The FRCR 2B oral examination: is it reliable?

AIM: To investigate the reliability of the oral component of the Fellowship of the Royal College of Radiologists (FRCR) 2B examination. MATERIALS AND METHODS: Anonymized candidate test scores were analysed from nine consecutive sittings of the FRCR 2B oral examination covering the period from spring 2006 to spring 2010. Interobserver reliability was assessed using weighted Kappa coefficient, intraclass correlation coefficient, and a modified Bland-Altman plot. RESULTS: During the study period, 2235 candidates sat the FRCR 2B examination. Eighty-five point one percent of candidates obtained paired oral assessment scores within one mark of each other. This figure rises to 95.7% for paired scores within 1.5 marks of each other. Mean difference in scores was 0.67 (95% CI: 0.65-0.70). Agreement rises at the extremities of mean score. Reliability coefficients for the FRCR 2B oral examination were calculated as 0.27 (weighted Kappa) and 0.44 (intraclass correlation coefficient). CONCLUSION: The calculated reliability coefficients indicate fair to, at best, moderate interobserver reliability in the FRCR 2B oral examination. These findings are disappointing but are comparable with other oral assessment reliability studies. There is scope for improvement, although further work to measure the combined reliability of all the components of the FRCR 2B examination is desirable. Measures that could potentially increase reliability must be carefully considered against any negative impact on test validity, acceptability, and cost.

Overdose with levetiracetam: a case report and review of the literature.

WHAT IS KNOWN AND OBJECTIVE: Levetiracetam is an anticonvulsant agent that was first approved for use in the United States in 1999 and has a maximum recommended adult dose of 3000 mg daily. It has been noted to have a relatively mild adverse effect profile, with the most common side effects being somnolence, asthenia, infection, and dizziness. Although it has been widely prescribed, there have been few reports on the safety of this agent in overdose. CASE SUMMARY: We present the case of a 49-year-old man who ingested over 22 500 mg of levetiracetam in a suicide attempt. The patient arrived at the Emergency Department 6·5 h after the ingestion and was noted to have no significant sequelae from the ingestion. Based on the patient's weight, he ingested 358 mg/kg of levetiracetam. WHAT IS NEW AND CONCLUSION: The few cases of levetiracetam overdose reported in the literature were associated with relatively mild, if any, symptoms. However, one patient who overdosed on levetiracetam became obtunded and developed significant respiratory distress that required intubation and ventilatory support. Therefore, clinical vigilance is still required in the cases of levetiracetam overdose.

Zero-gap semiconductor to excitonic insulator transition in Ta2NiSe5.

The excitonic insulator is a long conjectured correlated electron phase of narrow-gap semiconductors and semimetals, driven by weakly screened electron-hole interactions. Having been proposed more than 50 years ago, conclusive experimental evidence for its existence remains elusive. Ta2NiSe5 is a narrow-gap semiconductor with a small one-electron bandgap EG of <50 meV. Below TC=326 K, a putative excitonic insulator is stabilized. Here we report an optical excitation gap Eop ∼0.16 eV below TC comparable to the estimated exciton binding energy EB. Specific heat measurements show the entropy associated with the transition being consistent with a primarily electronic origin. To further explore this physics, we map the TC-EG phase diagram tuning EG via chemical and physical pressure. The dome-like behaviour around EG∼0 combined with our transport, thermodynamic and optical results are fully consistent with an excitonic insulator phase in Ta2NiSe5.

Dopamine in the nucleus accumbens modulates the memory of social defeat in Syrian hamsters (Mesocricetus auratus).

Conditioned defeat (CD) is a behavioral response that occurs in Syrian hamsters after they experience social defeat. Subsequently, defeated hamsters no longer produce territorial aggression but instead exhibit heightened levels of avoidance and submission, even when confronted with a smaller, non-aggressive intruder. Dopamine in the nucleus accumbens is hypothesized to act as a signal of salience for both rewarding and aversive stimuli to promote memory formation and appropriate behavioral responses to significant events. The purpose of the present study was to test the hypothesis that dopamine in the nucleus accumbens modulates the acquisition and expression of behavioral responses to social defeat. In Experiment 1, bilateral infusion of the non-specific D1/D2 receptor antagonist cis(z)flupenthixol (3.75 µg/150 nl saline) into the nucleus accumbens 5 min prior to defeat training significantly reduced submissive and defensive behavior expressed 24h later in response to a non-aggressive intruder. In Experiment 2, infusion of 3.75 µg cis-(Z)-flupenthixol 5 min before conditioned defeat testing with a non-aggressive intruder significantly increased aggressive behavior in drug-infused subjects. In Experiment 3, we found that the effect of cis-(Z)-flupenthixol on aggression was specific to defeated animals as infusion of drug into the nucleus accumbens of non-defeated animals did not significantly alter their behavior in response to a non-aggressive intruder. These data demonstrate that dopamine in the nucleus accumbens modulates both acquisition and expression of social stress-induced behavioral changes and suggest that the nucleus accumbens plays an important role in the suppression of aggression that is observed after social defeat.

Prospective study of extraction atherectomy in patients with acute myocardial infarction.

Although percutaneous transluminal coronary angioplasty (PTCA) has been an effective treatment for primary reperfusion in acute myocardial infarction, patients with thrombolytic ineligibility, thrombolytic failure, cardiogenic shock, and vein graft occlusion remain at high risk for complications with PTCA treatment. The transluminal extraction catheter may be useful for treatment for such patients owing to its ability to aspirate thrombus. At 2 clinical centers, extraction atherectomy was prospectively evaluated in 100 patients (age 62 +/- 10 years). High-risk features included thrombolytic failure in 40%, postinfarct angina in 28%, presence of angiographic thrombus in 66%, presence of cardiogenic shock in 11%, and a saphenous vein graft occlusion in 29%. Procedural success, defined as a final residual stenosis <50% and Thrombolysis in Myocardial Infarction 2 or 3 grade flow, was seen in 94%. Events during the hospitalization included death in 5%, bypass surgery in 4%, and blood transfusion in 18%. In a substudy, patients enrolled at William Beaumont Hospital (n = 65) underwent elective predischarge angiography, which revealed a patent infarct-related vessel in 95%. These patients were also followed for 6 months with angiographic follow-up in 60%. Target vessel revascularization was necessary in 38%, and 6-month mortality was 10%. Although long-term vessel patency was 90%, angiographic restenosis occurred in 68%. Acute myocardial infarction patients can be treated with extraction atherectomy with a high technical success rate and a low incidence of complication. Infarct artery patency at 1 week and 6 months was excellent; however, angiographic restenosis remains a problem. Extraction of thrombus in this high-risk group of patients is associated with low in-hospital mortality and a high rate of vessel patency at 6 months.

Optic disk edema as a presentation of Propionibacterium acnes endophthalmitis.

PURPOSE: To report a patient with an initial presentation of optic disk edema secondary to Propionibacterium acnes endophthalmitis. METHODS: Interventional case report. The patient had surgery and treatment related to endophthalmitis. Nine months after cataract surgery with posterior chamber lens implant, a 79-year-old man receiving topical corticosteroids in the same eye presented with best-corrected visual acuity of 20/60, a superior visual field defect, and optic nerve edema without intraocular inflammation. One year postoperatively, the eye presented a further decrease in best-corrected visual acuity, and a dense white plaque was noted on the posterior capsule. RESULTS: One year postoperatively, a partial capsulectomy with vitrectomy and injection of intravitreal antibiotics was performed. Hematoxylin and eosin stain of the posterior capsule plaque revealed gram-positive coccobacilli characteristic of P. acnes. CONCLUSION: Propionibacterium acnes endophthalmitis may present after cataract surgery with intraocular lens implant with decreased vision, optic disk edema, and a visual field defect.

The determination of palladium in fosinopril sodium (monopril) by ICP-MS.

A rapid, sensitive ICP-MS method was developed to determine palladium in fosinopril sodium. The assay could not be carried out in a purely aqueous solvent owing to the instability of the palladium species in this media. It was found that the most appropriate vehicle for solubilization of this material was a solution of 25% (v/v) 2-butoxyethanol and water. A minimum quantifiable limit of 0.1 microns g-1 for Pd in the sample (corresponding to 1 ng Pd mL-1 in the analyte solution) was obtained.

Building a comprehensive clinical information system from components. The approach at Intermountain Health Care.

OBJECTIVES: To discuss the advantages and disadvantages of an interfaced approach to clinical information systems architecture. METHODS: After many years of internally building almost all components of a hospital clinical information system (HELP) at Intermountain Health Care, we changed our architectural approach as we chose to encompass ambulatory as well as acute care. We now seek to interface applications from a variety of sources (including some that we build ourselves) to a clinical data repository that contains a longitudinal electronic patient record. RESULTS: We have a total of 820 instances of interfaces to 51 different applications. We process nearly 2 million transactions per day via our interface engine and feel that the reliability of the approach is acceptable. Interface costs constitute about four percent of our total information systems budget. The clinical database currently contains records for 1.45 m patients and the response time for a query is 0.19 sec. DISCUSSION: Based upon our experience with both integrated (monolithic) and interfaced approaches, we conclude that for those with the expertise and resources to do so, the interfaced approach offers an attractive alternative to systems provided by a single vendor. We expect the advantages of this approach to increase as the costs of interfaces are reduced in the future as standards for vocabulary and messaging become increasingly mature and functional.

Retinitis pigmentosa and schizophrenia.

There have been previous suggestions in the literature of a link between schizophrenia and retinitis pigmentosa (RP) or its associated syndromes. In this article, we describe two cases of schizophrenía and two cases of delusional disorder occurring in patients with RP. We explore possible reasons for an association between RP and schizophrenia including shared genetic predisposition, sensory deprivation, coarse brain disease and retinoid dysregulation. Awareness of an association may help to direct future research into the aetiology of these disorders, especially in the areas of neurochemistry and medical genetics.

Pain management in the special operations environment: regional anesthetics.

Pain relief is an essential component of combat casualty care. For the injured soldier, analgesia is not only a matter of comfort. Alleviating pain may allow the soldier to remain quiet when noise discipline is at a premium. It may also allow that person to continue to move, thus avoiding detection and potentially permitting the mission to carry on. Regional anesthetics provide an alternative to systemic medications and thus may avoid a clouded sensorium, limit narcotic administration, and provide superior pain relief. Standard local anesthetics and newer agents with potential field applicability are discussed along with their side effect profiles. Simple nerve block techniques that can be used by Army Special Forces medics, Navy SEAL and Reconnaissance corpsmen, and Air Force pararescuemen in the far forward environment are described step by step. The advantages of these regional anesthetic methods should make their use a must for every special operations medical care provider.

Dietary combination of soy with a probiotic or prebiotic food significantly reduces total and LDL cholesterol in mildly hypercholesterolaemic subjects.

OBJECTIVE: We hypothesized that a dietary combination of soy with either a probiotic (yoghurt) or a prebiotic (resistant starch) would result in enhanced lipid-lowering effects compared with a control soy diet, possibly via improvements in isoflavone bioavailability. SUBJECTS: Mildly hypercholesterolaemic subjects (men and post-menopausal women) older than 45 years were recruited via the local media. Thirty-six subjects commenced the study; five withdrew. RESULTS: Soy+probiotic significantly decreased total cholesterol (4.7+/-2.0%; P=0.038) and soy+prebiotic significantly decreased total and low-density lipoprotein cholesterol (5.5+/-1.6%; P=0.003 and 7.3+/-2.2%; P=0.005, respectively). The bioavailabilities of daidzein, genistein or equol were not affected by probiotic or prebiotic consumption or associated with lipid changes. CONCLUSION: Dietary combination of soy with either a probiotic or a prebiotic resulted in significant lipid lowering, not related to isoflavone bioavailability.