Medical teachers conceptualize a distinctive form of clinical knowledge.

For over four decades, there have been efforts to specify the types of knowledge that medical students need, how that knowledge is acquired and how its constituent parts are related. It is one of the areas of continuing concern underlying medical education reform. Despite their importance to medical students' learning and development, the perspectives of medical teachers in hospitals are not always considered in such discourse. This study sought to generate an understanding of these teachers' values, perspectives and approaches by listening to them and seeing them in their everyday teaching work, finding and understanding the meanings they bring to the work of medical teaching in hospitals. In interviews, all of the teachers talked more about the optimal forms of knowledge that are important for students than they talked about the form of the teaching itself. Many revealed to students what knowledge they do and do not value. They had a particular way of thinking about clinical knowledge as existing in the people and the places in which the teaching and the clinical practice happen, and represented this as 'real' knowledge. By implication, there is other knowledge in medical education or in students' heads that is not real and needs to be transformed. Their values, practices and passions add texture and vitality to existing ways of thinking about the characteristics of clinical knowledge, how it is depicted in the discourse and the curriculum and how it is more dynamically related to other knowledge than is suggested in traditional conceptualizations of knowledge relationships.

Postprostatectomy ultrasound-guided transrectal implantation of gold markers for external beam radiotherapy. Technique and complications rate.

BACKGROUND AND PURPOSE: Postprostatectomy radiotherapy (RT) improves survival in adjuvant and salvage settings. The implantation technique and complications rate of gold markers in the prostate bed for high-precision RT were analyzed. PATIENTS AND METHODS: Patients undergoing postprostatectomy RT for prostate-specific antigen (PSA) relapse or high-risk disease were enrolled in the study. Under transrectal ultrasound guidance, three fine gold markers were implanted in the prostate bed and the technical difficulties of insertion were documented. Patients received our self-designed questionnaires concerning complications and pain. The influence of anticoagulants and coumarins on bleeding was analyzed, as was the effect of potential risk factors on pain. RESULTS: In 77 consecutive patients, failure of marker implantation or marker migration was seen in six cases. Rectal bleeding was reported by 10 patients and 1 had voiding complaints. No macroscopic hematuria persisting for more than 3 days was observed. Other complications included rectal discomfort (n = 2), nausea (n = 1), abdominal discomfort (n = 1), and pain requiring analgesics (n = 4). No major complications were reported. On a 0-10 visual analogue scale (VAS), the mean pain score was 3.7. No clinically significant risk factors for complications were identified. CONCLUSION: Transrectal implantation of gold markers in the prostate bed is feasible and safe. Alternatives like cone beam computed tomography (CBCT) should be considered, but the advantages of gold marker implantation for high-precision postprostatectomy RT would seem to outweigh the minor risks involved.

A proposal for funding and monitoring medical education supervision in expanded clinical settings--a 'meducation' card.

CONTEXT: Entry to practice medical programs (graduate- and undergraduate-entry) in Australia are under considerable pressure to provide clinical training as a result of increased student numbers. At the same time modern medical curricula require the development of active placements in expanded settings to achieve graduate medical practitioners who are clinically able. These dual imperatives require a mechanism to fund and maintain the quality of clinical placements outside the traditional hospital setting. ISSUE: For teaching outside traditional teaching hospitals the Australian government's Practice Incentives Program (PIP) currently provides a student-related payment of AU$100 for each half-day teaching session in a general practice setting. This payment is not linked to the quality of the placement and does not support clinical placements in other settings, for example specialist consulting rooms or allied health practices. SOLUTION: This short communication proposes a 'meducation' card as an efficient funding mechanism to facilitate an expansion of quality clinical placements in expanded settings including specialist and allied health practices. This student meducation card would use current Medicare Australia infrastructure to facilitate the payment of clinical teachers in expanded settings. Meducation payments would only be available to practitioners and practices that maintain quality teaching practices certified by medical or allied health schools.

Comparison of positive lymph node ratio with an inflammation-based prognostic score in colorectal cancer.

BACKGROUND: Two prognostic scoring systems have been proposed in colorectal cancer: the pathologically based positive lymph node ratio (pLNR) and the inflammation-based modified Glasgow Prognostic Score (mGPS). This study compared these two scores with the tumour node metastasis (TNM) staging system in terms of cancer survival. METHODS: Between 2003 and 2005, 206 patients, of mean(s.d.) age 69·9(10·6) (range 40-95) years, underwent curative resection for colorectal cancer in two centres. Age, sex, primary tumour site and whether radio/chemotherapy was given were recorded in addition to the three scores (TNM stage, pLNR and mGPS). Univariable and multivariable analyses of overall survival were performed. RESULTS: Age, rectal cancer, TNM stage, pLNR and mGPS were significant factors in univariable analysis. On multivariable analysis, N category and tumour stage (I-III) were removed from the model, leaving pLNR and mGPS as independent predictors of overall survival: hazard ratio 1·51 (95 per cent confidence interval 1·24 to 1·84; P < 0·001) and 1·56 (1·18 to 2·08; P = 0·020) respectively. C-statistic analysis, used to compare pLNR and mGPS directly, found only pLNR to be significant (P < 0·001) CONCLUSION: This study found pLNR to be the superior prognostic scoring system in determining long-term survival in patients undergoing resection for colorectal cancer.

Inflammatory arthritis-like and other MR findings in wrists of asymptomatic subjects.

OBJECTIVE: To describe magnetic resonance (MR) imaging findings in the wrists of asymptomatic subjects that might be confused with pathologic findings. DESIGN: MR examination of the dominant wrist was performed in 30 asymptomatic volunteers aged 22-49 years using pre-contrast and post-contrast sequences in the coronal and axial planes. The bases of the metacarpals, the carpus and the distal radius and ulna were evaluated by two musculoskeletal radiologists for lesions, notches, blood vessels and synovial enhancement. RESULTS: There were 24 bright osseous lesions (erosions, intraosseous ganglia, oedema or cysts) in 14 subjects. Intraosseous blood vessels were seen in all but one wrist examined, most commonly in the capitate and lunate bones. Enhancement was present in 26 of 27 notches identified at the base of the second metacarpal and less commonly in the capitate, hamate and triquetral notches. A small joint effusion was present in 14 subjects. Joint or soft-tissue enhancement was identified in 16 wrists. CONCLUSIONS: Many MR abnormalities and variants may be detected in the wrists of asymptomatic subjects. Many of these could be confused with pathologic findings usually associated with inflammatory arthritis.

Tumour necrosis factor antagonists improve disease activity but not arterial stiffness in rheumatoid arthritis.

OBJECTIVES: Systemic inflammation may play an important role in the accelerated atherosclerosis and increased cardiovascular mortality of rheumatoid arthritis (RA). Atorvastatin reduced arterial stiffness in RA patients after only 6 weeks, an effect that may be partially mediated by the immunomodulatory effects of this drug. Suppression of inflammation with tumour necrosis factor (TNF) antagonists may therefore also improve vascular function in RA; however, TNF antagonists have also been shown to cause or exacerbate congestive heart failure in patients with RA and heart failure. The aim of the present study was to examine the effect of treatment with TNF antagonists on arterial stiffness in RA patients with active disease. METHODS: Fourteen RA patients (age 55.1 +/- 3.8 yr; disease duration 7.9 +/- 1.3 yr) with high disease activity [disease activity score (DAS28) 7.1 +/- 0.3] commencing treatment with TNF antagonists for the first time were studied. Clinical status and arterial stiffness were measured before and after 6 weeks of TNF antagonist therapy (etanercept, adalimumab or infliximab). RESULTS: Arterial stiffness did not change during the study period (the mean augmentation index was 29.1 +/- 2.2% at baseline vs 30.1 +/- 1.8% at week 6; P = 0.504). The DAS28 improved significantly from 7.1 +/- 0.3 to 4.3 +/- 0.4 (P < 0.0001). The erythrocyte sedimentation rate and C-reactive protein [median (range)] were reduced from 44 (12-85) to 15 (3-82) mm/h (P = 0.02) and from 34 (3-95) to 10 (2-61) mg/l (P = 0.007), respectively. CONCLUSIONS: Despite significant reductions in synovitis and inflammatory markers in these RA patients, arterial stiffness was not improved by 6 weeks of treatment with TNF antagonists. This result is of relevance given recent reports of potential adverse cardiovascular effects of TNF antagonists in some RA patients.

Efficacy of physiotherapy management of knee joint osteoarthritis: a randomised, double blind, placebo controlled trial.

OBJECTIVE: To determine whether a multimodal physiotherapy programme including taping, exercises, and massage is effective for knee osteoarthritis, and if benefits can be maintained with self management. METHODS: Randomised, double blind, placebo controlled trial; 140 community volunteers with knee osteoarthritis participated and 119 completed the trial. Physiotherapy and placebo interventions were applied by 10 physiotherapists in private practices for 12 weeks. Physiotherapy included exercise, massage, taping, and mobilisation, followed by 12 weeks of self management. Placebo was sham ultrasound and light application of a non-therapeutic gel, followed by no treatment. Primary outcomes were pain measured by visual analogue scale and patient global change. Secondary measures included WOMAC, knee pain scale, SF-36, assessment of quality of life index, quadriceps strength, and balance test. RESULTS: Using an intention to treat analysis, physiotherapy and placebo groups showed similar pain reductions at 12 weeks: -2.2 cm (95% CI, -2.6 to -1.7) and -2.0 cm (-2.5 to -1.5), respectively. At 24 weeks, pain remained reduced from baseline in both groups: -2.1 (-2.6 to -1.6) and -1.6 (-2.2 to -1.0), respectively. Global improvement was reported by 70% of physiotherapy participants (51/73) at 12 weeks and by 59% (43/73) at 24 weeks. Similarly, global improvement was reported by 72% of placebo participants (48/67) at 12 weeks and by 49% (33/67) at 24 weeks (all p>0.05). CONCLUSIONS: The physiotherapy programme tested in this trial was no more effective than regular contact with a therapist at reducing pain and disability.

Tumour necrosis factor inhibitors: risks and benefits in patients with rheumatoid arthritis.

Rheumatoid arthritis (RA) is the most common form of inflammatory arthritis and can, if left untreated, result in significant disability and early death. It is also associated with large direct and indirect costs to the individual and to society. Early and aggressive disease modifying anti-rheumatic drug (DMARD) treatment of patients at risk of erosive disease has improved the outcome in the majority, but not all, RA patients. Tumour necrosis factor (TNF) appears to be a key mediator of the inflammatory and destructive process in RA, and consequently inhibitors of TNF action have been tested in randomized controlled trials in patients with RA. The results of these studies have suggested that TNF inhibitors are potent DMARD particularly when combined with methotrexate. They appear well tolerated with the commonest adverse events related to their parenteral route of administration, and the serious but rare side-effects being various infections, notably tuberculosis, multiple sclerosis, and worsening of cardiac failure. Treatment costs are high and range from $15 000 to $25 000 per patient per year. Etanercept, adalimumab and infliximab have recently been subsidised under the Pharmaceutical Benefits Scheme in Australia for patients with severe DMARD-resistant RA. The availability of TNF inhibitors in RA represents a significant advance in the treatment of patients with severe RA.

Atorvastatin reduces arterial stiffness in patients with rheumatoid arthritis.

BACKGROUND: Chronic systemic inflammation may contribute to accelerated atherosclerosis and increased arterial stiffness in patients with rheumatoid arthritis (RA). In addition to lowering cholesterol, statins have immunomodulatory effects which may be especially beneficial in patients with RA who have systemic immune activation. OBJECTIVE: To investigate the effect of atorvastatin on the augmentation index (AIx: a measure of arterial stiffness) and systemic inflammation in RA. METHODS: 29 patients with RA (mean (SD) age 55 (13) years) with moderately active disease of long duration were studied. AIx, lipid levels, serum inflammatory markers, and disease activity score were measured before and after 12 weeks of atorvastatin 20 mg daily. RESULTS: AIx improved significantly from 34.1 (11.6)% to 29.9 (11)% (p = 0.0002), with the greatest improvements in AIx occurring in those subjects with the highest disease activity scores (r = -0.5, p = 0.007). Total and LDL cholesterol were reduced from 5.5 (0.9) to 3.9 (0.7) mmol/l and 3.3 (0.8) to 1.9 (0.6) mmol/l, respectively (p = 0.0001). Serum inflammatory markers remained unchanged during the study. CONCLUSIONS: Atorvastatin significantly reduced arterial stiffness in patients with RA. The greatest improvements were seen in patients with more active disease, suggesting that, in addition to the beneficial effects of cholesterol reduction, immune modulation may contribute to the cardioprotective effect of statins.

Screening for atherosclerosis in patients with rheumatoid arthritis: comparison of two in vivo tests of vascular function.

OBJECTIVE: Inflammation appears to play a central role in atherosclerosis, and endothelial damage mediated by systemic inflammation may contribute to the increased cardiovascular mortality in rheumatoid arthritis (RA). Brachial artery flow-mediated dilatation (FMD) and pulse wave analysis (PWA) are measures of vascular function. The aim of this study was to determine if FMD and PWA are abnormal in patients with RA. METHODS: Twenty-five RA patients and 25 matched healthy controls were studied. All were free of traditional cardiovascular risk factors. FMD was measured in all subjects. PWA was performed in 18 RA patients and 18 controls, with results expressed as large and small artery compliance (C1 and C2). Modified Sharp scores were calculated in 13 RA patients. RESULTS: Results (mean +/- SD) in RA patients and controls, respectively, were as follows: FMD 107.6 +/- 4.6% versus 108.5 +/- 4.1% (P = 0.49), C1 14.8 +/- 2.8 ml/mm Hg x 10 versus 17.9 +/- 3.1 ml/mm Hg x 10 (P = 0.0033), C2 4.5 +/- 2.3 ml/mm Hg x 100 versus 7.7 +/- 3.7 ml/mm Hg x 100 (P = 0.0039). There was an inverse correlation between C2 and modified Sharp scores in the RA patients (Spearman's rho -0.69, P = 0.0085). CONCLUSION: FMD was normal in these RA patients, whereas arterial compliance was markedly reduced. PWA appears to be a more sensitive measure of vascular dysfunction than FMD in RA and may be the preferred surrogate marker of vascular dysfunction in longitudinal studies of RA patients. The inverse correlation between C2 and the modified Sharp score, a measure that reflects disease activity over time, supports the notion that chronic inflammation plays a role in RA-associated atherosclerosis.

The effect of ball carrying method on sprint speed in rugby union football players.

Different methods of ball carrying can be used when a player runs with the ball in rugby union. We examined how three methods of ball carrying influenced sprinting speed: using both hands, under the left arm and under the right arm. These methods were compared with running without the ball. Our aim was to determine which method of ball carrying optimizes sprinting speed. Altogether, 48 rugby union players (age 21 +/- 2 years, height 1.83 +/- 0.1 m, body mass 85.3 +/- 12 kg, body fat 14 +/- 5%; mean +/- s) were recruited. The players performed twelve 30-m sprints in total (each player performed three trials under each of three methods of carrying the ball and sprinting without the ball). The design of the study was a form of Latin rectangle, balanced across the trial order for each of the methods and for pairwise combinations of the methods in blocks of four per trial. Each sprint consisted of a 10-m rolling start, followed by a 20-m timed section using electronic timing gates. Compared with sprinting 20 m without the ball (2.58 +/- 0.16 s), using both hands (2.62 +/- 0.16 s) led to a significantly slower time (P < 0.05). Sprinting 20 m with the ball under the left arm (2.61 +/- 0.15 s) or under the right arm (2.60 +/- 0.17 s) was significantly quicker than when using 'both hands' (P < 0.05), and both these methods were significantly slower than when running without the ball (P < 0.05). Accordingly, running with the ball in both hands led to the greatest decrement in sprinting performance, although carrying the ball under one arm also reduced the players' sprinting ability. Our results indicate that to gain a speed advantage players should carry the ball under one arm.

Early rheumatoid arthritis: can we predict its outcome?

The continuing trend towards more aggressive treatment of rheumatoid arthritis (RA) has seen an increasing interest in the early phase of this chronic inflammatory disease. Optimal benefit from present and emerging therapies is limited by our prognostic abilities during this period. The present review attempts to outline first the many methodological issues encountered in studies of early RA, and second the extent to which each major outcome measure can be explained, both by readily available clinical variables and by HLA-DR genotyping. The evidence supporting the clinical usefulness of genotyping is discussed separately. Based on this information, a clinically appropriate approach to the management of early RA and the identification of patients suitable for experimental therapies is suggested.

Heat shock protein accumulation is upregulated in a long-lived mutant of Caenorhabditis elegans.

We present evidence for elevated levels of heat shock protein 16 (HSP16) in an intrinsically thermotolerant, long-lived strain of Caenorhabditis elegans during and after heat stress. Mutation of the age-1 gene, encoding a phosphatidylinositol 3-kinase catalytic subunit, results in both extended life span (Age) and increased intrinsic thermotolerance (Itt) in adult hermaphrodites. We subjected age-synchronous cohorts of worms to lethal and nonlethal thermal stress and observed the accumulation of a small (16-18 kd) heat-shock-specific polypeptide detected by an antibody raised against C. elegans HSP16. Strains carrying the mutation hx546 consistently accumulated HSP16 to higher levels than a wild-type strain. Significantly, overaccumulation of HSP16 in the age-1(hx546) strain following heat was observed throughout the adult life span. A chimeric transgene containing the Escherichia coli beta-galactosidase gene fused to a C. elegans HSP16-41 transcriptional promoter was introduced into wild-type and age-1(hx546) backgrounds. Heat-inducible expression of the transgene was elevated in the age-1(hx546) strain compared with the wild-type strain under a wide variety of heat shock and recovery conditions. These observations are consistent with a model in which Age mutations exhibit thermotolerance and extended life span as a result of elevated levels of molecular chaperones.

What's new in rheumatoid arthritis? An evidenced based review.

BACKGROUND: Rheumatoid arthritis (RA) is the most common inflammatory arthritis and has been associated with significant functional impairment and a shortened life expectancy. Fortunately, over the past 10 years, there has been a significant change in its management, which has resulted in improved outcomes for RA patients. OBJECTIVE: To critically appraise the recent evidence which affects the contemporary management of RA. DISCUSSION: The bulk of recent evidence suggests that disease modifying anti-rheumatic drugs (DMARDs) should be commenced early and continued indefinitely in RA patients. Single DMARD therapy may be sufficient in some patients but combinations, particularly those which include methotrexate, improve symptomatic and radiological outcomes. The use of newer therapies, including leflunomide and tumour necrosis factor-alpha blocking drugs, promise to further improve these outcomes.

Prolonged prodrome, systemic vasculitis, and deafness in Cogan's syndrome.

Cogan's syndrome is a rare, multisystem disease which occurs predominantly in children and young adults. It was originally described as the combination of interstitial keratitis and audiovestibular disturbance, but other forms of ocular disease, as well as systemic vasculitis, have since been recognised as part of the syndrome. Diagnosis can be difficult if the various manifestations occur separately, but early recognition is important because prompt treatment may prevent deafness. Two cases are presented here illustrating the features of this disease, and providing histological evidence of systemic vasculitis in both.

Pharmacological therapies for the treatment of osteoarthritis.

Non-pharmacological interventions are the first-line therapy for osteoarthritis. If non-pharmacological therapy fails, paracetamol (up to 4 g daily) should be added. If paracetamol fails, the patient's risk factors for gastrointestinal and renal disease should be assessed. In patients with gastrointestinal risk factors, a COX-2-specific inhibitor (CSI) would be used in preference to a conventional non-steroidal anti-inflammatory drug (NSAID). In patients with renal risk factors, NSAIDs and CSIs should be used with care. In patients who continue to have problems, other treatments should be considered; these might include intra-articular hyaluronan or depot corticosteroid, analgesia or glucosamine.

Common corticosteroid injections. An anatomical and evidence based review.

BACKGROUND: The injection of depot corticosteroid preparations into soft tissues and joints has been used for some time to alleviate pain in a variety of musculoskeletal conditions. However the evidence, supporting the efficacy for these procedures, until recently, has been poor. OBJECTIVES: To review the recent literature on the efficacy and toxicity of commonly used corticosteroid injections in musculoskeletal medicine and to illustrate the key anatomy of the injection sites. DISCUSSION: Injections of corticosteroid into the lateral epicondyle, subacromial bursa, carpal tunnel, knee and plantar fascia all result in short term (weeks to months) alleviation of pain and other symptoms in the studies reviewed. The natural history of these conditions, however, is that the majority of patients improve over longer periods (months to a year) whether or not an injection has been given.

SAPHO: rare or just not recognized?

OBJECTIVE: The SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome describes an association between musculoskeletal disorders, in particular hyperostosis involving the bones and joints of the anterior chest wall, and various dermatologic conditions. It has been reported in Europe and Japan, but no Australian series have been published. We describe the clinical, laboratory, and radiographic features of a group of patients with the SAPHO syndrome and compare this with the literature. METHODS: We performed a retrospective review of patients seen in our department between 1990 and 1998 who met the proposed diagnostic criteria for SAPHO. Information regarding age, sex, disease duration, skeletal site(s) of disease, presence of skin disease, previous treatment, and response to treatment was collected. Laboratory tests were reviewed, as was all available radiology and bone scintigraphy. RESULTS: Six women with a mean age of 40 years fulfilled the criteria for SAPHO. The skeletal manifestations were similar to those reported in the literature, with hyperostosis of the anterior chest wall being the central feature. Cervical spine and pubic bone were other sites of involvement, whereas sacroiliitis and peripheral joint synovitis were not seen. Skin disease was less frequent in our population than has been reported in other series. Nonsteroidal anti-inflammatory drugs were frequently prescribed as first-line treatment but had limited efficacy. Intravenous pamidronate was administered to two patients, resulting in complete resolution of pain in one patient and 50% reduction in pain in the other. CONCLUSIONS: The SAPHO syndrome may be underrecognized as the skin manifestations in our patients were mild or absent. Although optimal treatment for these patients remains unclear, it is important to make the diagnosis of SAPHO to avoid unnecessary investigations and treatment.