Family Medicine Musculoskeletal Medicine Education: A CERA Study.

BACKGROUND AND OBJECTIVES: Musculoskeletal (MSK) concerns constitute up to 40% of primary care outpatient visits. Despite Accreditation Council for Graduate Medical Education (ACGME) family medicine program requirements for musculoskeletal medicine and sports medicine training, previous studies have shown that family medicine residency graduates do not have adequate training to manage common musculoskeletal conditions. Factors for this may include deficiencies in education at both the undergraduate and graduate medical education training levels. METHODS: A Council of Academic Family Medicine Educational Research Alliance survey of 287 family medicine program directors assessed the current state of the delivery of musculoskeletal medicine education. Opinions were gathered on the scope and delivery of training requirements as well as potential areas for further curricular attention. RESULTS: Two hundred eighty-seven program directors responded to the survey (response rate 41.53%). Most (72.60%) were in university based or affiliated programs and had a fellowship-trained primary care sports medicine physician (59.85%) curricular lead. A majority (77.4%) did not feel that PGY-1 residents enter residency with the physical exam skills needed to evaluate common musculoskeletal (MSK) conditions , and most (81.15%) did not feel that there should be changes to the current ACGME requirements. An area highlighted for further investment is faculty development in point-of-care ultrasound (39.85%). CONCLUSIONS: Although program directors believe that current ACGME MSK curricular requirements are likely appropriate, they do not feel residents arrive with the examination skills needed to evaluate common MSK conditions.Therefore, further attention can be given to medical student education in musculoskeletal exam skills prior to residency. Future research should develop objective measures using multiple assessors-students, residents, teaching faculty, and patients-to assess both the baseline and graduating competency in MSK medicine of our residents.

Correct disulfide pairing is required for the biological activity of crustacean androgenic gland hormone (AGH): synthetic studies of AGH.

Androgenic gland hormone (AGH) of the woodlouse, Armadillidium vulgare, is a heterodimeric glycopeptide. In this study, we synthesized AGH with a homogeneous N-linked glycan using the expressed protein ligation method. Unexpectedly, disulfide bridge arrangement of a semisynthetic peptide differed from that of a recombinant peptide prepared in a baculovirus expression system, and the semisynthetic peptide showed no biological activity in vivo. To confirm that the loss of biological activity resulted from disulfide bond isomerization, AGH with a GlcNAc moiety was chemically synthesized by the selective disulfide formation. This synthetic AGH showed biological activity in vivo. These results indicate that the native conformation of AGH is not the most thermodynamically stable form, and correct disulfide linkages are important for conferring AGH activity.

Lymphoepithelioma-like carcinoma of the uterine cervix.

PURPOSE: To elucidate the clinicopathologic features of lymphoepithelioma-like carcinoma (LELC) of the uterine cervix, we examined three Japanese cases. METHODS: We collected three cases of LELC of the uterine cervix between 2000 and 2007. We examined these patients' clinicopathologic data, Epstein-Barr virus (EBV) and human papilloma virus (HPV) infectious status, and infiltrated lymphocyte population. RESULTS: Our patients had disease Fédération Internatinale de Gynécologie et d'Obstétrique stages I and II. All of them were free of disease at the time of the study. Macroscopically, one of the three tumors was polypoid. All tumor cells were negative for EBV and HPV using in situ hybridization and immunohistochemistry. The inflammatory background contained many CD3(+) and CD8(+) cells, but there were few CD4(+), CD20(+), or CD79a(+) cells. CONCLUSIONS: In our Japanese series, LELC of the uterine cervix showed good prognosis, and there is no relationship between this carcinoma and EBV or HPV infection.

Intrauterine growth restriction and the proliferation of smooth muscle cells in umbilical vessels.

AIMS: The purpose of this study was to investigate the proliferation of smooth muscle cells in umbilical vessels of fetuses affected by intrauterine growth restriction (IUGR) and to compare the findings with gestational age-matched control cases. METHODS: Sixty umbilical cords from fetuses at 36-37 weeks gestation were examined. Fetuses were divided into three groups: group I, appropriate for dates birthweight; group II, IUGR with reassuring fetal status; and group III, IUGR with abnormal umbilical Doppler waveforms. Umbilical cords were immunostained with an antibody to proliferating cell nuclear antigen and Ki-67; stained smooth muscle cells were subsequently counted. Smooth muscle cell density was determined by counting the total number of cells in a representative area of vessel wall and the wall thickness of each vessel was also measured. RESULTS: Proliferation marker-positive cells were increased in the umbilical vessels of group II compared to group I, and there were more proliferating smooth muscle cells in the umbilical vessels of group III compared to the other two groups. The umbilical vessels of group III showed the highest smooth muscle cell density, but the wall thickness of all vessels was significantly thinner in group III than the other two groups. CONCLUSIONS: This study showed overproliferation of smooth muscle cells in the umbilical vessel walls associated with IUGR. It is hypothesised that hypoxia might induce this overproliferation given the further proliferation in IUGR fetuses with abnormal umbilical Doppler waveforms. Coexistence of a high cell density and lean vessel walls suggests small smooth muscle cells in umbilical vessels with IUGR.

Relationship between urinary albumin and serum soluble fms-like tyrosine kinase 1 (sFlt-1) in normal pregnancy.

OBJECTIVE: To investigate if the circulating level of soluble fms-like tyrosine kinase 1 (sFlt-1) and vascular endothelial growth factor (VEGF) correlates with urinary albumin excretion in normal pregnancy. STUDY DESIGN: Serum specimens and 24h urine collections were requested from normal pregnant women at 28-30 weeks of gestation and the following laboratory tests were performed: serum creatinine, urinary protein, urinary albumin and creatinine clearance. For the present study, 117 normal pregnant women were selected as subjects. Subjects' serum was tested to determine sFlt-1 and VEGF concentrations by ELISA. The correlation between sFlt-1 or VEGF concentrations in the serum and renal laboratory variables were analyzed. Simple regression was used to evaluate the correlations. RESULTS: A significant association was noted between serum sFlt-1 concentration and urinary albumin excretion (r=0.68; P<.0001). Similarly, a significant association was noted between serum VEGF concentration and urinary albumin excretion (r=-0.39; P<.0001). Other urinary variables showed no correlations with either sFlt-1 or VEGF. CONCLUSION: Even in normal pregnancy, albumin excretion is affected by an increase in placentally derived sFlt-1. If the sFlt-1 level is kept within normal range, only glomerular endothelial cells are affected and this phenomenon does not spread to the endothelial cells of a whole body.