Does treatment with donepezil improve memory for patients with mild cognitive impairment?

Donepezil (Aricept) has potential benefit in delaying risk of progression to Alzheimer's disease in the first year of treatment, but this benefit is not seen at 3 years. Donepezil does not improve memory for patients with mild cognitive impairment (strength of recommendation: B)

What evaluation is best for an isolated, enlarged cervical lymph node?

The evaluation and follow-up of an isolated, enlarged cervical lymph node is determined by the presence of inflammation, duration, size, and associated symptoms. For patients with inflammatory symptoms (ie, fever, pain, erythema, and recent infection), a single course of broad-spectrum antibiotic and reassessment in 1 to 2 weeks is reasonable (strength of recommendation [SOR]: C, expert opinion). If lymph node enlargement persists despite antibiotics, yet an infectious or inflammatory cause is still suspected, further evaluation may include a PPD skin test and chest radiograph1 (SOR: C, expert opinion)

Extensive Genetic Diversity, Unique Population Structure and Evidence of Genetic Exchange in the Sexually Transmitted Parasite Trichomonas vaginalis

The human parasite Trichomonas vaginalis causes trichomoniasis, the world's most common non-viral sexually transmitted infection. Research on T. vaginalis genetic diversity has been limited by a lack of appropriate genotyping tools. To address this problem, we recently published a panel of T. vaginalis-specific genetic markers; here we use these markers to genotype isolates collected from ten regions around the globe. We detect high levels of genetic diversity, infer a two-type population structure, identify clinically relevant differences between the two types, and uncover evidence of genetic exchange in what was believed to be a clonal organism. Together, these results greatly improve our understanding of the population genetics of T. vaginalis and provide insights into the possibility of genetic exchange in the parasite, with implications for the epidemiology and control of the disease. By taking into account the existence of different types and their unique characteristics, we can improve understanding of the wide range of symptoms that patients manifest and better implement appropriate drug treatment. In addition, by recognizing the possibility of genetic exchange, we are more equipped to address the growing concern of drug resistance and the mechanisms by which it may spread within parasite populations

Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda

An unresolved issue in the field of implementation research is how to conceptualize and evaluate successful implementation. This paper advances the concept of “implementation outcomes” distinct from service system and clinical treatment outcomes. This paper proposes a heuristic, working “taxonomy” of eight conceptually distinct implementation outcomes—acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability—along with their nominal definitions. We propose a two-pronged agenda for research on implementation outcomes. Conceptualizing and measuring implementation outcomes will advance understanding of implementation processes, enhance efficiency in implementation research, and pave the way for studies of the comparative effectiveness of implementation strategies

Aortic stiffness in lone atrial fibrillation: A novel risk factor for arrhythmia recurrence

BACKGROUND Recent community-based research has linked aortic stiffness to the development of atrial fibrillation. We posit that aortic stiffness contributes to adverse atrial remodeling leading to the persistence of atrial fibrillation following catheter ablation in lone atrial fibrillation patients, despite the absence of apparent structural heart disease. Here, we aim to evaluate aortic stiffness in lone atrial fibrillation patients and determine its association with arrhythmia re currence following radio-frequency catheter ablation. METHODS We studied 68 consecutive lone atrial fibrillation patients who underwent catheter ablation procedure for atrial fibrillation and 50 healthy age- and sex-matched community controls. We performed radial artery applanation tonometry to obtain central measures of aortic stiffness: pulse pressure, augmentation pressure and augmentation index. Following ablation, arrhythmia recurrence was monitored at months 3, 6, 9, 12 and 6 monthly thereafter. RESULTS Compared to healthy controls, lone atrial fibrillation patients had significantly elevated peripheral pulse pressure, central pulse pressure, augmentation pressure and larger left atrial dimensions (all P<0.05). During a mean follow-up of 2.9±1.4 years, 38 of the 68 lone atrial fibrillation patients had atrial fibrillation recurrence after initial catheter ablation procedure. Neither blood pressure nor aortic stiffness indices differed between patients with and without atrial fibrillation recurrence. However, patients with highest levels (≥75th percentile) of peripheral pulse pressure, central pulse pressure and augmentation pressure had higher atrial fibrillation recurrence rates (all P<0.05). Only central aortic stiffness indices were associated with lower survival free from atrial fibrillation using Kaplan-Meier analysis. CONCLUSION Aortic stiffness is an important risk factor in patients with lone atrial fibrillation and contributes to higher atrial fibrillation recurrence following catheter ablation procedure.Dennis H. Lau, Melissa E. Middeldorp, Anthony G. Brooks, Anand N. Ganesan, Kurt C. Roberts-Thomson, Martin K. Stiles, Darryl P. Leong, Hany S. Abed, Han S. Lim, Christopher X. Wong, Scott R. Willoughby, Glenn D. Young, Jonathan M. Kalman, Walter P. Abhayaratna, Prashanthan Sander

Distribution and Abundance of Glucocorticoid and Mineralocorticoid Receptors throughout the Brain of the Great Tit (Parus major)

The glucocorticoid stress response, regulated by the hypothalamic-pituitary-adrenal (HPA) axis, enables individuals to cope with stressors through transcriptional effects in cells expressing the appropriate receptors. The two receptors that bind glucocorticoids-the mineralocorticoid receptor (MR) and glucocorticoid receptor (GR)-are present in a variety of vertebrate tissues, but their expression in the brain is especially important. Neural receptor patterns have the potential to integrate multiple behavioral and physiological traits simultaneously, including self-regulation of glucocorticoid secretion through negative feedback processes. In the present work, we quantified the expression of GR and MR mRNA throughout the brain of a female great tit (Parus major), creating a distribution map encompassing 48 regions. This map, the first of its kind for P. major, demonstrated a widespread but not ubiquitous distribution of both receptor types. In the paraventricular nucleus of the hypothalamus (PVN) and the hippocampus (HP)-the two brain regions that we sampled from a total of 25 birds, we found high GR mRNA expression in the former and, unexpectedly, low MR mRNA in the latter. We examined the covariation of MR and GR levels in these two regions and found a strong, positive relationship between MR in the PVN and MR in the HP and a similar trend for GR across these two regions. This correlation supports the idea that hormone pleiotropy may constrain an individual's behavioral and physiological phenotype. In the female song system, we found moderate GR in hyperstriatum ventrale, pars caudalis (HVC), and moderate MR in robust nucleus of the arcopallium (RA). Understanding intra- and interspecific patterns of glucocorticoid receptor expression can inform us about the behavioral processes (e.g. song learning) that may be sensitive to stress and stimulate future hypotheses concerning the relationships between receptor expression, circulating hormone concentrations and performance traits under selection, including behavior

WISE-Family Medicine: A Statewide Faculty Development Collaborative

Background: In many states, family medicine residencies and medical schools compete clinically for patients, educationally for trainees and, more recently, for community preceptors (CPs). As Wisconsin’s medical schools and health care systems have expanded their geographic footprints, our CPs now teach trainees from competing institutions. Yet residency and medical student accrediting bodies require faculty and preceptor development. Purpose: To evaluate the impact of a statewide collaborative of family medicine educators on meeting faculty development needs of our CPs and collaborative members. Methods: Faculty development leaders representing the three largest family medicine residency training sponsors in the state created the Wisconsin Institute of Scholars & Educators in Family Medicine (WISE-FM). This statewide collaborative of family medicine educators is comprised of 3 to 4 representatives per sponsor –– both junior and senior educators to further support their development as faculty –– committed to developing common preceptor clinical teaching tools. Through online discussions and half-day WISE-FM meetings, WISE-FM participants identified preceptor development needs and designed highly regarded clinical teacher infographics for these priority topics. These tools are available for use statewide, providing CPs with a consistent teaching approach. To determine infographic value, a brief (\u3c 5 items) parallel form survey was distributed to and voluntarily completed by: 1) CPs who received the infographics, and 2) WISE-FM participants. Item results on a 5-point Likert scale (5 = strongly agree, 1 = strongly disagree) were analyzed using descriptive statistics. Results: Forty-two CP infographics recipients and the 11 WISE-FM participants completed the evaluations. Results revealed that faculty development infographics were a time-efficient (CP: 4.1, WISE-FM: 4.2) and effective way (CP: 4.0, WISE-FM: 4.2) to enrich skills as clinical teachers. Both groups intend to or have incorporated the infographics into their own teaching (CP: 4.2, WISE-FM: 4.2). WISE-FM respondents strongly agreed (4.6) that the overall “returns” from participating were worth their investments (time, effort). Conclusion: The WISE-FM provides a statewide faculty development model that can be adopted by others to meet accreditation requirements for CP teaching skill development through shared authoring of CP development resources while concurrently advancing the development of WISE-FM participants

Preceptor Development with Infographics: A Gift of Time

Background: Traditionally, faculty development material is static and text based. Infographics are synoptic communication tools that use visual images such as a chart, diagram or picture to represent information or data. Studies show that: People remember 10% of what they hear, 20% of what they read and 80% of what they see and do. By pairing concepts with visuals, one is more likely to store this information into their long-term memory and to transmit the message more quickly. Community faculty have limited time to do faculty development. Objectives: Form a statewide partnership among family medicine departments to development faculty development materials. Create and disseminate time efficient Faculty Development materials using infographic format. Conclusions: The WISE FM Collaboration successfully developed innovative and dynamic faculty development material in a time efficient manner. Preceptors positively evaluated infographics and reporting intent to use strategies in teaching. Dissemination initiatives underway