The Enneagram and its application in medical education.

Personality testing has become increasingly popular in healthcare with multiple modalities and implementations. Although personality testing has been utilized to inform various facets of graduate medical education, little is known about how the Enneagram can be utilized throughout postgraduate training. This narrative review explores the use of personality testing in graduate medical education, how personality testing has been used in the workplace, what research is available showing its use in medical residencies, and the need for additional studies on the Enneagram's use in these areas. We conclude the Enneagram may serve as a valuable tool that can be used in postgraduate medical education to improve learning, interpersonal relationships, and teaming.

Associations between maternal inflammation during pregnancy and infant birth outcomes in the Seychelles Child Development Study.

PROBLEM: Markers of maternal inflammation may determine infant birth outcomes. METHOD OF STUDY: Maternal serum samples were collected at 28 weeks gestation (n = 1418) in the Seychelles Child Development Study Nutrition Cohort 2 and analyzed for immune markers by MSD multiplex assay, including cytokines from the Th1 (IFN-γ, IL-1ß, IL-2 and TNF-α) and Th2 (IL-4, IL-5, IL-10) subsets, with IL-6, MCP-1, TARC, sFlt-1 and VEGF-D. Associations of log-transformed immune markers with birthweight, length, head circumference and gestational age were assessed by multiple linear regression models, which were adjusted for maternal age, BMI, parity, child sex, gestational age and socioeconomic status. RESULTS: Neither total Th1, Th2 nor Th1:Th2 were significantly associated with any birth outcome. However, the angiogenesis marker VEGF-D was predictive of a lower birthweight, (ß = -0.058, P = 0.017) and birth length (ß = -0.088, P = 0.001) after adjusting for covariates. Higher concentrations of CRP were predictive of a lower birthweight (ß = -0.057, P = 0.023) and IL-2 (ß = 0.073, P = 0.009) and the chemokine MCP-1 (ß = 0.067, P = 0.016) were predictive of a longer gestational age. CONCLUSIONS: In our cohort of healthy pregnant women, we found no evidence for associations between the Th1 or Th2 inflammatory markers with birth outcomes. However, VEGF-D and CRP appear to predict lower birthweight and IL-2 and MCP-1 a longer gestation. Greater understanding is required of the variation in these immune markers at different gestational stages, as well as the factors which may regulate their balance in healthy pregnancy. n = 233.

Estimating the burden on general practitioner services in England from increases in respiratory disease associated with seasonal respiratory pathogen activity.

Understanding the burden of respiratory pathogens on health care is key to improving public health emergency response and interventions. In temperate regions, there is a large seasonal rise in influenza and other respiratory pathogens. We have examined the associations between individual pathogens and reported respiratory tract infections to estimate attributable burden. We used multiple linear regression to model the relationship between doctor consultation data and laboratory samples from week 3 2011 until week 37 2015. We fitted separate models for consultation data with in-hours and out-of-hours doctor services, stratified by different age bands. The best fitting all ages models (R2 > 80%) for consultation data resulted in the greatest burden being associated with influenza followed by respiratory syncytial virus (RSV). For models of adult age bands, there were significant associations between consultation data and invasive Streptococcus pneumoniae. There were also smaller numbers of consultations significantly associated with rhinovirus, parainfluenza, and human metapneumovirus. We estimate that a general practice with 10 000 patients would have seen an additional 18 respiratory tract infection consultations per winter week of which six had influenza and four had RSV. Our results are important for the planning of health care services to minimise the impact of winter pressures. •Respiratory pathogen incidence explains over 80% of seasonal variation in respiratory consultation data.•Influenza and RSV are associated with the biggest seasonal rises in respiratory consultation counts.•A third of consultation counts associated with respiratory pathogens were due to influenza.

ReaxFF molecular dynamics simulations on lithiated sulfur cathode materials.

Sulfur is a very promising cathode material for rechargeable energy storage devices. However, sulfur cathodes undergo a noticeable volume variation upon cycling, which induces mechanical stress. In spite of intensive investigation of the electrochemical behavior of the lithiated sulfur compounds, their mechanical properties are not very well understood. In order to fill this gap, we developed a ReaxFF interatomic potential to describe Li-S interactions and performed molecular dynamics (MD) simulations to study the structural, mechanical, and kinetic behavior of the amorphous lithiated sulfur (a-LixS) compounds. We examined the effect of lithiation on material properties such as ultimate strength, yield strength, and Young's modulus. Our results suggest that with increasing lithium content, the strength of lithiated sulfur compounds improves, although this increment is not linear with lithiation. The diffusion coefficients of both lithium and sulfur were computed for the a-LixS system at various stages of Li-loading. A grand canonical Monte Carlo (GCMC) scheme was used to calculate the open circuit voltage profile during cell discharge. The Li-S binary phase diagram was constructed using genetic algorithm based tools. Overall, these simulation results provide insight into the behavior of sulfur based cathode materials that are needed for developing lithium-sulfur batteries.

Prenatal methyl mercury exposure in relation to neurodevelopment and behavior at 19 years of age in the Seychelles Child Development Study.

BACKGROUND: Fish are important sources of protein and contain a variety of nutrients, such as n-3 long-chain polyunsaturated fatty acids (PUFA), essential for normal brain development. Nevertheless, all fish also contain methyl mercury (MeHg), a known neurotoxicant in adequate dosage. Our studies of the Seychelles Child Development Study (SCDS) Main Cohort enrolled in 1989-1990 (n=779) have found no consistent pattern of adverse MeHg effects at exposures achieved by daily fish consumption. Rather, we have observed evidence of improved performance on some cognitive endpoints as prenatal MeHg exposure increases in the range studied. These observations cannot be related to MeHg and may reflect the role of unmeasured covariates such as essential nutrients present in fish. To determine if these associations persist into young adulthood, we examined the relationship between prenatal MeHg exposure, recent PUFA exposure and subjects' neurodevelopment and behavior at 19 years of age. METHODS: We examined 533 participants using the following test battery: the Profile of Mood States-Bipolar (POMS-Bi); Finger Tapping; Kaufman Brief Intelligence Test (K-BIT); measures of Fine Motor Control and Complex Perceptual Motor Control; and Visual Spatial Contrast Sensitivity. We collected the following covariates: maternal IQ, family life course stressors, socioeconomic status, and subjects' recent postnatal MeHg, sex, and computer use. Primary analyses (based on N=392-475) examined covariate-adjusted associations in multiple linear regression models with prenatal MeHg as the primary exposure measure. Secondary analyses additionally adjusted for total n-6 and fish-related n-3 PUFA measured in the subjects' serum at the 19-year examination. RESULTS: Study participants had a mean prenatal MeHg exposure of 6.9 ppm, and a mean recent postnatal exposure of 10.3 ppm. There were no adverse associations between prenatal MeHg and any of the measured endpoints. For recent postnatal MeHg exposure, however, adverse associations were observed for Finger Tapping (non-dominant hand) among women and for the K-BIT Matrices for both sexes, with or without adjustment for PUFA. CONCLUSION: Our findings continue to provide no evidence for an adverse effect of prenatal MeHg exposure on development in a cohort that consumes fish daily. Observations for postnatal MeHg exposure will need to be confirmed using more comprehensive exposure measures.

Developing a new syndromic surveillance system for the London 2012 Olympic and Paralympic Games.

Syndromic surveillance is vital for monitoring public health during mass gatherings. The London 2012 Olympic and Paralympic Games represents a major challenge to health protection services and community surveillance. In response to this challenge the Health Protection Agency has developed a new syndromic surveillance system that monitors daily general practitioner out-of-hours and unscheduled care attendances. This new national system will fill a gap identified in the existing general practice-based syndromic surveillance systems by providing surveillance capability of general practice activity during evenings/nights, over weekends and public holidays. The system will complement and supplement the existing tele-health phone line, general practitioner and emergency department syndromic surveillance systems. This new national system will contribute to improving public health reassurance, especially to meet the challenges of the London 2012 Olympic and Paralympic Games.

Topological constraints on magnetic relaxation.

The final state of turbulent magnetic relaxation in a reversed field pinch is well explained by Taylor's hypothesis. However, recent resistive-magnetohydrodynamic simulations of the relaxation of braided solar coronal loops have led to relaxed fields far from the Taylor state, despite the conservation of helicity. We point out the existence of an additional topological invariant in any flux tube with a nonzero field: the topological degree of the field line mapping. We conjecture that this constrains the relaxation, explaining why only one of three example simulations reaches the Taylor state.

Flexible dosing of adjunctive zonisamide in the treatment of adult partial-onset seizures: a non-comparative, open-label study (ZEUS).

OBJECTIVES: To assess the efficacy and tolerability of zonisamide in a study allowing flexible dosing in a more diverse and less refractory population than assessed in randomized controlled trials. METHODS: This 19-week, non-comparative study of adjunctive zonisamide included 281 adults who had at least four partial-onset seizures within 8 weeks on one or two antiepileptic drugs. Alterations to zonisamide doses were allowed after titration, except during two fixed-dose periods (weeks 10-13 and 16-19). RESULTS: At the end of the second fixed-dose period (median dose 300 mg/day), the median reduction in monthly seizure frequency was 33.3-41.1%; > or =50% responder rate was 40.9-44.2%; and seizure freedom rate was 15.0-15.9%, depending on the analysis used. The most common adverse events were fatigue (16.7%) and somnolence (15.3%). CONCLUSIONS: Zonisamide demonstrated efficacy in a setting more reflective of clinical practice and was generally well tolerated.

Long-term safety and efficacy of zonisamide in patients with refractory partial-onset epilepsy.

OBJECTIVES: To investigate whether zonisamide remains effective and well tolerated in the treatment of refractory partial epilepsy during long-term treatment and with flexible dosing in clinical practice. MATERIALS AND METHODS: Patients with refractory partial epilepsy who completed a fixed-dose, randomized, double-blind clinical trial were recruited in an open-label extension study with adjustment of zonisamide and other antiepileptic drug dosage according to the treating physician's usual clinical practice. RESULTS: An intention-to-treat analysis of 317 patients showed that zonisamide was well tolerated with a predictable safety profile. Patient retention rates at 1, 2 and 3 years were 65.3%, 44.5% and 28.8%, respectively. Zonisamide treatment was associated with a maintained reduction in seizure frequency, with some patients achieving prolonged periods of seizure freedom. CONCLUSIONS: Flexible dosing with zonisamide demonstrated a good safety profile and sustained efficacy in the long-term adjunctive treatment of refractory partial epilepsy.

Altered venous function and deep venous thrombosis following proximal femoral fracture.

The effect of surgery for femoral neck fracture on lower limb venous blood flow and its relationship to deep vein thrombosis was investigated in 179 patients. Blood flow was measured using strain gauge plethysmography before surgery, in the 1st week after surgery, and at 6 week review. There was a significant reduction in both venous outflow and venous capacitance, affecting both fractured and non-fractured legs but significantly greater in the fractured leg. Venous function remained significantly impaired in both lower limbs 6 weeks after surgery. There was a significant correlation between the reduction in venous function and the development of deep vein thrombosis.

Changes in coagulability as measured by thrombelastography following surgery for proximal femoral fracture.

The effect of surgery for femoral neck fracture on whole blood coagulation and the relationship of altered coagulation to deep venous thrombosis were investigated in 250 patients. Whole blood coagulation was measured using thrombelastography preoperatively, in the early postoperative period and at 6-week review. Significant hypercoagulability was demonstrated after surgery and persisted to 6-week review. A significant correlation between hypercoagulability and the development of deep venous thrombosis is demonstrated. Hypercoagulability is shown to be a major factor in thrombosis formation following proximal femoral neck fracture surgery.

Significant extracranial carotid stenosis: detection on routine cerebral MR images.

Severe stenosis of the cervical internal carotid artery was detected on magnetic resonance images in three patients from a series of eight with abnormality of flow. In contrast to complete loss of "flow void" in the horizontal carotid within the petrous bone seen in patients with complete occlusion, these three patients had partial flow void in which there was a central area of signal void in the artery, surrounded by circumferential increase in signal in the outer third of the artery. This was seen on axial views at right angles to the long axis of the artery below the petrous bone and on "in-plane" sections through the horizontal carotid canal. An animal model with 70% and 90% carotid stenosis and carotid occlusion was created. The model with 70% stenosis showed no significant change. The 90% stenosis model showed partial flow void in the center of the lumen with peripheral signal exactly as seen in the human patients.

Adipose tissue in the filum terminale: a computed tomographic finding that may indicate tethering of the spinal cord.

Adipose tissue in the filum terminale is frequently associated with tethering of the spinal cord in patients with spina bifida occulta. We recently saw a patient with low back pain and no spina bifida occulta, in whom adipose tissue was noted in the area of the filum on an unenhanced computed tomographic (CT) scan. The patient had a tethered cord. This case suggested that, when CT scanning is done as the first imaging study in the evaluation of low back pain, fatty tissue in the area of the filum may be an indicator for tethering of the spinal cord. The present study was undertaken to determine the validity of using CT scan-detectable filal fat in the identification of possible tethered spinal cords among a group of patients experiencing low back pain. The presence of fat in the fila of 12 patients with the radiologically and histologically tethered cord syndrome was evaluated and the fila of 47 autopsied patients whose clinical history showed no back pain were examined histologically. There were accumulations of adipose tissue in the fila of 11 of the 12 (91%) patients with the tethered cord syndrome and in the fila of 9 of the 47 patients (17%) in the autopsy series. Of the 9 autopsy patients with fat in their fila, however only 3 patients (6%) exhibited collections of adipose tissue in the CT detection range (2 mm).(ABSTRACT TRUNCATED AT 250 WORDS)

Subcortical arteriosclerotic encephalopathy: brain stem findings with MR imaging.

Magnetic resonance images of 44 patients who had varying degrees of supratentorial signal abnormalities compatible with subcortical arteriosclerotic encephalopathy (SAE) were reviewed for posterior fossa findings. Brain stem lesions frequently accompanied supratentorial SAE and were seen as multiple, fairly symmetric areas of poorly defined, increased signal intensity on axial T2-weighted images. Involvement was generally confined to the central portions of the mid and upper pons. The typical appearance of brain stem involvement by SAE and its probable pathogenesis are reviewed.

Perineural tumor extension to the cavernous sinus from superficial facial carcinoma: CT manifestations.

The mechanism of cavernous sinus involvement by metastatic carcinoma from a facial primary tumor is poorly understood. The lack of lymphatic and obvious direct extension implicate either a vascular or perineural method of spread. The authors describe four patients who exhibited cavernous sinus metastases from facial carcinoma, all of whom experienced cranial nerve symptoms before the diagnosis of cavernous sinus involvement was made. Furthermore, the pathologic specimens from these patients exhibited extensive perineural involvement. The authors propose that the mechanism of metastasis in these patients is perineural extension.

Craniofacial mucormycosis: assessment with CT.

Computed tomographic (CT) scans of ten patients with rhinocerebral mucormycosis were reviewed. Early paranasal sinus involvement appeared as mucosal thickening on CT scans, usually without air/fluid levels. Recognition as mucormycosis was facilitated by knowledge of the clinical setting or by identification of invasive disease. Evidence of bone destruction on CT scans was seen in only two patients, was a late finding, and usually was absent despite deep extension of disease beyond the bony confines of the paranasal sinus. Five cases had intracranial involvement, either as fungal abscess or infarction. Intracranial mucormycosis usually involved the base of the brain and cerebellum following invasion of the infratemporal fossa or orbit. Intracerebral fungal abscess appeared as low-density masses on CT scans, with variable peripheral enhancement and little surrounding vasogenic edema. Identification of a rim of spared cortex was useful in distinguishing infection from bland infarct. Serial CT scans were also useful in assessing response to hyperbaric oxygen treatment, surgery, and chemotherapy.

Ventricular shunt therapy of the brain: long-term rubber-catheter-induced inflammation.

Three cases of catheter-induced inflammation are presented, two of which involved brain parenchyma and the ventricular system and one that involved the soft tissues of the scalp. All of the catheters were composed of natural rubber and had been in place for several years. Abnormalities seen on computed tomographic scans in these patients were variable but included mass effect, vasogenic edema, catheter destruction, calcification, and abnormal contrast enhancement of the parenchyma adjacent to the catheters. Certain features on the scans of the two patients with intracranial disease, however, were common to both cases, allowing the correct preoperative diagnosis to be made in the second patient encountered.

Intra-arterial digital subtraction angiography of the spinal cord.

Digital subtraction angiography (DSA) of the spinal cord was performed in 6 patients using selective intra-arterial injections of contrast material. Two arteriovenous malformations of the spinal cord, 1 dural fistula, and 1 case of multiple hemangioblastomas were studied. Contrast and spatial resolution were satisfactory for defining normal and abnormal vascularity while reducing examination time, contrast dosage, patient discomfort, and film cost. The only significant limitation was misregistration artifacts seen on lateral views encompassing the diaphragm.