Factors Involved in Selection of a Career in Surgery and Orthopedics for Medical Students in Malawi

AimsThere is a critical shortage of Orthopedic Surgeons in Malawi as well as all countries in sub-Saharan Africa. To date, there is no published literature that has investigated surgical or Orthopedic career selection amongst African medical trainees. With the goal of facilitating recruitmentinto Surgery and Orthopedics in Malawi, we explored the key aspects of Malawian Medical Students’ choice of careers in surgical disciplines.MethodsAn on-line survey of all students in clinical years at the College of Medicine in Blantyre, Malawi was performed. The survey was anonymous and constructed de novo by a stringent process including Item Generation, Item reduction, Survey composition, Pre-testing, Assessment of Validity by a recognized survey expert, Pilot testing in on-line format byseveral Malawian Medical Students, and then formal survey testing.ResultsSurgery was the most popular specialty choice among the medical trainees (46%). General Surgery was the popular surgical specialty (27%), followed by Neurosurgery (22%) and Orthopedics (19%). The majority of students (67%) feared occupational exposure to HIV but this did not appearto be a factor in specialty choice (p=0.9). Students with Orthopedic mentors were significantly more likely to choose Orthopedics as their first choice surgical specialty (p = 0.01). Despite limited resources and surgeons in sub-Saharan Africa, surgical specialties are desirable career choices.ConclusionsThis is the first evaluation of factors involved in surgical or Orthopedic career selection in any African context. Future initiatives to improve exposure and mentorship in Orthopedics are fundamental to recruitment into the specialty

Observations of the variability of shallow trade wind cumulus cloudiness and mass flux

Two years of ground-based remote sensing observations are used to study the vertical structure of marine cumulus near the island of Barbados, including their cloud fraction and mass flux profile. Daily radar derived cloud fraction profiles peak at different height levels depending on the depth of the cumuli and thus the extent to which they precipitate. Nonprecipitating cumuli have a peak cloud fraction of about 5% near mean cloud base (700m), whereas precipitating cumuli tend to have a peak of only 2% near cloud base. Nineteen percent of the precipitating cumuli are accompanied by large cloud fractions near the detrainment level of cumulus tops (similar to 1700m). Day-to-day variations in cloud fraction near cloud base are modest (similar to 3%). Nonprecipitating cumuli have their largest reflectivities near cloud top and an ascending core surrounded by a subsiding shell. Precipitating cumuli with enhanced elevated cloudiness (stratiform outflow) are deeper and contain larger vertical gradients in reflectivity and Doppler velocity than precipitating cumuli without such outflow. Bulk (3h) statistics reveal that nonprecipitating shallow cumuli are active and organized. They contain on average 79% in-cloud updrafts with 86% of them being organized in large coherent structures contributing to a maximum updraft mass flux of 8-36gm(-2)s(-1) just above cloud base. Alternatively, downdrafts contribute insignificantly to the mass flux and show little vertical and temporal variability (0-7gm(-2)s(-1)). Complementary Raman lidar information suggests that updraft mass flux profile slope is inversely related to environmental relative humidity

Deriving Mixed-Phase Cloud Properties from Doppler Radar Spectra

In certain circumstances, millimeter-wavelength Doppler radar velocity spectra can be used to estimate the microphysical composition of both phases of mixed-phase clouds. This distinction is possible when the cloud properties are such that they produce a bimodal Doppler velocity spectrum. Under these conditions, the Doppler spectrum moments of the distinct liquid and ice spectral modes may be computed independently and used to quantitatively derive properties of the liquid droplet and ice particle size distributions. Additionally, the cloud liquid spectral mode, which is a tracer for clear-air motions, can be used to estimate the vertical air motion and to correct estimates of ice particle fall speeds. A mixed-phase cloud case study from the NASA Cirrus Regional Study of Tropical Anvils and Cloud Layers-Florida Area Cirrus Experiment (CRYSTAL-FACE) is used to illustrate this new retrieval approach. The case of interest occurred on 29 July 2002 when a supercooled liquid cloud layer based at 5 km AGL and precipitating ice crystals advected over a ground measurement site. Ground-based measurements from both 35- and 94-GHz radars revealed clear bimodal Doppler velocity spectra within this cloud layer. Profiles of radar reflectivity were computed independently from the liquid and ice spectral modes of the velocity spectra. Empirical reflectivity-based relationships were then used to derive profiles of both liquid and ice microphysical parameters, such a

Immune and inflammatory responses in TNF alpha-deficient mice: A critical requirement for TNF alpha in the formation of primary B cell follicles, follicular dendritic cell networks and germinal centers, and in the maturation of the humoral immune response

To investigate the role of TNF alpha in the development of in vivo immune response we have generated TNF alpha-deficient mice by gene targeting. Homozygous mutant mice are viable and fertile, develop lymph nodes and Peyer's patches and show no apparent phenotypic abnormalities, indicating that TNF alpha is not required for normal mouse development. In the absence of TNF alpha mice readily succumb to L. monocytogenes infections and show reduced contact hypersensitivity responses. Furthermore, TNF alpha knockout mice are resistant to the systemic toxicity of LPS upon D-galactosamine sensitization, yet they remain sensitive to high doses of LPS alone. Most interestingly, TNF alpha knockout mice completely lack splenic primary B cell follicles and cannot form organized follicular dendritic cell (FDC) networks and germinal centers. However, despite the absence of B cell follicles, Ig class-switching can still occur, yet deregulated humoral immune responses against either thymus-dependent (TD) or thymus-independent (TI) antigens are observed. Complementation of TNF alpha functioning by the expression of either human or murine TNF alpha transgenes is sufficient to reconstitute these defects, establishing a physiological role for TNF alpha in regulating the development and organization of splenic follicular architecture and in the maturation of the humoral immune response

Mast Cells Control Neutrophil Recruitment during T Cell–Mediated Delayed-Type Hypersensitivity Reactions through Tumor Necrosis Factor and Macrophage Inflammatory Protein 2

Polymorphonuclear leukocytes (PMNs) characterize the pathology of T cell–mediated autoimmune diseases and delayed-type hypersensitivity reactions (DTHRs) in the skin, joints, and gut, but are absent in T cell–mediated autoimmune diseases of the brain or pancreas. All of these reactions are mediated by interferon γ–producing type 1 T cells and produce a similar pattern of cytokines. Thus, the cells and mediators responsible for the PMN recruitment into skin, joints, or gut during DTHRs remain unknown. Analyzing hapten-induced DTHRs of the skin, we found that mast cells determine the T cell–dependent PMN recruitment through two mediators, tumor necrosis factor (TNF) and the CXC chemokine macrophage inflammatory protein 2 (MIP-2), the functional analogue of human interleukin 8. Extractable MIP-2 protein was abundant during DTHRs in and around mast cells of wild-type (WT) mice but absent in mast cell–deficient WBB6F1-KitW/KitW-v (KitW/KitW-v) mice. T cell–dependent PMN recruitment was reduced >60% by anti–MIP-2 antibodies and >80% in mast cell–deficient KitW/KitW-v mice. Mast cells from WT mice efficiently restored DTHRs and MIP-2–dependent PMN recruitment in KitW/KitW-v mice, whereas mast cells from TNF−/− mice did not. Thus, mast cell–derived TNF and MIP-2 ultimately determine the pattern of infiltrating cells during T cell–mediated DTHRs

Effect of phospholipase A(2 )inhibitory peptide on inflammatory arthritis in a TNF transgenic mouse model: a time-course ultrastructural study

We evaluated the therapeutic effect of secretory phospholipase A(2 )(sPLA(2))-inhibitory peptide at a cellular level on joint erosion, cartilage destruction, and synovitis in the human tumor necrosis factor (TNF) transgenic mouse model of arthritis. Tg197 mice (N = 18) or wild-type (N = 10) mice at 4 weeks of age were given intraperitoneal doses (7.5 mg/kg) of a selective sPLA(2 )inhibitory peptide, P-NT.II, or a scrambled P-NT.II (negative control), three times a week for 4 weeks. Untreated Tg197 mice (N = 10) were included as controls. Pathogenesis was monitored weekly for 4 weeks by use of an arthritis score and histologic examinations. Histopathologic analysis revealed a significant reduction after P-NT.II treatment in synovitis, bone erosion, and cartilage destruction in particular. Conspicuous ultrastructural alterations seen in articular chondrocytes (vacuolated cytoplasm and loss of nuclei) and synoviocytes (disintegrating nuclei and vacuoles, synovial adhesions) of untreated or scrambled-P-NT.II-treated Tg197 mice were absent in the P-NT.II-treated Tg197 group. Histologic scoring and ultrastructural evidence suggest that the chondrocyte appears to be the target cell mainly protected by the peptide during arthritis progression in the TNF transgenic mouse model. This is the first time ultrastructural evaluation of this model has been presented. High levels of circulating sPLA(2 )detected in untreated Tg197 mice at age 8 weeks of age were reduced to basal levels by the peptide treatment. Attenuation of lipopolysaccharide- and TNF-induced release of prostaglandin E(2 )from cultured macrophage cells by P-NT.II suggests that the peptide may influence the prostaglandin-mediated inflammatory response in rheumatoid arthritis by limiting the bioavailability of arachidonic acid through sPLA(2 )inhibition

Improving the Price of Anarchy for Selfish Routing via Coordination Mechanisms

We reconsider the well-studied Selfish Routing game with affine latency functions. The Price of Anarchy for this class of games takes maximum value 4/3; this maximum is attained already for a simple network of two parallel links, known as Pigou's network. We improve upon the value 4/3 by means of Coordination Mechanisms. We increase the latency functions of the edges in the network, i.e., if $\ell_e(x)$ is the latency function of an edge $e$, we replace it by $\hat{\ell}_e(x)$ with $\ell_e(x) \le \hat{\ell}_e(x)$ for all $x$. Then an adversary fixes a demand rate as input. The engineered Price of Anarchy of the mechanism is defined as the worst-case ratio of the Nash social cost in the modified network over the optimal social cost in the original network. Formally, if \CM(r) denotes the cost of the worst Nash flow in the modified network for rate $r$ and \Copt(r) denotes the cost of the optimal flow in the original network for the same rate then [\ePoA = \max_{r \ge 0} \frac{\CM(r)}{\Copt(r)}.] We first exhibit a simple coordination mechanism that achieves for any network of parallel links an engineered Price of Anarchy strictly less than 4/3. For the case of two parallel links our basic mechanism gives 5/4 = 1.25. Then, for the case of two parallel links, we describe an optimal mechanism; its engineered Price of Anarchy lies between 1.191 and 1.192.Comment: 17 pages, 2 figures, preliminary version appeared at ESA 201

Extensive spherical amyloid deposition presenting as a pituitary tumor

A 71-yr-old man was admitted for further evaluation and trans-sphenoidal surgery of a pituitary tumor. He complained of impotence and decreased libido over a period of about 40 yr. Thirty-eight yr ago he was treated for bilateral gynecomastia with galactorrhea. Endocrinological investigation at presentation revealed only mild hyperprolactinemia and hypogonadotropic hypogonadism. Pituitary magnetic resonance imaging (MRI) showed a tumor up to 2.5 cm in diameter with infiltration of the sphenoid sinus and right cavernous sinus. The tumor exhibited a heterogeneous hyperintense signal on T1-weighted images and hypointense signal on T2-weighted images. Standard trans-sphenoidal surgery was performed and a brownish mass was found inside the sella, which was removed. Histological examination of the mass revealed extensive spherical amyloid deposits with strongly positive immunohistochemical staining for prolactin. Therefore, a prolactinoma with extensive spherical amyloid deposition was diagnosed. Extensive spherical amyloid deposition is a rare finding in prolactin-secreting pituitary adenomas. So far, characteristic radiological findings by MRI have been described only twice. Due to characteristic MRI findings, the diagnosis of extensive intrasellar amyloid deposition can be entertained pre-operatively. Trans-sphenoidal surgical resection is essential to confirm the diagnosis histologically and because of the potential lack of tumor shrinkage under dopaminagonist therapy in this type of prolactinom