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Meeting medical challenges in a changing world: the international program of the U.S. Army Telemedicine and Advanced Technology Research Center (TATRC).

The U.S. Army Telemedicine and Advanced Technology Research Center (TATRC) manages more than 200 research projects in advanced medical technologies, with concentration in disciplines such as simulation, distance learning, information and communications, or robotics to name a few. In recent years, TATRC has progressively increased its international portfolio and is now overseeing several programs in cooperation with foreign countries. This paper describes the mechanisms through which TATRC supports funding foreign projects, training colleagues from other countries, and sponsoring international meetings.

Biomedical Technology↗

Retinoic acid synthesis in the postnatal mouse brain marks distinct developmental stages and functional systems.

Retinoic acid (RA) affects development and function of the brain, but little is known about how much is made locally and where it is distributed. To identify RA-sensitive neural processes, we mapped the RA-synthesizing retinaldehyde dehydrogenases (RALDHs) during postnatal brain formation of the mouse. High and stable RALDH expressions mark the basal ganglia, olfactory bulbs, hippocampus and auditory afferents as major sites of RA actions in the functional brain. During the early postnatal period, transient and very high RALDH3 expressions distinguish two developmental events: (i) the colonization of the nucleus accumbens and the olfactory bulbs by neuronal precursors and (ii) the maturation of selected parts of the cerebral cortex. In the cortex, RALDH3 is transiently activated in postmigratory layer II/III neurons during formation of their dendritic arbors and it is transported in their axons across the corpus callosum. RALDH3-expressing cortical regions include most of the limbic lobe, with strongest expression in the anterior cingulate cortex, medial and lateral secondary visual cortices, auditory cortical areas, the secondary motor cortex and some association areas. The transient cortical expression points to a brief RA-critical period during differentiation of the cortical network that serves in the coordination of sensory-motor activity with emotional and recently learned information.

Aldehyde Oxidoreductases↗

The Na-(K)-Cl cotransporter family in the mammalian kidney: molecular identification and function(s).

A new solute carrier gene family, SLC12, was recently described based on the molecular identification of three electroneutral Na-(K)-Cl cotransport proteins. In mammals, these proteins are encoded by three distinct but related genes: SLC12A1, SLC12A2, SLC12A3, which are located on different chromosomes. Although the expression patterns of these three cotransport proteins differ significantly, all of them are expressed in the mammalian kidney and participate in several important aspects of renal function. This review summarizes the information learned from the molecular identification of these cotransporters, evaluates the patterns of expression within the kidney, and discusses the roles that these cotransporters play in renal physiology and pathophysiology.

Animals↗

Musculoskeletal ultrasonography in Europe: results of a rheumatologist-based survey at a EULAR meeting.

OBJECTIVE: To document the practice of musculoskeletal ultrasound (US) by a sample of European rheumatologists attending an annual general meeting of the European League Against Rheumatism (EULAR). METHODS: English-language questionnaires were distributed to 180 randomly selected participants attending imaging-related sessions at the XIV EULAR meeting in Glasgow, UK, in 1999. The questionnaire was divided into four sections: Demographics, Education and Training, Current Practice, and Equipment. RESULTS: Ninety-two rheumatologists responded, representing 74 centres from 19 European countries. Seventy-eight (85%) of the respondents either already used US in their clinical practice or would like to use it in the future. Thirty-seven (40%) respondents performed US within their own department. Few had received training at undergraduate level and most had learned informally or by attending courses. Scans were considered most useful for large joints and ligaments/tendons. Only 28 (30%) respondents valued US for guided injections. CONCLUSIONS: This study, although containing an element of selection bias, confirms a great interest in musculoskeletal US by rheumatologists across Europe and a demand which is likely to increase. The reported variation in training and practice between countries suggests a need for standardized training guidelines.

Education, Medical, Undergraduate↗

The search for Harvey Cushing's patient, Minnie G., and the cause of her hypercortisolism.

The case of Harvey Cushing's historical patient, Minnie G, is now closed. Recent investigation has succeeded in identifying her, locating her death certificate, and finding her family. Information learned about the patient's personality is consistent with Cushing's assertion that her syndrome, although ameliorated, was persistent. The cause of her Cushing's syndrome remains unknown.

Adult↗

Quality of life in head and neck cancer.

Because treatments for patients with cancer of the head and neck can have major impact on physical, social, and psychological function, the collection of quality of life (QOL) data in this group of patients is critical for our specialty. The University of Washington Quality of Life data have been collected and analyzed on three subsets of cancer patients. Information learned from these patients is summarized and strategies for future projects are outlined.

Attitude to Health↗

Memory deficits among children with craniopharyngiomas.

OBJECTIVE: To describe neuropsychological functioning (with a specific focus on cognition and memory) after surgical treatment of craniopharyngiomas. METHODS: Sixteen patients who were between 6 and 15 years of age at the time of surgery comprised the sample. Each child had been treated for a craniopharyngioma with surgery only, on Dana-Farber Cancer Institute Protocol 92-077. RESULTS: The overall level of cognitive functioning was well within the average range, with both language and visuospatial functioning being generally intact; however, specific memory problems, in both the language and visuospatial domains, were evident. CONCLUSION: Although general cognitive functioning was intact after the surgical treatment of craniopharyngiomas, difficulties in the retrieval of learned information were observed. Neuropsychological assessments, with a focus on memory recall, should be a component of the medical management plan for each child.

Adolescent↗

Readability of patient education materials: a comparison of rural and urban cardiac rehabilitation sites in Minnesota.

PURPOSE: Printed materials play a major role in cardiac rehabilitation (CR) patient education. Past studies have demonstrated a marked disparity between the average American reading ability (8th grade) and the readability levels of printed CR patient materials. This study compares the readability of facility-developed patient education materials used by rural and urban CR sites in Minnesota. METHODS: By random selection, 30 rural and 30 urban CR sites were invited to submit printed education materials addressing home programs, exercise and activity guidelines, and leisure and recreation. Materials from 7 rural and 10 urban sites were submitted and assessed using the SMOG and SMOG-C readability formulas. RESULTS: On the average, the materials from both urban and rural CR sites were written at a 10th-grade level. More than 87% of the sites required reading skills above the eighth-grade level. An independent t test showed no significant difference in the readability levels between the urban and rural sites. This study primarily compared readability across sites. However, the distribution of the 36 pieces of written material also was examined. Only 9% of the urban materials and 14% of the rural materials were written at or below the targeted eighth-grade level. CONCLUSIONS: There was no significant difference in mean readability levels between urban and rural CR sites in Minnesota. On the average, the readability levels were two grades higher than recommended, with 87.5% of the CR sites expecting patients to learn information from materials too difficult for average American adults. The large number of polysyllabic words appears to be the main culprit for difficult readability levels.

Comprehension↗

Acute withdrawal from repeated cocaine treatment enhances latent inhibition of a conditioned fear response.

Psychostimulant-induced locomotor sensitization and disrupted latent inhibition (LI) of a classically conditioned association are two paradigms that have been widely studied as animal behavioural models of psychosis. In this study we assessed the effects of withdrawal from the repeated intermittent administration of cocaine on LI of a conditioned fear response. Animals which were either preexposed (PE) to a tone conditioned stimulus (CS) or naive to the tone (i.e. non-preexposed: NPE) subsequently experienced 10 pairings of the tone CS with footshock. Afterwards, both groups received five daily injections of cocaine (20 mg/kg, i.p.) or saline. After 3 days of withdrawal from drug treatment, animals were tested for conditioned freezing to the context of the footshock chamber, and 1 day later, for conditioned freezing to the tone CS. Cocaine-sensitized animals exhibited markedly enhanced LI compared to saline-treated animals, due to the fact that NPE-cocaine animals spent more time freezing during the tone CS than NPE-saline animals, whereas PE-cocaine animals showed a tendency toward reduced freezing compared to the saline groups. While these results suggest the presence of increased anxiety in cocaine-withdrawn NPE animals, the absence of this effect in cocaine-withdrawn PE rats indicates that cocaine withdrawal also influences the retrieval of previously learned information.

Acoustic Stimulation↗

Affect and research in medical education.

All studies addressing affective issues were identified from a review of the Proceedings of Research in Medical Education (RIME) volumes between 1970 and 1982. A total of seventy-seven papers were sorted into the following seven categories according to the major issues addressed: (1) descriptive studies of personality, values and attitudes; (2) changes in attitudes; (3) interviewing skills; (4) personality and admission; (5) personality and career choice; (6) stress and coping style; and (7) miscellaneous. Several trends emerged from 13 years of research with implications for medical education. This review clarifies findings which could contribute to a better understanding of student affect and how it may be influenced by teachers. The potency of role models and informal learning in shaping student affect is particularly noteworthy. The authors suggest that studies involving role models need to go beyond observation and description and incorporate feed-back to the subjects of the study.

Affect↗

Evaluation of interns by senior residents and faculty: is there any difference?

INTRODUCTION: Both senior residents and faculty members evaluate family practice interns (PGY-1) on the inpatient family medicine service at the University of Missouri-Columbia. The purpose of this study was to investigate the content and nature of narrative comments on a clinical evaluation sheet. METHODS: Objective 1. The authors placed the subjective comments made by faculty and senior residents in their evaluations of PGY-1 residents into 12 distinctive categories. Objective 2. Comments were coded with a positive or negative valence. Objective 3. The genders of the evaluator and learner were recorded. RESULTS: All evaluations made between 1996 and 1999 were analysed. A total of 1341 individual comments were reviewed. Objective 1. Categories used most often were generic comments (20.2%), personal attributes (18%), and clinical competence (14.1%). There was no difference in category use based on the experience level of the evaluator (P = 0.17). Objective 2. The majority of the comments (81.9%) were positive in nature. Senior faculty members were significantly less likely to make negative comments than were junior faculty members or senior residents (P = 0.004). Objective 3. There were no differences in category use based on the gender of the evaluator (P = 0.13). CONCLUSIONS: Objective 1. Narrative evaluation comments may be placed into 12 distinctive categories. Most comments are generic and do not help to inform learning. Objective 2. A total of 82% of comments were positive. Residents were more likely to make negative comments than senior faculty members. Objective 3. There was no demonstrable gender bias in writing negative comments.

Clinical Competence↗

Cognitive event-related potential components during continuous recognition memory for pictures.

Event-related brain potentials (ERPs) were recorded from 28 young adult subjects during a continuous recognition memory paradigm, with pictures as stimuli. Subjects were required to determine on each trial if the picture was "new" (never before presented) or "old" (seen previously). To assess differences between primary and secondary memory, old items were presented after lags of 2, 8, and 32 intervening pictures (equiprobable) following their first presentation. The results suggested that a negativity (Cz maximum) at 300 ms was the most likely candidate for the brain event reflecting the retrieval of the item from memory. Old/new effects were modulated by two types of activity, both of which were larger in the ERPs elicited by new items. The earlier of these, possibly similar to the N400, had a duration from about 250-600 ms, began with the N300 deflection, and lasted until "P300" began to decrement. The other was positive, resembled "positive slow wave," onset as P300 began to decrement, and lasted until the end of the recording epoch. There were no consistent effects of item lag on the behavioral data or on any of the ERP components, suggesting that for pictorial stimuli, the distinction between the two types of memory store, primary (i.e., immediate memory) and secondary (newly learned information), may not be relevant. In consonance with the lack of lag effects, it was suggested that the lack of a robust subsequent memory effect on the ERP waveform could have been due to the use of pictures, which may have required less elaborative processing in order to be encoded at input.

Adult↗

The environmental context of patient safety and medical errors.

The environmental context of patient safety and medical errors was explored with specific interest in rural settings. Special attention was paid to unique features of rural: healthcare organizations and their environment that relate to the patient safety issue and medical errors (including the distribution of patients, types of adverse events associated with learning, information flows, triage and transfer decisions, and culture of safety). Relevant organizational theories and strategies fo medical error reduction and prevention in rural health care settings were identified. Financial and technical assistance are needed to support the systematic collection of data from rural hospitals and other entities and to enhance relevant patient safety practices for rural America.

Humans↗

Bitemporal hypoperfusion in transient global amnesia: 99m-Tc-HM-PAO SPECT and neuropsychological findings during and after an attack.

We report a patient who was evaluated neuropsychologically and with single photon emission computed tomography (SPECT) during and after an episode of transient global amnesia. During the attack, there was patchy retrograde amnesia and an inability to learn both verbal and non-verbal material. SPECT showed severe bitemporal hypoperfusion. Serial neuro-psychological testing documented a rapid recovery of recognition, but delayed recovery in reproduction of learned information. Recovery of spontaneous verbal and figural fluency was even further delayed. Follow up SPECT examination showed a recovered cerebral perfusion. This case supports the hypothesis that TGA is associated with transient hypoperfusion of bilateral medial-temporal brain structures and suggests an additional involvement of structures responsible for drive and initiation.

Aged↗

Neuropsychological and psychiatric complications in endoscopic third ventriculostomy: a clinical case report.

The clinical case report of a patient who underwent an endoscopic third ventriculostomy for the treatment of a slit ventricle syndrome is presented. After surgery the patient developed a severe complication consisting of an organic personality disorder, characterised by impulsiveness, physical heteroaggressiveness, binge eating, hypersomnia and impairment of memory, and frontal-executive functions.A frontal lobe lesion may explain some of the symptoms presented, such as the uncontrolled impulses, the aggressive behaviour, and even the binge eating. However, a longitudinal neuropsychological evaluation showed a severe deficit in immediate memory and difficulties in planning and consolidation of newly learned information, which may be best related to damage in the frontal basal structures of the brain: the fornix and its connection to the hippocampus and the mamillary bodies. Postoperative MR images confirmed the clinical hypothesis. The emergence of such a severe organic personality disorder and cognitive disturbances as a psychiatric complication of an endoscopic third ventriculostomy has not, it seems, been previously reported elsewhere. Clinicians should take these possible complications into account when recommending this so-called minimally invasive neuroendoscopic procedure.

Adult↗

Merck Frosst award lecture 1995. La conference Merck Frosst 1995. Structural studies of lipoproteins and their apolipoprotein components.

Lipid transport processes via the circulatory system of animals are a vital function that utilizes highly specialized lipoprotein complexes. These complexes of protein and lipid impart solubility to otherwise insoluble lipids. The apoprotein components of lipoprotein complexes serve to stabilize the lipid components and modulate particle metabolism and function as ligands for receptor-mediated endocytosis of lipoproteins. We have used an insect (Manduca sexta) model system for studies of lipid transport. In this system, flight activity elicits a dramatic increase in the demand for glycerolipid fuel molecules by flight muscle tissue. These lipids are mobilized from a storage organ and transported through the hemolymph (blood) to the flight muscle by the lipoprotein, lipophorin. This system possesses the unique property that lipids are loaded onto pre-existing high density lipophorin through the action of a lipid transfer particle (LTP). LTP is a high molecular weight hemolymph component that facilitates net vectorial lipid transfer from fat body tissue to lipophorin. The increase in lipid content of the lipoprotein induces association of a low molecular weight amphipathic exchangeable apolipoprotein, apolipophorin III (apoLp-III). ApoLp-III is a 18 kDa protein that normally exists as a water-soluble monomeric hemolymph protein. The structural properties of apoLp-III have been investigated by X-ray crystallography. ApoLp-III from Locusta migratoria adopts a five helix bundle conformation wherein each of the amphipathic helices orients with its hydrophobic face directed toward the interior of the bundle. It has been hypothesized that lipid association requires a dramatic conformational change wherein the helix bundle opens about putative hinge domains located in the loops between helices. The data accumulated support the concept that apoLp-III is a member of the broad class of exchangeable apolipoproteins and structural information learned from this system is directly applicable to analogous proteins in higher organisms.

Animals↗

The final F.F.A.R.A.C.S. examination.

The development of the Final Examination of Fellowship of the Faculty of Anaesthetists of the Royal Australasian College of Surgeons is described from its inception in 1956 to the present. A statistical analysis was made of the examinations in 1969 and 1970. The correlations between marks for essay questions, within the multiple choice examination and between clinical examinations were low, suggesting that the reliability of these tests was unsatisfactory. At this same time, applied anatomy was added to the subjects in this examination. The examination was restructured with more emphasis on the oral and multiple choice examination and the marking system was revised. Continuing analysis has shown higher correlations between and within most parts of the examination. The correlations for the essay marks have remained lower, but essays have been retained in an attempt to assess and encourage the skills involved. Feedback of teaching and learning information obtained from analysis of the examination is provided to Regional Education Officers and Supervisors of Training.

Anesthesiology↗

Cloning, stem cells, and the current national debate: incorporating ethics into a large introductory biology course.

Discussing the ethical issues involved in topics such as cloning and stem cell research in a large introductory biology course is often difficult. Teachers may be wary of presenting material biased by personal beliefs, and students often feel inhibited speaking about moral issues in a large group. Yet, to ignore what is happening "out there" beyond the textbooks and lab work is to do a disservice to students. This essay describes a semester-long project in which upperclass students presented some of the most complex and controversial ideas imaginable to introductory students by staging a mock debate and acting as members of the then newly appointed President's Council on Bioethics. Because the upperclass students were presenting the ideas of real people who play an important role in shaping national policy, no student's personal beliefs were put on the line, and many ideas were articulated. The introductory audience could accept or reject what they were hearing and learn information important for making up their own minds on these issues. This project is presented as an example of how current events can be used to put basic cell biology into context and of how exciting it can be when students teach students.

Bioethical Issues↗