Redesigning journal club in residency

The gap between production and implementation of knowledge is the main reason for the suboptimal quality of health care. To eliminate this gap and improve the quality of patient care, journal club (JC) in graduate medical education provides an opportunity for learning the skills of evidence-based medicine. JC, however, continues to face many challenges mainly due to poorly defined goals, inadequate preparation, and lack of interest. This article presents an innovative model to prepare and present JC based on three pillars: dialogical learning through group discussion, mentored residents as peer teachers, and including JC as part of a structured curriculum to learn evidence-based medicine. This engaging model has the potential to transform JC from a moribund session that is daunting for residents into a lively discussion to redefine clinical practice using the most current evidence

أثر التكنولوجيا على التغيير البنائي للأسرة المعاصر

Nowadays there are many different types of family compared to 50 years ago when the ‘nuclear’ family, considered the ‘normal’ one, was the most dominant type. Affected by the advancement of many aspects, particularly technology, communication and globalization, the main changes have been changes to marriage and partnership as well as changes to children and families. In respect to changes to marriage fewer people, who are getting married later in life, are getting married nowadays with higher divorce rate. However, in regard to partnership, more couples are now living together without marriage –co-habitation with an increased number of same sex couples who are becoming more and more legally recognized in developed countries such as European, North Americans and Australia as well as more people are living alone. On the other hand, changes to children and families are noticed through women are having fewer or no children with more births outside marriage. With focus on the family patterns in the human history, this paper addresses the changes that occurred to family types between modernity and post- modernity as well as the main social aspects that led to these changes. الملخص: تشهد المجتمعات المعاصرة أنواعاً مختلفة من الأسر، بالمقارنة مع ما عرفته منذ خمسين سنة حيث كانت الأسرة النواة تعتبر النموذج الطبيعي والمسيطر في اغلب المجتمعات المتقدمة، وذلك كنتيجة للتطور الحاصل في تلك الدول في كافة المجالات خاصة: التكنولوجيا، وسائل التواصل والعولمة. أدت هذه التغييرات الاساسية الى تغييرات في نظام الزواج والعلاقات الثنائية بين الجنسيين بالإضافة الى تغيير في علاقة الأسرة والأبناء. بالنسبة لنظام الزواج: ارتفع متوسط سن الزواج وقل عدد الذين يقدمون عليه مع تزايد في احتمال الطلاق، وازداد عداد الذين يتساكنون خارج مظلة الزواج مع ارتفاع نسبة الأزواج من نفس الجنس (المثليين) الذين يحصلون على المزيد من الاعتراف القانوني بعلاقتهم في الكثير من الدول المتقدمة. بالنسبة للأسرة والأبناء، فالتغيير واضح في انخفاض عدد الأطفال للمرأة، او اختيارها عدم الانجاب، مع المزيد من الولادات خارج الزواج. تقوم هذه الورقة البحثية بتوضيح التغييرات المختلفة التي مرت بها الاسرة من الماضي وحتى الآن ، مع محاولة التعرف على اسباب نشوء الأسر اللانمطية ، وانواعها وأثارها على الفرد والمجتمع في العالم المتقدم بين الحداثة وما بعد الحداثة

Biclonal myelodysplastic syndrome involving six chromosomes and monoallelic loss of RB1 - A rare case

<p>Abstract</p> <p>Background</p> <p>Myelodysplastic syndrome (MDS) represents a group of clonal hematological disorders characterized by progressive cytopenia, and reflects to defects in erythroid, myeloid and megakaryocytic maturation. MDS is more frequently observed in older aged patients with cytogenetic abnormalities like monosomy of chromosome(s) 5 and/or 7. In 50% of de novo MDS cases, chromosomal aberrations are found and rearrangements involving the retinoblastoma (<it>RB1</it>) gene in 13q14 are found.</p> <p>Results</p> <p>Here, we are presenting a case report of a rare biclonal MDS with a karyotype of 45, XY,-4, der(6)t(4;6)(p15.1;p21.3), der(8)t(4;8)(q31.2;q22), t(13;16)(q21.3;p11.2)<abbrgrp><abbr bid="B11">11</abbr></abbrgrp>/45, XY, der(7)t(7;13)(p22.2~22.3;q21.3),-13 <abbrgrp><abbr bid="B9">9</abbr></abbrgrp>. The patient was diagnosed according to WHO classification as refractory anemia with excess of blasts (RAEB-II).</p> <p>Immunophenotyping was positive for CD11b, CD11c, CD10, CD13, CD15, CD16 and CD33.</p> <p>Conclusion</p> <p>We report, a novel and cytogenetically rare case of a biclonal MDS with complex chromosomal aberrations and deletion of <it>RB1</it>-gene in both clones. These findings are associated with a poor prognosis as the patient died 3 months after diagnosis.</p

Partial trisomy 9p22 to 9p24.2 in combination with partial monosomy 9pter in a Syrian girl

<p>Abstract</p> <p>Background</p> <p>Partial trisomy of the short arm of chromosome 9 is among the most common autosomal structural chromosomal anomalies leading to chromosomal imbalance in human. Clinical characteristics are craniofacial dysmorphism including hypertelorism, prominent nose, deep-set eyes, and down-slanting palpebral fissures. The degree of clinical severity in partial trisomy 9p roughly correlates with the size of the chromosomal imbalance. Therefore, breakpoints as well as clinical findings need to be precisely defined for differential diagnosis.</p> <p>Results</p> <p>Chromosomes of a young female were analyzed due to primary amenorrhea, short stature, developmental delay and a characteristic facial appearance. Cytogenetic analysis using GTG banding identified a karyotype 46, XX, add(9pter). Surprisingly the application of high resolution molecular cytogenetic techniques characterized a partial trisomy 9p24.2-p22 and partial monosomy 9pter-p24.2. To the best of our knowledge only four similar case were reported by now.</p> <p>Conclusion</p> <p>Attempts for genotype-phenotype correlations for partial trisomy 9p might have been hampered by the fact that more complex, cryptic aberrations were neither considered nor detected in comparable clinical cases.</p

A rare case of chronic myeloid leukemia with secondary chromosomal changes including partial trisomy 17q21 to 17qter and partial monosomy of 16p13.3

<p>Abstract</p> <p>Background</p> <p>The so-called Philadelphia (Ph) chromosome is present in almost all cases with chronic myeloid leukemia (CML). Around 5-10% of these patients show complex translocations involving other chromosomes in addition to and/or besides chromosomes 9 and 22. As nowadays most CML cases are treated with Imatinib, variant rearrangements have in general no specific prognostic significance, though events of therapy resistance remain to be studied.</p> <p>Results</p> <p>Here we report a Ph chromosome positive patient with hematological typical chronic phase CML. Untypically, an unbalanced complex rearrangement involving chromosomes 16 and 17 leading to a deletion of 16pter and partial trisomy of 17q21 to 17qter, was identified besides a trisomy 8 and an additional Ph chromosome in a part of malignant cells.</p> <p>Conclusion</p> <p>Here a novel and cytogenetically unique case of a Ph chromosome positive CML clinically in chronic phase is reported, having complex secondary chromosomal aberrations. Thus, CML patients with complex chromosomal changes are nonetheless treatable by Imatinib.</p

Novel complex translocation involving 5 different chromosomes in a chronic myeloid leukemia with Philadelphia chromosome: a case report

<p>Abstract</p> <p>Background</p> <p>The well-known typical fusion gene BCR/ABL can be observed in connection with a complex translocation event in only 2-10% of cases with chronic myeloid leukemia (CML). As currently most CML cases are treated with Imatinib, variant rearrangements have in general no specific prognostic significance, though the emergence of therapy resistance remains to be studied.</p> <p>Results</p> <p>Here we report an exceptional CML case with complex chromosomal aberrations not observed before, involving a 5 chromosome translocation implying chromosomal regions such as 1q42, 4p14 and 5q31 besides 9q34 and 22q11.2.</p> <p>Conclusion</p> <p>The reported rearrangement developed most probably in one initial step and had no influence on a good response during Imatinib treatment.</p

Cisplatin based therapy: The role of the mitogen activated protein kinase signaling pathway

Cisplatin is a widely used chemotherapeutic agent for treatment of various cancers. However, treatment with cisplatin is associated with drug resistance and several adverse side effects such as nephrotoxicity, reduced immunity towards infections and hearing loss. A Combination of cisplatin with other drugs is an approach to overcome drug resistance and reduce toxicity. The combination therapy also results in increased sensitivity of cisplatin towards cancer cells. The mitogen activated protein kinase (MAPK) pathway in the cell, consisting of extracellular signal regulated kinase, c-Jun N-terminal kinase, p38 kinases, and downstream mediator p90 ribosomal s6 kinase (RSK); is responsible for the regulation of various cellular events including cell survival, cell proliferation, cell cycle progression, cell migration and protein translation. This review article demonstrates the role of MAPK pathway in cisplatin based therapy, illustrates different combination therapy involving cisplatin and also shows the importance of targeting MAPK family, particularly RSK, to achieve increased anticancer effect and overcome drug resistance when combined with cisplatin. - 2018 The Author(s).Scopu

Changing trends in residents-as-teachers across graduate medical education

BACKGROUND: Teaching residents how to teach is a critical part of residents' training in graduate medical education (GME). The purpose of this study was to assess the change in resident-as-teacher (RaT) instruction in GME over the past 15 years in the US. METHODS: We used a quantitative and qualitative survey of all program directors (PDs) across specialties. We compared our findings with a previous work from 2000-2001 that studied the same matter. Finally, we qualitatively analyzed PDs' responses regarding the reasons for implementing and not implementing RaT instruction. RESULTS: Two hundred and twenty-one PDs completed the survey, which yields a response rate of 12.6%. Over 80% of PDs implement RaT, an increase of 26.34% compared to 2000-2001. RaT instruction uses multiple methods with didactic lectures reported as the most common, followed by role playing in simulated environments, then observing and giving feedback. Residents giving feedback, clinical supervision, and bedside teaching were the top three targeted skills. Through our qualitative analysis we identified five main reasons for implementing RaT: teaching is part of the residents' role; learners desire formal RaT training; regulatory bodies require RaT training; RaT improves residents' education; and RaT prepares residents for their current and future roles. CONCLUSION: The use of RaT instruction has increased significantly in GME. More and more PDs are realizing its importance in the residents' formative training experience. Future studies should examine the effectiveness of each method for RaT instruction

Billing by residents and attending physicians in family medicine: the effects of the provider, patient, and visit factors

BACKGROUND: Medical billing and coding are critical components of residency programs since they determine the revenues and vitality of residencies. It has been suggested that residents are less likely to bill higher evaluation and management (E/M) codes compared with attending physicians. The purpose of this study is to assess the variation in billing patterns between residents and attending physicians, considering provider, patient, and visit characteristics. METHOD: A retrospective cohort study of all established outpatient visits at a family medicine residency clinic over a 5-year period was performed. We employed the logistic regression methodology to identify residents' and attending physicians' variations in coding E/M service levels. We also employed Poisson regression to test the sensitivity of our result. RESULTS: Between January 5, 2009 and September 25, 2015, 98,601 visits to 116 residents and 18 attending physicians were reviewed. After adjusting for provider, patient, and visit characteristics, residents billed higher E/M codes less often compared with attending physicians for comparable visits. In comparison with attending physicians, the odds ratios for billing higher E/M codes were 0.58 (p = 0.01), 0.56 (p = 0.01), and 0.63 (p = 0.01) for the third, second, and first years of postgraduate training, respectively. In addition to the main factors of patient age, medical conditions, and number of addressed problems, the gender of the provider was also implicated in the billing variations. CONCLUSION: Residents are less likely to bill higher E/M codes than attending physicians are for similar visits. While these variations are known to contribute to lost revenues, further studies are required to explore their effect on patient care in relation to attendings' direct involvement in higher E/M-coded versus their indirect involvement in lower E/M-coded visits

Characterization of Cephalosporinases Produced by Clinical Isolates of Enterobacteriacae in North Lebanon

Background: The problem of Enterobacteriacae resistance to β-Lactamase drugsis of growing concern in hospitals. Enterobacteria have developed multiple mechanismsof resistance to antibiotics, the main one is the enzymatic resistance mediatedby the beta-lactamases. This study aims to characterize the occurrence ofcephalosporinases in clinical isolates of Enterobacteriacae isolates in North Lebanon.Methods. Twenty two strains of Enterobacteriacae producing high level of cephalosporinaseshave been studied. The antibiotic susceptibility of each strain wastested on Mueller Hinton agar contains cloxacilline (250 mg/L) and by using E-testaccording the guidelines of the Antibiogram Committee of the French Society forMicrobiology. The search for plasmid-mediated cephalosporinases was performedusing PCR and primers for plasmid-mediated cephalosporinases genes (CMY-2,DHA-1, ACT-1, ACC-1, FOX-1 and MOX-1).Results: Thirteen positive strains were detected, of these 9 strains produced theplasmid-mediated cephalosporinase (CMY-2) and one strain produced the plasmidmediatedcephalosporinase (DHA-1). The remaining 9 strains were high-level chromosomalcephalosporinase producers since they belong to group-three Enterobacteria.They did neither produce plasmid-mediated cephalosporinase, nor did theyhave resistance to third generation cephalosporins except for cefepim. Two strains(CMUL E. coli 021) and CMUL E. coli 255) which were not susceptible for cefepim byE-test produced plasmid-mediated cephalosporinase The sequencing result of these2 E.coli strains did not show any mutation in the promoter that is responsible forhigh expression level of the chromosomal cephalosporinase. All examined strainsproducing plasmid-mediated cephalosporinase CMY-2 were analyzed by ERIC-PCRtechnique. The results showed that two of these strains had the same pattern (C4and C5) and three others had another pattern (C10, C12 and C13).Conclusion: This study shows the variations of cephalosporinases produced byclinical isolates of Enterobacteriacae in North Lebanon