Development of a Near Peer Clinical Anatomy Review Session during the Surgery Clerkship: Pre- and Post-Test Results among Third Year Medical Students.

Introduction: Our institution created a review of anatomy relevant to general surgery for third-year medical students. This study was designed to evaluate this review program and determine if participation increased third-year medical students' anatomy knowledge and confidence identifying anatomical structures in the operating room. Methods: A formalin-embalmed cadaver-based review of anatomy was created and taught in near-peer fashion to third-year medical students. An anonymous survey and anatomy test were administered to participants pre- and post-session. The survey and test were designed to evaluate anatomy knowledge as well as student confidence identifying structures in the operating room. Survey data were compared using the Wilcoxon signed rank test. Results: Seventy third-year medical students completed the anatomy review. There was a statistically significant improvement in students' confidence levels identifying structures in the operating room (p < 0.001) and in anatomy test scores (p < 0.001). Subjectively, students were thankful for the review session and found it helpful. Conclusions: This near-peer review session designed at our institution was successful in improving immediate anatomy test scores and confidence levels identifying structures in the operating room. A course similar to this could be included at other medical schools to improve medical student confidence in identifying relevant anatomic structures in the operating room.

Why Have So Many Intravascular Glucose Monitoring Devices Failed?

Secondary to the inherent limitations of both point-of-care and central laboratory glucose technologies, continuous glucose measurement has recently enjoyed a high level of investment. Because of the perceived advantages by some of measuring in the intravascular space compared to the subcutaneous tissue, a number of technologies have been developed. In this review, we evaluate nine systems that have shown promise, although only one of these has been cleared for sale in the United States. The detection methodology, regulatory status, technical issues, and company circumstance surrounding each technology are examined.

billingsMentor: Adapting natural family planning to information technology and relieving the user of unnecessary tasks.

BillingsMentor is an automated Web-based service for the Billings Method of natural family planning in which the guidance and interpretation previously communicated from teacher to student is provided by programmed algorithms. There are two functions: (1) to instruct the client to generate proper descriptions of her fertility symptoms; and (2) to interpret the symptoms efficiently according to the Billings Method and to communicate the results to the client. The efficiency of billingsMentor was tested by using the historical records of students who were under the guidance of a teacher to emulate their experience under the guidance of billingsMentor. The results indicate that billingsMentor performs as well as the teacher/student in recognizing the peak of fertility but it is slightly less efficient than the teacher/student in establishing the basic infertile pattern. Advantages that arise from adapting natural family planning to information technology are discussed.

Sharing kidneys across donor-service area boundaries with sensitized candidates can be influenced by HLA C.

The United Network for Organ Sharing (UNOS) implemented the virtual crossmatch system in UNet as a way to improve the likelihood of a negative crossmatch when kidneys are shared with HLA-sensitized candidates across donor service area (DSA) boundaries. The role of HLA C in that process is not universally appreciated. We recently experienced an unexpected positive flow T and B cell crossmatch for an imported, HLA zero-mismatched kidney because of donor-specific HLA C antibodies and transplanted it into the backup candidate. HLA C locus antigens were not typed by the OPO's laboratory that sent the kidney so the UNet virtual crossmatch could not "strike" our candidate from the UNOS match run. HLA C locus typing data of donors for kidneys our DSA imported from other DSAs revealed that C typing was not performed in 23% (14/60) and was discrepant with our molecular type for 10% (6/60) and was concordant in 67% (40/60) of cases. The rate of positive donor-specific crossmatches was higher (83%) for HLA C discrepantly typed donors than for concordantly typed donors (44%). Sensitization for HLA C (42%) is less frequent than for A (80%) or B (83%) locus antigens but the immunogenicity of C locus antigens in patients who make C locus antibodies is equivalent in black and white patients. Finally, the transplant rate of imported kidneys into class I-sensitized candidates was 24%, and C locus-sensitized candidates comprised 55% of those transplanted.

Surgical treatment of infected prosthetic dialysis arteriovenous grafts: total versus partial graft excision.

BACKGROUND: Thirty-five percent of hemodialysis patients with polytetrafluoroethylene grafts lose their access secondary to infection. We hypothesized that partial graft excision (PGE) for infection increases the incidence of vascular anastomotic complications when compared with total graft excision (TGE). METHODS: The medical records of hemodialysis patients with a polytetrafluoroethylene graft infection from 1994 through 2004 were reviewed for PGE or TGE surgeries. RESULTS: A total of 111 infected grafts were managed surgically in 90 patients: 91 grafts by PGE and 20 grafts by TGE. Complication rates were 26.4% versus 5% in the PGE and TGE groups, respectively (P = .038). The incidence of hemorrhage and graft-associated systemic sepsis was similar, whereas the incidence of local infection was increased in the PGE group (19.8% vs. 0%, P = .030). CONCLUSIONS: Because potential access sites are limited, using PGE to salvage a site, even with a known increased incidence of local infection, represents an acceptable method for the treatment of graft infection.

Molecular analysis of T-cell receptor beta genes in cutaneous T-cell lymphoma reveals Jbeta1 bias.

Molecular characterization of T-cell receptor junctional region sequences in cutaneous T-cell lymphoma had not been previously reported. We have examined in detail the features of the T-cell receptor beta (TCRB) gene rearrangements in 20 individuals with well-defined stages of cutaneous T-cell lymphoma (CTCL) comprising 10 cases with early-stage mycosis fungoides (MF) and 10 cases with late-stage MF or Sezary syndrome. Using BIOMED-2 PCR primers, we detected a high frequency of clonally rearranged TCR gamma and TCRB genes (17/20 and 15/20 cases, respectively). We carried out sequencing analysis of each complete clonal variable (V)beta-diversity (D)beta-joining(J)beta fingerprint generated by PCR amplification, and determined the primary structure of the Vbeta-Dbeta-Jbeta junctional regions. We observed considerable diversity in the T-cell receptor Vbeta gene usage and complementarity-determining region 3 loops. Although we found that TCRB gene usage in CTCL and normal individuals share common features, our analysis also revealed preferential usage of Jbeta1 genes in all cases with advanced stages of disease.

T-cell receptor molecular diagnosis of T-cell lymphoma.

Malignant and reactive lymphoproliferations in most cases can be distinguished by histology and immunohistology alone; however, in T-cell lymphoproliferations and lymphoproliferations of unknown origin, histology often is inconclusive, and there is no reliable protein marker of malignancy. At the genomic level T-cell neoplasms clonally rearrange T-cell receptor (TCR) genes that can serve as clonal markers. In comparison with Southern blot analysis, polymerase chain reaction (PCR) techniques increasingly are being used to detect these rearrangements because PCRs are rapid, easy to perform, and can be used to amplify poor-quality deoxyribonucleic acid (DNA) from paraffin-embedded formalin-fixed biopsies. Nevertheless there are a number of problems associated with the detection of gene rearrangements using PCR. The foremost of these is improper primer annealing that will lead to false-negative or false-positive PCR results that may arise from poor primer design, especially for TCRB genes with an extensive variable (V), diversity (D), and joined (J) gene repertoire. There also can be difficulty in discriminating between clonal and polyclonal PCR products unless specific methods such as heteroduplex analysis or gene scanning are used. In this chapter, we describe methods, derived from a recent European collaborative BIOMED-2 program, for the detection of TCRG, B, and D rearrangements. TCRB VJ and DJ gene rearrangements are detected using 23 VB primers, 13 JB primers, and 2 DB primers in 3 multiplex tubes. TCRG VJ gene rearrangements are detected with four VG and two JG primers in two multiplex tubes, and TCRD VJ, VD, DJ, and DD rearrangements are detected with six VD primers, four JD primers, and two DD primers in one multiplex tube. Gaussian distributions of polyclonal PCR products are seen at specific size ranges for both TCRB and TCRG. Interpretation of TCRD rearrangements is more complex because of the wide range in PCR product size and often low numbers of TCRGD cells in target tissue. For all loci, some indication of gene usage can be ascertained by labeling the primers with different fluorochromes and gene scan analysis of PCR products. Furthermore the complementarity of the TCR loci affords an unprecedented high clonal detection rate. In addition, we also describe a set of control gene primers designed to amplify amplicons of 100, 200, 300, 400, and 600 bp for the assessment of the integrity and amplifiability of DNA.

Omenn's syndrome occurring in patients without mutations in recombination activating genes.

Omenn syndrome (OS) is characterised by hepatosplenomegaly, lymphadenopathy, erythema, eosinophilia, elevated IgE, oligoclonal T cell expansions and recombinase activating gene (RAG) mutations. We investigated 9 cases of OS to correlate genotype with immunophenotype using a two-color flow cytometry with monoclonal antibodies against CD3 and TCRVB families to map TCRVB usage. T and B clonal cell populations were examined in peripheral blood lymphocytes by PCR and sequencing of TCRB/TCRG T cell and IGH FR2/FR3 B cell products. RAG and Artemis genes were sequenced from genomic DNA. All patients demonstrated absent TCRVB families; six had predominant TCRVB families, six oligoclonal TCR gene rearrangements including TCRGD rearrangements. One demonstrated functional IGH rearrangement, an observation not previously reported. In this clinically homogeneous population, with similar immunological phenotype, RAG mutations were identified in only 2/9 patients. OS is a genetically heterogeneous condition, and patients with similar immunophenotypes may have as yet unidentified gene defects.

Gene therapy of X-linked severe combined immunodeficiency by use of a pseudotyped gammaretroviral vector.

BACKGROUND: X-linked severe combined immunodeficiency (SCID-X1) is caused by mutations in the common cytokine-receptor gamma chain (gamma(c)), resulting in disruption of development of T lymphocytes and natural-killer cells. B-lymphocyte function is also intrinsically compromised. Allogeneic bone-marrow transplantation is successful if HLA-matched family donors are available, but HLA-mismatched procedures are associated with substantial morbidity and mortality. We investigated the application of somatic gene therapy by use of a gibbon-ape-leukaemia-virus pseudotyped gammaretroviral vector. METHODS: Four children with SCID-X1 were enrolled. Autologous CD34-positive haemopoietic bone-marrow stem cells were transduced ex vivo and returned to the patients without preceding cytoreductive chemotherapy. The patients were monitored for integration and expression of the gamma(c) vector and for functional immunological recovery. FINDINGS: All patients have shown substantial improvements in clinical and immunological features, and prophylactic medication could be withdrawn in two. No serious adverse events have been recorded. T cells responded normally to mitogenic and antigenic stimuli, and the T-cell-receptor (TCR) repertoire was highly diverse. Where assessable, humoral immunity, in terms of antibody production, was also restored and associated with increasing rates of somatic mutation in immunoglobulin genes. INTERPRETATION: Gene therapy for SCID-X1 is a highly effective strategy for restoration of functional cellular and humoral immunity.

Food, health and psychology: competing recipes for research and understanding.

Mainstream and post-postivist approaches to psychological research are compared with regard to healthy eating and eating disorders. The tendency of the mainstream operationally to define key concepts is contrasted with the post-positive preference for conceptual analysis and an example of this is considered in relation to theory of planned behaviour research. The reason why the search for a causal mechanism for major eating disorders such as anorexia nervosa has proved unfruitful becomes transparent once the phenomena are construed as action, as opposed to behaviour. Some of the methodological problems and issues arising within the post-positivist approaches are discussed using illustrative examples of autoethnographic research into eating episodes.

CD3+CD4-CD8+NK- large granular lymphocytosis with neutropenia and evidence for clonality and T-cell receptor gene rearrangement: two pediatric cases.

The authors describe two pediatric cases of large granular lymphocytosis presenting early in the second decade of life with neutropenia and sepsis. They are among the youngest described in the literature. This report focuses on the advantages of detailed immunophenotypic and molecular analysis and highlights some of the controversies and uncertainties in the management of these patients, particularly the choice of immunosuppressive therapy. Immunosuppressive therapy in the two children described in this report resulted in improvement of neutropenia and clinical status, but this was not accompanied by the disappearance of the clonal population.