Ayudantías universitarias: influencia académica percibida en el desempeño en el examen de residencias médicas municipales / Teaching assistants: perceived academic influence on performance in municipal medical residency exams

Introducción: el ejercicio de la docencia universitaria por parte de estudiantes de Medicina ofrecería múltiples beneficios. Sin embargo, no hay evidencia de que mejore el desempeño en los exámenes estandarizados en el posgrado. El objetivo de este estudio fue describir la diferencia de los puntajes en el examen de residencias médicas municipales entre ayudantes y no ayudantes, y evaluar la autopercepción del efecto de ser ayudante sobre el desempeño en dicho examen y sobre las habilidades académicas. Métodos: estudio observacional, descriptivo, de corte transversal, con un muestreo por conveniencia de médicos participantes del examen de residencias médicas municipales de la Ciudad Autónoma de Buenos Aires (CABA) de 2018, a partir del listado oficial. Se excluyeron aquellos a quienes fue imposible contactar, que se negaran a participar o cuya identidad discrepara con la de la persona seleccionada para incluir en el estudio. Resultados: de los 3579 médicos que concursaron en el examen de residencias médicas básicas municipales de CABA 2018, se tomó una muestra aleatoria de 300 sujetos, de los cuales se contactó a 87. De ellos, 20 sujetos cumplían con criterios de exclusión; por lo tanto fueron 67 sujetos los que finalmente participaron del estudio. La proporción de respuestas con respecto a los sujetos que pudieron ser contactados mediante redes sociales fue 77%. El puntaje de examen entre los ayudantes fue de 32,3 ± 5,7 puntos mientras que entre los no ayudantes fue 29,5 ± 6,1 puntos. Entre los ayudantes, el 68% informó percibir que el hecho de haber realizado una ayudantía en el pregrado tuvo un efecto de levemente a muy positivo sobre su desempeño en el examen, un 76% refirió la profundización de conocimientos específicos, el 73% informó una mejoría en sus habilidades comunicacionales y el 59% una mayor capacidad para jerarquizar contenidos. Conclusión: el desarrollo de una actividad docente en el pregrado sería percibida por quienes la desarrollan como una actividad promotora de habilidades comunicacionales y de jerarquización de contenidos y, ulteriormente, como una influencia positiva en el desempeño académico en el examen de residencias médicas municipales. Estas conclusiones deben confirmarse con estudios futuros. (AU)

Introduction: medical students could benefit from teaching university courses. However, there is no evidence showing that this activity improves academic performance on standardized tests in graduate school. The objective of this study was to describe the differences in scores on the municipal medical residency exam between physicians who were teaching assistants and those who weren't, and to evaluate the self-perception of the effect of being a teaching assistant on the performance on this exam and on academic skills in general. Methods: this is an observational, descriptive, cross-sectional study, with a convenience sample of physicians participating in the 2018 municipal medical residency exam of the Autonomous City of Buenos Aires (CABA) based on official lists. Those who could not be contacted, refused to participate, or whose identity diverged from the person selected to include in the study, were excluded. Results: of the 3,579 physicians who participated in the basic municipal medical residency exam in CABA 2018, a random sample of 300 subjects was taken, of which 87 were contacted. Of those, 20 subjects met the exclusion criteria, having 67 subjects finally participating in the study. The proportion of subjects who could be contacted through social networks was 77%. The exam score among physicians who were teaching assistants was 32.3 ± 5.7 points while among the non-teaching assistants it was 29.5 ± 6.1 points. Among the teaching assistants, 68% perceived that the fact of having been a teaching assistant as an undergraduate had a slight to very positive effect on their performance in the exam, 76% referred the deepening of their specific knowledge on the subject they taught, 73% reported an improvement in their communication skills, and 59% referred a greater ability to rank content. Conclusions: undergraduate teaching would be perceived as an activity that promotes communication skills and ability to rank content and, therefore, as a positive influence on academic performance in the municipal medical residency exam. These conclusions need to be confirmed with future studies. (AU)

The CITIMERIVA Study: CITIcoline plus MEmantina plus RIVAstigmine in Older Patients Affected with Alzheimer's Disease.

OBJECTIVE: Combined therapy of memantine or acetylcholinesterase inhibitors, with cholinergic precursors such as citicoline, can be effective in Alzheimer's disease. Indeed, they are able to increase the intrasynaptic levels of acetylcholine more than the single drug. Our aim was to evaluate the efficacy and safety of oral citicoline plus memantine plus rivastigmine in patients with Alzheimer's disease. METHODS: This was a multi-centric, retrospective case-control study conducted in Italian Centers for Cognitive Impairment and Dementia on consecutive patients aged 65 years or older affected with Alzheimer's disease. Overall, 104 patients were recruited (27% male, mean age 76.04 ± 4.92 years); 41 (39.42%) treated with citicolin 1000 mg/day given orally + memantine + rivastigmine (Cases) and 63 (60.58%) treated with memantine + rivastigmine (Controls). At baseline (T0), month 6 (T1) and month 12 (T2), cognitive functions were assessed by the Mini Mental State Examination (MMSE), functional dependence by basal Activities (ADL) and Instrumental Activities of Daily Living (IADL), comorbidity by the Cumulative Illness Rating Scale (CIRS), mood by the Geriatric Depression Scale (GDS), and behavioural disturbances by the Neuropsychiatric Inventory (NPI). Adverse events were reported during the study. RESULTS: The difference in MMSE score was not significant when comparing the two groups at T0, T1 or T2. However, in the case group, the MMSE total score showed a statistically significant difference at T0 versus T1 (13.63 ± 2.46 vs. 14.17 ± 2.24; p = 0.008), and at T0 versus T2 (13.63 ± 2.46 vs. 14.32 ± 2.53; p = 0.002). In the control group, no statistical differences were found at baseline (T0), T1 and T2. ADL, IADL, GDS and NPI total score did not improve during the study in either the case or the control group. CONCLUSIONS: In our study we observed absence of a statistically significant difference between case and control groups for the MMSE total scores. However, in the case group in the MMSE total scores, there was a statistically significant increase between the baseline and the end of the study.

A Retrospective Study on the Benefits of Combined Citicoline, Memantine, and Acetylcholinesterase Inhibitor Treatments in Older Patients Affected with Alzheimer's Disease.

BACKGROUND: Background: Citicoline has been proven to have beneficial effects in patients with cognitive impairment. In previous studies, combined treatment with memantine and acetylcholinesterase inhibitors (AChEIs) maintained cognitive function in patients with Alzheimer's disease (AD) better than memantine or AChEIs alone. OBJECTIVE: To evaluate the effectiveness and safety of a combination therapy of oral citicoline, memantine, and an AChEI in AD when compared with memantine and an AChEI without citicoline. METHODS: This was a retrospective multi-centric case-control study, conducted in Italian Centers for Cognitive Impairment and Dementia. Overall, 170 patients were recruited (34.11%of men, mean age 76,81±4.93 years): 48.8%treated with memantine and donepezil; 48.2%with memantine and rivastigmine; 2.9%with memantine and galantamine. 89 patients (control-group) were treated with memantine and an AChEI, whereas 81 patients (case-group) were treated with oral citicoline 1000 mg/day added to memantine and an AChEI given orally. Cognitive functions, activities of daily living, instrumental activities of daily living, comorbidities, mood and behavioral disturbances were assessed at baseline, month 6, and month 12. RESULTS: In the case group, MMSE score had a statistically significant increasing trend between T0 and T2 (14.88±2.95 versus 15.09±3.00; p = 0.040), whereas in the control group, MMSE score showed a statistically significant decrease trend (14.37±2.63 versus 14.03±2.92 p = 0.024). CONCLUSION: In older patients with AD, a triple therapy with citicoline, memantine, and AChEI was more effective than memantine and AChEI without citicoline in maintaining the MMSE total score after 12 months.

Prediction equation for estimating cognitive function using physical fitness parameters in older adults.

Ageing is associated with declines in cognitive functions and physical fitness (PF). Physical exercise training and physical activity (PA) have been shown to have positive effects on cognitive functions and brain plasticity. This study aims to establish a practical equation for evaluating cognitive functions using PF parameters in healthy older adults. One-hundred and two older subjects were physically and clinically evaluated. Participants performed the Short Physical Performance Battery (SPPB) and handgrip test (HG); general cognitive functions were examined using the Mini Mental State Examination (MMSE). For all of them, a multiple regression analysis was used to predict MMSE from age, SPPB and HG variables. The new equation was cross validated to determine its prediction accuracy. Considering that SPPB and MMSE reference score are not different between genders, only one equation was developed for females and males. Age, SPPB and HG correlated significantly (p<0.01) with the MMSE score. The developed equation was MMSE = 19.479 + (1.548 x SPPB)-(0.130 x age) (R2 = 0.72 and root mean square errors of 3.6). The results of PF are useful for exercise specialists to achieve the best physical exercise training and PA in older adults. In conclusion, this study showed for the first time that our new equation can be used to predict subjects' cognitive functions based on SPPB results and subject age. We suggest its use when patients' cognitive functions or more appropriate clinical tests cannot be pursued.

Depressive symptoms in caregivers of patients with dementia: demographic variables and burden.

OBJECTIVE: Individuals suffering from dementia are affected by a progressive and significant global deterioration and, consequently, might require longer assistance in the advanced stage of the illness. The illness is a great burden on the person who takes care of a patient, namely, the caregiver. This study aims to analyze the presence and relationship of specific sociodemographic variables, subjective burden, and depressive symptoms among caregivers of patients with dementia. METHODS: The participants of this study were caregivers at a health care unit for the elderly in southern Italy. An evaluation of the burden of patients with dementia on caregivers was carried out using the Caregiver Burden Inventory (CBI) and depressive symptoms using the Self-Rating Depression Scale (SDS). RESULTS: A total of 150 caregivers completed the study. In all, 83 (55%) caregivers showed a total CBI score ≥36, of whom 70% showed pathological depression scores in SDS. According to SDS, 28 (19%) caregivers showed a total CBI score from 24 to 36, of whom 32% were depressed. Depression was present in 5% of the caregivers whose CBI score was <24. Hence, an association between burden and depression was evident (χ(2)=47.446, P<0.001). A multiple linear regression analysis showed that depression (adjusted R(2)=0.622, F=50.123, P<0.001) was associated with higher physical (ß=0.666, P=0.001) and developmental (ß=0.712, P<0.001) burdens, lower socioeconomic status (ß=-4.282; P=0.002), higher level of urbanicity (ß=3.070; P=0.012), and advanced age (ß=2.132; P=0.08). CONCLUSION: Our study confirms the presence of depressive symptoms in a large number of caregivers with high burden. Nevertheless, this study demonstrates that depressive symptoms are mainly associated with sociodemographic variables and, to a lesser degree, physical and developmental burdens.

Retrospective study on the benefits of combined Memantine and cholinEsterase inhibitor treatMent in AGEd Patients affected with Alzheimer's Disease: the MEMAGE study.

BACKGROUND: Combined therapy of memantine and acetylcholinesterase inhibitors (AChEIs) in patients with Alzheimer's disease (AD) may be associated with higher benefits than either monotherapy. OBJECTIVE: This retrospective multicentric study conducted in seven Italian Ambulatory Centers for Dementia assessed the efficacy and safety of memantine 20 mg/day administered for 6 months in addition to an AChEI in AD patients with worsened cognitive functions and behavioral disorders. METHODS: A total number of 240 patients (61.7% of women, 38.3% men, mean age 77.9 ± 7.32 years old) who had started treatment with the combination therapy were recruited. At baseline (T0), Month 3 (T1), and Month 6 (T2), cognitive functions were assessed by Mini-Mental State Examination (MMSE), functional dependence by activities of daily living (ADL) and instrumental ADL, behavioral disturbances by the Neuropsychiatric Inventory (NPI), and comorbidities by Cumulative Illness Rating Scale. Adverse events were reported during the study. RESULTS: MMSE total score significantly increased at Month 6 (p = 0.029 versus month 3) and IADL total score significantly decreased from baseline to endpoint (p = 0.033). There were no significant changes from baseline in mean ADL, despite significant improvements in NPI total score. The mean MMSE total score significantly increased with the combination donepezil + memantine compared to rivastigmine + memantine. The adverse events profile was in line with the expected range of the drugs studied and concomitant therapies. Overall, 17 patients discontinued treatment in the observation time. CONCLUSION: Combined treatment with memantine and AChEIs was effective in patients with AD, particularly in slowing cognitive impairment and preventing the onset of agitation and aggression in elderly AD patients.

Effectiveness and safety of citicoline in mild vascular cognitive impairment: the IDEALE study.

BACKGROUND: The studio di intervento nel decadimento vascolare lieve (IDEALE study) was an open multicenter Italian study, the aim of which was to assess the effectiveness and safety of oral citicoline in elderly people with mild vascular cognitive impairment. METHODS: The study was performed in 349 patients. The active or citicoline group was composed of 265 patients and included 122 men and 143 women of mean age 79.9 ± 7.8 years selected from six Italian regions. Inclusion criteria were age ≥ 65 years, Mini-Mental State Examination (MMSE) score ≥ 21, subjective memory complaints but no evidence of deficits on MMSE, and evidence of vascular lesions on neuroradiology. Those with probable Alzheimer's disease were excluded. The control group consisted of 84 patients, including 36 men and 48 women of mean age 78.9 ± 7.01 (range 67-90) years. Patients included in the study underwent brain computed tomography or magnetic resonance imaging, and plasma dosage of vitamin B12, folate, and thyroid hormones. Functional dependence was investigated by scores on the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scales, mood was assessed by the Geriatric Depression Scale (GDS), and behavioral disorders using the Neuropsychiatric Inventory scale. Comorbidity was assessed using the Cumulative Illness Rating Scale. An assessment was made at baseline (T0), after 3 months (T1), and after 9 months (T2, ie, 6 months after T1). The main outcomes were an improvement in MMSE, ADL, and IADL scores in the study group compared with the control group. Side effects were also investigated. The study group was administered oral citicoline 500 mg twice a day throughout the study. RESULTS: MMSE scores remained unchanged over time (22.4 ± 4 at T0; 22.7 ± 4 at T1; 22.9 ± 4 at T2), whereas a significant difference was found between the study and control groups, both in T1 and in T2. No differences were found in ADL and IADL scores between the two groups. A slight but not statistically significant difference was found in GDS score between the study and control groups (P = 0.06). No adverse events were recorded. CONCLUSION: In this study, citicoline was effective and well tolerated in patients with mild vascular cognitive impairment. Citicoline activates biosynthesis of phospholipids in neuronal membranes, increases brain metabolism as well as norepinephrine and dopamine levels in the central nervous system, and has neuroprotective effects during hypoxia and ischemia. Therefore, citicoline may be recommended for patients with mild vascular cognitive impairment.

Somatic comorbidities and Alzheimer's disease treatment.

Therapeutic strategies in Alzheimer's disease (AD) must take into account the characteristics of elderly people, who often have somatic comorbidities. Moreover, demented patients are more frequently frailer than older people. They have a higher number of admissions to hospital, a greater prevalence of complications and an increased risk of death. Therapeutic decisions for these patients have to be approached cautiously: aging, a more elevated comorbidity/polytherapy index and frailty contribute to enhance the risk of pharmacological adverse events and drug interactions. The aim of the present study was to focus on risk-benefit profile of pharmacological therapy for AD in relation to somatic comorbidities that often affect these patients. A Medline search (from 2001 to 2012) was performed using as key words dementia, Alzheimer's disease, drug treatment, somatic comorbidities, side effects/adverse events and elderly. Cholinesterase inhibitors (ChEIs) and memantine represent the main pharmacological strategies effective in reducing the progression of cognitive decline and functional loss in AD. Many conditions very common in the elderly may restrict the use of ChEIs and/or treatment efficacy in AD patients. Memantine has a good efficacy and tolerability profile with better safety in pulmonary, cardiovascular and central nervous system comorbidities compared to ChEIs. Drug interactions with memantine are also more favorable since they concern mostly drugs not commonly used in the elderly. Only a careful evaluation of the associated somatic diseases, taking into account different drugs safety indexes and tolerability, can lead to personalized treatment management, in order to maximize drug efficacy and optimize quality of life.

Social environment affects acquisition and color of structural nuptial plumage in a sexually dimorphic tropical passerine.

Structural colors result from the physical interaction of light with organic materials of differing refractive indexes organized at nanoscale dimensions to produce significant interference effects. Because color properties emerge from these finely organized nanostructures, the production of structural coloration could respond to environmental factors and be developmentally more plastic than expected, functioning as an indicator of individual quality. However, there are many unknown factors concerning the function and mechanisms regulating structural coloration, especially relative to social environment. We hypothesized that social environment, in the form of competitive settings, can influence the developmental pathways involving production of feather structural coloration. We experimentally assessed the impact of social environment upon body condition, molt and spectral properties of two types of structural color that compose the nuptial plumage in blue-black grassquits: black iridescent plumage and white underwing patches. We manipulated male social environment during nine months by keeping individuals in three treatments: (1) pairs; (2) all-male groups; and (3) male-female mixed groups. All morphological characters and spectral plumage measures varied significantly through time, but only acquisition of nuptial plumage coverage and nuptial plumage color were influenced by social environment. Compared with males in the paired treatment, those in treatments with multiple males molted into nuptial plumage faster and earlier, and their plumage was more UV-purple-shifted. Our results provide experimental evidence that social context strongly influences development and expression of structural plumage. These results emphasize the importance of long-term experimental studies to identify the phenotypic consequences of social dynamics relative to ornament expression.

Retrospective and observational study to assess the efficacy of citicoline in elderly patients suffering from stupor related to complex geriatric syndrome.

A significant percentage of elderly subjects (50%-80%) suffering from sub-acute ischemic cerebrovascular disease, with or without moderate or severe cognitive memory decline and with or without associated behavioral and psychological symptoms, shows a complex syndrome. This syndrome is related to the progressive impairment of health conditions and/or stressing events (ie, hospitalization), characterized by confusion and/or stupor, which are consequently difficult to manage and require a great deal of care. Geriatric patients often suffer from multiple chronic illnesses, may take numerous medications daily, exhibit clinical instability, and may experience worsening of medical conditions following cerebral ischemic events and thus have an increased risk of disability and mortality. There are several studies in literature which demonstrate the efficacy of citicoline, thanks to its neuroprotective function, for the recovery and in postischemic cerebral rehabilitation. It has been shown that, even soon after an ischemic stroke, administration of oral citicoline (500-4000 mg/day) improves the general conditions evaluated with the Rankin scale and the National Institute of Health Stroke Scale 12. In particular, it has been shown that the CDP-choline improves the cognitive and mental performance in Alzheimer's dementia and vascular dementia. We have evaluated the administration of citicoline in geriatric patients following a protocol of intravenous study on improvement of individual performances.

Brugada syndrome (BS) and syncope: a complex therapeutic issue.

A 66 year-old man was brought to the emergency room (ER) for syncope and sphincter incontinence; syncope duration was about 15 min. Similar short duration episodes had been referred by his relatives during the last months, following small traumas; no seizures had been registered. Patient told he was affected with BS, having already been diagnosed 5 years before, after performing an electrocardiogram (ECG) highly suggestive for it. He had performed an electrophysiologic study, which had not shown any sustained ventricular arrhythmias after scheduled stimulation. This finding together to the lack of symptoms had suggested a conservative treatment, notwithstanding that familiar history documented his father's sudden death. Patient was also affected with hypertension and gastroesophageal reflux disease. Clinical examination did not suggest any significant findings. Laboratory tests, supra aortic Doppler ultrasound, electroencephalogram (EEG) and brain CT were normal. ECG showed sinus rhythm with a heart frequency of 82 bpm, QRS axis was normal, as well as atrioventricular conduction. ST coved-type elevation with right bundle branch block pattern and repolarization abnormalities were found. Holter ECG and Doppler echocardiography were also performed. The onset of syncope in presence of BS suggested the evaluation of this case report together with electrophysiolgists and neurologists. Therefore, an implantable cardioverter defibrillator (ICD) was implanted through left subclavian vein. He was discharged eight days after hospitalization, diagnosis was "Syncope in patient affected with BS, hypertension". Arrhythmogenic risk stratification is necessary; the indication for implanting this device is obvious in symptomatic patients, whereas it is controversial in patients presenting only ECG patterns of BS. In conclusion, the above mentioned case report rises remarkable diagnostic and therapeutic issues. The finding of BS in a patient with syncope indicates the opportunity of implanting a defibrillator and only clinical experience and common opinions may help doctors in taking the most appropriated, often difficult, decisions.

Social environment affects testosterone level in captive male blue-black grassquits.

The challenge hypothesis proposes that testosterone (T) elevation above what is needed for breeding is associated with social factors, and males possibly modulate their hormonal response to variations in population density and sex ratio. We investigated the role of social environment in altering testosterone levels and aggression in a tropical, seasonally breeding grassquit (Volatinia jacarina). We exposed males to three social conditions during 1 year: all-males treatment (six males), mixed treatment (three males-three females), and paired treatment (one male-one female). We quantified aggressiveness among males and T plasma concentration for each individual in each treatment monthly. We found that more aggressive interactions occurred in the all-males treatment than in the mixed treatment. The data also revealed that, coincident with these behavioral changes, the patterns of T variation through time in each treatment were markedly different. The all-males treatment exhibited an early increase in T concentration, which was sustained for a lengthy period with two distinctive peaks, and subsequently declined sharply. The mixed treatment presented an intermediate pattern, with more gradual increase and decrease in T levels. At the other extreme, the paired treatment presented a later rise in T concentration. We conclude that the more competitive environment, with higher density of males, caused the early and higher elevation in T level, thus the presence of competitors may influence the decision of how much a male should invest in reproduction. We suggest that the male's perception of his social environment ultimately mediates hormonal production and alters his reproductive strategy.

Laxative-induced rhabdomyolysis.

The present study describes a case of laxative-induced rhabdomyolysis in an elderly patient. An 87-year-old woman was hospitalized for the onset of confusion, tremors, an inability to walk, and a fever that she had been experiencing for 36 hours. She often took high dosages of lactulose and sorbitol syrup as a laxative (about 70 g/day). During her physical examination, the patient was confused, drowsy, and she presented hyposthenia in her upper and lower limbs, symmetric and diffuse moderate hyporeflexia, and her temperature was 37.8 degrees C. Laboratory tests revealed severe hyponatremia with hypokalemia, hypocalcemia, hypochloremia, and metabolic alkalosis. Moreover, rhabdomyolysis markers were found. The correction of hydroelectrolytic imbalances with saline, potassium and sodium chlorure, calcium gluconate was the first treatment. During her hospitalization the patient presented acute delirium, treated with haloperidol and prometazine chloridrate intramuscularly. She was discharged 12 days later, after resolution of symptoms, and normalized laboratory tests. Over-the-counter drugs such as laxatives are usually not considered dangerous; on the other hand, they may cause serum electrolytic imbalance and rhabdomyolysis. A careful monitoring of all the drugs taken by the elderly is one of the most important duties of a physician since drug interactions and their secondary effects may be fatal.