Abstract Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in ...young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On February 26-27, 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.
Background Endoscopist quality is benchmarked by the adenoma detection rate (ADR)—the proportion of cases with 1 or more adenomas removed. However, the ADR rewards the same credit for 1 versus more ...than 1 adenoma. Objective We evaluated whether 2 endoscopist groups could have a similar ADR but detect significantly different total adenomas. Design We retrospectively measured the ADR and multiple measures of total adenoma yield, including a metric called ADR-Plus, the mean number of incremental adenomas after the first. We plotted ADR versus ADR-Plus to create 4 adenoma detection patterns: (1) optimal (↑ADR/↑ADR-Plus); (2) one and done (↑ADR/↓ADR-Plus); (3) all or none (↓ADR/↑ADR-Plus); (4) none and done (↓ADR/↓ADR-Plus). Setting Tertiary-care teaching hospital and 3 nonteaching facilities servicing the same patient pool. Patients A total of 3318 VA patients who underwent screening between 2005 and 2009. Main Outcome Measurements ADR, mean total adenomas detected, advanced adenomas detected, ADR-Plus. Results The ADR was 28.8% and 25.7% in the teaching (n = 1218) and nonteaching groups (n = 2100), respectively ( P = .052). Although ADRs were relatively similar, the teaching site achieved 23.5%, 28.7%, and 29.5% higher mean total adenomas, advanced adenomas, and ADR-Plus versus nonteaching sites ( P < .001). By coupling ADR with ADR-Plus, we identified more teaching endoscopists as optimal (57.1% vs 8.3%; P = .02), and more nonteaching endoscopists in the none and done category (42% vs 0%; P = .047). Limitations External generalizability, nonrandomized study. Conclusion We found minimal ADR differences between the 2 endoscopist groups, but substantial differences in total adenomas; the ADR missed this difference. Coupling the ADR with other total adenoma metrics (eg, ADR-Plus) provides a more comprehensive assessment of adenoma clearance; implementing both would better distinguish high- from low-performing endoscopists.
Applying Adult Learning Practices in Medical Education Reed, Suzanne, MD; Shell, Richard, MD; Kassis, Karyn, MD ...
Current problems in pediatric and adolescent health care,
07/2014, Letnik:
44, Številka:
6
Journal Article
Recenzirano
The application of the best practices of teaching adults to the education of adults in medical education settings is important in the process of transforming learners to become and remain effective ...physicians. Medical education at all levels should be designed to equip physicians with the knowledge, clinical skills, and professionalism that are required to deliver quality patient care. The ultimate outcome is the health of the patient and the health status of the society. In the translational science of medical education, improved patient outcomes linked directly to educational events are the ultimate goal and are best defined by rigorous medical education research efforts. To best develop faculty, the same principles of adult education and teaching adults apply. In a systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education, the use of experiential learning, feedback, effective relationships with peers, and diverse educational methods were found to be most important in the success of these programs. In this article, we present 5 examples of applying the best practices in teaching adults and utilizing the emerging understanding of the neurobiology of learning in teaching students, trainees, and practitioners. These include (1) use of standardized patients to develop communication skills, (2) use of online quizzes to assess knowledge and aid self-directed learning, (3) use of practice sessions and video clips to enhance significant learning of teaching skills, (4) use of case-based discussions to develop professionalism concepts and skills, and (5) use of the American Academy of Pediatrics PediaLink as a model for individualized learner-directed online learning. These examples highlight how experiential leaning, providing valuable feedback, opportunities for practice, and stimulation of self-directed learning can be utilized as medical education continues its dynamic transformation in the years ahead.
Cardiovascular Screening in College Athletes Drezner, Jonathan A., MD; Prutkin, Jordan M., MD, MHS; Harmon, Kimberly G., MD ...
Journal of the American College of Cardiology,
06/2015, Letnik:
65, Številka:
21
Journal Article
Recenzirano
Odprti dostop
Physician expertise, cardiology, and institutional resources vary among NCAA institutions, which will affect both the capacity and ability to implement ECG screening. ...the findings of this study ...may not be applicable to institutions with less experience. Athlete Diagnosis Screening Secondary Testing Management 19-year-old African-American male; basketball Hypertrophic cardiomyopathy History (-)Physical (-)ECG (+)Inferolateral ST-segment depression and deep T-wave inversion Echo: IVS, 1.2 cm; posterior wall, 1.2 cm; LVEDD, 5.3 cmCardiac MRI: apical wall thickness, 2.0 cm, with late gadolinium enhancement Disqualified from competitive sports; underwent risk stratification, activity recommendations, and close follow-up 20-year-old Caucasian male; crew Long QT syndrome History (-)Physical (-)ECG (+)QTc interval, 465 ms ETT: prolongation of the QTc interval at higher heart ratesGenetic testing: confirmed KCNQ1 gene mutation for long QT type I Extensive patient and family counseling by outside expert, declined beta-blocker therapy, allowed to continue rowing, no events over 4 yrs 18-year-old Caucasian male; baseball Wolff-Parkinson-White History (-)Physical (-)ECG (+)Ventricular pre-excitation, short PR interval, delta wave Echo: normalEP study: high-risk accessory pathway; status post-ablation Returned to sport 18-year-old Caucasian male; baseball Wolff-Parkinson-White History (-)Physical (-)ECG (+)Ventricular pre-excitation, short PR interval, delta wave ETT: abrupt loss of pre-excitation (low-risk pathway) Returned to sport 18-year-old Caucasian female; basketball Wolff-Parkinson-White History (-)Physical (+)MurmurECG (+)Ventricular pre-excitation, short PR interval, delta wave Echo: normalETT: abrupt loss of pre-excitation Returned to sport, interval episode of palpitations and near-syncope led to EP study with ablation, returned to sport Table 1 Athletes Identified With Cardiac Disorders Associated With Sudden Cardiac Death (-) = negative; (+) = positive; ECG = electrocardiogram; Echo = echocardiogram; EP = electrophysiological; ETT = exercise treadmill test; IVS = interventricular septum; LVEDD = left ventricular end-diastolic diameter; MRI = magnetic resonance imaging.
Distal biceps tendon insertion: An anatomic study Hutchinson, Hank L., MD; Gloystein, David, MD; Gillespie, Martin, MD
Journal of shoulder and elbow surgery,
03/2008, Letnik:
17, Številka:
2
Journal Article
Recenzirano
Knowledge of the exact location of the distal biceps brachii insertion is crucial when performing tendon reconstruction or repair. To quantitatively describe the morphology of the distal biceps ...brachii insertion, 20 cadaveric arms were examined. Linear and angular measurements, including the footprint dimensions and shape, radial tuberosity dimensions and irregularities, and the rotational position of the tuberosity and footprint, were obtained. The axial and transverse dimensions of the radial tuberosity and distal biceps tendon footprint measured 24.2 x 12 mm and 18.7 x 3.7 mm, respectively. The insertion footprint is on the posterior/ulnar aspect of the radial tuberosity centered at approximately 30° anterior to the lateral/coronal plane with the forearm fully supinated. This explains why any preoperative limitation in supination may make an anatomic repair difficult through a single anterior incision. To our knowledge, this is the first study to quantitatively describe the angular location of the radial tuberosity and the relationship of the distal biceps tendon on the tuberosity.
Florbetapir F-18 is a molecular imaging agent combining high affinity for β-amyloid, pharmacokinetic properties that allow positron emission tomography (PET) imaging within a convenient time after ...dose administration, and the wide availability of the radionuclide fluorine-18. Florbetapir F-18 is prepared by nucleophilic radiofluorination in approximately 60 minutes with a decay-corrected yield of 20%-40% and with a specific activity typically exceeding 100 Ci/mmol. The florbetapir F-18 dissociation constant (Kd ) for binding to β-amyloid in brain tissue from Alzheimer's disease (AD) patients was 3.7 ± 0.3 nmol/L, and the maximum binding capacity (Bmax ) was 8800 ± 1600 fmol/mg protein. Autoradiography studies have shown that florbetapir F-18 selectively binds to β-amyloid aggregates in AD patient brain tissue, and the binding intensity is correlated with the density of β-amyloid quantified by standard neuropathologic techniques. Studies in animals revealed no safety concerns and rapid and transient normal brain uptake (6.8% injected dose/g at 2 minutes and 1.9% injected dose/g at 60 minutes in the mouse). Florbetapir F-18 has been well-tolerated in studies of more than 2000 human subjects. Biodistribution studies in humans revealed predominantly hepatobiliary excretion. The whole body effective dose was 7 mSv from a dose of 370 MBq. The pharmacokinetic of florbetapir F-18 make it possible to obtain a PET image with a brief (10 minutes) acquisition time within a convenient time window of 30-90 minutes after dose administration. Clinical studies have demonstrated a clear correlation between in vivo PET imaging with florbetapir F-18 and postmortem histopathologic quantitation of β-amyloid in the brain.
Background Toll-like receptors contribute to the establishment of adaptive immune responses. Objective The reported studies were conducted to examine the effects of the Toll-like receptor (TLR)–7 ...ligand, resiquimod, on human naive B-cell differentiation. Methods Naive human B cells were cultured with resiquimod in the presence or absence of IL-2 and IL-10. Secreted IgM and IgG were measured by ELISA, and IL-6, IL-10, and IFN-α were measured by a multiplex protein array. Cell proliferation was assessed by measuring 3 Hthymidine uptake. mRNA for activation-induced cytidine deaminase and Iγ1 -Cμ circle transcripts was measured by means of RT-PCR. Results Resiquimod induced the production of IgM and, to a lesser extent, IgG by naive human B cells in association with the secretion of IL-6 and IL-10, and a weak proliferative response. IL-2 and IL-10 synergized with resiquimod in markedly augmenting resiquimod-induced IgM and IgG production and proliferation. Resiquimod also stimulated production of IgG by B cells isolated from the blood of a patient with the X-linked hyper-IgM syndrome, with a greater response when these cells were costimulated with IL-2 and IL-10. The stimulated naive B cells from healthy volunteers displayed molecular evidence of immunoglobulin class-switch recombination—namely the appearance of activation-induced cytidine deaminase and Iγ1 -Cμ circle transcripts. Conclusion Perturbation of TLR-7 on naive human B cells can lead to the induction of immunoglobulin class switch and IgG production in the absence of B-cell receptor cross-linking and CD40-CD40L interaction. The results are relevant to vaccine development and mechanisms by which microbial infection may lead to autoimmunity.
Objectives The purpose of our study was to assess the impact of revised versus original criteria on the prevalence of arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) criteria in ...cardiac magnetic resonance (CMR) studies. Background Recently, the ARVC/D task force criteria have been revised, aiming for a better diagnostic sensitivity. The implications of this revision on clinical decision making are unknown. Methods We retrospectively evaluated the CMR scans of 294 patients referred for ARVC/D between 2005 and 2010, and determined the presence or absence of major and minor CMR criteria using the original and the revised task force criteria. Previously, major and minor abnormalities were identified by the presence of right ventricle dilation (global or segmental), right ventricle microaneurysm, or regional hypokinesis. The revised criteria require the combination of severe regional wall motion abnormalities (akinesis or dyskinesis or dyssynchrony) with global right ventricle dilation or dysfunction (quantitative assessment). Results Applying the original criteria, 69 patients (23.5%) had major original criteria, versus 19 patients (6.5%) with the revised criteria. Forty-three patients (62.3%) with major original criteria did not meet any of the revised criteria. Using the original criteria, 172 patients (58.5%) had at least 1 minor criterion versus 12 patients (4%) with the revised task force criteria; 167 patients (97%) with minor original criteria did not meet any of the revised criteria. In the subgroup of 134 patients with complete diagnostic work-up of ARVC, 10 patients met the diagnosis of proven ARVC/D without counting imaging criteria. Only 4 of 10 met major criteria according to the revised CMR criteria; none met minor criteria. However, 112 of 124 patients without ARVC/D were correctly classified as negative by major and minor criteria (specificity 94% and 96%, respectively). Conclusions In our experience, the revision of the ARVC/D task force imaging criteria significantly reduced the overall prevalence of major and minor criteria. The revision, although maintaining a high specificity, may not have improved the sensitivity for identifying patients with ARVC/D. Larger studies including follow-up are required.
As a key regulator of serotonergic activity and target of many antidepressant treatments, the serotonin transporter (SERT) represents a potential mediator of anxiety- and depression-related ...behaviors. Using mice lacking the SERT (SERT KO), we examined the role of SERT function in anxiety- and depression-related behaviors and serotonergic neuron function.
Serotonin transporter knockout mice were evaluated in paradigms designed to assess anxiety-, depression-, and stress-related behaviors. Dorsal raphe nucleus (DRN) function was assessed by quantitative serotonergic cell counting and extracellular electrical recording of neuronal firing properties.
Serotonin transporter knockout mice showed an increase in latency to feed in a novel situation, more immobility in a forced swim, increased escape latency in a shock escape paradigm, and decreased immobility in tail suspension. No differences in anxiety-related behaviors were seen in the open field and the elevated plus maze. Serotonin transporter knockout mice exhibit a 50% reduction in serotonergic cell number and a fourfold decrease in firing rate in the DRN.
Developmental loss of SERT produces altered behaviors in models of depression that are generally opposite to those produced by antidepressant treatment. The reduced serotonergic cell number and firing rate in the DRN of adult SERT KO mice suggest a mechanism for these altered behaviors.
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