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There have been challenges in deciding the curricular content in obstetrics and gynecology (Ob/Gyn) for medical students because the core knowledge, competencies, and duration of Ob/Gyn clerkships, varies widely by country.To investigate current recommendations for Ob/Gyn curricula for medical students globally, in a rapid review of the literature and websites of a selection of medical schools.A targeted search of selected databases (PubMed and Google Scholar) using relevant key words and a search of university websites.Studies that applied to medical or undergraduate students in Ob/Gyn.A standardized extraction form on Microsoft excel to extract and chart data.We identified recommendations from national professional bodies (Royal College of Obstetricians and Gynaecologists, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Association of Professors of Gynecology and Obstetrics, and the Turkish-National Core Curriculum), and descriptions from five university websites. We also identified additional objectives, including teaching on intimate partner violence, health priorities in low- and middle-income countries, and a variation in practical skills recommended.Fitting all the recommended curricula content into medical student Ob/Gyn clerkships is a challenge. A framework to address this, for consideration by the International Federation of Gynaecology and Obstetrics and other stakeholders, is proposed in which priority is given to topics related to emergency Ob/Gyn, history taking, and examination of the pregnant and non-pregnant patient.

Renal denervation is a potential therapeutic option for resistant hypertension. A thorough clinical assessment to exclude reversible/spurious causes of resistance to antihypertensive therapy is required prior to this procedure. The extent to which non-adherence to antihypertensive treatment contributes to apparent resistance to antihypertensive therapy in patients considered for renal denervation is not known. Patients (n=34) referred for renal denervation entered the evaluation pathway that included screening for adherence to antihypertensive treatment by high-performance liquid chromatography-tandem mass spectrometry-based urine analysis. Biochemical non-adherence to antihypertensive treatment was the most common cause of non-eligibility for renal denervation-23.5% of patients were either partially or completely non-adherent to prescribed antihypertensive treatment. About 5.9% of those referred for renal denervation had admitted non-adherence prior to performing the screening test. Suboptimal pharmacological treatment of hypertension and 'white-coat effect' accounted for apparently resistant hypertension in a further 17.7 and 5.9% of patients, respectively. Taken together, these three causes of pseudo-resistant hypertension accounted for 52.9% of patients referred for renal denervation. Only 14.7% of referred patients were ultimately deemed eligible for renal denervation. Without biochemical screening for therapeutic non-adherence, the eligibility rate for renal denervation would have been 38.2%. Non-adherence to antihypertensive treatment and other forms of therapeutic pseudo-resistance are by far the most common reason of 'resistant hypertension' in patients referred for renal denervation. We suggest that inclusion of biochemical screening for non-adherence to antihypertensive treatment may be helpful in evaluation of patients with 'resistant hypertension' prior to consideration of renal denervation.

Objectives: The UK's National Institute for Health and Clinical Excellence (NICE) and the Jordan office of the Medicines Transparency Alliance embarked on a pilot project to design an evidence-based guideline for cost-effective pharmacological treatment of essential hypertension in Jordan. The project's objectives were to directly address a major health problem for Jordan by producing a guideline; and to delineate the strengths and weaknesses of Jordan's healthcare process to allow similar future efforts to be planned more efficiently.Methods: The pilot spanned a period of approximately 8 months. Activities were overseen by local technical and guideline development teams, as well as experts from NICE. NICE's hypertension guidelines and economic model were used as a starting point. Parameters in the economic model were adjusted according to input and feedback from local experts with regards to Jordanian physician and patient practices, resource costs, and quality of life estimates. The results of the economic model were integrated with the updated available clinical trial literature.Results: The outputs of the economic model were used to inform recommendations, in the form of a clinical algorithm. A report of the process and the strengths and weaknesses observed was developed, and recommendations for improvements were made.Conclusions: The pilot represented the start of what is intended to be a healthcare process change for the country of Jordan. Issues emerged which can inform strategies to ensure a more cohesive and comprehensive approach to the cost-effective use of appropriate drugs in managing chronic disease in Jordan and countries operating in a similarly resource-constrained environment. Furthermore, our pilot highlights how richer countries with relevant experience in evidence-informed healthcare policy making can assist others in strengthening their decision-making methods and processes.

Failure of ligamentous support of the genital tract to resist intra-abdominal pressure is a plausible underlying mechanism for the development of pelvic organ prolapse, but the nature of the molecular response of pelvic tissue support remains unknown. We hypothesized that the expression of genes coding for proteins involved in maintaining the cellular and extracellular integrity would be altered as a result of mechanical stretch. Therefore, cDNA microarrays were used to examine the difference in transcriptional profile in RNA of primary culture fibroblasts subjected to mechanical stretch and those that remained static. Out of 34 mechano-responsive genes identified (P < 0.05), four were coding for regulation of actin cytoskeleton remodelling, and its interaction with the extracellular matrix proteins; these are phosphatidyl inositol-4-phosphate 5-kinase (PIP5K1C), the human signal-induced proliferation associated gene-1 (SIPA-1), TNFRSF1A-associated via death domain (TRADD) and deoxyribonuclease 1-like 1 (DNase 1-L1). The transcriptosomal changes led us to investigate the phenotypic consequences of stretch, levormeloxifene and estradiol (E(2)) on the cytoskeleton of cultured fibroblasts. The percentage of cells with abnormal F-actin configuration was significantly higher in fibroblasts subjected to stretch compared with the static model (P < 0.0001). Levormeloxifene caused similar significant alterations in actin morphology of the static fibroblasts. The use of E(2) did not reverse the process or protect the cells from the effect of stretch, but significantly increased the rate of fibroblast proliferation, suggestive of a role in healing process. Mechanical stretch and/or levormeloxifene disturb the fibroblasts ability to maintain the cytoskeleton architecture and we speculate that they may disrupt ligamentous integrity and result in clinical prolapse.

A decline in the number of doctors pursuing careers in academic medicine poses a risk to medical research and training in the UK. This is happening at a time of major changes to postgraduate training, with the introduction of the Foundation Programme for newly qualified medical graduates in August 2005 and further changes to basic and higher specialist training expected thereafter.1,2 This paper describes an innovative training programme in academic medicine for foundation-year-two (F2) trainees. The 12-month programme provides training and practice in research, audit and medical undergraduate teaching in addition to traditional clinical training in medicine. Although in part dependent on the local infrastructure, it has key components that can be adapted by any academic unit in the UK. The impending changes to postgraduate medical training were driven by several reports highlighting the lack of formal training and career progression for senior house officers (SHOs).3-5 Although some of the changes have yet to be fully confirmed, training is likely to become shorter, more intensive and competency based. All newly qualified UK graduates will enter a two-year foundation that equips them with the skills to enter higher specialist training.6 These reforms offer new opportunities to address the growing reluctance of middle-grade junior doctors to take an academic career path.7 The Academy of Medical Sciences has pointed to lack of infrastructure, inadequate funding and the complexity of legal and ethical governance frameworks as reasons for a declining base8 together with the personal academic disincentives of insufficient flexibility, prolonged insecurity and lack of career structure.9 A British Medical Association (BMA) report indicates that, of specialist registrars working towards a postgraduate research degree, two-thirds are doing so primarily for reasons of career progression and only 17% because of an interest in research. It is possible that some of those who begin with career motives have their interest ignited and switch to academic medicine; consequently, the Academy argued for preservation of key appointments at specialist registrar grades along with new opportunities for senior SHOs at the completion of their general professional training.9 The National Health Service, as the main provider of UK healthcare, depends on a healthy research environment.11 In addition to research, medical academics provide leadership in healthcare delivery and teaching.13 Teaching is becoming increasingly important as medical undergraduate numbers rise. The two-year foundation programme provides an opportunity to develop innovative F2 posts in academic medicine. The Leicestershire, Northamptonshire and Rutland Deanery has funded two pilot posts, which started in August 2004 for one year, with further programmes planned for August 2005. Trainees are based in the Academic Medical Unit at the Leicester Royal Infirmary and the Department of Cardiovascular Sciences at the University of Leicester. The basic 40-hour week is split equally between clinical medicine and academic pursuits. In addition, trainees participate in emergency out-of-hours work on a rota identical to that of their SHO colleagues. The specific aims of this programme are: To achieve all competencies in the Foundation Programme in preparation for higher specialist training To provide exposure to academic medicine, clinical science and evidence-based clinical practice as a foundation for a career in academic medicine To provide training and practice in bedside and tutorial-based undergraduate teaching To provide continuing professional development, including preparation for successful completion of part I of the MRCP examination Effectively, these posts offer a 'taster' of academic medicine—ideal for trainees who contemplate embarking on a clinical research training fellowship as a prelude to academic study as well as for those who are unsure whether they should commit themselves to such a career. Whatever the level of commitment, the trainee will get comprehensive clinical training in an academic environment. Importantly, he or she will be excluded from the Research Assessment Exercise, so this period can be specifically dedicated to training. The educational supervisors, the trainees and the postgraduate deanery will all contribute to the continuous assessment and evaluation of these posts.

Increased arterial stiffness is a risk factor for cardiovascular disease and is a feature associated with diabetes. Pulse wave velocity (PWV) is an accepted index of arterial stiffness and augmentation index (AI) derived from radial applanation tonometry has been advocated as a measurement of arterial stiffness. This study compares the relationship between PWV and AI in people with and without diabetes.A total of 66 people with diabetes and 66 age-matched non-diabetic controls were studied. Central aortic pressure waves were generated using applanation tonometry over the radial artery and used to calculate AI. Carotid-femoral PWV (PWVcf) was measured simultaneously.Relative to controls, diabetes was associated with increased pulse pressure (PP) and PWVcf (P0.01). In contrast, AI did not differ between groups even after adjustment for heart rate. This observation remained consistent irrespective of diabetes type, arterial site, and the presence or absence of antihypertensive therapy. Multiple regression analysis revealed diabetes to be a significant determinant of PWVcf, but not AI.PP and PWVcf are increased in people with diabetes, but this is not associated with increased AI. These findings conclusively demonstrate that AI is not a reliable measure of arterial stiffness in people with diabetes.

Nevertheless, its licence for the treatment of heart failure and primary hyperaldosteronism was not withdrawn and internationally, spironolactone remains licensed for hypertension. Historically high doses (100 mg to 150 mg daily) of spironolactone were prescribed. There is good evidence for its efficacy and safety in short-term trials as monotherapy in lowering blood pressure, 2,3 compared to nifedipine 4 and in combination therapy with ACE inhibitors and thiazide-like diuretics. 5 As monotherapy, these studies reported a mean BP fall of 26/13.3 mmHg from baseline. 2-4

Career progression during undergraduate and early postgraduate years is currently determined by successfully passing examinations. Both academic factors (secondary school examination results, learning style and training opportunities) and non-academic factors (maturity, ethnic origin, gender and motivation) have been identified as predicting examination outcome. Few studies have examined organization skills. Disorganized medical students are more likely to perform poorly in end-of-year examinations but this observation has not been examined in junior doctors. This study asked whether organization skills relate to examination outcome amongst junior doctors taking the clinical Part II examination for the Membership of the Royal College of Physicians (Practical Assessment of Clinical Examination Skills). The study was conducted prospectively at four consecutive clinical courses that provided clinical teaching and practice to prepare trainees for the examination. Arrival time at registration for the course was the chosen surrogate for organization skills. Trainees were advised that they should arrive promptly at 8.00 a.m. for registration and it was explained that the course would start at 8.30 a.m. Recorded arrival times were compared with the pass lists published by the Royal College of Physicians. The mean arrival time was 8.17 a.m. A total of 81 doctors (53.3%) passed the examination with a mean arrival time of 8.14 a.m. However, 71 doctors failed the exam and arrived, on average, six minutes later than doctors who passed (p?=?0.006). Better-prepared junior doctors were more likely to pass the final examination. Arriving on time represents a composite of several skills involved in the planning of appropriate travel arrangements and is therefore a valid marker of organization skills and preparation. This novel study has shown that good time-keeping skills are positively associated with examination outcome.

Many studies show an association between ageing and mean telomere length in DNA isolated from peripheral blood mononuclear cells, few studies have examined less accessible tissues. This study has two objectives: (i) to define the best method to prepare rodent DNA for telomere length measurement by Southern blotting and (ii) to determine whether there are differential rates of telomere attrition in different rodent tissues. We found that the use of agarose plugs for DNA isolation was essential for the accurate measurement of rodent telomere length. Tissue was collected from neonatal (3 days) or aged (18-24 months) male Wistar rats and terminal restriction fragment (TRF) length was measured by Southern blotting. Cardiac tissue from aged rats showed a 38% loss of TRF length compared with newborn animals (p

The matrix metalloproteinases play an important role in matrix degradation, but there is limited information about this family of enzymes in either normal or diseased human liver. In this study, we have examined the synthesis of a 72 kDa type IV collagenase/gelatinase by human hepatic lipocytes in primary culture. Hepatic lipocytes were isolated from wedges of normal human donor liver by Pronase/collagenase perfusion, purified by density-gradient centrifugation, and established in primary culture on uncoated plastic. By Northern-blot analysis, the total RNA extracted from cultured human lipocytes was found to contain 3.4 kb mRNA for the 72 kDa type IV collagenase/gelatinase. Low levels of expression of this mRNA were observed in freshly isolated lipocytes but expression increased with the duration of lipocyte culture. Using anti-human 72 kDa type IV collagenase/gelatinase IgG, synthesized enzyme was immunolocalized to monensin-treated human lipocyte cultures. De novo synthesis and secretion of 72 kDa type IV collagenase/gelatinase were confirmed by immunoprecipitation of radiolabelled enzyme from medium obtained from [35S]methionine-treated cells. Activity of the secreted enzyme was demonstrated by gelatin-zymography and by degradation of soluble, radiolabelled [14C]gelatin. The enzyme was released both in active and latent pro-enzyme forms and its inhibition profile was that of a metalloproteinase. These studies indicate that cultured human hepatic lipocytes express the gene for the 72 kDa type IV collagenase/gelatinase, and secrete this enzyme, particularly in prolonged primary culture. As this enzyme exhibits degradative activity against basement membrane collagen, its release by activated hepatic lipocytes in the space of Disse could lead to disruption of the normal subendothelial liver matrix. It is suggested that this enzyme may have an important role in human liver injury and fibrosis.

Objectives: the UK's National Institute for Health and Clinical Excellence (NICE) and the Jordan office of the Medicines Transparency Alliance embarked on a pilot project to design an evidence-based guideline for cost-effective pharmacological treatment of essential hypertension in Jordan. The project's objectives were to directly address a major health problem for Jordan by producing a guideline; and to delineate the strengths and weaknesses of Jordan's healthcare process to allow similar future efforts to be planned more efficiently. Methods: the pilot spanned a period of approximately 8 months. Activities were overseen by local technical and guideline development teams, as well as experts from NICE. NICE's hypertension guidelines and economic model were used as a starting point. Parameters in the economic model were adjusted according to input and feedback from local experts with regards to Jordanian physician and patient practices, resource costs, and quality of life estimates. The results of the economic model were integrated with the updated available clinical trial literature. Results: the outputs of the economic model were used to inform recommendations, in the form of a clinical algorithm. A report of the process and the strengths and weaknesses observed was developed, and recommendations for improvements were made. Conclusions: the pilot represented the start of what is intended to be a healthcare process change for the country of Jordan. Issues emerged which can inform strategies to ensure a more cohesive and comprehensive approach to the cost-effective use of appropriate drugs in managing chronic disease in Jordan and countries operating in a similarly resource-constrained environment. Furthermore, our pilot highlights how richer countries with relevant experience in evidence-informed healthcare policy making can assist others in strengthening their decision-making methods and processes.

Introduction: Reduced vascular compliance in patients with hypertension results from an increase in extra-cellular matrix (ECM) protein deposition in blood vessels. At least two key factors, namely mechanical strain and neurohumoral mediators, for example Angiotensin II (Ang II), promote fibrogenesis within vessel walls; however potential interactions between these have not been clearly defined. This work examined the direct effect of mechanical strain on matrix mRNA expression and protein synthesis by human vascular smooth muscle (VSM) cells and identified the importance of renin-angiotensin system (RAS) activation in stretch-induced matrix production. Methods: Human VSM cells were exposed either to a cyclical mechanical strain regimen or to Ang II in the presence or absence of the Ang II receptor (AT1 R) antagonist losartan or its more potent metabolite EXP3174. Analysis of matrix mRNA expression (Northerns) and protein synthesis (ELISA) and cellular AT1-receptor protein expression (Westerns) were determined. Results: Ang II increased both collagen α1 (92%, SEM +/-20%) mRNA expression and fibronectin (21% +/- 6%) protein synthesis in static VSM cells compared with unstimulated controls.The effect of Ang II was attenuated by antagonism of the AT 1-receptor (AT1 R). Similarly, mechanical strain induced an increase in both collagen α1 (102% +/- 30%) mRNA expression and fibronectin (50% +/-21%) protein synthesis. Surprisingly, in the absence of exogenous Ang II, AT1-receptor blockade attenuated this stretch-induced increase in matrix synthesis. Mechanical strain also induced an increase in total cellular AT1-receptor protein (30.7% +/- 3.5%) compared with static cells. Conclusion: Both mechanical strain and Ang II increased matrix gene expression and protein synthesis by human VSM cells. The effect of strain was attenuated by AT 1-receptor antagonism. Our results further suggest that mechanical strain may sensitise human VSM cells to the fibrogenic actions of Ang II, perhaps via upregulation of the AT1-receptor.

Author Posting. © The Authors 2008. This is the author's version of the work. It is posted here for personal use, not for redistribution. The definitive version was published in British Journal of Dermatology, 2008, 159 (2), pp. 505-506. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2133.2008.08654.x/abstract