Influence of the HLA-Cw6 Allele and IFIH1/MDA5 Gene Variants on the Cardiometabolic Risk Profile of Patients with Psoriatic Disease.

BACKGROUND: Cardiovascular comorbidity is a common companion of psoriasis and psoriatic arthritis (PsA). Recently, a significant link has been found between the HLA-Cw6 allele and a better cardiometabolic profile in these patients. We aimed to check this finding in our setting. METHODS: A cross-sectional observational study (n: 572 psoriasis patients, 30% with PsA) was conducted. Different study variables were collected in detail, as well as classic cardiometabolic risk factors. The distribution of the HLA-Cw6 allele and the IFIH1/MDA5 gene variants previously linked to disease risk were determined in the study cohort and stratified according to the cardiometabolic comorbidity. Linear and logistic regression models were constructed to analyze these associations. RESULTS: The study cohort included 309 men and 263 women, with a mean age of 46.7 years (SD 14.5) and a mean disease duration of 19.4 years (SD 14.8). We confirmed the known association between HLA-Cw6 and type I psoriasis (familial, severe, and early onset). Psoriasis severity (OR: 2.14), female sex (OR: 1.63), and the IFIH1/MDA5 rs1990760 TT genotype (OR: 1.62) were significantly related to PsA, while HLA-Cw6 was protective (OR: 0.65). HLA-Cw6 carriers showed a lower waist perimeter, lower BMI, and lower risk of both hypertension (OR: 0.52, p < 0.001) and diabetes (OR: 0.36, p < 0.001), but these findings were no longer apparent upon adjusting the regression models. No IFIH1/MDA5 gene variant was associated with any cardiometabolic risk factor. CONCLUSIONS: The influence of HLA-Cw6 on the cardiometabolic risk profile of psoriatic patients seems to be explained by other factors (age, sex, duration of the disease or arthritis) and not by this biomarker itself.

Acroosteólisis y dismorfia facial: un nuevo caso de síndrome de Hajdu-Cheney / Acroosteolysis and facial dysmorphia: a new case of Hajdu-Cheney Syndrome

El síndrome de Hajdu-Cheney o síndrome acro-dento-osteo-displasia es una enfermedad rara caracterizada por osteólisis en banda de las falanges distales y dismorfia facial, entre otras manifestaciones. Describimos el caso de un varón de 45 años que consultó por dolor articular de características mecánicas en las manos, asociando dismorfia facial, alteraciones craneofaciales y deformidades digitales en telescopaje con acroosteólisis.(AU)

Hajdu-Cheney syndrome or acro-dento-osteo-dysplasia syndrome is a rare disease characterized by band osteolysis of distal phalanges and facial dysmorphia, among other manifestations. We present the case of a 45-year-old male who consulted for mechanical joint pain of both hands, facial dysmorphism, cranio-facial alterations, and digital telescoping with acroosteolysis.(AU)

Acroosteolysis and facial dysmorphia: a new case of Hajdu-Cheney syndrome.

Hajdu-Cheney syndrome or acro-dento-osteo-dysplasia syndrome is a rare disease characterized by band osteolysis of distal phalanges and facial dysmorphia, among other manifestations. We present the case of a 45-year-old male who consulted for mechanical joint pain of both hands, facial dysmorphism, cranio-facial alterations, and digital telescoping with acroosteolysis.

Are Patients with Axial Spondyloarthritis Who Were Breastfed Protected against the Development of Severe Disease?

BACKGROUND AND AIMS: Breastfeeding is recognized as one of the most influential drivers of the gut microbiome. In turn, alterations in the gut microbiome may play a role in the development and severity of spondyloarthritis (SpA). We aimed to analyze different disease outcomes in patients with axial SpA (axSpA) based on the history of breastfeeding. PATIENTS AND METHODS: A random sample was selected from a large database of axSpA patients. Patients were divided based on history of breastfeeding and several disease outcomes were compared. Both groups were also compared based on disease severity. Adjusted linear and logistic regression statistical methods were used. RESULTS: The study included 105 patients (46 women and 59 men), and the median age was 45 years (IQR: 16-72), and the mean age at diagnosis was 34.3 ± 10.9 years. Sixty-one patients (58.1%) were breastfed, with a median duration of 4 (IQR: 1-24) months. After the fully adjusted model, BASDAI [-1.13 (95%CI: -2.04, -0.23), p = 0.015] and ASDAS [-0.38 (95%CI: -0.72, -0.04), p = 0.030] scores were significantly lower in breastfed patients. Forty-two percent had severe disease. In the adjusted logistic model for age, sex, disease duration, family history, HLA-B27, biologic therapy, smoking, and obesity, breastfeeding had a protective effect against the development of severe disease (OR 0.22, 95%CI: 0.08-0.57, p = 0.003). The selected sample size was sufficient to detect this difference with a statistical power of 87% and a confidence level of 95%. CONCLUSION: Breastfeeding might exert a protective effect against severe disease in patients with axSpA. These data need further confirmation.

Treatment Retention and Safety of Ixekizumab in Psoriatic Arthritis: A Real Life Single-Center Experience.

Background and objectives: Information on the performance of ixekizumab (IXE) in patients with psoriatic arthritis (PsA) in clinical practice is scarce. We aimed to analyze the retention rate and safety of IXE in patients with PsA in routine clinical practice. Methods: A retrospective longitudinal observational single-center study of all patients with PsA who had received at least one dose of IXE. Adverse events (AEs) and drug retention rate were the main study focus. Survival was analyzed using Kaplan−Meier curves and predictive factors using multivariate Cox regression analysis. The hazard ratio (HR) was used as a measure of the association. Results: Seventy-two patients were included (52 women and 20 men). Median disease duration was 5 years (IQR 3−9). More than 90% received ≥2 biologic and/or targeted synthetic disease-modifying anti-rheumatic drugs (DMARDs) prior to IXE. Ixekizumab showed a 1-year retention rate of 65% and a 2-year retention rate of 57%. Regarding discontinuation due to AEs, 0.18 AEs per person-year were identified. The number of previous biologics did not influence drug survival but prior use of methotrexate (HR 2.31 (95% CI 1.05−5.10), p < 0.05) and depression (HR 2.40 (95% CI 1.07−5.41), p < 0.05) increased the risk of IXE discontinuation. Conclusions: Ixekizumab showed a good retention rate in a PsA population mostly refractory to biologic and targeted synthetic DMARDs. Drug survival was consistently good regardless of age, gender, metabolic comorbidities, smoking status, or prior number of biologic therapies. This information may be of interest to better position this drug in the PsA treatment algorithms.

Photoelectrocatalytic degradation of diclofenac with a boron-doped diamond electrode modified with titanium dioxide as a photoanode.

The electrophoretic deposition of titanium dioxide (TiO2) nanoparticles (Degussa P25) onto a boron-doped diamond (BDD) substrate was carried out to produce a photoanode (TiO2/BDD) to apply in the degradation and mineralization of sodium diclofenac (DCF-Na) in an aqueous medium using photoelectrocatalysis (PEC). This study was divided into three stages: i) photoanode production through electrophoretic deposition using three suspensions (1.25%, 2.5%, 5.0% w/v) of TiO2 nanoparticles, applying 4.8 V for 15 and 20 s; ii) characterization of the TiO2/BDD photoanode using scanning electron microscopy and cyclic voltammetry response with the [Fe(CN)6]3-/4- redox system; iii) degradation of DCF-Na (25 mg L-1) through electrochemical oxidation (EO) on BDD and PEC on TiO2/BDD under dark and UVC-light conditions. The degradation of DCF-Na was evaluated using high-performance liquid chromatography and UV-Vis spectroscopy, and its mineralization measured using total organic carbon and chemical oxygen demand. The results showed that after 2 h, DCF-Na degradation and mineralization reached 98.5% and 80.1%, respectively, through PEC on the TiO2/BDD photoanode at 2.2 mA cm-2 under UVC illumination, while through EO on BDD applying 4.4 mA cm-2, degradation and mineralization reached 85.6% and 76.1%, respectively. This difference occurred because of the optimal electrophoretic formation of a TiO2 film with a 9.17 µm thickness on the BDD (2.5% w/v TiO2, time 15 s, 4.8 V), which improved the electrocatalysis and oxidative capacity of the TiO2/BDD photoanode. Additionally, PEC showed a lower specific energy consumption (1.55 kWh m-3). Thus, the use of nanostructured TiO2 films deposited on BDD is an innovative photoanode alternative for the photoelectrocatalytic degradation of DCF-Na, which substantially improves the degradation capacity of bare BDD.

Total mercury determination in bivalves Anadara tuberculosa sold in open markets from Quito, Ecuador.

This study aimed to quantify the amount of total mercury in bivalves Anadara tuberculosa supplied from Esmeraldas Province and sold in markets in the Metropolitan District of Quito, Ecuador. The determined total mercury concentration was compared to the permissible limits established by the European Commission and World Health Organization-Food and Agriculture Organization and health risk subsequently assessed. Sampling was conducted in five open markets and involved collecting fifteen specimens from each market. Total mercury was measured through cold vapor atomic fluorescence spectrophotometry. Results showed that samples did not exceed the total mercury threshold value (0.5 mg kg-1). However, samples of Anadara tuberculosa from the Ofelia market, which receives fresh products from Eloy Alfaro canton, contained the highest mean levels of mercury contamination, 0.055 mg kg-1. This result could be associated to the influence of illegal mining activity in this area. In addition, methylmercury potential non-carcinogenic risk for consumers exceeded the threshold limit (>1) established by the US Environmental Protection Agency. The daily consumption rate (Rclim) was determined to be 26.61-38.50 g for a child weight of 14.5 kg, and 128.44-185.84 g for an adult weight of 70 kg. Thus, consuming a higher amount of Anadara tuberculosa could negatively affect human health.

La propiocepción, método de prevención de lesiones de tobillo, en deportistas de categoría superior / The proprioception, method of preventing ankle injuries in top-level athletes

Resumen El objetivo de la investigación se enmarca en analizar el efecto propiocepción como método de prevención de lesiones de tobillo, en deportistas de la categoría superior. El estudio longitudinal y explicativo se realiza en el Centro Deportivo Olmedo de la ciudad de Riobamba, a una población de 30 jugadores que representó el 100 %. La metodología empleada se enmarca en métodos de campo exploratorio y documental bibliográfico, técnicas como la entrevista, fichas de evaluación fisioterapéuticas y test modificado de Romberg. El efecto del método de propiocepción proporciona como resultado que 17 (57 %) jugadores que presentaban molestias de tobillo, se logra disminuir a seis (20 %) jugadores, a la intervención fisioterapéutica. Para el análisis y procesamiento de los datos obtenidos en la aplicación del método, se emplea el paquete estadístico SPSS, versión 22.0 IBM.

Abstract The objective of this research is framed in analyzing the proprioception effect as a method of prevention of ankle injuries in athletes of the higher category. The longitudinal and explanatory study is carried out at the Olmedo Sports Center in the city of Riobamba, to a population of 30 players that represented 100 %. The methodology used is part of exploratory and bibliographic documentary field methods, techniques such as interview, physiotherapy assessment sheets and modified Romberg test. The effect of the method of proprioception provides as a result that 17 (57 %) players who presented ankle discomfort, is reduced to six (20 %) players to the physiotherapy intervention. For the analysis and processing of the data obtained in the application of the method, the statistical package SPSS version 22.0 IBM is used.

Infecciones por bacterias multirresistentes en pacientes cirróticos en un hospital terciario / Multidrug-resistant bacterial infections in patients with liver cirrhosis in a tertiary referral hospital

Introducción: Las infecciones por bacterias multirresistentes en pacientes cirróticos se encuentran en aumento y se asocian a una mayor morbimortalidad. Objetivos: Estudiar la epidemiología y los factores de riesgo y pronósticos de las infecciones por gérmenes multirresistentes en pacientes cirróticos. Pacientes y métodos: Estudio retrospectivo en el que se analizaron a pacientes con cirrosis hepática que presentaron una infección al ingreso o durante la hospitalización entre julio del 2014 y agosto del 2016 en el Hospital Universitario y Politécnico La Fe (Valencia, España). Resultados: La infección urinaria (30,2%) y la peritonitis bacteriana espontánea (22,1%) fueron las infecciones más frecuentes. Se analizaron 102 aislamientos microbiológicos: el 50% en infecciones comunitarias, el 36% en asociadas a los cuidados de la salud y el 14% en nosocomiales. Escherichia coli fue el germen más frecuentemente aislado (29,4%). La tasa de multirresistencia fue del 28,4%. El análisis univariante mostró que la infección por gérmenes multirresistentes (28,4%) se asoció a infección nosocomial respecto a las asociadas a los cuidados de la salud (OR 5,46; IC del 95%: 1,22-24,43; p = 0,039) y asociada a los cuidados de la salud (respecto a las comunitarias OR 3,39; IC del 95%: 1,09-10,54; p = 0,048), uso de antibióticos (OR 4,37; IC del 95%: 1,59-11,99; p = 0,005) e ingreso hospitalario en los últimos 90 días (OR 3,18; IC del 95%: 1,19-8,47; p = 0,018), neoplasia activa (OR 2,93; IC del 95%: 1,08-7,99; p = 0,038) y toma de norfloxacino profiláctico (OR 3; IC del 95%: 1,02-8,79; p = 0,012). Además, se asoció a mayor frecuencia de sepsis (OR 3,13; IC del 95% 1,18-8,32; p = 0,025). El fracaso del tratamiento inicial se relacionó con mayor desarrollo de insuficiencia renal aguda (p < 0,001), sepsis (p = 0,012), shock séptico (p = 0,002), ingreso en UCI (p < 0,001) y mortalidad (p < 0,001). Conclusión: La tasa de infecciones por gérmenes multirresistentes en nuestro centro es comparable con la de otros centros europeos de características similares. Los resultados obtenidos hacen recomendable la adopción de las pautas de tratamiento antibiótico contempladas en las guías de práctica clínica actuales, limitando el uso de carbapenemes a las infecciones nosocomiales y a las asociadas a los cuidados de salud con otros factores de riesgo de multirresistencia o con signos de gravedad. Un tratamiento empírico adecuado de forma precoz se correlaciona con un mejor pronóstico

Introduction: Infections in cirrhotic patients caused by multidrug-resistant bacteria are currently increasing and are associated with greater morbidity and mortality. Objectives: To assess the epidemiology, risk factors and prognoses of infections caused by multidrug-resistant bacterial infections in cirrhotic patients. Patients and methods: Retrospective study on patients with liver cirrhosis who developed an infection during hospitalisations between July 2014 and August 2016 at our centre (Hospital Universitari i Politècnic La Fe, Valencia, Spain). Results: Urinary tract infection (30.2%) and spontaneous bacterial peritonitis (22.1%) were the most common infections. A total of 102 microbiological isolates were analysed: 50% in community-acquired infections, 36% in isolates associated with healthcare infections and 14% in nosocomial infections. Escherichia coli was the main aetiology (29.4%). The overall multiresistance rate was 28.4%. The univariate analysis showed that infection caused by multidrug-resistant bacteria (28.4%) was associated with nosocomial infection compared to those associated with healthcare (OR 5.46; 95% CI: 1.22-24.43; P=.039) and healthcare-associated infections (compared to community-acquired infections, OR 3.39; 95% CI: 1.09-10.54; P=.048), use of antibiotics (OR 4.37; 95% CI: 1.59-11.99; P=.005), hospital admission in the previous 90 days (OR 3.18; 95% CI: 1.19-8.47; P=.018), active cancer (OR 2.93; 95% CI: 1.08-7.99; P=.038), and use of prophylactic norfloxacin (OR 3; 95% CI: 1.02-8.79; P=.012). Moreover, it was associated with a higher rate of sepsis (OR 3.13; 95% CI: 1.18-8.32; P=.025). The failure of initial treatment was related to greater development of acute renal failure (P<.001), sepsis (P=.012), septic shock (P=.002), ICU admission (P<.001) and mortality (P<.001). Conclusion: The rate of multidrug-resistant bacteria infections in our centre is comparable to that of other European centres with similar characteristics. The results obtained make it recommendable to implement the antibiotic treatment guidelines in current clinical practice guidelines, limiting the use of carbapenems to nosocomial infections and healthcare-associated infections with other risk factors of multidrug resistance or signs of severe sepsis. Early and adequate empirical treatment correlates with a better prognosis

Multidrug-resistant bacterial infections in patients with liver cirrhosis in a tertiary referral hospital. / Infecciones por bacterias multirresistentes en pacientes cirróticos en un hospital terciario.

INTRODUCTION: Infections in cirrhotic patients caused by multidrug-resistant bacteria are currently increasing and are associated with greater morbidity and mortality. OBJECTIVES: To assess the epidemiology, risk factors and prognoses of infections caused by multidrug-resistant bacterial infections in cirrhotic patients. PATIENTS AND METHODS: Retrospective study on patients with liver cirrhosis who developed an infection during hospitalisations between July 2014 and August 2016 at our centre (Hospital Universitari i Politècnic La Fe, Valencia, Spain). RESULTS: Urinary tract infection (30.2%) and spontaneous bacterial peritonitis (22.1%) were the most common infections. A total of 102 microbiological isolates were analysed: 50% in community-acquired infections, 36% in isolates associated with healthcare infections and 14% in nosocomial infections. Escherichia coli was the main aetiology (29.4%). The overall multiresistance rate was 28.4%. The univariate analysis showed that infection caused by multidrug-resistant bacteria (28.4%) was associated with nosocomial infection compared to those associated with healthcare (OR 5.46; 95% CI: 1.22-24.43; P=.039) and healthcare-associated infections (compared to community-acquired infections, OR 3.39; 95% CI: 1.09-10.54; P=.048), use of antibiotics (OR 4.37; 95% CI: 1.59-11.99; P=.005), hospital admission in the previous 90 days (OR 3.18; 95% CI: 1.19-8.47; P=.018), active cancer (OR 2.93; 95% CI: 1.08-7.99; P=.038), and use of prophylactic norfloxacin (OR 3; 95% CI: 1.02-8.79; P=.012). Moreover, it was associated with a higher rate of sepsis (OR 3.13; 95% CI: 1.18-8.32; P=.025). The failure of initial treatment was related to greater development of acute renal failure (P<.001), sepsis (P=.012), septic shock (P=.002), ICU admission (P<.001) and mortality (P<.001). CONCLUSION: The rate of multidrug-resistant bacteria infections in our centre is comparable to that of other European centres with similar characteristics. The results obtained make it recommendable to implement the antibiotic treatment guidelines in current clinical practice guidelines, limiting the use of carbapenems to nosocomial infections and healthcare-associated infections with other risk factors of multidrug resistance or signs of severe sepsis. Early and adequate empirical treatment correlates with a better prognosis.

The bony horncore of the common eland (Taurotragus oryx): composition and mechanical properties of a spiral fighting structure.

Horns are permanent structures projecting from the head of bovids, consisting of a bony horncore covered with a layer of skin and then a sheath of keratinous material showing variability of growth intensity based on nutrition. From the point of view of the horn's mechanical properties, the keratin sheath has been widely studied, but only a few studies have considered the complete structure of the horn and fewer studies have focused on the bony horncore and its characteristics. The latter showed the important role of the bony core, when cranial appendages are subject to mechanical stress (as happens during fighting). The mechanical properties of bone material, along with its mineral profile, are also important, because they can show effects of different factors, such as nutrition and mineral deficiencies in diet. For this reason, eight horncores of captive common eland male were sampled at four positions along the vertical axis of the horn. The main aim was to study variation in mechanical properties and the mineral content along the vertical axis of the horncores. We further analysed whether the spiral bony ridge present on eland horncores differs in any of the studied properties from adjacent parts of the horncore. In other antelopes, spiral ridges on the horns have been proposed to increase grip during wrestling between males. Cross-sections of the horncores were performed at four positions along the longitudinal axis and, for each position, two bone bars were extracted to be tested in impact and bending. Moreover, in the first sampling position (the closest position to the base) two bars were extracted from the spiralled bony area. The resulting fragments were used to measure ash content, bone density and mineral content. Results showed that horn bone decreased along the vertical axis, in ash (-36%), density (-32%), and in impact work 'U' (marginally significant but large effect: -48%). The concentration of several minerals decreased significantly (Mg, Cr, Mn and Tl by -33%, -25%, -31%, -43%, respectively) between the basal and the uppermost sampling site. The bone tissue of the horncore spiral compared with non-spiral bone of the same position showed a lower ash content (53% vs. 57%), Mg and Mn; in addition to showing approximately half values in work to peak force 'W', bending strength 'BS' and 'U', but not in Young's modulus of elasticity 'E'. In conclusion, similarly to the results in a totally different fighting bony structure, the antlers, the horncore of eland shows advantageous parameters in bone tissue of the base in respect to the tip, with higher values for mechanical properties, density and mineral profile. Moreover, the spiral bone tissue showed lower material mechanical properties. Probably the spiral tissue of the horn may have a role in deflecting potential cross-sectional fractures during wrestling. In addition, it may serve to improve the grip during wrestling, and we propose that it may also prevent risk of rotation of sheath with respect to internal bone not only in this, but also in other straight bovid horns.

Análisis de la maduración del juicio moral en el proceso de aprendizaje de la bioética / Analysis of the maturation of moral judgment in the learning process of bioethics

Objetivo: Medir el razonamiento moral de los estudiantes de medicina antes y después de recibir formación en bioética en dos ámbitos culturales diferentes (Zaragoza y Doha) y de los residentes al inicio de su residencia (MIR1), correlacionando el razonamiento moral con el ámbito cultural y el ambiente de aprendizaje. Sujetos y métodos: Estudio observacional transversal del razonamiento moral con estudiantes de medicina y MIR1 y de intervención con seguimiento longitudinal del razonamiento moral antes y después de la formación en bioética, utilizando el test de razonamiento moral de Lind. Resultados: Se obtuvieron 273 cuestionarios iniciales de estudiantes (200 de Zaragoza y 73 de Qatar) y 141 de MIR1. Se tiene información antes y después de 122 estudiantes (44,7% del total), una quinta parte de Qatar. Antes de bioética, la media del C-score era de 14,24 ± 8,698 (n = 273). Después, la media era de 14,30 ± 10,111 (n = 194). La diferencia media antes-después fue de 0,79 ± 12,162 (n = 122). No hay diferencias del C-score por región, pero sí al dicotomizarlo en preconvencional (< 10) y convencional-posconvencional (> 10): 49% < 10 en Qatar frente a 30% en Zaragoza. También hay diferencias significativas en las respuestas dadas a los dos dilemas que conforman el test de razonamiento moral entre ambas regiones. Los MIR de Zaragoza muestran el mismo patrón de respuestas ante los dilemas que los estudiantes, pero su C-score es significativamente inferior (10,4 frente a 14,3). Conclusiones: Se confirman las hipótesis iniciales, aunque conviene profundizar en esta línea de investigación durante más cursos académicos, o incluyendo otros campus universitarios de las mismas zonas culturales

Aim: To measure the moral reasoning of medical students before and after training in bioethics in two different cultural settings (Zaragoza and Doha), as well as MIR1s in Zaragoza, correlating in both cases the possible changes in their moral reasoning with their cultural and learning environment. Subjects and methods: Observational study of moral reasoning with medical students and MIR1 and intervention with longitudinal follow up moral reasoning before and after training in bioethics, using Georg Lind's Moral Judgement Test. Results: There were 273 initial questionnaires of students (200 from Zaragoza, 73 from Qatar) and 141 MIR1. There were information before-after 122 students (44.7%, of which 1/5 from Qatar). Before bioethics training the average C-score was 14.24 ± 8.698 (n = 273). After training, the average was 14.30 ± 10.111 (n = 194). The mean difference before and after was 0.79 ± 12.162 (n = 122). No C-score differences by region were found, but the dichotomization in preconventional (< 10) and conventional-postconventional showed differences between Qatar and Zaragoza (> 10): 49% < 10 versus 30%, respectively). There were also significant regional differences in the responses to the two dilemmas that compose the Moral Judgement Test. The MIR of Zaragoza showed the same pattern of responses to the dilemmas than students but their C-score is significantly lower (10.4 versus 14.3). Conclusions: We confirm the initial hypothesis, although this line of research should be furthered to more academic years and more university campuses

Truth-telling and cancer diagnoses: physician attitudes and practices in Qatar.

There is limited information regarding physicians' attitudes toward revealing cancer diagnoses to patients in the Arab world. Using a questionnaire informed by a seminal study carried out by Oken in 1961, our research sought to determine present-day disclosure practices in Qatar, identify physician sociodemographic variables associated with truth-telling, and outline trends related to future practice. A sample of 131 physicians was polled. Although nearly 90% of doctors said they would inform cancer patients of their diagnosis, ∼66% of respondents stated that they made exceptions to their policy, depending on patient characteristics. These data suggest that clinical practices are somewhat discordant on professed beliefs about the ethical propriety of disclosure.

The hidden and implicit curricula in cultural context: new insights from Doha and New York.

The authors report their longitudinal experience teaching a clerkship in clinical ethics and palliative care at the Weill Cornell Medical College campuses in New York and Doha. This course uses participant observation and reflective practice to counteract the hidden curriculum when learning about clinical ethics and end-of-life care. The authors consider how this formal element of the curriculum is influenced by the implicit and hidden curricula in different cultural contexts and how these differing venues affect communication and information exchange, using the anthropological concept of high- and low-context societies. The authors' analysis provides additional information on Weill Cornell's educational efforts in the medical humanities, bioethics, and palliative care across the curriculum and across cultural settings. By contrasting high-context Doha, where much information is culturally embedded and seemingly hidden, with low-context New York, where information is made overt, the authors theorize that in each setting, the proportion of implicit and explicit curricular elements is determined by the extramural cultural environment. They argue that there are many hidden and implicit curricula and that each is dependent on modes of communication in any given setting. They assert that these variations can be seen not only across differing societies but also, for example, among individual U.S. medical schools because of local custom, history, or mission. Because these contextual factors influence the relative importance of what is implicit and explicit in the student's educational experience, medical educators need to be aware of their local cultural contexts in order to engage in effective pedagogy.

Muslim patients and cross-gender interactions in medicine: an Islamic bioethical perspective.

As physicians encounter an increasingly diverse patient population, socioeconomic circumstances, religious values and cultural practices may present barriers to the delivery of quality care. Increasing cultural competence is often cited as a way to reduce healthcare disparities arising from value and cultural differences between patients and providers. Cultural competence entails not only a knowledge base of cultural practices of disparate patient populations, but also an attitude of adapting one's practice style to meet patient needs and values. Gender roles, relationship dynamics and boundaries are culture specific, and are frequently shaped by religious teachings. Consequently, religion may be conceptualised as a cultural repertoire, or dynamic tool-kit, by which members of a faith adapt and negotiate their identity in multicultural societies. The manner in which Islamic beliefs and values inform Muslim healthcare behaviours is relatively under-investigated. In an effort to explore the impact of Islam on the relationship between patients and providers, we present an Islamic bioethical perspective on cross-gender relations in the patient-doctor relationship. We will begin with a clinical scenario highlighting three areas of gender interaction that bear clinical relevance: dress code, seclusion of members of the opposite sex and physical contact. Next, we provide a brief overview of the foundations of Islamic law and ethical deliberation and then proceed to develop ethicolegal guidelines pertaining to gender relations within the medical context. At the end of this reflection, we offer some practice recommendations that are attuned to the cultural sensitivities of Muslim patient populations.

Gastric perforation during removal of an intragastric balloon.

The intragastric balloon system is licensed for temporary use in moderately obese patients who have significant health risks related to their obesity and have failed to achieve and maintain significant weight loss with a supervised weight control program alone. Although intragastric balloons are advocated as safe devices, major complications have been described. We report a case of a gastric perforation during the removal of an intragastric balloon. This is the first case reported in the literature.