CRISP: An Inpatient Pediatric Curriculum for Family Medicine Residents Using Clinical Reasoning and Illness Scripts.

Introduction: Clinical reasoning enables safe patient care and is an important competency in medical education but can be challenging to teach. Illness scripts facilitate clinical reasoning but have not been used to create pediatric curricula. Methods: We created CRISP (Clinical Reasoning with Illness Scripts in Pediatrics), a curriculum comprising four 1-hour learning sessions that deliberately incorporated clinical reasoning concepts and illness scripts to organize how four common chief complaints were taught to family medicine residents on inpatient pediatric rotations. We performed a multisite curriculum evaluation project over 6 months with family medicine residents at four institutions to assess whether the use of clinical reasoning concepts to structure CRISP was feasible and acceptable for learners and instructors and whether the use of illness scripts increased knowledge of four common pediatric chief complaints. Results: For all learning sessions, family medicine residents and pediatric hospitalists agreed that CRISP's format was preferable to traditional didactic lectures. Pre-/posttest scores showed statistically significant increases in family medicine resident knowledge (respiratory distress [n = 42]: pretest, 72%, posttest, 92%; abdominal pain [n = 44]: pretest, 82%, posttest, 96%; acute febrile limp [n = 44]: pretest, 68%, posttest, 81%; well-appearing febrile infant [n = 42]: pretest, 58%, posttest, 73%; ps < .05). Discussion: By using clinical reasoning concepts and illness script comparison to structure a pediatric curriculum, CRISP represents a novel instructional approach that can be used by pediatric hospitalists to increase family medicine resident knowledge about diagnoses associated with common pediatric chief complaints.

Implementation of a multidisciplinary discharge videoconference for children with medical complexity: a pilot study.

BACKGROUND: The hospital to home transition for children with medical complexity (CMC) poses many challenges, including suboptimal communication between the hospital and medical home. Our objective was to evaluate the implementation of a discharge videoconference incorporating the patient, caregiver, primary care provider (PCP), hospitalist physician, and case manager. METHODS: We evaluated implementation of this pilot intervention at a freestanding tertiary care children's hospital using mixed methods. A discharge videoconference was conducted for hospitalized children (< 18 years old) meeting complex chronic disease (C-CD) criteria. We collected field notes and conducted surveys and semi-structured interviews. Outcomes included adoption, cost, acceptability, feasibility, and appropriateness. Adoption, cost, and acceptability were analyzed using descriptive statistics. Acceptability, feasibility, and appropriateness were summarized using thematic content analysis. RESULTS: Adoption: A total of 4 CMC (9% of the 44 eligible children) had discharge videoconferences conducted. Cost (in provider time): On average, videoconferences took 5 min to schedule and lasted 21.5 min. Acceptability: All hospitalists involved (n = 4) were very likely to participate again. Interviews with caregivers (n = 4) and PCPs (n = 5) demonstrated that for those participating, videoconferences were acceptable and appropriate due to benefits including development of a shared understanding, remote physical assessment by the PCP, transparency, and humanization of the care handoff, and increased PCP comfort with care of CMC. Feasibility: Barriers included internet connection quality and scheduling constraints. CONCLUSIONS: This novel, visual approach to discharge communication for CMC had low adoption, possibly related to recruitment strategy. The videoconference posed low time burdens, and participating physicians and caregivers found them acceptable due to a variety of benefits. We identified several feasibility barriers that could be targeted in future implementation efforts.

Association between p53 protein phosphorylated at serine 20 expression and ovarian carcinoma stem cells phenotype: correlation with clinicopathological parameters of ovarian cancer.

Biological behavior of ovarian carcinomas might be the result of cellular diversity existing in tumor tissue, which consists of differentiated and undifferentiated cells showing stem cells biological properties and function. We examined correlation between p53 protein phosphorylated at serine 20 (p-p53(Ser20)) and CD133, SOX2, Notch1 expression, in order to reveal p-p53(Ser20) stemness function in ovarian cancer. p-p53(Ser20), CD133, Notch1, SOX2 expression was analyzed on 104 ovarian carcinomas using immunohistochemical staining. The positive correlation between p53 and p-p53(Ser20) (p=0.02), p53 and SOX2 (p=0.02), p-p53(Ser20) and Notch1 (p=0.03), p-p53(Ser20) and CD133 (p=0.01) expression was observed in ovarian carcinomas. The parallel expression of p-p53(Ser20)/CD133, p-p53(Ser20)/Notch1 reflecting co-expression of these proteins in single carcinoma cell, and p-p53(Ser20)/SOX2 expression was associated with advanced stage and p-p53(Ser20)/Notch1, p53/SOX2, p-p53(Ser20)/SOX2 parallel expression correlated with high tumor grade. The correlation between p-p53(Ser20) and CD133, Notch1, SOX2 expression and clinical parameters indicate, that malignancy and biological behavior of ovarian carcinomas depend on interaction between p-p53(Ser20) and carcinoma stem cells biomarkers expression.

Mental health and quality-of-life concerns related to the burden of food allergy.

As food allergy increases, more research is devoted to its influence on patient and family mental health and quality of life (QoL). This article discusses the effects on parent and child QoL, as well as distress, while appraising the limitations of knowledge given the methods used. Topics include whether QoL and distress are affected compared with other illnesses, assessment of distress and QoL in parents compared with children, concerns about food allergy-related bullying, and the necessity for evidence-based interventions. Suggestions are offered for how to improve QoL and reduce distress on the way to better coping with food allergy.

Child and parental reports of bullying in a consecutive sample of children with food allergy.

OBJECTIVE: The social vulnerability that is associated with food allergy (FA) might predispose children with FA to bullying and harassment. This study sought to quantify the extent, methods, and correlates of bullying in a cohort of food-allergic children. METHODS: Patient and parent (83.6% mothers) pairs were consecutively recruited during allergy clinic visits to independently answer questionnaires. Bullying due to FA or for any cause, quality of life (QoL), and distress in both the child and parent were evaluated via questionnaires. RESULTS: Of 251 families who completed the surveys, 45.4% of the children and 36.3% of their parents indicated that the child had been bullied or harassed for any reason, and 31.5% of the children and 24.7% of the parents reported bullying specifically due to FA, frequently including threats with foods, primarily by classmates. Bullying was significantly associated with decreased QoL and increased distress in parents and children, independent of the reported severity of the allergy. A greater frequency of bullying was related to poorer QoL. Parents knew about the child-reported bullying in only 52.1% of the cases. Parental knowledge of bullying was associated with better QoL and less distress in the bullied children. CONCLUSIONS: Bullying is common in food-allergic children. It is associated with lower QoL and distress in children and their parents. Half of the bullying cases remain unknown to parents. When parents are aware of the bullying, the child's QoL is better. It is important to proactively identify and address cases in this population.

Anatomical analysis of preangular mandibular notch in humans.

The authors have analysed in detail the mandibular preangular notch on the basis of 273 human cadaver mandibles. They have revealed that the pregonial notch is present in almost 90% of cases and that it is generally asymmetric and elliptical in shape. The depth and length of the anterior part of the notch is greater in males. Moreover, the preangular notch depth is greater on the right side (regardless of sex). Knowledge of the preangular notch anatomy can be useful for surgeons during reconstructive and plastic procedures on the mandibular shaft.

Altered microRNA expression in mycosis fungoides.

BACKGROUND: MicroRNAs are small noncoding RNA molecules involved in the regulation of various physiological and pathological processes. Altered expression of different microRNAs has been observed in both solid tumours and haematological malignancies. OBJECTIVES: To investigate expression of several microRNAs in early and advanced mycosis fungoides (MF). METHODS: Biopsies were obtained from 43 patients with MF (18 early MF and 25 advanced MF) and 23 healthy volunteers. After microRNA isolation, reverse transcriptase reactions were performed, followed by cDNA amplification. The following microRNAs were analysed: miR-15a, miR-16, miR-155, let-7a, let-7d and let-7f. The relative amount of each microRNA was normalized according to the reference RNU48 level. RESULTS: Among the microRNAs studied, only MiR-155 was found to be slightly overexpressed in MF compared with healthy controls. Early MF showed a higher level of all analysed microRNAs after normalization against RNU48 level. Furthermore, metastatic MF demonstrated lower concentrations of let-7a, let-7d and let-7f when compared with MF limited to the skin. The univariate survival analysis and multivariate Cox's regression model revealed that the level of let-7a expression was an independent prognostic indicator. CONCLUSIONS: Altered expression of studied microRNAs and the differences between early and advanced MF may suggest that microRNAs play a significant role in MF pathogenesis. It seems that microRNAs could serve as potential therapeutic targets in the future.

Different patterns of activation markers expression and CD4+ T-cell responses to ex vivo stimulation in patients with clinically quiescent multiple sclerosis (MS).

Patients with relapsing-remitting (RR) and secondary progressive (SP) forms of multiple sclerosis (MS), although in long-term clinical remission, showed different patterns of increased expressions of the activation markers: CD69, CD40L, and both membrane/surface and cytoplasmic CTLA-4 (mCTLA-4 and cCTLA-4, respectively) in freshly isolated peripheral blood (PB) CD4+ T cells compared with controls. Also observed were dysregulated responses to ex vivo stimulation in both groups of MS patients accompanied by increased IFN-gamma synthesis. Our findings may suggest that the mechanisms leading to each clinical form of the disease may be heterogeneous.

Progression of multiple sclerosis is associated with exon 1 CTLA-4 gene polymorphism.

OBJECTIVES: Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system which is widely believed to have a T-cell-mediated etiology. The cytotoxic T-lymphocyte antigen-4 (CTLA-4) antigen molecule plays a key role in the downregulation of T-cell responses. To examine the genetic association of the CTLA-4 gene locus with MS, we analyzed an exon 1 (A49G) transition. MATERIAL AND METHODS: One hundred and fifty-two MS patients and 154 controls were examined. The A/G transition was genotyped by a polymerase chain reaction followed by labeling with a SNaPshot kit and detection using a capillary genetic analyzer. RESULTS: The genotype, allele and phenotype frequencies did not differ significantly between MS patients and controls. Those MS patients with AA and AG genotypes had 4.36 times greater risk of progressing from the relapsing-remitting to the secondary progressive form of the disease than those with the GG genotype. CONCLUSION: The results of our study indicate that CTLA-4 (A49G) exon 1 polymorphism is associated with MS progression.

Activity of cysteine protease inhibitors in human brain tumors.

BACKGROUND: Cysteine proteases (mainly cathepsins B and L) are thought to play an important role in the progress of cancer, including brain tumors. Together with other proteases, they hydrolyze the extracellular matrix and basement membrane proteins, thus enabling the tumor to grow and spread. Therefore cysteine protease inhibitors are regarded as protective factors, able to prevent tumor growth and dissemination. MATERIAL AND METHODS: In this study, the activity of cysteine protease inhibitors (CPIs) was investigated in material derived from patients with brain tumors (astrocytoma and meningioma). The activity of CPIs was measured as antipapain activity in tissue homogenates, cerebrospinal fluid, and serum, with N-benzoyl-DL-arginine-2-naphthylamide hydrochloride (BANA) as a substrate, according to Barret's method. RESULTS: Tumorous tissues showed higher activity of cysteine protease inhibitors than control tissues, but this difference proved to be statistically insignificant. The activity of CPIs was lower in cerebrospinal fluid and serum from patients with brain tumors. CONCLUSIONS: The activity of CPIs measured in brain tumor tissue cannot be taken as a marker of any type of tumor, whereas CPI activity in cerebrospinal fluid and serum may be considered a marker of meningioma. In meningioma patients the level of CPIs may be too low to prevent the host tissues from the growing tumor.

Plasma proteinase inhibitor activity and hemostasis tests in children with nephrotic syndrome. Effect of prednisone alone and prednisone plus epsilon-aminocaproic acid treatment regimens: a preliminary report.

Neutrophil-derived proteinases cause glomerular injury by proteolysis of the glomerular basement membrane and alterations in glomerular metabolism. Recently, a marked elevation of the plasma elastase complex with alpha1-proteinase inhibitor (alpha 1-PI) both in the acute phase and during remission of nephrotic syndrome (NS) compared with age-matched controls was reported. In experimental immune-mediated glomerulonephritis epsilon-aminocaproic acid (EACA) significantly reduced albuminuria, and it was suggested that this may be linked with the antiproteolytic activity of the drug. We studied plasma antithrombin III (AT-III), alpha 1-PI, alpha 2-antiplasmin (alpha 2-A), alpha 2-macroglobulin (alpha 2-M) activity, and some blood coagulation and fibrinolysis tests in children with frequently relapsing prednisone-responsive NS. Also, the effect of prednisone alone (Group I, n = 9) and prednisone plus EACA (Group II, n = 10) treatment regimens on the studied parameters was estimated. All investigations were performed on admission to the hospital and after approximately 13 days of prednisone alone therapy (Group I), as well as before the administration of prednisone plus EACA and 24 hours after the last dose of EACA, ie, after approximately 5 days of treatment (Group II). Prednisone was administered at the usual dose of approximately 2 mg/kg/d and EACA was given orally at the doses of 72 to 230 mg/kg of body weight per day for 3 to 10 days. In the acute phase of disease, NS patients (n = 19) were shown to have a statistically significant decrease of plasma AT-III (16.4 +/- 4.7 vs. 21.9 +/- 2.5 IU/mL) and alpha 1-PI (1.28 +/- 0.6 vs. 1.97 +/- 0.34 IU/mL) activity, as well as a marked increase in plasma alpha 2-M activity (14.96 +/- 5.81 vs. 9.6 +/- 1.6 IU/mL), and fibrinogen concentration (5.51 +/- 1.78 vs. 2.96 +/- 0.34 g/L) compared to the age-matched controls; no significant changes in plasma alpha 2-A activity, plasminogen concentration, euglobulin clot lysis time, activated partial thromboplastin time (APTT), or thromboplastin time were noted. In children treated with prednisone alone, a marked increase in plasma AT-III (by 76%, P < 0.001) and alpha 2-A (36%, P < 0.019) activity, and a significant decrease of the plasma fibrinogen concentration (6.07 +/- 1.66 vs. 3.17 +/- 1.64 g/L, P < 0.001), and APTT (45.1 +/- 7.6 vs. 33.8 +/- 4.4 s, P < 0.001) were found. Prednisone plus EACA therapy resulted in a significant increase in plasma AT-III activity (by 53%, P < 0.003), whereas plasma fibrinogen concentration and APTT remained unchanged. However, statistically significant differences between the pre- and posttreatment plasma AT-III, alpha 1-PI, and alpha 2-A activities in these patients were observed. There was also a relationship between EACA dose and the percentage change in plasma alpha 2-A activity. In a few patients receiving prednisone plus EACA regimen, side effects that included purulent rhinitis, pharyngitis, increases in body temperature, loose stools, and an approximately 20% to 30% decrease in systolic and diastolic arterial blood pressure were observed. Thus, although the prednisone plus EACA treatment regimen seems to offer new therapeutic possibilities in some patients with NS, it should not be used in acute phase of the disease.

Expression and mutation of p53 in tumor effusion cells of patients with ovarian carcinoma: response to cisplatin-based chemotherapy.

p53 alterations are considered as one of the most important factors responsible for drug resistance in ovarian carcinomas, although the relationship between p53 gene status and response to cisplatin-based chemotherapy in ovarian cancer patients remains unclear. The aim of the study was to evaluate the relationship between p53 protein accumulation, p53 gene mutation and response to cisplatin-based chemotherapy in patients with ovarian carcinoma considering conventional clinicopathological parameters. Tissue sections and corresponding cyst and/or ascitic fluid cells from 79 patients with epithelial ovarian cancer were analyzed immunohistochemically for p53 expression. The PCR-SSCP analysis was performed in 25 cases and the results were compared with immunohistochemical data. It was demonstrated that p53 expression reaching approximately 50% of positive cells in immunostaining was usually associated with PCR-amplified exons showing abnormal migration and suspected for mutation. p53 gene changes were not correlated with histological structure, grade of differentiation or residual tumor after cytoreductive surgery, despite being detected more frequently in III/IV than in II FIGO stages and in patients with residual disease above 2 cm. A significant correlation between p53 accumulation and p53 gene alteration and poor response to cisplatin-based chemotherapy was shown. The overall survival time of patients decreased with an increase in p53 protein expression. A strong p53 expression especially accompanied by p53 changes detectable by PCR-SSCP analysis appears to be a good indicator of the resistance to cisplatin-based chemotherapy. The association between strong p53 overexpression and shorter overall survival time was also revealed.

[The analysis of sodium, potassium and calcium concentration in myomas, myometrium and peripheral blood]. / Analiza zawartosci sodu, potasu i wapnia w miesniakach i miesniu trzonu macicy oraz w pelnej krwi zylnej.

We have examined the concentration of sodium and potassium in myomas, myometrium and peripheral blood of 55 women and in 69 women calcium was examined. The levels of these elements were correlated to the phase of the menstrual cycle. The sodium concentration is similar in the examined tissues in both phases. The potassium concentration is significantly higher in myomas and myometrium in comparison with the peripheral blood in both phases of the menstrual cycle. The calcium concentration is significantly lower in myomas and myometrium during the proliferation and significantly lower in the myomas comparing to the myometrium and peripheral blood in the secretion. Concerning the differences between two phases of the cycle we observed that the level of the potassium is significantly lower in the myomas in the proliferative phase but the the level of the sodium is higher in the secretory phase.

Glutathione S-transferase M1 genotype influences sister chromatid exchange induction but not adaptive response in human lymphocytes treated with 1,2-epoxy-3-butene.

Induction of sister chromatid exchanges (SCEs) by 1,2-epoxy-3-butene (monoepoxybutene, MEB), an epoxide metabolite of 1,3-butadiene, in human whole-blood lymphocyte cultures has previously been observed to depend on the glutathione S-transferase M1 (GSTM1) and T1 (GSTT1) genotype of the blood donor. Pretreatment of lymphocyte cultures with a low dose of MEB has been shown to reduce the SCE response obtained by later treatment with a higher concentration of MEB. To investigate whether this adaptive response depends on the GSTM1 genotype of the donor, SCE induction by MEB (25 and 250 microM at 48 h for 24 h) was studied from whole-blood lymphocyte cultures of young non-smoking male and female subjects representing GSTM1 positive (n=7) and null (n=7) genotypes, with or without a MEB pretreatment (12.5 microM at 24 h). A higher mean number of induced SCEs per cell at 250 microM MEB was observed in lymphocytes of the GSTM1 null than positive donors, a statistically significant difference being obtained in the presence of the adaptive treatment (9.44 vs. 6.56; results from ethanol-treated controls subtracted). The pretreatment resulted in a statistically significant reduction in the response of the GSTM1 null group at both concentrations of MEB and in the GSTM1 positive group at 250 microM. However, there were no statistically significant differences in the adaptive response of the two genotypes. In conclusion, the present study further supported earlier findings on an increased sensitivity of GSTM1 null donors to SCE induction by MEB, suggesting that GSTM1 is involved in the detoxification of MEB in human lymphocyte cultures. As an adaptive response was observed in both GSTM1 positive and null donors, the phenomenon cannot be explained by GSTM1 induction. It may represent induction of other enzymes operating in MEB detoxification, or activation of DNA repair.

Mandible measurements in aspect of some muscles attachment.

The paper deals with a part of anatomical research in aspect of clinical evaluation of lowering mandible muscles attachments (mylohyoid m, digastric m, geniohyoid m.) and genioglossus muscle. The research was conducted on 183 adult males and 117 females crania. The variance analysis of Tukey's revealed, that crania traits established on the basis of statistical parameters of breadth-length index, and visceral cranium height-breadth index, are significant. In order to establish statistical characteristics of examined traits, including into research sexual dimorphism and bilateral differences is also very important.