'Going rural': driving change through a rural medical education innovation.

INTRODUCTION: Medical education across the globe is in a state of flux influenced by a number of drivers for change. In response, institutions are seeking to re-align their curricula to address the prevailing imperatives. Against this backdrop, the training of practitioners for practice in rural communities was identified as an educational priority, and led to the establishment of a rural clinical school (RCS) within a Faculty of Medicine and Health Sciences in South Africa in 2011. This article describes the students' experiences in the first year that this innovative educational model was implemented and explores the extent to which it influenced their thinking and practice. METHODS: A qualitative, formative evaluation study of the first year of implementation was undertaken. Data was generated from in-depth interviews. This article focuses on individual interviews conducted with the eight students at the RCS, which explored their experiences during a year-long clerkship. Transcripts of interviews were thematically analysed. RESULTS: Four themes emerged from the analysis: a learning experience that differed from what was experienced at the tertiary training hospital, an enabling clinical environment in the district and regional hospital, the positive role played by the specialists, and the influence of the community immersion. Underlying all of the responses was the building of relationships over time both with supervisors and with patients. Evident from the responses was that students' confidence in their clinical skills and decision-making abilities was heightened while their approaches to their own learning were enhanced. CONCLUSIONS: To respond to the call for educational reform and a heightened awareness of social realities, innovative approaches to the training of medical students, such as those adopted at the RCS, are indicated. It is argued that the learning facilitated by these rural medical education models has the potential to offer learning experiences that can lead to transformation through a change in practice and attitude among the students, and ultimately also enable curricular renewal at the institutional core.

Genetics coupled to quantitative intact proteomics links heritable aphid and endosymbiont protein expression to circulative polerovirus transmission.

Yellow dwarf viruses in the family Luteoviridae, which are the causal agents of yellow dwarf disease in cereal crops, are each transmitted most efficiently by different species of aphids in a circulative manner that requires the virus to interact with a multitude of aphid proteins. Aphid proteins differentially expressed in F2 Schizaphis graminum genotypes segregating for the ability to transmit Cereal yellow dwarf virus-RPV (CYDV-RPV) were identified using two-dimensional difference gel electrophoresis (DIGE) coupled to either matrix-assisted laser desorption ionization-tandem mass spectrometry or online nanoscale liquid chromatography coupled to electrospray tandem mass spectrometry. A total of 50 protein spots, containing aphid proteins and proteins from the aphid's obligate and maternally inherited bacterial endosymbiont, Buchnera, were identified as differentially expressed between transmission-competent and refractive aphids. Surprisingly, in virus transmission-competent F2 genotypes, the isoelectric points of the Buchnera proteins did not match those in the maternal Buchnera proteome as expected, but instead they aligned with the Buchnera proteome of the transmission-competent paternal parent. Among the aphid proteins identified, many were involved in energy metabolism, membrane trafficking, lipid signaling, and the cytoskeleton. At least eight aphid proteins were expressed as heritable, isoelectric point isoform pairs, one derived from each parental lineage. In the F2 genotypes, the expression of aphid protein isoforms derived from the competent parental lineage aligned with the virus transmission phenotype with high precision. Thus, these isoforms are candidate biomarkers for CYDV-RPV transmission in S. graminum. Our combined genetic and DIGE approach also made it possible to predict where several of the proteins may be expressed in refractive aphids with different barriers to transmission. Twelve proteins were predicted to act in the hindgut of the aphid, while six proteins were predicted to be associated with the accessory salivary glands or hemolymph. Knowledge of the proteins that regulate virus transmission and their predicted locations will aid in understanding the biochemical mechanisms regulating circulative virus transmission in aphids, as well as in identifying new targets to block transmission.

A comparison of protein extraction methods suitable for gel-based proteomic studies of aphid proteins.

Protein extraction methods can vary widely in reproducibility and in representation of the total proteome, yet there are limited data comparing protein isolation methods. The methodical comparison of protein isolation methods is the first critical step for proteomic studies. To address this, we compared three methods for isolation, purification, and solubilization of insect proteins. The aphid Schizaphis graminum, an agricultural pest, was the source of insect tissue. Proteins were extracted using TCA in acetone (TCA-acetone), phenol, or multi-detergents in a chaotrope solution. Extracted proteins were solubilized in a multiple chaotrope solution and examined using 1-D and 2-D electrophoresis and compared directly using 2-D Difference Gel Electrophoresis (2-D DIGE). Mass spectrometry was used to identify proteins from each extraction type. We were unable to ascribe the differences in the proteins extracted to particular physical characteristics, cell location, or biological function. The TCA-acetone extraction yielded the greatest amount of protein from aphid tissues. Each extraction method isolated a unique subset of the aphid proteome. The TCA-acetone method was explored further for its quantitative reliability using 2-D DIGE. Principal component analysis showed that little of the variation in the data was a result of technical issues, thus demonstrating that the TCA-acetone extraction is a reliable method for preparing aphid proteins for a quantitative proteomics experiment. These data suggest that although the TCA-acetone method is a suitable method for quantitative aphid proteomics, a combination of extraction approaches is recommended for increasing proteome coverage when using gel-based separation techniques.

Design of an intensive epilepsy monitoring unit.

Video-electroencephalography (EEG) telemetry is a crucial component in the comprehensive evaluation of patients with epilepsy. The reasons for patients needing to be monitored fall broadly into three groups: presurgical assessment (36% of our patients), diagnostic assessment (52%), and sleep disorders (12%). Video EEG can be used to differentiate unusual epilepsies from pseudo seizures or other causes of paroxysmal neurological events. The design of a unit depends on the case mix of patients expected to be referred. The key elements to a successful unit are a reliable, flexible, easy-to-use recording system and a team of dedicated, experienced staff, both nursing and technical. The unit at the National Hospital is a six-bed ward with 7 nurses to provide 24-hour coverage, 5 technicians working in shifts, and physics support. A minimum of two staff are on duty at all times. It operates on a five-day week with a throughput of approximately 500 patients per year. It is vital that investigations are performed as efficiently and effectively as possible, and the patient's safety and wellbeing is paramount at all times. Drug reduction is likely to be used to precipitate seizures, especially in those being considered for epilepsy surgery, and this poses a risk of provoked secondary generalized seizures. Continuous supervision of patients, and the ability to respond rapidly to a seizure, are therefore essential. We adopt a standardized easy-to-follow drug-reduction protocol, similar to that used by other centers.

The clinical and radiological features of tuberculosis in adolescents.

This retrospective review of clinical records and chest radiographs (CR) of adolescents aged 10-18 years was designed to determine age and sex differences in the clinical and radiological features of adolescent tuberculosis (TB). Records of adolescents who were admitted to Brooklyn Hospital for Chest Diseases (BCH) or who were treated at local authority health clinics were screened. Data from 324 adolescents (male:female ratio 1:1.2) were studied. Intra-thoracic lesions were present on CR in 306 (94%). Primary TB with mediastinal adenopathy was present in 32 (10%). Cavitation was present in 180 (56%), 16% at 10 and 73% at 18 years of age. Cavitation occurred in 55% of males and in 56% of females with increasing frequency from 15 years of age in the former and from age 14 in the latter. Microbiological confirmation of diagnosis was obtained in 254 (78%) cases, 52% in those aged 10-13 years and 86% in those > or = 14 years. Pleural effusion was present in 42 (13%), 26 males and 16 females (p < 0.05). Thirteen (7%) of the 182 hospitalized adolescents and 27 (19%) of the ambulant group did not complete therapy. The nature of tuberculous disease in adolescents changed dramatically with increasing age.

Outreach, consolidation, and networking: Columbia's approach to successful integration of laboratory services in California.

At the forefront of integrated laboratory services, Columbia Bay Area Healthcare Network's Lab Link provides a unique approach to operating hospital-based laboratories in today's heavily penetrated managed-care environment. Columbia recognizes that a combined strategy of laboratory consolidation, outreach, and networking is essential to compete successfully with commercial reference laboratories for local and statewide contracts. Implementing this model enables hospital laboratories to produce high quality, cost-effective test results while increasing volume and reducing duplication. When hospital laboratories consolidate and network with local and regional laboratories, inpatient and outpatients information is cross-fertilized through a web of information systems. Patients information can then be accessed easily and monitored throughout the continuum of care. The goal of this article is to provide hospital laboratories with a streamlined approach to structuring and delivering services while maintaining a competitive edge in the tumultuous healthcare market. The future of laboratory services within the hospital setting lies in the aggressive use of three elements--consolidation, outreach, and networking--to ensure quality service as well as economic viability.

Vocational evaluation of traumatic brain injury patients using the functional assessment inventory.

Impaired work capacity is one of the most common residual impairments encountered after either a severe or moderate traumatic brain injury (TBI), yet no instrument is available for screening TBI victims regarding their readiness to participate in more comprehensive vocational planning and evaluation. In the study reported here, the Functional Assessment Inventory (FAI) was administered to 76 subjects who suffered a moderate or severe TBI and the results obtained were compared to the Rancho Los Amigos Hospital Levels of Cognitive Functioning, the Mini-Mental State and the Glasgow Outcome Scale for sensitivity in discerning vocational readiness. The results obtained indicated that the FAI composite score has the greatest discriminating power in screening the vocational readiness of this population, followed by the Glasgow Outcome Scale. In addition, the FAI cluster scores demonstrated reasonable discriminative ability, which may prove useful in directing ongoing remediation.