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Continuing medical education providers accredited by the Accreditation Council for Continuing Medical Education (ACCME) may apply organizational assessment strategies beyond the ACCME Essential Areas, Elements, and Criteria. The Malcolm Baldrige National Quality Program offers an organizational assessment strategy commonly used in business, health care, and education settings. An analysis of both standards pointed out useful associations between the ACCME Essential Areas and the Baldrige National Quality Program Education Criteria (2003). Including leadership, governance, and social responsibility, the Baldrige Education Criteria provide a more comprehensive organizational assessment and stronger emphasis on a wider variety of results. The present analysis suggests that a continuing medical education provider could meet, and possibly exceed, the ACCME standards by applying the Baldrige Education Criteria in a 'self-study' process to define, measure, monitor, and document fundamental organizational responsibilities and performance. [ABSTRACT FROM AUTHOR]

Surface active phospholipids are present in fluids of biological relevance, and their adsorption may condition and determine the response of carbon and nanocarbon surfaces when they are immersed in physiological media. In this work, the adsorption and assembly of liposomes at carbon interfaces were investigated to understand the effect of surface termination on the extent and mode of assembly of lipid aggregates. Liposomes of natural lipids were prepared from a mixture of phosphatidylcholine (PC) and phosphatidylserine (PS), and their hydrodynamic size and surface zeta potential were studied as a function of pH. Adsorption was investigated at graphitic amorphous carbon surfaces (a-C) and at these surfaces after oxidative treatments (a-C:O). Infrared surface spectroscopy experiments show that PC/PS liposomes adsorb at a-C surfaces exclusively, independently of pH, while no adsorption is observed at a-C:O materials. Nanogravimetry and fluorescence imaging experiments in solution indicate that adsorption at a-C occurs as supported intact vesicles. Interestingly, PC/PS adsorption at oxidized surfaces was observed only in the presence of a dication such as Ca 2+ , a behavior that was attributed to screening of surface-liposome repulsive electrostatic interactions. Vesicle rupture experiments show that lipids adsorb as monolayers on graphitic surfaces, whereas adsorbate structures correspond to bilayers in the case of oxidized carbons. These results therefore demonstrate a strong dependence of adsorbate structure on both carbon chemistry and buffer composition. These findings have important implications for the design of carbon nanoparticles, carbon electrodes, or carbon coatings for applications in biology and medicine.

Carbon materials and nanomaterials are of great interest for biological applications such as implantable devices and nanoparticle vectors, however, to realize their potential it is critical to control formation and composition of the protein corona in biological media. In this work, protein adsorption studies were carried out at carbon surfaces functionalized with aryldiazonium layers bearing mono- and di-saccharide glycosides. Surface IR reflectance absorption spectroscopy and quartz crystal microbalance were used to study adsorption of albumin, lysozyme and fibrinogen. Protein adsorption was found to decrease by 30-90% with respect to bare carbon surfaces; notably, enhanced rejection was observed in the case of the tested di-saccharide vs. simple mono-saccharides for near-physiological protein concentration values. ζ-potential measurements revealed that aryldiazonium chemistry results in the immobilization of phenylglycosides without a change in surface charge density, which is known to be important for protein adsorption. Multisolvent contact angle measurements were used to calculate surface free energy and acid-base polar components of bare and modified surfaces based on the van Oss-Chaudhury-Good model: results indicate that protein resistance in these phenylglycoside layers correlates positively with wetting behavior and Lewis basicity.

Hypocalcemia is a recognized complication following thyroid surgery. Variability in the definition of hypocalcemia and different opinions on its management can lead to unnecessary patient morbidity and longer hospital stays as a result of inappropriate or untimely treatment. Therefore, we developed a management guideline for the recognition and treatment of post-thyroidectomy hypocalcemia, and we conducted a retrospective study to assess its impact on length of stay (LOS). Between April 1, 2007, and March 31, 2009, 29 adults had undergone a total or completion thyroidectomy at our large district general hospital. Of this group, postoperative hypocalcemia (defined as a serum calcium level of <2.00 mmol/L) developed in 13 patients (44.8%) during the first 3 postoperative days. Our guideline went into effect on July 1, 2009, and from that date through June 30, 2010, 18 more adults had undergone a total or completion thyroidectomy. Of that group, hypocalcemia developed in 7 patients (38.9%); the guideline was actually followed in 5 of these 7 cases (71.4%). In the preguideline group, the development of hypocalcemia increased the mean LOS from 2.0 days to 7.0 days (p < 0.001). The management of postoperative hypocalcemia in these cases was highly variable and was dictated by variations in practice rather than patient needs. In the postguideline group, postoperative hypocalcemia increased the mean LOS from 2.7 days to only 3.7 days (p = 0.07). While the difference between LOS in the two hypocalcemic groups did not reach statistical significance, we believe it merely reflects the relatively small number of patients rather than any lack of guideline efficacy. The implementation of a simple flowchart guideline for the management of postoperative hypocalcemia in our hospital has resulted in more uniform management and a reduced LOS.

Self-assembled organic layers are an important tool for modifying surfaces in a range of applications in materials science. Covalent modification of metal surfaces with aryldiazonium cations has attracted much attention primarily because this reaction offers a route for spontaneously grafting a variety of aromatic moieties from solution with high yield. We have investigated the kinetics of this process by performing real-time, in situ nanogravimetric measurements. The spontaneous grafting of 4-nitrobenzene diazonium salts onto gold electrodes was studied via quartz crystal microbalance (QCM) from aqueous solutions of the salt at varying concentrations. The concentration dependence of the grafting rate within the first 10 min is best modeled by assuming a reversible adsorption process with free energy comparable to that reported for arylthiols self-assembled on gold. Multilayer formation was observed after extended grafting times and was found to be favored by increasing bulk concentrations of the diazonium salt. Modified gold surfaces were characterized ex situ with cyclic voltammetry, infrared reflection absorbance spectroscopy, and X-ray photoemission spectroscopy. Based on the experimentally determined free energy of adsorption and on the observed grafting rates, we discuss a proposed mechanism for aryldiazonium chemisorption.

Objective: This study aimed to determine the age at which various ethnic groups present with thyroid cancer., Method: Retrospective, observational study based at three district general hospitals in the West Midlands, serving a widely diverse ethnic population. We assessed all patients undergoing an operative or core biopsy procedure for a thyroid nodule from 1 January 1998 to 31 December 2009. Only patients diagnosed with thyroid cancer were included. Variables examined included the patient's ethnic origin, sex and age at presentation., Result: We identified 263 patients diagnosed with thyroid cancer. Papillary carcinoma predominated. Ethnicity was categorised as Caucasian, Asian, black or other. Thyroid cancer was predominantly seen in women, in all ethnic groups. The mean age of thyroid cancer presentation was 50 years in Asians and 56 years in Caucasians, for both sexes combined. The mean presentation age of Asian women was significantly younger (46 years) than that of Caucasian women (56 years) (p = 0.01)., Conclusion: In this population, Asian women presented with thyroid cancer at a significantly younger mean age than Caucasian women.

Establishing diagnosis of a granulomatous lesion of the nose is often difficult. Here we report a case of granulomatous lesion of the nose caused by Leishmania--an unlikely cause in the UK. The diagnosis and management of the case is discussed here.

Purpose: The aim of the study was to determine the extent of use of the Internet for clinical information among family practitioners in New Zealand, their skills in accessing and evaluating this information, and the ways they dealt with patient use of information from the Internet., Method: A random sample of members of the Royal New Zealand College of General Practitioners was surveyed to determine their use of the Internet as an information source and their access to MEDLINE. They were asked how they evaluated and applied the retrieved information and what they knew about their patients' use of the Internet. Structured interviews with twelve participants focused in more depth on issues such as the physicians' skills in using MEDLINE and in evaluating retrieved material, their searches for evidence-based information, their understanding of critical appraisal, their patients' use of the Internet, and the ways they handle this use., Results: More than 80% (294/363) of members in the sample completed and returned the questionnaire. Of these, 48.6% reported that they used the Internet to look for clinical information. Gender and age were more significant in determining use than practice type or location. Information was primarily sought on rare diseases, updates on common diseases, diagnosis, and information for patients. MEDLINE was the most frequently accessed source. Search skills were basic, and abstracts were commonly used if the full text of an item was not readily available. Most reported that up to 10% of patients bring information from the Internet to consultations. Both Internet users and non-Internet users encouraged patients to search the Web. Internet users were more likely to recommend specific sites., Conclusions: Practitioners urgently need training in searching and evaluating information on the Internet and in identifying and applying evidence-based information. Portals to provide access to high-quality, evidence-based clinical and patient information are needed along with access to the full text of relevant items.

Demonstrating outcomes of continuing medical education (CME) efforts has become increasingly important to CME providers, accrediting organizations, and licensing bodies. Many CME providers have difficulty defining the nature of the outcomes, much less documenting the outcomes for which they are responsible. The vague nature of the terms "outcome," "impact," or "result" in the complexity of health care and medical education environments is a particular obstacle to many education providers. To overcome these barriers, the VA's Employee Education System (EES), a large CME provider, created a model identifying five major domains of possible outcomes for CME interventions; these are the domains of individual participants, employee teams, the larger organization, patients, and the community. These domains are useful in either assessing a single CME activity's outcomes or comprehensively assessing a CME provider's outcomes-assessment strategy. The use of such a domains-based outcomes-management strategy links organizational mission, needs assessment, specific activity assessment, and assessment of the overall education program. This approach may be useful to CME providers, accrediting and licensing bodies, or others interested in the relationship of CME outcomes to the activities of CME providers.

The application of a reliable adequate pressure dressing to one side of the neck has always proved difficult, because of the risk of occluding the airway and the vasculature. We describe a method of maintaining well-localized pressure to one side of the neck without undue pressure on the vasculature and the airway by using a stiff cervical collar. This method was used successfully in the conservative management of neck haematoma in two patients.

Cervicofacial actinomycosis is known to affect many soft tissues and bony structures in the head and neck. However to the authors' knowledge, actinomycosis of the post-cricoid region has not been previously reported. A case of a 74-year-old male who developed actinomycosis of the post-cricoid region after radiotherapy for a laryngeal carcinoma is presented. Actinomycosis should be considered in the differential diagnosis of dysphagia following radiotherapy for squamous cell carcinoma of the larynx, as early treatment is likely to result in a favourable outcome.

We present a case of a 15-year-old girl with bilateral parotid and sub-mandibular salivary gland enlargement as the sole presentation of primary Sjögren's syndrome. The clinical, radiological, immunological and pathological features have been discussed. The relevant literature has been reviewed. To our knowledge this is the only reported case of Sjögren's syndrome presenting as multicystic disease with bilateral major salivary gland involvement.

The disabilities following laryngectomy are well recognized. The incidence of these disabilities and the acceptability of the surgery to the patients were assessed by a questionnaire method. Sixty-five patients participated in the study. The incidence of disabilities are discussed. Total laryngectomy was felt to be a worthwhile operation by most of the patients in the study despite the disabilities they experienced afterwards.

While there is now evidence that health-promoting education can be effective at reducing transmission of human immunodeficiency virus (HIV) infection, little is known of the role of the practicing physician in this process. We have surveyed 301 practicing physicians in Northeastern Ohio over a 2-year period and we have assessed their attitudes, beliefs, and practices regarding preventive education with particular reference to HIV. We have found that while the majority of physicians believe strongly that HIV prevention is important and that physicians should play a prominent role in education, the incorporation of such measures in their practice lags far behind other areas of health prevention. Positive educational behavior was correlated with direct experience with HIV-infected patients and postgraduate education on HIV infection.

Verrucous carcinoma of the larynx is an uncommon but distinct variety of well differentiated squamous carcinoma and accounts for 1-2% of all laryngeal squamous carcinomata. Awareness of the condition both by clinician and histopathologist is essential otherwise the diagnosis may not be made. From a review of the literature and personal assessment of the cases presented here it would appear that local conservative endoscopic treatment with careful follow-up may be the treatment of choice for certain verrucous carcinomata. Such treatment may be either suction diathermy or cryosurgery or laser surgery. Anaplastic transformation has been said to occur following irradiation of these tumours, though this view is not held by all clinicians, some of whom recommend radiotherapy for selected cases.

Grand Rounds activities are an integral component of medical education. They present clinical problems in medicine by focusing on current or interesting cases. Grand Rounds originated as part of residency training wherein new information was taught and clinical reasoning skills were enhanced. Today, Grand Rounds also are used in continuing medical education as an instructional method for maintaining and improving clinical skills of practicing physicians. This study reviewed 43 Grand Rounds activities conducted by 12 departments in five affiliated hospitals as part of a program in Continuing Medical Education. All the Grand Rounds activities were developed to meet Category 1 requirements. They included the departmental Grand Rounds and the more specialized divisional Grand Rounds. An analysis of the 1138 physicians who attended one or more of the 1079 meetings of these Grand Rounds produced a preliminary description of a "typical" Grand Rounds activity. Analyses of these data suggest that Grand Rounds provides an important educational activity for medical students and graduate medical trainees as well as practicing physicians. The Category 1 accreditation requirements may serve to improve the educational outcomes of these activities and they provide an excellent mechanism for faculty role-modeling and improving clinical problem-solving skills.

Verrucous carcinoma (Ackerman's tumor) is a low-grade malignant lesion with distinct clinical and pathologic features, distinguishing it from other well-differentiated squamous cell carcinomas. Much of the confusion surrounding its natural history, response to therapy, and anaplastic transformation may be ascribed to the failure of critically reviewing accepted diagnostic criteria. A series of 44 patients with verrucous carcinoma of the larynx is presented, 18 of these being updated results of previously reported patients. Ackerman's tumor, although not radioresistant, seems less radiosensitive than ordinary squamous cell carcinoma. The tumor's rounded, pushing margins and inability to metastasize would seem to favor endoscopic removal, saving partial laryngectomy procedures for those lesions that cannot be managed endoscopically. Extensive lesions that would require total laryngectomy for complete removal of the tumor should be treated by primary radiotherapy. It is our belief that total laryngectomy should only be performed in large lesions that fail to respond to radiotherapy and whenever medical considerations preclude partial laryngectomy procedures.

We reviewed 173 laryngeal specimens that included thyroid tissue received from patients undergoing laryngectomy between 1966 and 1980 for evidence of thyroid gland invasion. Twenty-three (14%) of the larynges demonstrated thyroid involvement. In 15 specimens, involvement of the thyroid gland was by direct extension, and in eight the thyroid was involved metastatically. The survival in this group of patients was poor, with 18 patients dying of their disease within three years. Subglottic extension of 10 mm or greater was noted in 21 of 23 patients, and local recurrence was noted in 15 of 18 patients dying of their disease. The importance of removing one or both lobes of the thyroid gland in advanced laryngeal cancer is restated, and a surgically aggressive approach to the paratracheal nodes is recommended in patients with extensive subglottic involvement.