An innovative OSCE clinical log station: a quantitative study of its influence on Log use by medical students.

BACKGROUND: A Clinical Log was introduced as part of a medical student learning portfolio, aiming to develop a habit of critical reflection while learning was taking place, and provide feedback to students and the institution on learning progress. It was designed as a longitudinal self-directed structured record of student learning events, with reflection on these for personal and professional development, and actions planned or taken for learning.As incentive was needed to encourage student engagement, an innovative Clinical Log station was introduced in the OSCE, an assessment format with established acceptance at the School. This study questions: How does an OSCE Clinical Log station influence Log use by students? METHODS: The Log station was introduced into the formative, and subsequent summative, OSCEs with careful attention to student and assessor training, marking rubrics and the standard setting procedure. The scoring process sought evidence of educational use of the log, and an ability to present and reflect on key learning issues in a concise and coherent manner. RESULTS: Analysis of the first cohort's Log use over the four-year course (quantified as number of patient visits entered by all students) revealed limited initial use. Usage was stimulated after introduction of the Log station early in third year, with some improvement during the subsequent year-long integrated community-based clerkship. Student reflection, quantified by the mean number of characters in the 'reflection' fields per entry, peaked just prior to the final OSCE (mid-Year 4). Following this, very few students continued to enter and reflect on clinical experience using the Log. CONCLUSION: While the current study suggested that we can't assume students will self-reflect unless such an activity is included in an assessment, ongoing work has focused on building learner and faculty confidence in the value of self-reflection as part of being a competent physician.

Helicobacter pylori amoxicillin heteroresistance due to point mutations in PBP-1A in isogenic isolates.

OBJECTIVES: To investigate the Helicobacter pylori amoxicillin resistance rate, the occurrence of heteroresistance, and their related molecular mechanisms. METHODS: Eighty-seven H. pylori-positive patients were included: 45/87 with single biopsy and 42/87 with multiple biopsies. MICs were determined, and sequencing analysis of pbp1A gene and the variable regions of seven hop porins was performed in resistant and susceptible isolates. Clonal relationships were determined by lspA-glmM-RFLP and by random amplification of polymorphic DNA-PCR. An isogenic amoxicillin-susceptible isolate was transformed with pbp1A PCR products from the resistant isolates. RESULTS: Amoxicillin-resistant (MIC 2 mg/L) and amoxicillin-susceptible (MIC 0.06 mg/L) isolates, belonging to the same strain, were observed in different biopsies in one patient (inter-niche heteroresistance). Isolates from the remaining patients were amoxicillin-susceptible. Sequencing analysis of the pbp1A of two amoxicillin-resistant isolates and their susceptible partners revealed the same two point mutations: (i) in the third PBP motif of the resistant isolates (C1667G); (ii) a nonsense mutation at the 3' end of the gene. Replacement of pbp1A of a susceptible isolate by pbp1A from a resistant isolate increased the transformants MICs (2 mg/L). A similar MIC was observed when a pbp1A DNA fragment including both point mutations was transformed. Transfer of the smallest fragment (C1667G region only) yielded slightly lower MICs (0.5-1 mg/L). Identical hop gene sequences were observed in paired susceptible and resistant isolates. CONCLUSIONS: A low resistance rate was observed. However, inter-niche heteroresistance could hinder amoxicillin resistance detection when only one biopsy is obtained. Alteration in PBP-1A seems to be enough to reach an MIC of 2 mg/L in our resistant isolates.

Delivering a pathology curriculum in an integrated medical course.

Modern integrated medical curricula usually do not include a separate pathology course. Consequently, there is a risk that important pathological principles may be omitted. We aimed to ensure that pathology is properly represented by developing a core pathology curriculum created in consultation with local pathologists. Appropriate information technology to track the delivery of this material within the integrated curriculum structure was developed using a learning content management system in which a metadata schema was constructed. This allows a sophisticated view of where and how pathology appears in the course and can also increase the visibility of the subject by demonstrating the central place of pathology in medicine. In conclusion, a core curriculum in pathology that can be tracked by information technology with sufficient power and flexibility is a solution to the potential loss of pathology from integrated medical courses. We believe the result is superior to a stand-alone pathology course.

The intestinal mucosa as a reservoir of HIV-1 infection after successful HAART.

The presence of HIV-1 RNA in distal duodenal mucosa was evaluated in 44 HIV-1-positive patients. HIV-1 RNA was detected in gut tissue in antiretroviral-naive patients with high plasma viral loads, as well as in patients on HAART with plasma viral loads below the limit of detection and in patients on HAART with virological failure. The intestinal mucosa seems to serve as a reservoir poorly influenced by levels of plasma viral load or HAART.

Helicobacter pylori cag pathogenicity island genotype diversity within the gastric niche of a single host.

cag pathogenicity island (PAI) integrity was investigated in isolates from multiple biopsies recovered from 40 patients in an attempt to determine the co-existence of a varying cagPAI-positive to cagPAI-negative ratio in a single host. Six biopsies were obtained from each patient during the same endoscopic session. cagPAI analysis included amplification of seven loci (cagA, cagE, cagG, cagM, cagT, HP0527 and HP0524) and the left end of cagII (LEC). Absence of the island was confirmed by empty-site PCR. lspA-glmM RFLP and random amplified polymorphic DNA PCR were used for strain delineation. The number of biopsies with Helicobacter pylori-positive culture ranged from three to six per patient and a total of 218 isolates were recovered. Mixed infection was only found in two patients. Nearly one-third of the 40 patients harboured isolates with an intact cagPAI in all niches, another third of the isolates were empty-site-positive in all niches, whilst the remaining third of the isolates had a disrupted cagPAI in all or at least one of the niches. Co-existence of variants of the same strain with different cagPAI genotypes was observed in one-quarter of patients. The variations in cagPAI genotype included co-existence of: diverse cagPAI deletions in different niches, variants with intact and with partially deleted islands, variants with empty-site-positive and with partially deleted cagPAIs, and variants with an intact cagPAI and with empty-site-positive. Half of the patients with different cagPAI genotypes harboured an intact cagPAI in at least one niche. Co-existence of diverse genotypes of putative virulence factors in a single host must be considered when drawing a correlation with clinical presentation.

DNA sequence analysis of rdxA and frxA from paired metronidazole-sensitive and -resistant Helicobacter pylori isolates obtained from patients with heteroresistance.

Genomic variations of rdxA and frxA genes in eight pairs of metronidazole (MTZ)-sensitive and -resistant isolates of Helicobacter pylori were investigated. The paired strains from each single biopsy had identical lspA-glmM restriction fragment length polymorphism profiles, and the differences in MTZ susceptibility were mostly accounted for by mutations in the rdxA gene. Truncation of RdxA is associated with a minimum inhibitory concentration of 64-128 mg/L. Early truncation of FrxA was observed both in susceptible and resistant isolates of seven paired strains. Inactivation of frxA might play a significant role only in one low-level MTZ-resistant isolate where a missense mutation was found in the rdxA gene.

[Decision analysis: diagnostic approach in HIV infection associated chronic diarrhea]. / Análisis de decisión: diagnóstico de diarrea crónica asociada a la infección por HIV.

UNLABELLED: Chronic diarrhea is still a problem of difficult management in patients with AIDS, even in the HAART (Highly Active Antiretroviral Therapy) era. AIM: To establish the most appropriate diagnostic procedure for HIV infected patients, with CD4 count below 200 cells/ml and chronic diarrhea, starting on HAART. METHODS: Using a decision tree as the tool of a decision analysis, two alternatives were considered for the ethiologic diagnosis in AIDS associated chronic diarrhea. The compared alternatives were a minimal evaluation (stool culture and parasite stool examination), and complete evaluation (adding endoscopies with intestinal biopsies). The decision tree was constructed by TreeAge Data 32 software. Diagnostic and therapeutic data for both alternatives were obtained from medical publications. The outcome was the reported survival estimation for HIV infected patients with CD4 level bellow 200 cells/ml, starting HAART, with and without chronic diarrhea. RESULTS: In the basic analysis, as well as in the sensitivity analysis, a complete evaluation was the alternative that showed the highest expected value: 7.79 years of survival. The minimal evaluation showed a value of 7.05 years of survival. CONCLUSION: In HIV infected patients with chronic diarrhea and CD4 count below 200 cells/ml, starting on HAART, digestive endoscopies with biopsy samples are the best diagnostic approach.

[Oesophageal candidiasis: clinical and mycological analysis]. / Candidiasis esofágica: análisis clínico y micológico.

Oesophageal candidiasis is an epithelial infection which requires an immune deficiency. C. albicans is commonly the cause, although other species may also be responsible. Resistance to fluconazole, drug of choice for treatment, is an emerging problem. The objectives of the current paper were: to determine the frequency of oesophageal candidiasis in patients submitted to upper gastrointestinal endoscopy, analyze risk factors, identify Candida species and determine in vitro susceptibility to fluconazole. During 12 months, 34 patients with oesophageal candidiasis were detected. Out of 1.230 HIV negative and 91 HIV positive patients submitted to upper endoscopy, 11 (0.9%) and 23 (25.3%), respectively, had candidiasis. Risk factors for HIV negative patients were systemic antibiotic therapy in 2, deficient dental cleaning in 2 aged patients, use of proton pump inhibitors in 3, inhaled steroids in 2, malignancy in 1 and oral steroids in 1. The histopathologic diagnosis was confirmed in 48.6% of cases. Cultures were positive in 91.2% C. albicans was prevalent (93.5%), and was associated to other species in 5 cases (16.1%), (3 C. glabrata, 1 C. tropicalis and 1 C. parapsilosis). One case cultured only C. glabrata and 1, only C tropicalis. Out of 31 cultures, 25 were susceptible to fluconazole, 4 dose dependent (1 C. albicans, 3 C. glabrata), and 2 resistant (1 C. albicans, 1 C. glabrata). Frequency of oesophageal candidiasis was low, except for HIV positive patients. The most common etiologic agent was C. albicans, though other Candida species were also found. C. albicans and C. glabrata showed dose dependency and resistance to fluconazole.

[Endoscopic approach in HIV infected-patients with upper gastrointestinal symptoms]. / Evaluación endoscópica de pacientes VIH positivos con síntomas digestivos altos.

UNLABELLED: Upper gastrointestinal symptoms such as nausea, vomiting, upper abdominal pain, heartburn, early satiety, bloating and anorexia, are frequently reported by HIV positive patients; however, their prevalence and diagnostic approach are unknown. AIMS: To evaluate the frequency of endoscopic and histologic diagnosis in HIV positive patients with upper gastrointestinal symptoms referred to upper endoscopy, and to compare them with those found in a non-HIV infected group with similar symptoms. PATIENTS AND METHODS: Out of 132 HIV positive patients referred to upper endoscopy, 102 (75%) with upper gastrointestinal symptoms, and 177 non-HIV controls were prospectively included. All patients answered questionnaires assessing frequency, severity and impact of symptoms on quality of life, and underwent upper endoscopy with systematic mucosal biopsies from esophagus, stomach and distal duodenum. RESULTS: Upper abdominal pain, heartburn and bloating were the most common upper gastrointestinal symptom reported in both groups. Anorexia, nausea, vomiting and early satiety were more frequent among HIV positive patients (p = or < 0.01). Intensity and impact of symptoms quality of life were higher in this group (p = 0.0001). Opportunistic infections were detected in 29 (28.4%) HIV positive patients. This subgroup had a lower mean CD4 count (p = 0.0004). In 76 (75.4%) HIV positive non-opportunistic diseases were diagnosed, with similar frequency to HIV negative individuals. CONCLUSIONS: Upper endoscopy with biopsies detected opportunistic and non-opportunistic diseases in HIV positive patients with upper gastrointestinal symptoms. Opportunistic diseases were related to lower CD4 counts. Non-opportunistic diseases had similar frequency in both groups, HIV positive and negative controls.

Helicobacter pylori bab genes during chronic colonization.

Helicobacter pylori BabA adhesin metastability could yield variants with potential for periodic activation and deactivation of their mediated adherence. babA/B or babB/A chimeras could play an important role in translational regulation. We investigated the frequency of different bab gene profiles in paired isolates from antrum and corpus recovered from patients with chronic gastritis. Isolates from 174 biopsies from 34 patients were included, and bab genes at the three common chromosomal loci were investigated. Inter-micro-niche variation was found in 1/4 patients, counting duplicate copies of babA or babB, babB/A or babA/B chimeras, opposite location of babA and babB or babC and babB, and absence of babB ATG translational codon. Truncated BabA was identified in 2/34 patients without inter-micro-niche variation. Isolates from 12/34 patients harbored babA/B or babB/A chimeras -either in one, several or all micro-niches indicating that chimera formation is a common mechanism to control BabA expression. To note, babA gene was absent in 11/34 patients, and in this population, babA/B chimeras which lack expression predominated over babB/A, able to exhibit Le(b) binding phenotype.

Helicobacter pylori oipA, vacA and dupA genetic diversity in individual hosts.

Helicobacter pylori putative virulence factors can undergo a continuously evolving mechanism as an approach to bacterial adaptation to the host changing environment during chronic infection. oipA, vacA and dupA genetic diversity among isolates from multiple biopsies (niches) from the antrum and corpus of 40 patients was investigated. A set of 229 isolates was examined. Direct DNA sequence analysis of amplified fragments was used to study oipA 'on/off' expression status as well as the presence of C or T insertion in jhp0917 that originates a continuous (jhp0917-jhp0918) dupA gene. vacA alleles were identified by multiplex PCR. Different inter-niches oipA CT repeat patterns were observed in nine patients; in six of these, 'on' and 'off' mixed patterns were found. In three of these nine patients, different vacA alleles were also observed in a single host. Inter-niche dupA differences involved the absence and presence of jhp0917 and/or jhp0918 or mutations in dupA, including those that may originate a non-functional gene, and they were also present in two patients with mixed oipA CT patterns and in another seven patients. Evidence of mixed infection was observed in two patients only. In conclusion, oipA and dupA genes showed similar inter-niche variability, occurring in approximately 1/4 patients. Conversely, vacA allele microevolution seemed to be a less common event, occurring in approximately 1/10 patients, probably due to the mechanism that this gene evolves 'in vivo'.

Esophageal motility disorders in HIV patients.

Opportunistic esophageal infections (Candida, cytomegalovirus, herpes simplex virus) and idiophatic esophageal ulcerations are commonly found in HIV patients. However, motility disorders of the esophagus have seldom been investigated in this population. The aim of this prospective study was to determine the presence of motility disorders in HIV patients with esophageal symptoms (with or without associated lesions detected by endoscopy) and in HIV patients without esophageal symptoms and normal esophagoscopy. Eigthteen consecutive HIV patients (10 male, 8 female, ages 20-44 years, mean age 33.5; 8 HIV positive and 10 AIDS) were studied prospectively. Nine patients complained of esophageal symptoms, e.g, dysphagia/odynophagia (group 1) and 9 had symptoms not related to esophageal disease, such as diarrhea, abdominal pain, or gastrointestinal bleeding (group 2). All patients underwent upper endoscopy; mucosal biopsies were taken when macroscopic esophageal lesions were identified or when the patients were symptomatic even if the esophageal mucosa was normal. Esophageal manometry was performed in the 18 patients, using a 4-channel water-perfused system according to a standardized technique. Sixteen of the 18 patients (88.8%) had baseline manometric abnormalities. In group 1, 8/9 patients had esophageal motility disorders: nutcrackeresophagus in 1, hypertensive lower esophageal sphincter (LES) with incomplete relaxation in 2, nonspecific esophageal motility disorders (NEMD) in 3, diffuse esophageal spasm in 1, esophageal hypocontraction with low LES pressure in 1. Six of these 9 patients had lesions detected by endoscopy: CMV ulcers in 2, idiopathic ulcers in 1, candidiasis in 1, idiopathic ulcer + candidiasis in 1, nonspecific esophagitis in 1; and 3/9 had normal endoscopy and normal esophageal biopsies. In group 2, 8/9 patients had abnormal motility: hypertensive LES with incomplete relaxation in 1, nutcracker esophagus in 2, esophageal hypocontraction in 3, and NEMD in 2. All these patients had a normal esophageal mucosa at endoscopy. In conclusion, our findings suggest that HIV patients have esophageal motility disorders independent of esophageal symptoms and/or the presence of mucosal esophageal lesions.

Coinfection: Helicobacter pylori/human immunodeficiency virus.

To compare H. pylori infection prevalence and gastric mucosa damage in HIV-infected and non-HIV-infected patients, gastric biopsies were systematically taken in 209 individuals who underwent upper Gl endoscopy (102 HIV-infected and 107 non-HIV-infected). H. pylori was found in 42 (41.1%) HIV-infected patients and in 53 (49.5%) non-HIV patients (P = 0.22, chi2 = 1.47, NS). In HIV-positive patients infected with H. pylori the mean CD4 count was higher than in HIV-positive patients without H. pylori (364 and 228 cells/mm3, respectively; P = 0.0001). H. pylori gastritis was more severe in the HIV-positive group (chi2 = 15.02, P = 0.0001). The frequency of H. pylori in gastric mucosa in HIV-infected and non-HIV patients was similar. HIV-infected patients with H. pylori had a higher mean CD4 count than HIV-infected individuals without H. pylori. Gastric lesions associated with H. pylori were more severe in the HIV-positive population.

The spectrum of GI strongyloidiasis: an endoscopic-pathologic study.

BACKGROUND: The aim of this study was a detailed endoscopic-pathologic assessment of patients with various forms of GI strongyloidiasis. METHODS: Six patients with a diagnosis of GI strongyloidiasis who underwent endoscopic evaluation during a 3-year period (January 1998-January 2001) were included. Published information was reviewed in detail, focusing on the endoscopic features and the diagnostic approach to this parasitosis. OBSERVATIONS: Strongyloidiasis has a broad range of endoscopic features. In the duodenum, the findings included edema, brown discoloration of the mucosa, erythematous spots, subepithelial hemorrhages, and megaduodenum. In the colon, the findings included loss of vascular pattern, edema, aphthous ulcers, erosions, serpiginous ulcerations, and xanthoma-like lesions, and, in the stomach, thickened folds and mucosal erosions. A histopathologic diagnosis of strongyloidiasis was made in all cases. CONCLUSIONS: Strongyloidiasis can involve any segment of the GI tract. EGD with procurement of biopsy specimens from the duodenum was the most accurate method of diagnosis in this case series.

Fijación de prioridades en investigación en VIH/Sida. Uso de la matriz de estrategias combinadas, herramienta recomendada por el Foro Global de Investigación en Salud / Research priority setting in HIV/AIDS using the comined approach matrix, a tool recommended by TH Global Forum For Health Research

A partir de la aplicación de la matriz de estrategias cominadas, un equipo interdisciplinario de investigadores elaboró un diagnóstico sobre la epidemia de VIH/Sida en Argentina... En el taller se discutieron la situación epidemiológica argentina en VIH/SIDA, sus determinantes y las eventuales intervenciones útiles para mejorar o revertir dicha situación. Estas opiniones junto con las respuestas obetenidas de la encuesta y el material provisto por el equipo interdisciplinario, ayudaron a completar la matriz desde la cuál se elaboró un listado de prioridades en investigación en VIH/SIDA.

The combined approach matrix, tool recommended by the Global Forum for Health Research to set priorities for selection, organises information from different sources to establish the current situation on any sanitary problem form the point of view of the individual, the family, the community, the ministry of health, other institutions related or not to health and macroeconomic politics. By the application of the combined approach matrix, an interdisciplinary teams of researchers elaborated a diagnosis on HIV/aids epidemics in Argentina.

Metodologías de fijación de prioridades en la selección de investigaciones / Methodology of priority setting in the investigations selection

La matriz de estrategias combinadas (MEC), instrumento para fijar prioridades en investigación, permite la organización de información procedente de diversas fuentes y la configuración del estado de situación sobre determinada enfermedad desde el punto de vista del individuo, la familia y la comunidad, el ministerio, otras instituciones relacionadas o no con la salud, y de políticas macroeconómicas. Objetivos: Adaptar y validar la MEC como herramienta para establecer prioridades en investigación en salud en Argentina. Metodología: Se analizaron las prioridades de cinco áreas problemáticas: enfermedades transmisibles, factores de riesgo de enfermedades no transmisibles, salud sexual y reproductiva, lesiones y salud del niño y de la niña. Un equipo de trabajo interdisciplinario (ETI) de 19 profesionales fue responsable de la ejecución del protocolo. Expertos en cada tema completaron una encuesta que permitió conocer su perspectiva. Se organizaron 5 talleres abiertos con invitados especiales representantes de distintas dimensiones institucionales. Resultados: Un total de 48 asesores, 81 expertos y 266 participantes de diferentes provincias y de la Ciudad Autónoma de Buenos Aires concurrieron a los talleres donde en pequeños grupos discutieron el proceso de validación de la MEC que sumado a la búsqueda, recuperación y análisis crítico de la información a cargo del ETI permitió construir una matriz para la mayoría de las entidades propuestas inicialmente. Conclusión: El proceso de validación indica que la MEC es una herramienta útil, factible de ser completada, que facilita el diálogo entre diversos actores con diferentes conocimientos, intereses y necesidades en materia de investigación sanitaria.

The Combined Approach Matrix (CAM), a tool to set research priorities, helps to organize the information coming from different sources and present the current knowledge about a certain disease from the point of view of the individual, household and community, the health ministry and other institutions related or not with health, and macroeconomic policies. Objective: adapt and validate the CAM as a tool to set research priorities in health in Argentina. Methodology: the priorities for five health problems were analyzed: communicable diseases, risk factors for non-communicable diseases, sexual and reproductive health, disabilities and children's health. An interdisciplinary working group (IWG) of 19 professionals was responsible for the execution of the protocol. Experts in each topic filled a survey that presents their perspective. Five open workshops were organized with special guests representing the different institutional dimensions. Results: A total of 48 advisors, 81 experts and 266 participants from different provinces and Ciudad Autónoma de Buenos Aires attended the workshops, where in small groups they discussed the validation process of the CAM, that together with the search, retrieval and critical analysis of the information in charge of the IWG allowed the filling of the CAM for the majorities of the health problems initially proposed. Conclusions: the validation process indicates that the CAM is a useful tool, feasible to be completed, which fosters dialogue between the various stakeholders or participants needing health research.

Depuración plasmática de alfa-1-antitripsina, método simple para el estudio de la pérdida proteica intestinal / Plasma clearance of alpha 1-antitrypsin, a simple method for the study of intestinal protein losing

Tratamos de corroborar el valor del clearence de alfa-antitripsina como una técnica eficaz para objetivar la pérdida de proteínas a través del tubo digestivo y su aplicación como método de diagnóstico en tal patología. Se estudiaron 22 individuos; 11 con patología intestinal capaz de producir pérdida proteica y 11 controles sin daño de la mucosa intestinal. Se determinó la concentración de alfa-1-antitripsina tanto en suero como en materia fecal en días consecutivos y pesando la materia fecal de 24 horas se pudo obtener el clearence intestinal de dicha proteína. En los pacientes con enfermedad perdedora de proteínas el valor del clearence fue siempre patológico mientras que en los controles se obtuvieron valores normales. Este método es útil para diagnosticar la pérdida proteica intestinal y tiene la ventaja de no utilizar material radioactivo para su determinación

Lesiones hepáticas por drogas: presentación de 26 casos / Hepatic lesions induced by drugs: report of 26 cases

Se revisaron 2671 biopsias hepáticas entre los años 1972 y 1985 en el Hospital A. Posadas. Hubo 26 pacientes con daño hepático producido por drogas, habiéndose incluido aquellos enfermos con los siguientes criterios: contacto con un fármaco capaz de producir efecto hepatotóxico; cuadro clínico, biológico e histológico compatible con la droga examinada; remisión completa del cuadro al interrumpir la droga; ausencia de otros tóxicos hepáticos. Catorce pacientes mostraron colestasis intrahepática inducida por estrógenos; 5 tuvieron lesiones hepatitis-like debido a: alfametildopa (3), ketoconazol (1) e indometacina (1). Dos presentaron cambios inflamatorios y cambios grasos por tetracloruro de carbono mientras que la fenibutazona produjo una granulomatosis hepática y una hepatitis colestática. Los últimos tres casos fueron lesiones colestáticas después de la administración de clorpromazina allopurinol y penicilina respectivamente. La evolución en 24 pacientes fue excelente después que se retiró la droga. Dos pacientes murieron por complicaciones quirúrgicas ya que fueron operados con el diagnóstico erróneo de colestasis extrahepática