Cushing Syndrome due to Adrenocortical Carcinoma During Pregnancy.

Cushing syndrome resulting from adrenocortical carcinoma in pregnancy is exceedingly rare. There are no validated guidelines to establish a diagnosis or guide management in pregnancy. We provide a case of a 31-year-old woman presenting for management of diabetes in pregnancy who appeared cushingoid. She was subsequently diagnosed with ACTH-independent Cushing syndrome and experienced preterm labor at 33 weeks' gestation, delivering a healthy infant. Four weeks postpartum, the patient underwent a left adrenalectomy and was subsequently diagnosed with adrenocortical carcinoma.

Development and validation of the student ratings in clinical teaching scale in Australia: a methodological study

PURPOSE: This study aimed to devise a valid measurement for assessing clinical students' perceptions of teaching practices. METHODS: A new tool was developed based on a meta-analysis encompassing effective clinical teaching-learning factors. Seventy-nine items were generated using a frequency (never to always) scale. The tool was applied to the University of New South Wales year 2, 3, and 6 medical students. Exploratory and confirmatory factor analysis (exploratory factor analysis [EFA] and confirmatory factor analysis [CFA], respectively) were conducted to establish the tool's construct validity and goodness of fit, and Cronbach's α was used for reliability. RESULTS: In total, 352 students (44.2%) completed the questionnaire. The EFA identified student-centered learning, problem-solving learning, self-directed learning, and visual technology (reliability, 0.77 to 0.89). CFA showed acceptable goodness of fit (chi-square P<0.01, comparative fit index=0.930 and Tucker-Lewis index=0.917, root mean square error of approximation=0.069, standardized root mean square residual=0.06). CONCLUSION: The established tool­Student Ratings in Clinical Teaching (STRICT)­is a valid and reliable tool that demonstrates how students perceive clinical teaching efficacy. STRICT measures the frequency of teaching practices to mitigate the biases of acquiescence and social desirability. Clinical teachers may use the tool to adapt their teaching practices with more active learning activities and to utilize visual technology to facilitate clinical learning efficacy. Clinical educators may apply STRICT to assess how these teaching practices are implemented in current clinical settings.

Effects of cardiovascular angiotensin II type 1 receptor blockade on nitric oxide synthase inhibition in patients with insulin resistance syndrome.

BACKGROUND: There is evidence that in the early stages of type II diabetes, the cardiovascular system compensates by increasing endothelial nitric oxide synthase (e-NOS) expression. In the advanced stages of disease, e-NOS is diminished, and is associated with endothelial dysfunction. Angiotensin II, acting via the angiotensin II type 1 (AT(1)) receptor, is central to the development of endothelial dysfunction. The effect of AT(1) receptor blockade on NOS expression and activity in humans with early insulin resistance syndrome (INSR) has not been previously investigated. Eight subjects with INSR participated in a randomized, double-blind, placebo-controlled, crossover study. Subjects were randomized to receive telmisartan or placebo (1 month of each) in a two-period crossover study with a 1-week washout period in between. The arterial stiffness and haemodynamic response to intravenous L-nitro-monomethyl arginine (L-NMMA 3mg/kg) was assessed at baseline and at the end of each treatment phase. SI (Stiffness index, a measure of large artery stiffness) and RI (Reflection index, small- to medium-sized arterial stiffness) were measured using digital photoplethysmography. Haemodynamic parameters [Heart rate (HR), Systolic blood pressure (SBP), Diastolic BP (DBP) and systemic vascular resistance index (SVRI)] were measured non-invasively using trans-thoracic bioimpedance. RESULTS: Telmisartan significantly reduced baseline SI, SBP, DBP and SVRI. Infusion of L-NMMA produced a significant increase in RI and a significant reduction in HR during placebo therapy. Telmisartan therapy attenuated these responses. CONCLUSION: Telmisartan therapy reduced NOS activity and/or expression in these subjects, possibly because of improved vascular function arising from AT(1) receptor blockade.