Enhanced Web-Based Otitis Study Case vs Simple Paper-Case: Impact on Medical Student Objec-tive Structured Clinical Exam (OSCE) Performance

Background: Distance education methods have taken on greater importance as medical student education has moved off campus into the community. What the best methods are for conveying information to students at distant sites has not been determined. Objective: To determine if students at distant community sites who received an otitis media study case by e-mail that was enhanced with a referral to a web-based otitis study case, performed better on otitis OSCE stations than students who received the same case not enhanced with visuals or referrals to a web-based otitis case. Design/Methods: Students were randomized by community site to receive either the enhanced (E) or simple otitis study case (S). Students were e-mailed an otitis media study case during the 5th week of the rotation. Those randomized to the E-case received a case that started with a case scenario followed by a "Task" that instructed them to go to this web address: http://www.aap.org/otitismedia/www/vc/ear/index.cfm (American Academy of Pediatrics Otitis Web Site). They were then to select "Case 1" which was a continuation of the case scenario present on their e-mail. A list of learning objectives was also printed on the e-mail. Students receiving the S-case viewed the same case scenario and objectives, but were not instructed to go to the web page. All students rotated through two OSCE otitis stations. In the first station they interviewed a simulated patient(OSCE-SP) and counseled her on the management of her 12 month old with otitis. Within that station they viewed a video of a pneumoscopic exam of two ears, one ear with otitis and the other ear normal. At the 2nd otitis station the student presented the case to a faculty and was asked a series of questions about otitis media(OSCE-PR). Scores on the two stations were compared by group. Results: There were 198 students who took the OSCE. 178 (90%) responded to a survey that indicated they had opened and read the e-mailed case. There were 87 students in the E-group and 91 in the S-group. The mean ±s.d. OSCE-SP station score for the E-group was 72.6 ±12.0 vs 75.4 ±9.8 for the S-group, p=0.09. For the otitis presentation station the scores for the E-group and S-group were respectively, 82.9 ±9.6 and 83.7 ±9.4, p=0.55. Conclusions: These data suggest that enhanced visual distance education cases may offer no distinct advantage over simple paper-type case study guide

Confrontations with Death: Psychological Responses During Internship

During internship, the daily confrontation with the consequences of disease contributes much to the distress which young physicians experience (I). Not only are interns responsible for first line medical care, they must also provide emotional support for their patients struggling with pain, disability and impending death. This paper seeks to examine some of the factors responsible for the turmoil involved in caring for these dying patients. Our conceptions of death and dying are determined to a large extent by the cultural context in which we live. Compared with other times in which death was not so ego alien, we presently live in a time and culture which Aries has called death-denying (2). Eissler has suggested that death is one of those unsavory facts which cannot be integrated into (our present), essentially hedonistic civilization . . . (It) must therefore remain a foreign body, denied by silence rather than recognized as the possible Alpha and Omega of life itself\u27 (3)

The Malingering of Psychotic Disorders

The phenomenon of malingered psychosis is examined through a review of the available literature. Possible motivations for malingering are discussed, and clinical indicators of feigned psychotic symptoms are reviewed. The methods discussed focus on the inpatient evaluation of suspected malingerers and include discussions of interview techniques and psychometric testing to supplement clinical impressions. A differential diagnosis is presented, and techniques for confronting a malingering patient are reviewed

The Interaction between Nef Protein and ABCA1 Mutants in Tangier Disease

The genetic disorder Tangier Disease is characterized by mutations at a chromosomal locus, 9q31, which affect proper function of the cholesterol transporter ATP-Binding Cassette A1 (ABCA1). Individuals with mutant ABCA1 have very low levels of high-density lipoprotein and are at high risk for development of neuropathy and atherosclerosis. Two of the ABCA1 mutations, Q597R and R587W, lead to retention of ABCA1 in the endoplasmic reticulum (ER) in a pattern that is reminiscent of a previously reported ABCA1 inactivation by HIV-1 protein Nef. The mechanism of that inactivation involves Nef binding to an ER chaperone calnexin, which disrupts the interaction between calnexin and ABCA1 preventing proper maturation of ABCA1. As a result, ABCA1 is retained in the ER and not transported to the plasma membrane where its main activity takes place. Thus, we speculated that the underlying mechanism of retention of ABCA1 in the ER of patients with Q597R and R587W mutations is caused by a weakened interaction between mutated ABCA1 and calnexin. However, our preliminary data suggests that it is actually an abnormally strong interaction between these two molecules that leads to the retention of ABCA1 in the ER. The main aim of my research is to attempt to use HIV-1 Nef to decrease the strength of interaction between these mutants and calnexin, which may enable the transport of ABCA1 molecules to cellular membrane, thus restoring the cholesterol efflux from the affected cells. If successful, this approach could lead to a potential therapeutic treatment for Tangier disease using Nef-mimicking peptides

Gallbladder Duplication: Case Report of a Rare Congenital Anomaly Treated by Single-Incision Laparoscopic Cholecystectomy in a Pediatric Patient

Introduction: Gallbladder duplication is a rare congenital anomaly. Preoperative diagnosis is essential for prevention of intra operative complications. Based on our review of the literature, this is the first description of gallbladder duplication treated with single-incision laparoscopic surgery (SILS) in a pediatric patient. Case Presentation: A 14 year-old girl presented to the pediatric surgery clinic with a 4-month history of right upper quadrant abdominal pain, nausea, and low- grade fevers. Preoperative imaging revealed gallbladder duplication. The single incision laparoscopic technique was employed. Intra operative ndings included two gallbladders that appeared to share a common wall. There were two parallel cystic ducts that inserted separately into the common hepatic duct. Gross pathology revealed two adjacent gallbladders separated by a thin septum, each with its own cystic duct. The postoperative course was unremarkable, and the patient was without symptoms at the 1 month follow-up visit. Conclusion: Gallbladder duplication is a rare congenital anomaly. This case report demonstrates successful treatment by excision using the single incision laparoscopic approach

Chronic Renal Failure, But Why? A Case Report.

Renal failure, both acute and chronic, can present from many different etiologies and if diagnosed with diabetes mellitus, it is commonly assumed to be due to diabetic nephropathy. Monoclonal gammopathy of renal significance (MGRS) is a disorder that combines monoclonal gammopathy of undetermined significance with end stage renal disease. Monoclonal immunoglobulins are secreted by B or plasma cells leading to deposition in the kidney causing end organ damage. Several different subtypes fall under this category of renal diseases including, but not limited to, amyloidosis, C3 glomeruopathy, and light chain proximal tubulopathy, or better known as Fanconi syndrome1. Fanconi syndrome, which can be acquired or inherited, occurs due to toxicity of the proximal renal tubule in the kidney which leads to hypophosphatemia, hypokalemia, metabolic acidosis due to impaired bicarbonate absorption, impaired glucose and uric acid absorption, and proteinuria. In this case, an 84 year old Caucasian male presented with shortness of breath and weakness. He denied chest pain, hemoptysis, polyuria, and hematuria. His past medical history includes chronic renal disease secondary to well-controlled type II diabetes mellitus (DM), perirenal lymphangiectasis, pulmonary fibrosis, hypertension, atrial fibrillation, hyperlipidemia, and anemia. He had a left radiocephalic AV fistula Permacath placement prior to admission for dialysis. A combined effort from general internal medicine, nephrology, hematology/oncology, cardiology, pulmonary, vascular, infectious disease, radiology, and pathology was made to investigate the patient’s illness over the course of his one-month stay. Though type II DM played a role in the development of this patient’s chronic kidney disease, MGRS is a significant causal factor of the progression to end stage renal disease. Currently, treatment with chemotherapy that targets plasma or B cells can be used for MGRS. Several case studies reported improvement or stabilization of renal function in those treated with chemotherapeutic agents vs. no therapy. (4,5) Though renal transplantation can be done, recurrence post-transplantation is common. (6) The main goal in managing MGRS with Fanconi syndrome is slowing the progression of renal disease and preventing associated extra-renal complications. (7) This case demonstrates the complexities of medical diagnostics and the step-wise progression involved in caring for a patient. It displays the value of interdisciplinary collaboration among different medical specialties to accurately provide patients with an etiology and treatment for their illness and related symptoms