A comprehensive approach to enhancing sexual health education in the Case Western Reserve University School of Medicine.

We report on the Sexual Health Curriculum Enhancement project at Case Western Reserve University School of Medicine. Using a US dollars 100000 grant from Pfizer Pharmaceuticals, Inc., we have developed and are in the process of implementing a comprehensive, cross-disciplinary and innovative curriculum that is based on three primary objectives for teaching sexual health: attitude change, behavior change, and knowledge acquisition. Five general strategies to incorporate specific sexual health content into the medical school curriculum have been implemented: (1). Faculty Development; (2). Additional Didactics; (3). Cased-Based Learning; (4). Testing and Assessment; and (5). Electronic (Computer/Web-Based Enhancements).

Manual differential cell counts help predict bacterial infection. A multivariate analysis.

We developed logistic regression models that combine information from the automated CBC and manual 100-cell differential counts to predict bacterial infection. The logistic models were fitted from a case group of 116 patients with proven bacterial infection and a control group of 930 presumably uninfected outpatients. A 4-variable, 15-parameter model, which includes automated absolute neutrophil, manual band, and manual immature granulocyte counts, performed best with a receiver operating characteristic (ROC) curve area of 89%. A more practical 2-variable model including automated absolute neutrophil and manual band counts performed almost as well with an ROC curve area of 86%. The automated neutrophil count-only model is less informative with an ROC curve area of 78%. The combined information from automated and manual differential cell counts more accurately predicts bacterial infection than automated counting alone. Despite these modest improvements, the high cost of manual differential cell counts dictates careful patient selection. The supplemental information gained from manual differential counts is most useful for patients with low to normal neutrophil counts (8,000/microL [8.0 x 10(9)/L] or less). Further studies are indicated to determine the characteristic patient populations deriving maximal benefit from this information.

Gynecomastia-like changes of the female breast.

OBJECTIVES: Gynecomastia-like changes of the female breast are only sparsely reported and are not well defined in the literature to our knowledge. Our objectives were to determine the incidence, clinical presentation, mammographic findings, and the medical background of patients with these changes. DESIGN: Two thousand seven hundred nine female breast surgical cases from 1995 to 1999 were searched by SNOMED. Three observers further reviewed all cases with gynecomastia-like changes. Strict criteria were developed and cases that fulfilled the criteria were analyzed further. RESULTS: We found the incidence of female gynecomastia-like changes to be 0.15% (4/2709) of all female breast lesions, which represents an underestimation. Patients were usually young and had an average age of 32 years. The usual clinical presentation was a palpable mass with a size ranging from about 3.5 x 2 x 2 cm to 5 x 4 x 2.5 cm. Mammography showed either negative findings or a nonspecific density. Gross examination of these specimens revealed no distinct lesions. Histologically, the lesions consisted of ductal hyperplasia with periductal stromal fibrosis or edema. They were associated with fibrocystic changes in the adjacent breast. The patients had no significant medical history. CONCLUSION: We propose that the gynecomastia-like change is a specific benign entity within the spectrum of benign fibrocystic changes and that it usually occurs in young patients.

Donor-recipient sharing of HLA class II alleles predicts earlier recurrence and accelerated progression of hepatitis C following liver transplantation.

Both direct viral cytopathic effects and host immune responses appear to be important in the pathogenesis of hepatitis C virus (HCV) infection. Liver transplantation provides a means to explore the role of the immune system in the development of HCV-related liver damage through comparing the natural history of HCV in patients with different degrees of donor-recipient human leukocyte antigen (HLA) matching. We evaluated 36 patients with recurrent hepatitis C viremia following liver transplantation to determine whether hepatocellular injury or progression to bridging fibrosis occur more rapidly when donor and recipients share HLA alleles. HLA typing for the HLA-A and HLA-B loci was performed by serological techniques and PCR-based oligotyping was used to type alleles of the DRB1, DRB3, DQA1, and DQB1 loci. A median of eight liver biopsies, obtained during a median follow-up of 36 months, were reviewed per patient. Donor-recipient sharing of alleles of HLA-DQB1 or DRB1 was associated with more rapid development of recurrent hepatitis by univariate analysis (chi2=5.7, P=0.02 and chi2=5.54, P=0.02 respectively). However, only sharing of HLA-DRB1 alleles was identified as an independent predictor of reduced time to recurrent histologic injury by multivariate analysis (chi2 =5.74, P=0.02). Furthermore, sharing of HLA-DRB3 and histologic evidence of rejection were associated with more rapid progression to bridging fibrosis both by univariate methods (chi2=4.12, P=0.04 and chi2=4.66, P=0.03 respectively), and by multivariate analysis (chi2=13.01, P=0.001). These findings suggest that HLA class II-restricted immune responses may contribute to the pathogenesis of HCV-related liver injury in liver transplant recipients.

Learning and teaching in dermatology. A practitioner's guide.

BACKGROUND: The explosion of medical knowledge, the influence of communications technology, and the pressures for health care reform challenge dermatologists to learn efficiently and teach effectively. OBSERVATIONS: The vast body of material on teaching and learning in the education literature contrasts sharply with the limited information on these topics in the dermatology literature. Gaining an understanding of these approaches to learning provides a foundation for the design of personal continuing medical education plans and lesson plans for students. Practical teaching skills are emphasized in this review. CONCLUSIONS: Learning and teaching skills can be improved through study. Successful teaching often produces positive feedback, which can lead to renewed enthusiasm for educating clinicians in the field of dermatology.

Therapeutic and neurotoxic effects of 2-chlorodeoxyadenosine in adults with acute myeloid leukemia.

Despite expectations that 2-chlorodeoxyadenosine (2-CdA) would prove active primarily in lymphoproliferative diseases, early reports suggested unexpected high activity of this drug in heavily pretreated children with acute myeloblastic leukemia (AML) at a maximally tolerated dose of 8.9 mg/m2/day for 5 days. In view of these findings, we conducted an escalating dose trial of 2-CdA in adult patients with relapsed or resistant AML. Thirty-six patients who had received extensive prior therapy were treated at 9 dose levels of 2-CdA at daily doses ranging from 5 to 21 mg/m2 for 5 days. 2-CdA eliminated leukemic blasts from the peripheral blood in 32 of 36 cases; however, bone marrow hypoplasia was seen only at daily dose levels > or = 15 mg/m2. We observed a total of 3 complete remissions: 1 at the 15 mg/m2/d dose level and 2 at the 21 mg/m2/d dose level; these responses persisted for 3, 2, and 3 months, respectively. Although prolonged myelosuppression would have been dose-limiting at 21 mg/m2/d for 5 days, the most important adverse effect was the development of a sensorimotor peripheral neuropathy. This reaction, whose onset was substantially delayed after completion of drug treatment, was observed in 2 of 5 patients at the 19 mg/m2/d level and in 4 of 4 evaluable patients at the 21 mg/m2/d level. Pathologically, this process was characterized by axonal degeneration and secondary demyelination. Other side effects included reactivation of a posttransplant Epstein-Barr virus-related lymphoma in 1 patient and tumor lysis syndrome. We conclude that the maximally tolerable dose of 2-CdA in adult patients (17 mg/m2/d for 5 days) in approximately twofold in excess of that previously reported in children and that the limiting toxic effect is a degenerative neuropathic disorder. We confirm that this drug has definite activity in AML, but the magnitude of this effect needs to be determined in larger numbers of patients who have received less extensive therapy. This agent deserves further evaluation in patients with both AML and acute lymphoblastic leukemia at these higher doses and perhaps as part of a preparative regimen for patients undergoing bone marrow transplantation.

Academic outreach: health careers enhancement program for minorities.

This article describes the 6-week Health Careers Enhancement Program for Minorities inaugurated in the summer of 1988 at Case Western Reserve University School of Medicine. The program was developed for minority and economically disadvantaged college undergraduates and postbaccalaureate premedical students. Its major objectives were to stimulate and maintain the interest of minority students in health careers and prepare these students for entry into health professions and for successful completion of these programs. A unique aspect of the program was academic outreach. Case Western Reserve University minority alumni and community minority physicians participated as clinical role models, mentors, and teachers; community and state minority leaders served as inspirational speakers and role models. The program was designed not only to incorporate cognitive and skill development activities, but to also include features distinctive to the Case Western Reserve University curriculum, specifically, organ system teaching, preceptor groups, medical apprenticeship program, and student tutors.

Students teaching students: a medical school peer tutorial programme.

A peer tutorial programme which is available to all first- and second-year medical students has been in operation at Case Western Reserve University School of Medicine since 1972. A retrospective study of the classes of 1982, 1983 and 1984 was undertaken to assess the participation levels in the tutorial programme and to compare the participation level to available performance parameters. The analysis revealed that 54% of the first-year classes and 22% of the second-year classes participated in the peer tutorial programme. X2 analysis of the data demonstrated that the relationship between participation in the tutorial programme and performance on examinations reached statistical significance. The results suggested that an open peer tutorial programme responded to the needs, both cognitive and affective, of medical students.

Purification of a glycoprotein vascular endothelial cell mitogen from a rat glioma-derived cell line.

A growth factor that is mitogenic for vascular endothelial cells, with an ED50 of approximately 1 ng/ml, has been purified 170,000-fold to apparent homogeneity from tissue culture medium conditioned by a rat glioma-derived cell line. The pure protein is a 46-kDa dimer composed of two subunits of equivalent mass as established by comparison of migration in SDS/polyacrylamide gels with and without prior reduction. This glioma-derived growth factor is a glycoprotein and is not mitogenic for BALB/c 3T3 fibroblasts, properties that further distinguish it from other well-characterized vascular endothelial cell mitogens. In contrast to acidic and basic fibroblast growth factors and to platelet-derived endothelial cell growth factor, which have no secretory leader sequences and might only be released by leakage from damaged cells, the glycoprotein nature of this mitogen implies that it is processed through the glycosylating secretory pathway. This secretable growth factor could, therefore, be readily available in the extracellular space under normal physiological conditions in vivo to promote vascular endothelial cell proliferation associated with blood-vessel growth and maintenance.

Cognitive learning during surgical residency. A model for curriculum evaluation.

The program summary of the American Board of Surgery In-Service Training Exam (ABSITE) can be used to quantitate cognitive learning during a surgical residency and to identify areas of curricular weakness in a residency program. Knowledge on each question is categorized as high (known) or low (unknown) depending on the percentage of residents who answered correctly. Knowledge of Level 1 (entry) residents is then compared with Level 5 (exit) residents. Each ABSITE question can thus be categorized on entry versus exit as known-known, unknown-unknown, unknown-known, and known-unknown. Only about half of unknown knowledge on entry appears to become known on exit. Very little knowledge known on entry becomes unknown on exit. Weaknesses in specific subject areas can be readily identified by ranking questions according to the number of exiting residents who answer incorrectly. Use of this technique to quantitate cognitive learning in a residency program may allow objective assessment of changes in curriculum.

Stress-related illnesses and sources of stress: comparing M.D.-Ph.D., M.D., and Ph.D. students.

A study was conducted to determine the prevalence and incidence of stress-associated illnesses and to identify possible sources of stress among students enrolled in the M.D.-Ph.D. program of a midwestern university. Specially constructed questionnaires were completed by 45 M.D.-Ph.D. students, 334 M.D. students, and 42 Ph.D. students at this university. The information obtained from the M.D.-Ph.D. students was compared with the responses of the M.D. students and the Ph.D. students. Male M.D.-Ph.D. students had a significantly higher incidence of hypertension, colitis, and asthma, while female M.D.-Ph.D. students reported a higher usage of antacids and occurrence of gastritis or ulcers during the time that they were enrolled in their programs. M.D.-Ph.D. students indicated that the fear of flunking out of school and the grading system were more stressful than did the M.D. students. Additionally, relationship with the graduate adviser and the graduate committee was more stressful to M.D.-Ph.D. students than to Ph.D. students.

External examinations for internal evaluation: the National Board Part I Test as a case.

The appropriateness of the Part I examination of the National Board of Medical Examiners to evaluate second-year curricular performance of students at Case Western Reserve School of Medicine was examined. Review of the June 1974 examination by 37 faculty members revealed that 85% of the items reflected the content of the second-year curriculum and that 60% could be answered from information provided in the second-year teaching. Two-thirds of the items were related to the content of the first-year curriculum, and half could be answered on the basis of first-year material. The school's faculty used the study data in making policy-changing decisions.