Cardiac examination is an essential aspect of the physical examination. Previous studies have shown poor diagnostic accuracy, but most used audio recordings, precluding correlation with visible ...observations. The training spectrum from medical students (MSs) to faculty has not been tested, to our knowledge.
A validated 50-question, computer-based test was used to assess 4 aspects of cardiac examination competency: (1) cardiac physiology knowledge, (2) auditory skills, (3) visual skills, and (4) integration of auditory and visual skills using computer graphic animations and virtual patient examinations (actual patients filmed at the bedside). We tested 860 participants: 318 MSs, 289 residents (225 internal medicine and 64 family medicine), 85 cardiology fellows, 131 physicians (50 full-time faculty, 12 volunteer clinical faculty, and 69 private practitioners), and 37 others.
Mean scores improved from MS1-2 to MS3-4 (P = .003) but did not improve or differ significantly among MS3, MS4, internal medicine residents, family medicine residents, full-time faculty, volunteer clinical faculty, and private practitioners. Only cardiology fellows tested significantly better (P<.001), and they were the best in all 4 subcategories of competency, whereas MS1-2 were the worst in the auditory and visual subcategories. Participants demonstrated low specificity for systolic murmurs (0.35) and low sensitivity for diastolic murmurs (0.49).
Cardiac examination skills do not improve after MS3 and may decline after years in practice, which has important implications for medical decision making, patient safety, cost-effective care, and continuing medical education. Improvement in cardiac examination competency will require training in simultaneous audio and visual examination in faculty and trainees.
Primary ventricular fibrillation (VF) during an acute myocardial infarction (AMI) occurs with a high incidence and mortality rate with or without thrombolysis. The incidence varies from 2% to 19% ...depending on the definition of “primary.” Primary VF in this study refers to fibrillation occurring in the absence of shock or pulmonary edema. Mortality rate, when primary VF occurs, is 2 to 4 times greater than when it does not. Prevention of VF has been impeded by the publication of the 1996 recommendations of the American Heart Association and American College of Cardiology against the use of prophylactic lidocaine based on meta-analysis studies implying toxicity. This observational study of 4,254 patients with AMI reports the incidence and mortality rates of primary VF over 32 years. Of the 4,254 patients, 4,150 received prophylactic lidocaine, and 104 patients did not receive prophylactic lidocaine due to the 1996 guidelines, after which administration of prophylactic lidocaine was governed by physician choice. The incidence of primary VF was 0.5% among the 4,150 who received prophylactic lidocaine and 10% among the 104 who did not (p <0.0001). Among the 4,150 receiving prophylactic lidocaine, sinoatrial block occurred in 0.5% and complete infranodal atrial ventricular block occurred in 0.2%, all secondary to the site of infarction (concurrent serum lidocaine levels were <4μg/ml). Asystole was an agonal rhythm in 4%; these patients had been off lidocaine for 48 hours. Mortality rates were 10.5% in patients without primary VF and 25% in patients with VF (p <0.001). Thus, prophylactic lidocaine markedly decreased the incidence of VF in 4,150 patients with AMI to 0.5% compared with trials before and after thrombolysis (2% to 19%) and with the 104 patients in this study who did not receive prophylactic lidocaine (10%). No lidocaine-induced sinoatrial or atrial ventricular block or asystole occurred.
Minipig skin is one of the most widely used non‐rodent animal skin models for dermatological research. A thorough characterization of minipig skin is essential for gaining deeper understanding of its ...structural and functional similarities with human skin. In this study, three‐dimensional (3‐D) in vivo images of minipig skin was obtained non‐invasively using a multimodal optical imaging system capable of acquiring two‐photon excited fluorescence (TPEF) and fluorescence lifetime imaging microscopy (FLIM) images simultaneously. The images of the structural features of different layers of the minipig skin were qualitatively and quantitatively compared with those of human skin. Label‐free imaging of skin was possible due to the endogenous fluorescence and optical properties of various components in the skin such as keratin, nicotinamide adenine dinucleotide phosphate (NAD(P)H), melanin, elastin and collagen. This study demonstrates the capability of optical biopsy techniques, such as TPEF and FLIM, for in vivo non‐invasive characterization of cellular and functional features of minipig skin, and the optical image‐based similarities of this commonly utilized model of human skin. These optical imaging techniques have the potential to become promising tools in dermatological research for developing a better understanding of animal skin models, and for aiding in translational pre‐clinical to clinical studies.
Helicobacter hepaticus is a bacterial pathogen of mice that has been reported to cause chronic intestinal inflammation in A/JCr, germfree Swiss Webster, and immunodeficient mice. To the authors' ...knowledge, the influence of sex on development of chronic intestinal inflammation in H. hepaticus-infected mice has not been investigated. The purposes of the study reported here were to determine whether severity of intestinal inflammation differs between male and female A/JCr mice chronically infected with H. hepaticus and to characterize the mucosal immune response in these mice. The cecum of male and female A/JCr mice infected with H. hepaticus for 1 month and 3 months was objectively evaluated histologically for intestinal disease. Also, semi-quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) analysis was done to measure interferon-gamma (IFN-gamma), tumor necrosis factor-alpha (TNF-alpha), interleukin 4 (IL-4), IL-10, macrophage inflammatory protein-1alpha (MIP-1alpha), interferon-inducible protein of 10 kDa (IP-10), and monokine induced by gamma interferon (MIG) mRNA values in the cecal tissue of these mice. Significant differences in cecal lesion scores were not present at 1 month after infection. However, infected female mice had significantly up-regulated expression of cecal IL-10, MIP-1alpha, IP-10, and MIG mRNA compared with that in uninfected females, and expression of IL-10 and MIP-1alpha was significantly greater than that detected in infected male mice (P < or = 0.05). At 3 months after infection, cecal lesion scores were significantly (P < or = 0.05) increased in female and male mice compared with uninfected controls, and infected female mice had significantly (P < or = 0.05) higher cecal lesion scores than did infected male mice. In addition, infected females had significant (P < or = 0.05) increases in cecal IFN-gamma, TNF-alpha, IL-10, MIP-1alpha, IP-10, and MIG mRNA values compared with values in uninfected females and infected males, and male mice had significant (P < or = 0.05) increases in cecal TNF-alpha and IL-10 mRNA values compared with those for male control mice. These data indicate that, in H. hepaticus-infected A/JCr mice, females develop more severe intestinal inflammation than do males, and the chronic mucosal inflammation is polarized toward a Th1 response that is not down-regulated by increased activity of IL-10. We propose that H. hepaticus-infected A/JCr mice will serve as a good animal model with which to study the influence of sex on bacterial-induced mucosal inflammation.
Abstract
Introduction
Mild-to-moderate obstructive sleep apnea (OSA) affects 15-40% of the adult general population. However, it remains unclear when and how best to treat mild-to-moderate OSA. It ...has been shown that mild-to-moderate OSA in general random samples is associated with incident hypertension. The aim of this study was to compare the relative utility of apnea/hypopnea index (AHI) versus a biomarker of inflammation, C-reactive protein (CRP), in identifying the presence and severity of hypertension and insulin resistance (IR).
Methods
A clinical sample of 148 adults (53.79±12.45) with mild-to-moderate OSA (AHI between 5 and 29 events per hour) underwent 8-hour polysomnography, a clinical history and physical examination, including measures of blood pressure, body mass index (BMI), fasting blood glucose, insulin and CRP plasma levels. Hypertension was defined by previous diagnosis, past or present treatment, or blood pressure ≥140/90. IR was defined by homeostatic model assessment. Individuals with diabetes and/or on diabetes medication were excluded from analyses with IR. All analyses were conducted controlling for age, gender and BMI.
Results
CRP levels (OR=2.62, 95% CI=1.35-5.04, p=0.004), age (OR=1.75, 95% CI=1.11-2.75, p=0.016), and BMI (OR=2.74, 95% CI=1.20-6.26, p=0.017) were independently associated with greater odds for hypertension, whereas AHI (OR=1.33, 95% CI=0.61-2.92, p=0.477) was not. Additionally, CRP levels (β=0.21; p=0.04) and BMI (β=0.24; p=0.02) were independently associated with higher IR, while AHI (β=-0.03; p=0.75) was not. There was a trend for this association to be stronger in non-obese patients.
Conclusion
These preliminary findings suggest that including a measure of inflammation improves the ability for clinicians to detect cases of mild-to-moderate OSA with true cardiometabolic risk. CRP may be a simple, easy-to-use biomarker that can improve prognosis assessment and clarify which treatment option is best for patients with mild-to-moderate OSA.
Support
Department of Psychiatry, Penn State College of Medicine
Electrocardiographic (ECG) rhythm analysis is inadequately taught in training programs, resulting in undertrained physicians reading a large percentage of the 40 million ECGs recorded annually. The ...effective use of simple tools (calipers, ruler, and magnifier) required for crucial measurements and comparisons of intervals requires considerable time for interactive instruction and is difficult to teach in the classroom. The ECGViewer (Blaufuss Medical Multimedia Laboratories, Palo Alto, Calif) program was developed using virtual tools easily manipulated by computer mouse that can be used to analyze archived scanned ECGs on computer screens and classroom projection. Trainees manipulate the on-screen tools from their seats by wireless mouse while the instructor makes corrections with a second mouse, in clear view of the trainees. An on-screen ladder diagram may be constructed by the trainee and critiqued by the instructor. The ECGViewer program has been successfully used and well received by trainees at medical school, residence, and subspecialty fellow level.
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