.

Effect of thimerosal on Ca2+ movement and viability in human oral cancer cells

The effect of thimerosal on cytosolic free Ca2+ concentrations ([Ca2+]i ) in human oral cancer cells (OC2) is unclear. This study explored whether thimerosal changed basal [Ca2+]i levels in suspended OC2 cells using fura-2. Thimerosal at concentrations between 1and 50 μM increased [Ca2+]i in a concentration-dependent manner. The Ca2+ signal was reduced partly by removing extracellular Ca 2+. Thimerosal-induced Ca2+ influx was not blocked by L-type Ca2+ entry inhibitors and protein kinase C modulators (phorbol 12-myristate 13-acetate [PMA] and GF109203X). In Ca2+-free medium, 50 μM thimerosal failed to induce a [Ca2+]i rise after pretreatment with thapsigargin (an endoplasmic reticulum Ca2+ pump inhibitor). Inhibition of phospholipase C with U73122 did not change thimerosal-induced [Ca2+]i rises. At concentrations between 5 and 10 μM, thimerosal killed cells in a concentration-dependent manner. The cytotoxic effect of 8 μM thimerosal was potentiated by prechelating cytosolic Ca2+ with the Ca2+ chelator 1,2-bis(2-aminophenoxy)ethane-N,N,N′,N′-tetraacetate/acetomethyl (BAPTA/ AM). Flow cytometry data suggested that 1—7 μM thimerosal-induced apoptosis in a concentration-dependent manner. Collectively, in OC2 cells, thimerosal-induced [Ca2+]i rises by causing phospholipase C-independent Ca2+ release from the endoplasmic reticulum and Ca2+ influx through non—L-type Ca2+ channels. Thimerosal killed cells in a concentration-dependent manner through apoptosis.

Nonplanar tilts in very thin smectic films of one liquid-crystal compound

Surface effects cause tilted molecular arrangements in smectic layers near the surface of a free-standing liquid-crystal film in which the bulk of the film is in the smectic- A phase. One recent work has shown that the tilt directions in adjacent surface layers may be nonplanar. In this paper we study films with thicknesses of two to six smectic layers. Surface effects dominate in these very thin films. We show that the molecular tilts are nonplanar even in these very thin films.

Surface-induced ordering effect in one antiferroelectric liquid crystal compound

Null transmission ellipsometer was employed to study the surface-induced tilt transition of an antiferroelectric liquid crystal compound in the bulk smectic- A (SmA) temperature range. The data of the surface tilt transition can be fitted with an extended mean-field model. These results indicate the transition is near a mean-field tricritical point. The surface layers' tilt directions are found to be in different planes several degrees above the bulk SmA-SmC_{alpha};{ *} transition.

Recovery of a reversed phase sequence in one ternary liquid-crystal-mixture system

The nOHFBBB1M7 (n=10) compound, 10OHF, shows a reversed SmC{FI2}-SmC phase sequence, unique among all known antiferroelectric liquid crystals. This reversed phase sequence is stabilized when 10OHF is doped with 9OTBBB1M7(C9) or 11OTBBB1M7(C11). In contrast, doping of the homologous members ( n=9 , 11, or 12) eliminates the SmC{FI2} phase. One 10OHF/11OHF mixture without the SmC{FI2} phase was selected for further studies. By adding C9 into this particular mixture, the reversed phase sequence is revived. To our surprise, even though 11OHF destabilizes the SmC_{FI2} phase in binary mixtures with 10OHF, it significantly increases the SmC_{FI2} temperature range in the 10OHF/11OHF/C9 ternary mixtures.

Useful prediction of ureteral calculi visibility on abdominal radiographs based on calculi characteristics on unenhanced helical CT and CT scout radiographs

AIMS

To determine whether visibility of ureteral calculi on plain radiographs of the kidney, ureter and bladder (KUB) could be predicted based on characteristics on unenhanced helical computed tomography (UHCT) and CT scout radiographs (CTSR).

METHODS

One hundred and twenty-three patients diagnosed with 140 ureteral calculi on UHCT, had undergone both UHCT and KUB within 24 h and before calculus passage or intervention were included. The visibility of ureteral calculi on KUB and CTSR as well as their sizes, locations and densities on UHCT were recorded. The association of CTSR/UHCT characteristics of ureteral calculi and their visibility on KUB were analysed. Multivariate analyses using logistic regression were computed as predictors for visibility on KUB.

RESULTS

Of the 140 calculi, 56 (40%) and 98 (70%) were visible on CTSR and KUB respectively. All calculi detectable on CTSR were also visible on KUB. Multivariate analyses of the 84 CTSR undetectable calculi revealed that non-middle ureteral location and higher calculi densities on UHCT were significant predictors of visibility on KUB. All non-middle ureteral calculi with density > 800 Hounsfield units (HU) were visible on KUB. Of 23 calculi in the middle ureter or with density < 200 HU, 17 (74%) were invisible on KUB.

CONCLUSIONS

Ureteral calculi characteristics on UHCT and CTSR are useful for predicting their visibility on KUB. Patients with visible calculi on CTSR or non-middle ureteral calculi with density > 800 HU are suitable for KUB to follow-up calculi status.

Baculovirus-derived hemagglutinin vaccine protects chickens from lethal homologous virus H5N1 challenge

Since outbreaks of highly pathogenic avian influenza (HPAI) in both human and poultry from 2003, it is critical to have effective vaccines. A cDNA fragment coding the entire hemagglutinin (HA) gene derived from an H5N1 strain (A/duck/China/E319-2/03) was cloned and expressed using the baculovirus system. Two weeks after receiving two doses of recombinant HA (rHA) vaccines, chickens develop high antibody response for hemagglutination inhibition (HI) at titer 7.2 log(2). Challenge studies revealed that vaccinated chickens with HI titers greater than 3 log(2) could have immunoprotection against the same HPAI H5N1 strain virus challenge through intranasal route. Additionally, HI titer of 5 log(2) determined whether the live viruses could not be detected from oropharyngeal, cloacal discharge or in tissues. This result suggests that the rHA expressed from baculovirus system could be a candidate for the development of a safe and efficient subunit vaccine for HPAI (H5N1).

Primary plasmacytoma of the uterine cervix treated with three-dimensional conformal radiotherapy

Primary plasmacytoma of the uterine cervix is a rare neoplasm with limited known data, and only several cases sporadically reported in the published literature. Radiotherapy might have a role in the treatment of plasmacytoma of the uterine cervix. We describe primary plasmacytoma of the uterine cervix in a 45-year-old woman treated with three-dimensional conformal radiotherapy, and also reviewed the literature to evaluate the treatment modality and therapeutic outcome of this rare disease.

Particle size control of poly(dl-lactide-co-glycolide) nanospheres for sterile applications

Parameters affecting the particle sizes of poly(DL-lactide-co-glycolide) (PLGA) nanospheres produced by the Emulsion Solvent Diffusion (ESD) method were evaluated in this study, so that suitable PLGA nanospheres could be prepared to pass through a membrane filter with 0.2 microm pore size and used as a sterile product. Experimental results demonstrated that the particle sizes of PLGA nanospheres could be reduced by the following efforts. (1) Increase stirring rate of poor solvent. (2) Decrease feed rate of good solvent. (3) Increase poor solvent ratio. (4) Increase the temperature of poor solvent. (5) Decrease polyvinyl alcohol concentration in poor solvent. (6) Increase ethanol concentration in good solvent. (7) Decrease PLGA concentration in good solvent. After optimization, PLGA nanospheres with a mean particle size of 102-163 nm and the 100-98% of filtration fraction could be produced and passed the bacteria challenge tests. This study found PLGA nanospheres can be efficiently prepared as a sterile product.

Identification of interleukin-13 related biomarkers using peripheral blood mononuclear cells

Asthma is a chronic disorder characterized by airway inflammation, reversible bronchial obstruction, hyper-responsiveness and remodelling. Data from human in vitro studies and experimental in vivo models of asthma has implicated interleukin (IL)-13 in the asthma phenotype suggesting that a therapeutic agent against it could be effective in treating asthma. The role of biomarkers is becoming increasingly important in the clinical development of therapeutics. Here we describe the use of the GeneChip((R)) DNA microarray technology platform to explore and identify potential response to therapy biomarkers that are associated with the biology of IL-13. Peripheral blood mononuclear cells (PBMCs) from eight healthy donors were cultured in the presence of IL-13, IL-4, an anti-IL-13 monoclonal antibody (mAb) or an isotype control mAb, and RNA from the treated cells was subjected to microarray analysis. The results revealed a number of genes, such as CCL17 (TARC), CCL22 (MDC), CCL23 (MPIF-1), CCL26 (eotaxin 3) and WNT5A (human wingless-type MMTV integration site family member 5A), that showed increased expression in the IL-13 and IL-4 treatment groups. Real-time polymerase chain reaction (PCR) subsequently confirmed these results. A follow-up study in PBMCs from five additional healthy donors showed that the neutralization of IL-13 completely blocked IL-13-induced TARC, MDC and eotaxin 3 production at the protein level. These data suggest that TARC, MDC, eotaxin 3, CCL23 and WNT5A if validated could serve as potential biomarkers for anti-IL-13 therapeutics.

Predictors of mortality in patients with pyogenic liver abscess

BACKGROUND

Pyogenic liver abscess (PLA) is uncommon but potentially life-threatening. The objective of this study was to identify the prognostic factors for PLA.

METHODS

The medical records of 253 patients, 148 men and 105 women with a mean age of 56.4 years (SD : 15.0 years), who were hospitalised due to a PLA between January 1995 and June 2007 were reviewed. The underlying medical disorders, clinical signs and symptoms, laboratory values, imaging studies, microbiological features, treatments, morbidity and mortality were recorded. Factors related to in-hospital case fatality were analysed.

RESULTS

The mean Acute Physiology And Chronic Health Evaluation (APACHE) II score at admission in patients with PLA was 8.7 points (SD 5.4 points). The most common co-existing disease was diabetes mellitus (41.9%), followed by biliary stone disorders (32.0%). Klebsiella pneumoniae was the most frequent pathogen, followed by Escherichia coli. The in-hospital case-fatality rate was 9.1%. Multivariate analysis revealed that gas-forming abscess (p=0.019), multi-drug resistant isolates (p=0.026), anaerobic infection (p=0.045), blood urea nitrogen level >7.86 mmol/l (p=0.004), and APACHE II score > or =15 (p= 0.004) were associated with mortality.

CONCLUSIONS

The prognosis of PLA may depend chiefly on the severity of the basic physical condition and underlying pathology. As the primary treatment for PLA is not completely effective, a more aggressive approach should be considered, especially for patients with poor prognosis.

Organization-based performance measures of cancer care quality: core measure development for breast cancer in Taiwan

The purpose of the study was to develop organization-based core performance measures (CPMs) for breast cancer patients treated in hospitals that participated in cancer quality improvement programmes in Taiwan. CPMs were developed in three stages that included a preparation, a consensus building stage, and two stages of stakeholder feedback. Three criteria and seven subcriteria were applied in the development process. Indicators listed in a Delphi questionnaire were based on a literature search, indicators developed by relevant institutions and discussion by authors. Each indicator needed to meet inclusion criteria as a final indicator. Evidence-based guidelines, expert opinions from panel group, 27 hospitals and empirical data were all applied to develop and revise the core measures. Fifteen out of 28 indicators were selected and modified after the three stages. There were two pre-treatment indicators for screening and diagnosis, nine treatment-related indicators, and four monitoring-related indicators. Six indicators were supported by evidence level I, and four indicators by level II evidence. The CPMs for breast cancer can be developed systematically and be applied for internal quality improvement and external surveillance. Our experience can be extended to other cancer sites and adapted to link with pay for performance or certification program in cancer care.

Effects of doping on an unusual smectic- C*alpha-smectic-C*FI2-smectic-C* phase sequence

The compound 10OHF has a partially inverted phase sequence, unique among the series of nOHF homologous compounds and all other known liquid crystals, with the smectic-C*FI2 (SmC*FI2) phase occurring at higher temperature than the smectic-C* (SmC*) phase. We present ellipsometric data to identify the phase sequences of 9OHF, 10OHF, 11OHF, and 12OHF. Binary mixtures of 10OHF with C11, a compound with the typical phase sequence among the smectic phases, show that the unusual phase sequence of 10OHF stabilizes upon mixing and that SmC*FI2 predominates over SmC* throughout the entire mixing phase diagram. In thin films of some mixtures, surface interactions induce a reentrant SmC*FI2-SmC*-SmC*FI2 transition in the rest of the film.

Malignant mixed müllerian tumor of primary mesenteric origin associated with a synchronous ovarian cancer: case report and literature review

Malignant mixed müllerian tumor (MMMT) is a rare tumor in females and extragenital MMMT is even more so. We report a patient with MMMT primarily in the mesentery with synchronous ovarian cancer. In the English literature, 42 cases of extragenital MMMT have been reported other than the presented case, and this is only the second MMMT arising from the mesentery. Furthermore, among the cases reviewed, MMMTs tend to be associated with synchronous or metachronous colonic cancer or gynecologic tumors originating from the müllerian duct, including ovarian tumors, fallopian tube cancer, endometrial cancer, cervical cancer, and serous carcinoma of the peritoneum (14 out of 43 patients; 32.6%). The risk factors for MMMT include obesity, nulliparity, exogenous estrogen, and long-term tamoxifen use. The prognosis of MMMT is catastrophic and the treatment is based on the experience of those of uterine sarcomas, which is composed of operation, radiotherapy and chemotherapy.