A dual role for the RhoGEF Ephexin5 in regulation of dendritic spine outgrowth.

The outgrowth of new dendritic spines is closely linked to the formation of new synapses, and is thought to be a vital component of the experience-dependent circuit plasticity that supports learning. Here, we examined the role of the RhoGEF Ephexin5 in driving activity-dependent spine outgrowth. We found that reducing Ephexin5 levels increased spine outgrowth, and increasing Ephexin5 levels decreased spine outgrowth in a GEF-dependent manner, suggesting that Ephexin5 acts as an inhibitor of spine outgrowth. Notably, we found that increased neural activity led to a proteasome-dependent reduction in the levels of Ephexin5 in neuronal dendrites, which could facilitate the enhanced spine outgrowth observed following increased neural activity. Surprisingly, we also found that Ephexin5-GFP levels were elevated on the dendrite at sites of future new spines, prior to new spine outgrowth. Moreover, lowering neuronal Ephexin5 levels inhibited new spine outgrowth in response to both global increases in neural activity and local glutamatergic stimulation of the dendrite, suggesting that Ephexin5 is necessary for activity-dependent spine outgrowth. Our data support a model in which Ephexin5 serves a dual role in spinogenesis, acting both as a brake on overall spine outgrowth and as a necessary component in the site-specific formation of new spines.

Tele-pharmacy in remote medical practice: the Royal Flying Doctor Service Medical Chest Program.

In recent times remote medical practice has been developed into a unique discipline in its own right with telehealth one of the eight defining key features. Since 1942, the telemedicine consultation service provided by the Royal Flying Doctor Service in Australia has been supported by a tele-pharmacy program known as the Medical Chest Program. The contents of the chest comprise more than 85 items, including medications and equipment which can be prescribed during a telehealth consultation to cover both emergency care and definitive treatment for less serious conditions. By 2006 there were 3500 medical chests placed throughout Australia. Specifically, the state of Queensland had 21 470 telehealth consultations from 1 July 2005 to 30 June 2006, resulting in the prescription of at least one medical chest item in 2938 (13.7%) consultations. Queensland data regarding medication indicate that antibiotics (26%), analgesics (23%) and gastrointestinal medications (12%) were the most common categories of dispensed medications, and that the most common clinical diagnostic categories for the consultation resulting in dispensed medications were respiratory (17%), skin (15%) and abdominal conditions (13%). In summary, the RFDS medical chest program continues to be a successful large scale provider of medications to those living in remote Australia, enabling early access to medications for both emergencies and definitive care, while minimising the need for mail-order pharmacy or patient travel. This model of care may provide an important template for those designing service delivery models in other remote jurisdictions.

Clinical simulators: applications and implications for rural medical education.

Medical education has undergone significant changes globally. Calls for the revitalisation of centuries old pathways of learning have resulted in innovative medical curricula. Didactic modes of teaching which involved the learning of copious amounts of facts have given way to curricula that focus on the horizontal and vertical integration of basic and clinical sciences. Increasing concern for patient care and safety has led to a 'gap' between the needs of medical students to acquire necessary psychomotor skills and the safety and wellbeing of the patient. This has resulted in alternate teaching methods that include non-patient based training for the acquisition of clinical skills. The use of computerised, full-sized human simulators provides medical students with the necessary psychomotor and clinical reasoning skills in a realistic learning environment, while remaining risk free to patients. These clinical simulators are powerful learning tools that have applications at all levels of medical education across multiple disciplines, emphasising the multidisciplinary approach required in many medical situations. This article reviews the literature on medical simulation and provides the contextual basis for the establishment of a Clinical Simulation Learning Centre (CSLC) in a rural clinical school in Australia. The educational program, as well as the design, layout and equipment of the CSLC are described, as well as implications for rural practitioners. The CSLC has been a major capital investment in a relatively under-resourced part of regional Australia and has provided opportunities for ongoing education across a range of healthcare professionals in the community.

How can experience in clinical and community settings contribute to early medical education? A BEME systematic review.

REVIEW DATE: Review period January 1992-December 2001. Final analysis July 2004-January 2005. BACKGROUND AND REVIEW CONTEXT: There has been no rigorous systematic review of the outcomes of early exposure to clinical and community settings in medical education. OBJECTIVES OF REVIEW: Identify published empirical evidence of the effects of early experience in medical education, analyse it, and synthesize conclusions from it. Identify the strengths and limitations of the research effort to date, and identify objectives for future research. SEARCH STRATEGY: Ovid search of: BEI, ERIC, Medline, CINAHL and EMBASE Additional electronic searches of: Psychinfo, Timelit, EBM reviews, SIGLE, and the Cochrane databases. Hand-searches of:Medical Education, Medical Teacher, Academic Medicine, Teaching and Learning in Medicine, Advances in Health Sciences Education, Journal of Educational Psychology. EXPERIENCE: Authentic (real as opposed to simulated) human contact in a social or clinical context that enhances learning of health, illness and/or disease, and the role of the health professional. Early: What would traditionally have been regarded as the preclinical phase, usually the first 2 years. Inclusions: All empirical studies (verifiable, observational data) of early experience in the basic education of health professionals, whatever their design or methodology, including papers not in English. Evidence from other health care professions that could be applied to medicine was included. EXCLUSIONS: Not empirical; not early; post-basic; simulated rather than 'authentic' experience. DATA COLLECTION: Careful validation of selection processes. Coding by two reviewers onto an extensively modified version of the standard BEME coding sheet. Accumulation into an Access database. Secondary coding and synthesis of an interpretation. HEADLINE RESULTS: A total of 73 studies met the selection criteria and yielded 277 educational outcomes; 116 of those outcomes (from 38 studies) were rated strong and important enough to include in a narrative synthesis of results; 76% of those outcomes were from descriptive studies and 24% from comparative studies. Early experience motivated and satisfied students of the health professions and helped them acclimatize to clinical environments, develop professionally, interact with patients with more confidence and less stress, develop self-reflection and appraisal skill, and develop a professional identity. It strengthened their learning and made it more real and relevant to clinical practice. It helped students learn about the structure and function of the healthcare system, and about preventive care and the role of health professionals. It supported the learning of both biomedical and behavioural/social sciences and helped students acquire communication and basic clinical skills. There were outcomes for beneficiaries other than students, including teachers, patients, populations, organizations and specialties. Early experience increased recruitment to primary care/rural medical practice, though mainly in US studies which introduced it for that specific purpose as part of a complex intervention. CONCLUSIONS: Early experience helps medical students socialize to their chosen profession. It helps them acquire a range of subject matter and makes their learning more real and relevant. It has potential benefits for other stakeholders, notably teachers and patients. It can influence career choices.

Preliminary evidence from Queensland that rural clinical schools have a positive impact on rural intern choices.

INTRODUCTION: The unequal and inequitable distribution of the medical workforce between rural and urban parts of Australia has been well documented. Commonwealth and state governments have introduced several significant initiatives in an attempt to address this imbalance, including recruitment of many overseas trained doctors. One longer-term initiative is the funding of university departments of rural health and rural clinical schools in medical schools. OBJECTIVE: To determine the impact of the rural clinical division of the School of Medicine at the University of Queensland (UQ), Australia, on the intern workforce in central and southern Queensland, Australia. METHODS: Time series analysis of first preferences for intern allocation among UQ graduates and source of interns (UQ, interstate and overseas) from 2001-2005, and comparison of trends between Rockhampton and Toowoomba (UQ student placements since 2003) with Mackay (no placements). RESULTS: First preferences for Rockhampton increased from six in 2001 to 10 in 2005, and for Toowoomba from five in 2002 to 12 in 2005, while for Mackay preferences were stable at two. At Rockhampton while two interns came from overseas in 2001 and three were from interstate in 2002, UQ provided all interns in 2004 or 2005. UQ has provided 12/13 interns in 2004 and 13/14 in 2005 for Toowoomba. Mackay continues to source interns from interstate and overseas with UQ providing only 3/5 interns in 2004 and 2005. At Rockhampton, among non-bonded UQ graduates the number of interns choosing to work there increased from zero in 2001 to six in 2005. For Toowoomba, numbers were seven and 10 respectively, while for Mackay it was zero. CONCLUSIONS: UQ's rural clinical division is having a positive impact on the intern workforce in the regional hospitals most closely allied with it.

Improving diabetic patients' outcomes in family medicine in the United Arab Emirates.

We evaluated a diabetic mini-clinic by assessing adherence to American Diabetes Association guidelines and changes in glycosylated haemoglobin levels. Of 1063 patients, 721 were multiple attenders. Single and multiple attenders showed no significant differences in age, sex, time since diagnosis or body mass index. Female and male multiple attenders showed significant declines in glycosylated haemoglobin levels over the first 12 and 18 months respectively. After 2 years, these levels were similar to those at entry to the clinic. The clinic's compliance with standard measurement guidelines was high. The diabetic mini-clinic model, which is effective in industrialized countries, was equally effective in this setting.

Changing use of the emergency department by the elderly in the United Arab Emirates, 1989 and 1999.

Changes in use by the elderly of the emergency department of a major hospital in Al-Ain in the years 1989 and 1999 were examined. All patients aged 65 years or older who attended the emergency room were included in this cross-sectional survey. Patient numbers rose from 321 in 1989 to 1347 in 1999 with no significant change in the female to male ratio of 0.78 or the mean age of the elderly attendees 72.9 +/- 7.4 years. Attendance rose 5.4 fold while non-urgent attendance rose 14.7 fold, demonstrating rising use but falling illness severity over time.

Improving diabetic patients' outcomes in family medicine in the United Arab Emirates

We evaluated a diabetic mini-clinic by assessing adherence to American Diabetes Association guidelines and changes in glycosylated haemoglobin levels. Of 1063 patients, 721 were multiple attenders. Single and multiple attenders showed no significant differences in age, sex, time since diagnosis or body mass index. Female and male multiple attenders showed significant declines in glycosylated haemoglobin levels over the first 12 and 18 months respectively. After 2 years, these levels were similar to those at entry to the clinic. The clinic's compliance with standard measurement guidelines was high. The diabetic mini-clinic model, which is effective in industrialized countries, was equally effective in this setting

Changing use of the emergency department by the elderly in the United Arab Emirates, 1989 and 1999

Changes in use by the elderly of the emergency department of a major hospital in Al-Ain in the years 1989 and 1999 were examined. All patients aged 65 years or older who attended the emergency room were included in this cross-sectional survey. Patient numbers rose from 321 in 1989 to 1347 in 1999 with no significant change in the female to male ratio of 0.78 or the mean age of the elderly attendees 72.9 +/- 7.4 years. Attendance rose 5.4 fold while non-urgent attendance rose 14.7 fold, demonstrating rising use but falling illness severity over time

Breastfeeding patterns in Fujairah, United Arab Emirates.

The rate of breastfeeding initiation and continuation through the first 6 months of life were assessed via interview and telephone follow-up in a prospective study of 130 mothers who consecutively delivered in hospital in Fujairah, UAE. The rate of initiation (83.2 per cent) and continuation at 2 months (72.6 per cent) was not significantly different from earlier studies. However, the rate of breastfeeding at 6 months (46.9 per cent) was lower than a 1992 study (p = 0.02). There were no significant associated factors with not breastfeeding at discharge from the maternity hospital and 2 months later. However, a significant inverse relationship with the level of general education of the mother for breastfeeding at 6 months was found, which is in contradistinction to Western countries where the rate of breastfeeding rises with increasing general education. This has implications for the type and targeting of future breastfeeding education programmes.

Systematic bias in the measurement of water in oils by tubular oven evaporation and azeotropic distillation.

Water in oil has been measured by tubular oven evaporation and by azeotropic distillation into a coulometric moisture analyzer. The results of these measurements were compared to the results obtained by volumetric titration of water in oil. The volumetric measurements were consistently higher than the measurements made by tubular oven evaporation or azeotropic distillation. A mass balance study was performed by volumetric Karl Fischer titration of the water in the oil that remained in the tubular oven and in the distillation apparatus. This study indicated that measurable amounts of water were not removed after exhaustive evaporation or distillation. The sum of the water removed by distillation from toluene and that remaining in the distillation chamber was equal to the amount of water measured in the oil by the volumetric method. The data are consistent with the existence of an oil-water azeotrope that does not release water upon evaporation at 160 degrees C or upon dissolution in toluene and distillation of the water-toluene azeotrope. These results were obtained for oils varying in viscosity from 8 to 850 m2/s, and the amount of water remaining associated with the oil appears to be dependent upon the composition of the oil and the method of analysis.

Partnership for front-line success: a call for a national action agenda on workforce development.

Despite more than a decade of dialogue on the critical needs and challenges in public health workforce development, progress remains slow in implementing recommended actions. A life-long learning system for public health remains elusive. The Centers for Disease Control and Prevention and the Agency for Toxic Substances and Disease Registry in collaboration with other partners in federal, state, local agencies, associations and academia is preparing a national action agenda to address front-line preparedness. Four areas of convergence have emerged regarding: (1) the use of basic and crosscutting public health competencies to develop practice-focused curricula; (2) a framework for certification and credentialing; (3) the need to establish a strong science base for workforce issues; and (4) the acceleration of the use of technology-supported learning in public health.

Improving performance at the local level: implementing a public health learning workforce intervention.

In an effort to continually improve performance of the essential public health services with community partners, the diverse public health workforce in a major metropolitan area engaged in an organizational learning process. Core public health organizational competencies, identified in a multi-year collaborative applied research initiative, provided the curricula content for the public health learning experience. All members (about 600) of the Columbus and Franklin County (Ohio) Health Departments participated in four one-half day small group, highly interactive modules conducted during a 2-year period. The purpose of this article is to describe the design and implementation of this workforce intervention, the lessons learned, and implications for developing organizational capacity and improved performance.

EKG analysis skills of family practice residents in the United Arab Emirates: a comparison with US data.

BACKGROUND AND OBJECTIVES: Concern has been raised about the electrocardiogram (EKG) analysis skills of family practice residents in the United States. This study examined EKG analysis skills of family practice residents, medical students, interns, and general practitioners (GPs) in the United Arab Emirates (UAE), a different environment. METHODS: The measurement instrument was a set of 10 EKGs, used in a study of US family practice residents. Two of the EKGs were normal, and there were 14 clinical abnormalities in the remainder. RESULTS: There was no significant difference in the correct diagnosis of acute myocardial infarction between US family practice residents and UAE family practice residents, medical students, or GPs. Interns' diagnoses were significantly poorer. The mean score for correctly identifying acute myocardial infarction and both normal EKGs was not significantly different between groups: 2.50 medical students, 2.35 interns, 2.58 UAE family practice residents, 2.67 FD, and 2.55 US family practice residents. However, the US family practice resident mean score of 11.26 for all 16 clinical findings was significantly higher than any group in the UAE: 5.35 medical students, 5.87 interns, 6.08 UAE family practice residents, 5.69 family physicians. CONCLUSIONS: Difficulty in EKG interpretation transcends geographic boundaries, suggesting that new approaches to teaching these skills need to be explored. Improved EKG reading skills by family physicians are generally needed in both the United States and the UAE.

Institutionalized older adults in a health district in the United Arab Emirates: health status and utilization rate.

BACKGROUND: Little is known about the rate of institutionalization and health status of nursing home (NH) type patients living in the Middle East. This study was set in the Al-Ain Medical District, a geographically discrete region of the United Arab Emirates, a country with a developing economy located on the shores of the Arabian Gulf. NH-type patients were defined as people aged 60 years and older who were admitted to a hospital or a long-term institutionalized setting for at least 6 weeks and with no evidence of an expectation of discharge at the time of the evaluation. OBJECTIVE: To determine the clinical, functional, cognitive, and nutritional status of NH-type patients living in a defined community within a developing country. METHOD: Cross-sectional survey. RESULTS: All NH-type patients were identified, and all were included in this study (n = 47, 100% participation rate). All were located within three public institutions, none of which was a dedicated NH facility. The rate of institutionalization was 7.0-14.0 per 1,000 people aged 65 or older. The age distribution was 30% (60-74 years), 49% (75-84 years), and 21% (85+ years). The length of stay was 3.8 years. The female:male ratio was 1.6. All except 1 had a neurological disorder, and 89% had dementia. The cognitive deficits were severe with only 61% alert, 41% able to speak, 17% orientated in place, and 15% orientated in time. The functional status was also poor: 98% received assistance with all instrumental activities of daily living, 85% received assistance with five activities of daily living, and 94% were bed bound. The nutritional status was also impaired with a mean body weight of 45 +/- 14 kg and a mean albumin level of 3.1 +/- 0.6 g/dl. When compared with the USA data from the National Center for Health Statistics, the study population was younger, had a longer length of stay, a lower female:male ratio, a higher rate of neurological diseases and dementia, and were far more dependent and disoriented. The rate of institutionalization was one sixth to one third of that in the USA. CONCLUSION: From these data we concluded that this region has a distinctly different population of institutionalized older people who demonstrate greater impairments in all domains of health status.

Primary health care patients' knowledge about diabetes in the United Arab Emirates.

This study defined the baseline level of knowledge about diabetes and the perceived effectiveness of sources of diabetes information in an urban primary health care centre in Al-Ain. A validated questionnaire was administered to 300 randomly chosen adult patients with diabetes. Patient knowledge about diabetes was directly related to their level of general education. Written and electronic media, and contact with a nurse or doctor were effective sources of education on diabetes while "conversation with significant others", dietician or pharmacist were not effective. Nurse- or doctor-centred education appears to be an effective choice for future programmes to provide information to patients with diabetes.

Preliminary application of liquid chromatography-electrospray-ionization mass spectrometry to the detection of 5-methyltetrahydrofolic acid monoglutamate in human plasma.

Liquid chromatography (LC) in direct combination with mass spectrometry (MS) has been shown to be a good analytical technique for the selective separation and detection of labile folate monoglutamates. Reversed-phase LC and electrospray-ionization MS conditions were developed and optimized for the separation and detection of 5-methyltetrahydrofolic acid, 5-formyl tetrahydrofolic acid, tetrahydrofolic acid, dihydrofolic acid and folic acid in aqueous samples. Representative and reproducible positive ion mass spectra were generated for each folate under mild MS conditions. The selective MS detection and identification of endogenous 5-methyltetrahydrofolic acid in human plasma was accomplished through the development of a straightforward C18-based solid-phase extraction procedure. This procedure allows for the qualitative assessment of 5-methyltetrahydrofolic acid in plasma. Based upon an isotope-dilution internal standard calibration study with standards, the LC-MS limit of quantitation for 5M-THF was estimated to be 0.39 ng/mnl.