Effectiveness of a simulated patient training programme based on trainee response accuracy and appropriateness of feedback.

INTRODUCTION: Simulated patients (SPs) need education and training in required skills to be effective resources in education. This study was conducted to examine the effectiveness of an SP training programme based on the accuracy of trainee responses and the appropriateness of their feedback. METHODS: Thirty-two applicants to the training programme and 35 experienced SPs were included in this study. The experienced SPs served as a reference group. The rate of accurate responses and the rate of appropriate feedback were assessed with pre- and post-training tests, and these two outcome measures were compared with those of the experienced SPs. RESULTS: No significant differences were found in trainee response accuracy or appropriateness of feedback between pre- and post-training tests. The response accuracy rate of the trainees on the pre-training test was significantly lower than that of SPs with 1-2 years of experience, whilst there was no significant difference between these SPs and the trainees on the post-training test. CONCLUSIONS: Although our study suggests that more training is needed to improve the skills of SPs, the training programme may contribute to helping trainees reach a novice level in the skill of providing accurate responses. SP training should be encouraged to contribute to the effectiveness of such teaching and to establish the validity of the assessment.

[Complete resection of Pancoast tumor following induction chemoradiotherapy improves survival].

OBJECTIVE: Pancoast tumors are some of the most challenging thoracic malignant diseases to treat because of their proximity to vital structures at the thoracic inlet. We retrospectively analyzed 23 patients with pT3-4, N0-3 Pancoast tumors who underwent combined chest wall resection including the 1st rib, and discuss the anatomical considerations, assessment of induction therapy, and surgical approaches for these cancers. METHODS: Between 1983 and 2006, 23 patients with Pancoast tumors underwent combined resection of the 1st rib at our institute. Of those, 21 were male and 2 were female, with an average age of 58 years. There were 10 each of squamous cell carcinoma and adenocarcinoma, 2 large cell carcinoma, and 1 adenosquamous carcinoma. Over the past decade, induction chemoradiotherapy (>40Gy) was employed before surgery. RESULTS: A posterior approach was employed in 14 patients, an anterior approach in 7, and a combined anterior and posterior approach in 2. Sixteen patients underwent complete resection. One of 7 patients undergoing incomplete resection (4.3%) died on the 45th postoperative day. The 3- and 5-year survival rates were 50 and 22%, respectively, for patients with complete resection. No case survived for more than 8 months out of the 7 patients with incomplete resection. Fourteen patients with pN0 showed significantly better survival than those with pN1-3 (p = 0.0053). CONCLUSION: Recent literature and our results suggest that patients with pN0 and/or a pathological complete response (pCR) after induction chemoradiotherapy could achieve long-term survival after complete resection.

[Surgical treatment for the second double lung cancers following chemotherapy for small cell lung cancer].

We report a case with surgery for the 2nd primary double lung cancers-adenocarcinoma and squamous cell carcinoma which developed in the right upper lobe after 5 years successful control by chemotherapy for small cell lung cancer in the left upper lobe. Long term survivors with small cell lung cancer have recently increased as a result of progress of chemotherapy. Therefore, 2nd primary lung cancer is not rare after the treatment for the initial small cell lung cancer. Although several causes have been proposed on the development of 2nd primary lung cancer after small cell lung cancer treatment, smoking history was strongly suggested as a cause in this case. Careful follow-up especially focusing on 2nd primary lung cancer development is necessary for patients after successful treatment for small cell lung cancer.

Measurement of psychological state changes at low dopamine transporter occupancy following a clinical dose of mazindol.

RATIONALE: The beneficial effects of psychostimulant drugs in the treatment of psychiatric disorders occur because they increase the extracellular dopamine concentration by inhibiting re-uptake of extracellular dopamine at dopamine transporters. However, the psychological effects at low dopamine transporter occupancy have not been well demonstrated. OBJECTIVES: The purpose of the study was to evaluate the psychological effects, dopamine transporter occupancy, and dopamine release induced by a single oral administration of a clinical dose of mazindol. METHODS: Ten healthy male volunteers were orally administered a placebo and a clinical dose of mazindol (1.5 mg) on separate days. The psychological effects of mazindol were assessed using a visual analogue scale to detect alterations in the state of consciousness. The amount of blockade of dopamine transporters was assessed using positron emission tomography with [18F]FE-PE2I and extracellular dopamine release was measured as the amount of change in [11C]raclopride binding. RESULTS: Following administration of a clinical dose of mazindol, the dopamine transporters were blocked by 24-25 %, and the binding potential of [11C]raclopride was reduced by 2.8-4.6 %. The differences of a score measuring derealisation and depersonalization associated with a positive basic mood were significantly correlated with the change in the [11C]raclopride binding in the limbic striatum. CONCLUSIONS: A subtle alteration in the state of consciousness was detected with a correlation to the changes in the [11C]raclopride binding, which implies that a subtle alteration in extracellular dopamine concentration in the limbic striatum by a small amount of dopamine transporter occupancy can affect the state of consciousness. TRIAL REGISTRATION HTTPS://UPLOAD.UMIN.AC.JP/CGI-OPEN-BIN/CTR_E/CTR_VIEW.CGI?RECPTNO=R000009703 : UMIN000008232.

Social information-processing skills training to promote social competence and prevent aggressive behavior in the third grades.

This article describes a school-based study designed to promote social competence and reduce aggressive behavior by strengthening children's skills in processing social information and regulating emotions. Three successive cohorts of 3rd graders (N = 548) from 2 schools participated. In 2000-2001, children received a routine health curriculum; in 2001-2002, students received the Making Choices: Social Problem Solving Skills for Children (MC) program; and in 2002-2003, children received MC supplemented with teacher and parent activities. Compared with children in the routine condition, children in both MC conditions were rated lower on posttest social and overt aggression and higher on social competence. Moreover, they scored significantly higher on an information-processing skills posttest. The findings suggest that prevention programs can strengthen social- emotional skills and produce changes in aggressive behavior.

Presenile-onset cerebral adrenoleukodystrophy presenting as Balint's syndrome and dementia.

We describe a patient with presenile-onset cerebral adrenoleukodystrophy presenting as Balint's syndrome and dementia. There were demyelinating MRI changes in the parieto-occipital white matter bilaterally, including the splenium of the corpus callosum. Therapeutic trials using 1-deamino-(8-D-arginine)-vasopressin, very long-chain fatty acid-free diet, and gamma-globulin were of no benefit.

A comparison of endocrine and exocrine function after pancreatic fragment autotransplantation into splenic pulp, portal vein, and hepatic parenchyma.

Three sites were evaluated for potential pancreatic fragment autotransplantation. Both endocrine and exocrine functions were evaluated following autotransplantation into splenic pulp, portal vein, or hepatic parenchyma in 44 pancreatectomized dogs. Cholecystic bile amylase concentrations in the hepatic parenchyma group surviving more than 2 months were elevated significantly, and choledochal bile amylase concentrations increased markedly following pancreozymin-secretin injection. In contrast, bile amylase concentrations in dogs with intrasplenic or intraportal implants were low and did not respond to PS injection. Histologically pancreatic autografts in hepatic parenchyma revealed marked proliferation of exocrine tissue with abundant zymogen granules and reconstruction of the acinar lobules with a few islets. These acinar cells in the hepatic parenchyma were ultrastructurally normal. Transplant endocrine function, estimated by K values, was significantly better after splenic pulp and portal vein than after a hepatic parenchyma implantation, but no group improved during 1-year follow-up. Glucose-stimulated initial insulin responses were abnormally low in all recipients. Islet B cells lacked mature insulin granules, such as seen in normal resting B cells. This ultrastructural finding implies a persistent demand on the B cells and may explain the spontaneous recurrence of hyperglycemia and the diminished initial insulin response to a glucose load. This study indicates that euglycemic recipients of pancreatic fragment autotransplantation remain unstable and prediabetic.

Frequent association of 22q11.2 deletion with tetralogy of Fallot.

Chromosome 22q11.2 deletion causes DiGeorge syndrome, velocardiofacial syndrome, conotruncal anomaly face syndrome with tetralogy of Fallot (TOF), and sporadic or familial TOF. To determine the prevalence and clinical importance of the 22q11.2 deletion in TOF, a series of 212 Japanese TOF patients was studied. The type of pulmonary blood supply, which may lead to various clinical outcomes, and other additional anomalies were evaluated clinically. The 22q11.2 deletion was diagnosed by fluorescence in situ hybridization with N25 and TUPLE1 probes. Of the 212 patients examined, 28 (13%) had a 22q11.2 deletion, the frequency being higher than that in TOF patients with trisomy 21. The prevalence of the deletion in TOF patients with pulmonary atresia (PA) plus major aortico-pulmonary collateral arteries (MAPCA) was significantly higher than the value in patients with PA plus patent ductus arteriosus (PDA) (P = 0.04) or with pulmonary stenosis (PS) (P < 0.0001). All 28 patients with 22q11.2 deletion had one or more extracardiac abnormalities. Four of 9 patients with the 22q11.2 deletion and TOF-PA-MAPCA suffered from bronchomalacia, while none of 19 patients with TOF-PA-PDA or TOF-PS manifested bronchomalacia (P = 0.006). These results indicate that 22q11.2 deletion is the most frequent cause of syndromic TOF, especially for TOF-PA-MAPCA, and bronchomalacia is the clinically most important associated anomaly in TOF-PA-MAPCA patients.

Phenotypic discordance in monozygotic twins with 22q11.2 deletion.

We report on male monozygotic twins with 22q11.2 deletion and discordant phenotypes. The twins had twin-to-twin transfusion syndrome. Twin 1, the smaller of the pair, had Tetralogy of Fallot, a characteristic facial appearance, swallowing dysfunction, anal atresia, short stature, and mental retardation, whereas twin 2 had a characteristic facial appearance but no other signs of the 22q11 deletion syndrome. Fluorescence in situ hybridization analysis showed a microdeletion on chromosome 22q11.2 in both twins. Zygosity analysis gave a probability of monozygosity greater than 99.999%. These observations indicate that environmental factors or postzygotic events play a role in the phenotypic variability in the twins.

Nicotine withdrawal induces subsensitivity of hypothalamic-pituitary-adrenal axis to stress in rats: implications for precipitation of depression during smoking cessation.

Epidemiologic studies show that smokers with a past history of depression are more likely to relapse into depression after smoking cessation than those without a history of depression. These studies suggest the existence of a direct biological link between nicotine withdrawal and depression. To investigate the neuronal and hormonal mechanisms of the precipitation of depression during smoking cessation, we used an animal model of nicotine withdrawal and studied the function of the hypothalamic-pituitary-adrenal (HPA) axis, the abnormality of which is implicated in the pathogenesis of depression. Rats were implanted with a minipump delivering nicotine at 6.0 mg/kg/day for 12 days. The minipumps were removed in order to abruptly terminate nicotine infusion. The activity of the HPA axis was determined on day 2 of withdrawal using the stress-induced corticosterone response and the dexamethasone suppression test (DST). At the same time the expressions of glucocorticoid receptor (GR) mRNA in the hippocampus and paraventricular nucleus of hypothalamus (PVN) and corticotropin-releasing hormone (CRH) mRNA in PVN were determined by non-radioactive in situ hybridization. Nicotine withdrawal resulted in lower corticosterone levels during restraint stress, suggesting subsensitivity of the HPA axis to stress. The result of DST, however, did not show a significant difference between nicotine-withdrawal and control rats. These effects of nicotine withdrawal were not accompanied by any changes in the expressions of GR and CRH mRNA in either hippocampus or PVN. These results suggest that subsensitivity of the HPA axis to stress during nicotine withdrawal may be implicated in the precipitation of depression during smoking cessation, although GR and CRH in the HPA axis do not appear to play a significant role.

Exercise-induced silent myocardial ischemia in single vessel coronary artery disease associated with Q wave infarction. Assessment by thallium 201 single-photon emission computed tomography.

PURPOSE: To examine the relationship between the symptom of ischemia and the amount of abnormally perfused myocardium, coronary arteriography and exercise and redistribution thallium 201 single-photon emission computed tomography (SPECT) were analyzed. MATERIALS AND METHODS: The study group consisted of 153 patients with single-vessel coronary artery disease; 53 patients had no pathologic Q waves (group 1) and 100 patients had pathologic Q waves consistent with the area supplied by the diseased vessel (group 2). Twenty normal subjects were used as control subjects. The apical, mid, and basal left ventricular levels of the short-axis view and apical portion of the long-axis view were divided into 20 segments, and segmental images were scored blindly on a 0 (normal) to 4 (severely reduced uptake) scale. The redistribution score was defined as the thallium 201 defect score of exercise subtracted from that of the redistribution image and was used as a measure of the amount of ischemic myocardium. RESULTS: The redistribution score in 20 control subjects was 0.20 +/- 2.06, and the upper limit of normal redistribution score was defined as mean + 2 x SD (4.32). In group 1, 40 of 53 patients had a redistribution score above the normal range. In group 2, 34 of 100 patients had a redistribution score above the normal range. Of 40 patients in group 1, angina during exercise was observed in 22 patients (55 percent). Twenty-two patients who had angina had a redistribution score of 15.2 +/- 6.7, while those who did not have angina had a score of 13.7 +/- 5.2 (p = NS). Of 34 patients in group 2, angina was observed in 10 patients (29 percent) during exercise. Ten patients with angina had a redistribution score of 10.1 +/- 4.4, and those without angina had a score of 9.9 +/- 3.4 (p = NS). CONCLUSION: Thus, the incidence of silent ischemia without the Q wave infarct zone was found to be higher than that within the ischemic zone without Q wave. Patients with silent and symptomatic ischemia during exercise have similar amounts of ischemic myocardium demonstrated by tomographic thallium 201 imaging; this was found in patients who had Q wave infarction and in those who did not.

Needle-shaped inclusions in plasma cells in a patient with hypogammaglobulinemia.

A case of a patient with needle-shaped inclusions in plasma cells was reported. Some of the inclusions were positively stained for acid phosphatase and beta-glucuronidase. Ultrastructurally, each inclusion was surrounded by a single limiting membrane without any relation to rough-surfaced endoplasmic reticulum and composed of numerous fine fibrous bundles. By the enzyme-labeled antibody technic, the inclusions were found as "stain defects" in IgG-forming plasma cells, but not in IgM-forming plasma cells. Although the exact nature of the inclusions could not be clarified, they were quite different from both amyloid fibrils and immunoglobulin-derived inclusions, and were thought to be synthesized by a clone of differentiated plasma cells. The patient showed moderate hypogammaglobulinemia but no evidence of a direct correlation between the inclusions and hypogammaglobulinemia was obtained. Though the possibility that the case was non-secretory myeloma could not be ruled out, it was unlikely judged by the findings of various examinations.

Prolymphocytic leukemia with IgM hypogammaglobulinemia.

A case of prolymphocytic leukemia with IgM hypogammaglobulinemia in a 47-year-old man was presented. The leukemic cells possessed Ia-like antigen and receptors for the third component of complement but lacked surface immunoglobulins, cytoplasmic IgM, receptors for sheep red blood cells, or terminal deoxynucleotidyl transferase activity. In vitro immunoglobulin production experiments demonstrated that the leukemic cells did not have the capacity to produce IgM, while patient's T cells were shown to possess helper function on normal B cells to produce immunoglobulins. By these findings, together with the presence of selective IgM hypogammaglobulinemia, it was suggested that the leukemic cells were derived from a B-cell clone of a stage in differentiation and maturation of IgM-forming B-cell spectrum.

Palladium-catalyzed sulfinylzincation: 1-alkynyl sulfoxides as a sulfinyl anion equivalent.

[reaction--see text] Novel Pd-catalyzed sulfinylzincation of activated alkynes was developed, wherein 1-alkynyl sulfoxides work as a sulfinylating agent. Transfer of the sulfinyl group proceeded in a highly syn-selective fashion, giving a beta-sulfinyl vinylzinc species. Using 3,3-dimethyl-1-butynyl p-tolyl sulfoxide as a sulfinyl source, heterocoupling with propiolate derivatives was also accomplished.

Reorganization of corticorubral synapses following cross-innervation of flexor and extensor nerves of adult cat: a quantitative electron microscopic study.

A quantitative electron microscopic study of corticorubral synapses was performed in the red nucleus (RN) of adult cats to determine the morphological correlates for the changes in time course of corticorubral excitatory post-synaptic potentials, which occur following cross-innervation of forelimb extensor and flexor nerves. Corticorubral synaptic endings were identified by anterograde degeneration after lesions of the ipsilateral sensorimotor cortex. Rubrospinal neurons innervating upper spinal segments were electrophysiologically identified and filled with horseradish peroxidase (HRP). These cells were mainly situated in the dorsomedial part of RN. Electron micrographs of the degenerating corticorubral synaptic endings were taken in the region surrounding HRP-filled neurons and the diameter of the dendrites contacted by such terminals was measured. In the cross-innervated animals many degenerating terminals were found to synapse on dendrites with large diameter and the somata of neurons in RN. This is in contrast to the previous observations in normal cats, in which very few corticorubral synapses were found to synapse on proximal dendrites and somata of RN neurons. The diameter of HRP-filled neurons in cats which were cross-innervated was slightly smaller than those observed in normal animals. These results indicate that new corticorubral synapses were formed on proximal dendrites and somata of RN neurons as a consequence of cross-innervation.

Mesencephalic neurons controlling lens accommodation in the cat.

Thirty units were found in the midbrain of the anesthetized cat which discharged in correlation with spontaneously occurring lens accommodation. The frequency of spike potentials increased before the onset of the accommodation response. Increased discharges were followed by a silent period. These units were driven orthodromically by stimulating the interpositus nucleus of the cerebellum and the posterior commissure. Eleven of these units were identified antidromically as parasympathetic oculomotor neurons.

Cortical neurons in and around the Clare-Bishop area related with lens accommodation in the cat.

Single-unit discharges in the cat Clare-Bishop area were correlated with spontaneous accommodation responses. No appreciable change was found in accommodation responses evoked by stimulating the Clare-Bishop area, when cerebellar outflow was blocked reversibly by cooling the superior cerebellar peduncle. It is suggested, therefore, that the Clare-Bishop area plays an important role in the lens accommodation system through a pathway independent from that of the cerebellum.

Mecamylamine-precipitated nicotine-withdrawal aversion in Lewis and Fischer 344 inbred rat strains.

Many studies have indicated that Lewis and Fischer 344 inbred rat strains show marked differences in behavioral responses to abused drugs. In the present study, we sought to determine whether these two strains of rats show different responses in mecamylamine-precipitated nicotine-withdrawal aversion using the conditioned place preference paradigm. Rats were treated subcutaneously with 10 mg/kg/day nicotine for 7 days using an osmotic minipump. After chronic nicotine infusion, the nicotinic receptor antagonist mecamylamine produced a significant place aversion in Lewis, but not in Fischer 344 rats. These results suggest that mecamylamine-precipitated nicotine-withdrawal aversion is strongly regulated by genetic factors.

Mecamylamine-precipitated nicotine-withdrawal aversion in rats.

The present study examined a rapid and convenient model for evaluating nicotine dependence using the conditioned place preference paradigm. Rats were chronically infused subcutaneously with 9 mg/kg per day nicotine using an osmotic minipump. After nicotine infusion for 7 days, the nicotinic receptor antagonist mecamylamine produced a place aversion in nicotine-dependent rats, but not in acute nicotine-treated rats or sham-operated rats. These results suggest that the mecamylamine-precipitated withdrawal aversion in rats chronically treated with nicotine may result from physical dependence on nicotine, and may be useful for studying the physical dependence on nicotine.

Differential effects of mu-, delta- and kappa-opioid receptor agonists on the discriminative stimulus properties of cocaine in rats.

The effects of selective mu-, delta- and kappa-opioid receptor agonists on the discriminative stimulus properties of cocaine were examined in rats trained to discriminate between cocaine (10 mg/kg) and saline. Cocaine produced a dose-related increase in cocaine-appropriate responses in all of the rats. In generalization tests, neither morphine (mu-opioid receptor agonist) nor N-methyl-N-7-(1-pyrrolidinyl)-1-oxaspiro[4,5]dec-8-11-4-benzofu ranacetamide (U50,488H: kappa-opioid receptor agonist) generalized to the discriminative stimulus properties of cocaine. On the other hand, the newly synthesized non-peptide selective delta-opioid receptor agonist 2-methyl-4a alpha-(3-hydroxyphenyl)-1,2,3,4,4a,5,12,12a alpha-octahydro-quinolino(2,3,3,-g)isoquinoline (TAN-67) partially generalized (56.7% cocaine-appropriate responses) to the discriminative stimulus properties of cocaine. Intracerebroventricular (i.c.v.) administration of [D-Ala2]deltorphin II (peptide delta 2-opioid receptor agonist) completely generalized, while neither [D-Ala2,MePhe4,Gly-ol5]enkephalin (DAMGO: mu-opioid receptor agonist) nor [D-Pen2,D-Pen5]enkephalin (DPDPE; delta 1-opioid receptor agonist) generalized to the discriminative stimulus properties of cocaine. These results suggest that the discriminative stimulus properties of cocaine may be partially mediated by delta-opioid (especially delta 2-opioid) receptors. In combination tests, pretreatment with morphine (3.0 mg/kg) and TAN-67 (3.0 and 10 mg/kg) significantly potentiated the discriminative stimulus properties cocaine. In contrast, pretreatment with U50,488H (2.0 and 4.0 mg/kg) scarcely shifted the discriminative stimulus properties of cocaine. Furthermore, the potentiating effect of 3.0 mg/kg morphine on the discriminative stimulus properties of cocaine was attenuated by 2.0 mg/kg U50,488H. In contrast, the potentiating effect of 10 mg/kg TAN-67 on the discriminative stimulus properties of cocaine was not reversed by either 2.0 or 4.0 mg/kg U50,488H. These results suggest that mu-, delta- and kappa-opioid receptor agonists modulate the discriminative stimulus properties of cocaine through different mechanisms, perhaps through different effects on the dopaminergic system.