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Purpose. To enable an existing survey on primary care so that it can be used to assess the healthcare experiences reported by adults living with disabilities, and to evaluate its properties. Methods. Mixed-methods study. We first identified content areas for measurement as compared to the items in the existing instrument and then developed new candidate items. Cognitive testing was conducted in English and Spanish. After revisions to the primary care instrument based on the cognitive testing results, the draft-enabled instrument was field-tested by mail with telephone follow-up, in English and Spanish. Results. Consumer focus groups and a technical expert panel identified eight content areas in primary care that are particularly important to maximise function and well-being of people of with disabilities. Cognitive testing also revealed serious problems with several items in the existing survey when answered by or about people with disabilities. Field testing yielded 1086 surveys, of which 40% were completed by a proxy respondent. Learning disabilities were reported by 38% of respondents. Item non-response for revised and new questions was less than 4%. Conclusions. It is feasible to enable a survey of primary care and its administration. Survey administration instructions should be modified to accommodate proxy respondents. The screener item to identify people with mobility impairments on walking a distance should be replaced with walking for 6 min. Adding questions from the American Community Survey about functional ability will allow survey sponsors to identify respondents with various limitations, and to compare their experiences to those of people with no limitations. Careful development and testing of the items with input from interested parties throughout the design and testing stages yielded a survey with good psychometric properties and content validity in multiple languages. Health delivery systems can use the survey data to identify clinical processes needing improvement to provide high quality care for people with disabilities. [ABSTRACT FROM AUTHOR]

Objective: To describe how cognitive testing results were used to inform the modification and selection of items for the Consumer Assessment of Health Providers and Systems (CAHPS) Hospital Survey pilot test instrument.Data Sources: Cognitive interviews were conducted on 31 subjects in two rounds of testing: in December 2002-January 2003 and in February 2003. In both rounds, interviews were conducted in northern California, southern California, Massachusetts, and North Carolina.Study Design: A common protocol served as the basis for cognitive testing activities in each round. This protocol was modified to enable testing of the items as interviewer-administered and self-administered items and to allow members of each of three research teams to use their preferred cognitive research tools.Data Collection/extraction Methods: Each research team independently summarized, documented, and reported their findings. Item-specific and general issues were noted. The results were reviewed and discussed by senior staff from each research team after each round of testing, to inform the acceptance, modification, or elimination of candidate items.Principal Findings: Many candidate items required modification because respondents lacked the information required to answer them, respondents failed to understand them consistently, the items were not measuring the constructs they were intended to measure, the items were based on erroneous assumptions about what respondents wanted or experienced during their hospitalization, or the items were asking respondents to make distinctions that were too fine for them to make. Cognitive interviewing enabled the detection of these problems; an understanding of the etiology of the problem informed item revisions. However, for some constructs, the revisions proved to be inadequate. Accordingly, items could not be developed to provide acceptable measures of certain constructs such as shared decision making, coordination of care, and delays in the admissions process.Conclusions: Cognitive testing is the most direct way of finding out whether respondents understand questions consistently, have the information needed to answer the questions, and can use the response alternatives provided to describe their experiences or their opinions accurately. Many of the candidate questions failed to meet these standards. Cognitive testing only evaluates the way in which respondents understand and answer questions. Although it does not directly assess the validity of the answers, it is a reasonable premise that cognitive problems will seriously compromise validity and reliability. [ABSTRACT FROM AUTHOR]

BACKGROUND: Team learning, an innovative educational method combining interactive small group learning with expert-based content delivery, was introduced into our psychiatry clerkship in 2002. The main goal was to increase classroom engagement and improve educational outcomes. DESCRIPTION: Eight of 16 lectures were replaced with team learning activities, including prerequisite readings, readiness assurance tests, and application exercises. Data on students' performance and educational experiences were compared before and after curricular change. EVALUATION: Following implementation of team learning, students performed significantly better on the National Board of Medical Examiners (NBME) psychiatry subject test and scored higher on attitudes about working in teams. Students perceived team learning activities to be more engaging, effective, and enjoyable than conventional didactics. CONCLUSION: Incorporating team learning into the psychiatry clerkship was associated with improved student performance and increased student engagement and satisfaction. Team learning is a promising educational strategy that may prove useful in other clerkships. [ABSTRACT FROM AUTHOR]

Culture is defined and discussed as an important ingredient to treatment planning. Components of culture are identified and examples of how they pertain to treatment are given through a brief case example. [ABSTRACT FROM AUTHOR]

Abstract Introduction Myasthenia gravis is a neuromuscular junction post-synaptic autoimmune disorder. Myasthenic crisis is characterized by respiratory failure requiring mechanical ventilation. Takotsubo cardiomyopathy is a rare clinical syndrome defined as a profound but reversible left ventricular dysfunction in the absence of coronary artery disease. Case presentation We report a unique case of a 60-year-old Hispanic woman with myasthenia gravis who developed takotsubo cardiomyopathy and concomitant myasthenic crisis that appear to have been triggered by a stressful life event. On admission, she presented with severe mid-sternal chest pain and shortness of breath shortly after a personally significant stressful life event. A pertinent neurological examination showed bilateral facial weakness and right ptosis. The left ventriculogram showed apical ballooning with hyperdynamic proximal segments with sparing of the apex. Her troponin I level was elevated, while cardiac catheterization revealed no significant coronary artery disease. The findings were consistent with takotsubo cardiomyopathy. Shortly after cardiac catheterization, she developed bilateral ophthalmoparesis and significant bulbar and respiratory muscle weakness. Forced vital capacity values were persistently less than 1 L. The patient developed respiratory failure and required endotracheal intubation. After plasmapheresis and corticosteroid treatment, her clinical course improved with successful extubation. A normal left ventricle chamber size and a normal ejection fraction were noted by an echocardiogram repeated 10 months later. Conclusion This is the first reported case of the simultaneous triggering of both takotsubo cardiomyopathy and myasthenic crisis by the physiologic consequences of a state of severe emotional stress. We hypothesize that the mechanism underlying the rare association of takotsubo cardiomyopathy with myasthenic crisis involves excessive endogenous glucocorticoid release, a high-catecholamine state, or a combination of both. We advocate careful cardiac monitoring of myasthenia gravis patients during acute emotional or physical stress, as there is potential risk of developing takotsubo cardiomyopathy.

Abstract Background Ecological niche modeling is a method for estimation of species distributions based on certain ecological parameters. Thus far, empirical determination of significant differences between independently generated distribution maps for a single species (maps which are created through equivalent processes, but with different ecological input parameters), has been challenging. Results We describe a method for comparing model outcomes, which allows a statistical evaluation of whether the strength of prediction and breadth of predicted areas is measurably different between projected distributions. To create ecological niche models for statistical comparison, we utilized GARP (Genetic Algorithm for Rule-Set Production) software to generate ecological niche models of human monkeypox in Africa. We created several models, keeping constant the case location input records for each model but varying the ecological input data. In order to assess the relative importance of each ecological parameter included in the development of the individual predicted distributions, we performed pixel-to-pixel comparisons between model outcomes and calculated the mean difference in pixel scores. We used a two sample Student's t-test, (assuming as null hypothesis that both maps were identical to each other regardless of which input parameters were used) to examine whether the mean difference in corresponding pixel scores from one map to another was greater than would be expected by chance alone. We also utilized weighted kappa statistics, frequency distributions, and percent difference to look at the disparities in pixel scores. Multiple independent statistical tests indicated precipitation as the single most important independent ecological parameter in the niche model for human monkeypox disease. Conclusion In addition to improving our understanding of the natural factors influencing the distribution of human monkeypox disease, such pixel-to-pixel comparison tests afford users the ability to empirically distinguish the significance of each of the diverse environmental parameters included in the modeling process. This method will be particularly useful in situations where the outcomes (maps) appear similar upon visual inspection (as are generated with other modeling programs such as MAXENT), as it allows an investigator the capacity to explore subtle differences among ecological parameters and to demonstrate the individual importance of these factors within an overall model.

Although most students finish medical school, those who do not frequently have no obvious programmatic alternatives. In recent years, a growing number of medical schools have been developing "off-ramp" programs to help such learners. We surveyed 12 medical schools with off-ramp programs to understand their characteristics and challenges. Differences existed between programs but most were deemed helpful to the students and institutions they served. Advantages included the opportunity to acknowledge the students' hard work, increase career opportunities, and reduce debt. Understanding and promoting such programs will assist students for whom medical school does not represent the optimal career path., Competing Interests: Conflict of interestThe authors declare that they have no conflict of interest., (© International Association of Medical Science Educators 2021.)

Construct : We sought to evaluate the quality of Team-Based Learning facilitation in both large and small group settings. Background : Team Based Learning (TBL) is an increasingly popular small group instructional strategy in health science education. TBL facilitation skills are unique and differ from those needed to lecture or facilitate other types of small groups. Measuring facilitation skills and providing feedback to TBL instructors is important, yet to date no valid instrument has been developed and published for this purpose. Approach : We created an 11-item instrument (ratings of each item on a 7-point scale) designed to assess TBL facilitation skills, considering major sources of validity. Twelve experts in TBL facilitation and training developed the content of the FIT. To ensure response processes were valid, we used an immediate retrospective probing technique with 4th year medical students who were not part of the study. The Facilitator Instrument for Team-Based Learning (FIT) was piloted with 2,840 medical students in 7 schools in large (year 1 and 2) and small (year 3) courses. The internal structure of the FIT was analyzed. Results : In total, 1,559 and 1,281 medical students in large and small TBL classes, respectively (response rate 88%) rated 33 TBL facilitators. The composite mean score for the FIT was 6.19 (SD = 1.10). Exploratory factor analysis and Cronbach's alpha indicated that all items loaded on 1 factor, accounting for 77% of the item variance. Cronbach's alpha for the 11 items was 0.97. Analysis of facilitator variables and course context indicated that FIT scores were statistically significantly correlated with type of class (pre-clinical or clinical) and size of class as well as the facilitator enjoyment in using TBL as a method. Gender and the amount that facilitators used TBL each year was weakly correlated, with other factors not correlated (years facilitating TBL, confidence in facilitating TBL, and age). Conclusions : Analysis of FIT scores from 2,840 medical students across multiple institutions and teaching settings suggests the utility of the FIT in determining the quality of TBL facilitation across a range of medical education settings. Future research is needed to further analyze course contexts and facilitator variables that may influence FIT scores with additional facilitators. Additionally, FIT scores should be correlated with additional measures of TBL facilitator quality, such as direct observations, especially if these data are used for summative decision-making purposes.

Certain microbes can biotransform antibiotics. Little is known about these microbes or the biotransformation processes. The objective of this study was to determine the effects of background nutrient conditions on a sulfonamide degrading culture and on its biotransformation of sulfadiazine (SDZ) with respect to transformation kinetics and transformation products. The mixed culture capable of degrading SDZ consisted primarily of three genera, Brevibacterium, Castellaniella and Leucobacter. The maximum biotransformation rate was 4.55 mg L -1  d -1 in the absence of background nutrients. Among the three background nutrient conditions tested, diluted R2A medium lead to the highest maximum SDZ biotransformation rates, followed by humic acid and glucose. 2-aminopyrimidine was the major SDZ biotransformation product under the background nutrient conditions tested, while another previously reported biotransformation product, sulfanilic acid, was further degraded by the mixed culture. The findings from this study can help improve our estimation of the fate of antibiotics in the environment.

Phenomenon: Studies of high-stakes collaborative testing remain sparse, especially in medical education. We explored high-stakes collaborative testing in medical education, looking specifically at the experiences of students in established and newly formed teams., Approach: Third-year psychiatry students at 5 medical schools across 6 sites participated, with 4 participating as established team sites and 2 as comparison team sites. For the collaborative test, we used the National Board of Medical Examiners Psychiatry subject test, administering it via a 2-stage process. Students at all sites were randomly selected to participate in a focus group, with 8-10 students per site (N = 49). We also examined quantitative data for additional triangulation., Findings: Students described a range of heightened emotions around the collaborative test yet perceived it as valuable regardless if they were in established or newly formed teams. Students described learning about the subject matter, themselves, others, and interpersonal dynamics during collaborative testing. Triangulation of these results via quantitative data supported these themes. Insights: Despite student concerns, high-stakes collaborative tests may be both valuable and feasible. The data suggest that high-stakes tests (tests of learning or summative evaluation) could also become tests for learning or formative evaluation. The paucity of research into this methodology in medical education suggests more research is needed.

Neonatal mice are more susceptible than adults to mouse adenovirus type 1 (MAV1) respiratory infection. In adult mice, MAV-1 respiratory infection induces production of prostaglandin E2 (PGE2), a lipid mediator that exerts suppressive effects on a variety of host immune functions. We tested the hypothesis that exaggerated PGE2 production in neonatal mice contributes to increased susceptibility to MAV-1. PGE2 concentrations were lower in lungs of uninfected neonatal mice than in adults. PGE2 production was induced by both MAV-1 and a nonspecific stimulus to a greater degree in neonatal mice than in adults, but only in adults was PGE2 induced in a virus-specific manner. Lung viral loads were equivalent in PGE2-deficient neonatal mice and wild type controls, as was virus-induced expression of IFN-γ, IL-17A, and CCL5 in the lungs. PGE2 deficiency had minimal effect on production of virus-specific IgG or establishment of protective immunity in neonatal mice. Collectively, our data indicate that lung PGE2 production is exaggerated early in life, but this effect does not mediate increased susceptibility to MAV-1 infection., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Objective: This study examined the relationship between team emotional intelligence, quality of team interactions, and gender., Methods: Psychiatry clerkship students participating in Team-Based Learning (TBL, n = 484) or no TBL (control, n = 265) completed the Workgroup Emotional Intelligence Profile (WEIP-S) and the Team Performance Scale (TPS)., Results: Significant correlations (p < 0.01) existed between quality of team interactions (i.e., TPS) and team emotional intelligence (i.e., WEIP-S) subscales, but not gender. Control and TBL groups experienced significant increases in WEIP-S subscales pre to post (p < 0.01, η (2) = .08), with the TBL group experiencing significantly higher gains in three of four subscales. Control group scored higher on TPS., Conclusions: A significant relationship exists between team emotional intelligence and quality of team interactions. Gender was unrelated to TPS or WEIP-S subscales. TBL group experienced higher gains in WEIP-S subscales while the control group experienced slightly higher TPS scores. Results suggest implications for medical educators who use TBL.

Objectives: The purpose of this study was to explore the relationships among variables associated with teams in team-based learning (TBL) settings and team outcomes., Methods: We administered the National Board of Medical Examiners (NBME) Psychiatry Subject Test first to individuals and then to teams of Year three students at four medical schools that used TBL in their psychiatry core clerkships. Team cohesion was analysed using the Team Performance Scale (TPS). Bivariate correlation and linear regression analysis were used to analyse the relationships among team-level variables (mean individual TPS scores for each team, mean individual NBME scores of teams, team size, rotation and gender make-up) and team NBME test scores. A hierarchical linear model was used to test the effects of individual TPS and individual NBME test scores within each team, as well as the effects of the team-level variables of team size, team rotation and gender on team NBME test scores. Individual NBME test and TPS scores were nested within teams and treated as subsampling units., Results: Individual NBME test scores and individual TPS scores were positively and statistically significantly (p < 0.01) associated with team NBME test scores, when team rotation, team size and gender make-up were controlled for. Higher team NBME test scores were associated with teams rotating later in the year and larger teams (p < 0.01). Gender make-up was not significantly associated., Conclusions: The results of an NBME Psychiatry Subject Test administered to TBL teams at four medical schools suggest that larger teams on later rotations score higher on a team NBME test. Individual NBME test scores and team cohesion were positively and significantly associated with team NBME test scores. These results suggest the need for additional studies focusing on team outcomes, team cohesion, team size, rotation and other factors as they relate to the effective and efficient performance of TBL teams in health science education., (© 2015 John Wiley & Sons Ltd.)

The editorial by Jeremy Shiffman, "Knowledge, moral claims and the exercise of power in global health", highlights the influence on global health priority-setting of individuals and organizations that do not have a formal political mandate. This sheds light on the way key functions in global health depend on private funding, particularly from the Bill & Melinda Gates Foundation., (© 2015 by Kerman University of Medical Sciences.)

Respiratory viruses cause substantial disease and are a significant healthcare burden. Virus-induced inflammation can be detrimental to the host, causing symptoms during acute infection and leading to damage that contributes to long-term residual lung disease. Prostaglandin E2 (PGE2) is a lipid mediator that is increased in response to many viral infections, and inhibition of PGE2 production during respiratory viral infection often leads to a decreased inflammatory response. We tested the hypothesis that PGE2 promotes inflammatory responses to mouse adenovirus type 1 (MAV-1) respiratory infection. Acute MAV-1 infection increased COX-2 expression and PGE2 production in wild type mice. Deficiency of the E prostanoid 2 receptor had no apparent effect on MAV-1 pathogenesis. Virus-induced induction of PGE2, IFN-γ, CXCL1, and CCL5 was reduced in mice deficient in microsomal PGE synthase-1 (mPGES-1(-/-) mice). However, there were no differences between mPGES-1(+/+) and mPGES-1(-/-) mice in viral replication, recruitment of leukocytes to airways or lung inflammation. Infection of both mPGES‑1(+/+) and mPGES-1(-/-) mice led to protection against reinfection. Thus, while PGE2 promotes the expression of a variety of cytokines in response to acute MAV-1 infection, PGE2 synthesis does not appear to be essential for generating pulmonary immunity.

There is an incomplete understanding of the differences between neonatal immune responses that contribute to the increased susceptibility of neonates to some viral infections. We tested the hypothesis that neonates are more susceptible than adults to mouse adenovirus type 1 (MAV-1) respiratory infection and are impaired in the ability to generate a protective immune response against a second infection. Following intranasal infection, lung viral loads were greater in neonates than in adults during the acute phase but the virus was cleared from the lungs of neonates as efficiently as it was from adult lungs. Lung gamma interferon (IFN-γ) responses were blunted and delayed in neonates, and lung viral loads were higher in adult IFN-γ(-/-) mice than in IFN-γ(+/+) controls. However, administration of recombinant IFN-γ to neonates had no effect on lung viral loads. Recruitment of inflammatory cells to the airways was impaired in neonates. CD4 and CD8 T cell responses were similar in the lungs of neonates and adults, although a transient increase in regulatory T cells occurred only in the lungs of infected neonates. Infection of neonates led to protection against reinfection later in life that was associated with increased effector memory CD8 T cells in the lungs. We conclude that neonates are more susceptible than adults to acute MAV-1 respiratory infection but are capable of generating protective immune responses.

Medical and health sciences educators are increasingly employing team-based learning (TBL) in their teaching activities. TBL is a comprehensive strategy for developing and using self-managed learning teams that has created a fertile area for medical education scholarship. However, because this method can be implemented in a variety of ways, published reports about TBL may be difficult to understand, critique, replicate, or compare unless authors fully describe their interventions.The authors of this article offer a conceptual model and propose a set of guidelines for standardizing the way that the results of TBL implementations are reported and critiqued. They identify and articulate the seven core design elements that underlie the TBL method and relate them to educational principles that maximize student engagement and learning within teams. The guidelines underscore important principles relevant to many forms of small-group learning. The authors suggest that following these guidelines when writing articles about TBL implementations should help standardize descriptive information in the medical and health sciences education literature about the essential aspects of TBL activities and allow authors and reviewers to successfully replicate TBL implementations and draw meaningful conclusions about observed outcomes.

Background: Measurement of the quality of team processes in medical education, particularly in classroom-based teaching settings, has been limited by a lack of measurement instruments. Therefore, the purpose of this study was to develop and test an instrument to measure the quality of team interactions., Method: The authors created 30 items and reduced these to 18 items using factor analysis. They distributed the scale to 309 second-year medical students (RR = 95%) in a course that used teams and measured internal consistency, validity, and differences in scores between teams., Results: Cronbach's alpha for the scale was 0.97. Team ratings were variable, with a mean score of 95.7 (SD 8.5) out of 108. Team Performance Scale (TPS) scores correlated inversely with the spread of peer evaluation scores (r = -0.38, P = .003). Differences between teams were statistically significant (P < .001, eta = 0.33)., Conclusions: The TPS was short, had evidence of reliability and validity, and exhibited the capacity to distinguish between teams. This instrument can provide a measure of the quality of team interactions. More work is needed to provide further evidence of validity and generalizability.

Objective: Psychiatry clerkship training involves many learning components, one of which is acquisition of scholarly knowledge. The authors investigate the reading materials and learning methods used by clinical clerks in their preparation for the National Board of Medical Examiners (NBME) Psychiatry Subject Exam (PSE)., Methods: Clerkship students from six U.S. medical schools who had recently completed their psychiatry clerkship and PSE were surveyed regarding reading material use, teaching methods encountered, and other relevant resources which may have influenced their PSE scores., Results: The most frequently used PSE preparation material was a "step-or-prep" book, followed by practice questions, handouts, and assigned texts. No single preparation material type or combination proved significantly different in influencing PSE scores. The didactic methods used in clerkships did differ significantly in their influence on PSE scores. Students in the top quartile used slightly more books and different combinations of books than students in the bottom quartile., Conclusion: Students exhibited several trends in their preparation for the PSE. The most striking findings were the heavy student reliance on step-or-prep books over other learning resources and that step-or-prep books did not demonstrate significance as a superior preparation resource for the PSE. These trends in third-year psychiatric rotations have important implications for medical student education.

To increase student participation in the learning process, active learning methods, including small group learning, have become increasingly popular in modern curricula. One kind of small group learning, team-based learning, is a relatively new instructional strategy in health care education. Team-based learning uses theoretically based and empirically grounded strategies for ensuring the effectiveness of small groups working independently in classes with high student-to-faculty ratios (e.g., up to 200:1), without losing the benefits of faculty-led small groups with lower ratios (e.g., 7:1). To explore the effectiveness of this learning pedagogy, we evaluated students' level of engagement and attitudes toward the value of teams. Findings demonstrated that team-based learning is an effective teaching strategy for large groups of students.

Purpose: In 2003, we described initial use of team-based learning (TBL) at 10 medical schools. The purpose of the present study was to review progress and understand factors affecting the use of TBL at these schools during the subsequent 2 years., Methods: Representatives from 10 schools evaluated in 2003 were again evaluated in 2005. They were interviewed by members of the Team Based Learning Collaborative using a semistructured interview process. Data were analysed by 2 researchers using the constant comparative method and were triangulated through sharing results with other interviewers at regular intervals to verify conclusions and form consensus., Results: TBL continued to be used in all but 1 school. At the 9 remaining schools, TBL was added to 18 courses, continued to be used in 19 and was discontinued in 13 courses. At some schools, it was discontinued in single courses in lieu of new, longitudinal integration courses in which TBL was a main instructional strategy. Faculty, student, course and institutional factors were associated with changes in TBL use., Conclusion: Faculty, administration/curriculum, students and characteristics of specific courses influence ongoing utilisation of TBL. Those who desire to implement TBL would do well to take these factors into account as they plan implementation efforts at their schools.

Objective: The authors performed this study to determine whether clerkship peer evaluations, initiated as part of our "team-based learning" curriculum in 2002, correlated with other student performance measures, and to determine what qualities students rate in their peer evaluations., Method: The authors correlated peer evaluation scores with other student performance measures and performed a qualitative examination of student comments to assess reasons students gave for giving high and low scores., Results: Peer evaluation scores correlated modestly with the National Board of Medical Examiners' (NBME) subject test, in-class quiz, and clinical scores. Qualitative comments demonstrated that students made assessments based on three thematic areas: personal attributes, team contributions, and cognitive abilities., Conclusions: Peers' evaluation scores modestly predict which students will perform well on other measures. However, there may be other qualities that are also important factors in peer evaluation. For example, most students value qualities of preparation and participation. Though students sometimes dislike peer evaluations, their assessments may enhance traditional course assessments and complement a comprehensive evaluation strategy.

This cross-sectional study compared the distribution of anxiety symptoms among pregnant, non-pregnant, and postpartum women of lower socioeconomic status. Participants were 807 women who were pregnant (24-36 weeks), postpartum (2-8 weeks), or not pregnant. Anxiety and depressive symptoms were assessed by the state-trait anxiety index and the Beck depression inventory, respectively. English and Spanish versions of the instrument were available. Group differences in anxiety were evaluated using analysis of variance. Multivariate regression was performed to evaluate differences in anxiety while controlling for marital status, education, race/ethnicity, employment, cohabitation, income, parity, history of depression/anxiety, and depressive symptoms. Anxiety scores were lower among postpartum women relative to pregnant and non-pregnant women (both P < 0.001), who did not differ (P = 0.99). After controlling for depressive symptoms and patient characteristics, anxiety remained lowest among postpartum women. Additionally, history of depression/anxiety and depressive symptoms were significant predictors of anxiety in the multivariate analysis. Comparatively low anxiety and depressive symptoms were observed among women who were 2-8 weeks postpartum. Anxiety symptoms that occur postpartum may not appear until later in the postpartum period.

Objective: To assess depression rates in contemporary medical students., Method: The Beck Depression Inventory (BDI) was administered anonymously to two medical school classes at matriculation, the end of first year, and the end of second year., Results: Median scores for both classes were low at all points. The proportion of students scoring in the moderate or severely depressed range increased from 5.8% at matriculation to 10.5% by end of Year 2 for the Class of 2004, and from 5.1% to 11.9% over the same time period for the Class of 2005. Overall, 75-83% of students at every administration scored in the lowest BDI score range., Conclusions: The percentage of medical students who experience depressed mood increased over time, but to a lesser degree than in previous studies.

Objective: Finding time to teach psychiatry has become increasingly difficult. Concurrently, changes in medical student education are elevating demands for teaching. Academic psychiatry is challenged by these pressures to find innovative ways to recruit, retain, and reward faculty for teaching efforts. To address this challenge, the authors recommend a multifactorial approach to meeting the medical student educational mission of psychiatry departments., Methods: This approach includes a variety of efforts including having Chairs serve as role models, enforcing the service requirements of volunteer faculty, expanding teaching venues, providing faculty development, elevating the status of teaching through academies, attending to promotion of faculty educators, establishing and nominating faculty for teaching awards, and using medical center resources to provide rewards for teachers., Conclusion: Academic leaders must acknowledge the inherent value of teaching to the academic enterprise and delegate sufficient resources to recruit, retain, and reward educators for the essential work that they perform.

Objective: The clinical grade assessment is the most frequently used and heavily weighted component in the overall assessment of U.S. psychiatry clerkship students, yet the topic is understudied. The authors aimed to learn more about the nature, perceived virtues, and deficiencies of the clinical grade evaluation., Methods: A 26-item questionnaire regarding the psychiatry clerkship clinical grading form was distributed to the clerkship directors of 129 medical schools in the U.S. and U.S. territories. The design of the document, its strengths, its weaknesses, grading outcomes, and utilization were assessed., Results: Trends regarding clinical grading in psychiatry clerkships were detected. The clerkship grade form similarities, differences, desirable features, and utilization were ascertained, as were areas for improvement., Conclusions: The search for an optimal clinical grading process for the thousands of third-year medical students rotating annually is formidable. However, collaboration among psychiatry clerkship directors on development and improvement of clinical evaluation forms can clarify learning objectives and lead to better clinical evaluation tools.

Objective: The authors explored the time that is currently devoted to psychiatry clerkships to determine whether "shortened" clerkships differ in course director satisfaction and evaluation strategies., Method: An 18-item questionnaire was sent to 150 U.S. and Canadian clerkship directors., Results: The return rate was 74% (111 questionnaires). Clerkship length ranged from 4 to 8 weeks, with 6 weeks being most common (49.5% of clerkships). Only 18.9% had clerkships lasting 8 full weeks. Shorter clerkships were more likely to rely on the NBME subject test, and less likely to rely on Objective Standardized Clinical Examinations (OSCEs) or oral examinations. Most clerkship directors (81.9%) felt their evaluation procedures reflected their clerkship objectives. Among those who did not or were not sure, a majority (77.7%) felt having too few weeks was among the causes, except for 8-week clerkship directors, who did not mention clerkship length as an issue., Conclusions: The number of clerkships having 2 full months devoted to psychiatry has decreased in recent years. Shorter clerkships rely heavily on the National Board of Medical Examiners (NBME) Subject Examination as an evaluation tool, testing for book knowledge rather than clinical skills.

Objective: The authors explored psychiatry clerkship usage of the National Board of Medical Examiners (NBME) Subject Test., Methods: U.S. and Canadian psychiatry clerkship directors (N=150) were sent an 18-item questionnaire surveying evaluation and remediation practices., Results: Of 111 questionnaires (74%) returned, 76 (69%) reported using the NBME Subject Test. As part of the overall grade, the test was granted a mean weight of 31% and a median weight of 25%. Of 72 clerkship directors who use the test for grading, 42% convert the percentile score and 38% convert the subject score. Of 60 clerkship directors who use the test for passing, 72% convert the raw score (mean=58.3, median=58), and 28% convert the percentile score (mean=12.2(th), median=11(th) percentile)., Conclusions: Most psychiatry clerkship directors use the NBME Subject Test, but no predominant method exists for weighing the test or converting it into a grade.

Objective: To evaluate students' attitudes and concerns regarding potential repercussions of completing the Beck Depression Inventory (BDI)., Methods: A survey based on focus group data was developed and distributed., Results: One hundred and ninety-one of 400 surveys (48%) were returned. Of 160 students who remembered completing the BDI, 31 (19%) admitted to concerns about the research, and nearly 10% admitted to recording dishonest answers., Conclusions: These findings emphasize the importance of conducting anonymous assessments of medical students, particularly when assessing sensitive psychological states.

An impaired physician is one unable to fulfill professional or personal responsibilities because of psychiatric illness, alcoholism, or drug dependency. Current estimates are that approximately 15% of physicians will be impaired at some point in their careers. Although physicians may not have higher rates of impairment compared with other professionals, factors in their background, personality, and training may contribute and predispose them to drug abuse and mental illness, particularly depression. Many physicians possess a strong drive for achievement, exceptional conscientiousness, and an ability to deny personal problems. These attributes are advantageous for "success" in medicine; ironically, however, they may also predispose to impairment. Identifying impairment is often difficult because the manifestations are varied and physicians will typically suppress and deny any suggestion of a problem. Identification is essential because patient well-being may be at stake, and untreated impairment may result in loss of license, health problems, and even death. Fortunately, once identified and treated, physicians often do better in recovery than others and typically can return to a productive career and a satisfying personal and family life.

The efficacy of anterior cruciate ligament (ACL) reconstruction in the knee using hamstring tendon or patellar tendon grafts is thought to depend on the relative amounts of graft elongation, or creep, following postoperative rehabilitation. In this study, the creep responses of the tendinous portions of these two graft types were compared during 1 hour of cyclic loading to 200 N at 1 Hz. In the hamstring tendon grafts, strains were measured in both the tissue and in the length-augmentation tape to identify the relative contribution of this particular graft fixation to overall creep. Differences in tissue strain between graft types during cyclic loading were not statistically significant. For both types of grafts, overall graft length significantly increased after 3600 cycles while tissue creep was not significant. The greatest creep in the hamstring tendon grafts occurred at the tissue-tape interface, indicating a potential disadvantage of this composite graft construct.

The enhanced palpebral spring and the gold weight are the modern devices that should nearly completely replace tarsorrhaphy in the management of ocular problems secondary to facial paralysis. They actually reanimate the lid, rather than merely hold the lids closed in a disfigured position, as does tarsorrhaphy. The surgical techniques of each procedure, results, and pros and cons of each are compared. Personal experience with over 1400 spring implantations is discussed, as is experience with the use of bandage contact lenses in lieu of lid surgery. The gold weight implantation is simpler to learn and perform than the enhanced spring procedure, in which the levator is tightened in addition to implanting the spring. However, when it is really important to close the eye well, the spring is the superior procedure. Unlike the weight, the spring closes the eye well in the supine position, such as when the patient sleeps.

Objective: This paper describes the clinical characteristics of 20 hospitalized psychiatric patients in the Hebei province of China who believed they were possessed., Methods: A structured interview focused on clinical characteristics associated with possession phenomena was developed and administered to 20 patients at eight hospitals in the province. All patients had been given the Chinese diagnosis of yi-ping (hysteria) by Chinese physicians before being recruited for the study., Results: The subjects' mean age was 37 years. Most were women from rural areas with little education. Major events reported to precede possession included interpersonal conflicts, subjectively meaningful circumstances, illness, and death of an individual or dreaming of a deceased individual. Possessing agents were thought to be spirits of deceased individuals, deities, animals, and devils. Twenty percent of subjects reported multiple possessions. The initial experience of possession typically came on acutely and often became a chronic relapsing illness. Almost all subjects manifested the two symptoms of loss of control over their actions and acting differently. They frequently showed loss of awareness of surroundings, loss of personal identity, inability to distinguish reality from fantasy, change in tone of voice, and loss of perceived sensitivity to pain., Conclusions: Preliminary findings indicate that the disorder is a syndrome with distinct clinical characteristics that adheres most closely to the DSM-IV diagnosis of dissociative trance disorder under the category of dissociative disorder not otherwise specified.

The unique relationship between hypnotist and subject has been theorized as one explanation for the effectiveness of hypnosis. This relationship carries a power differential, present in most therapeutic relationships, but accentuated by hypnosis. The power differential is sometimes perceived as the ability of the hypnotist to control the subject. Perceptions of hypnosis offered by stage hypnotists, the popular media, and some clinicians perpetuate the notion that the hypnotist has the ability to exert undue influence upon the client. The present article examines the relationship between hypnotist and subject focusing on issues of power and control. The authors examine the unique dynamics accompanying the use of hypnosis and their impact on the therapeutic dyad. Evidence is offered demonstrating the power differential, and how this differential can serve as either a positive or negative agent of change. Therapists should be aware of the dynamics created by using hypnosis. Implications for training therapists in the use of hypnosis are suggested.

Although it has been reported that several growth factors modulate soft-tissue healing, the specific effects of growth factors on protein synthesis during ligament healing have not been widely investigated. In this study, we examined the effects of basic and acidic fibroblast growth factors, transforming growth factor beta 1, and epidermal growth factor on collagen and noncollagenous protein synthesis by cultured fibroblasts from medial collateral ligament and anterior cruciate ligament in vitro. Uptake of tritiated proline was used to measure synthesis of collagen and noncollagenous protein, and sodium dodecyl sulfate-polyacrylamide gel electrophoresis was used to analyze the type of collagens synthesized. Our data showed that transforming growth factor beta 1 increased both collagen and noncollagenous protein synthesis by medial collateral and anterior cruciate ligament fibroblasts on a dose-dependent basis. Collagen synthesis by cultured fibroblasts from the medial collateral and anterior cruciate ligaments was increased by treatment with transforming growth factor beta 1 by as much as approximately 1.5 times that of untreated controls. Although the response to transforming growth factor beta 1 by anterior cruciate ligament fibroblasts was equal to that by medial collateral ligament fibroblasts, the amounts of matrix proteins synthesized by anterior cruciate ligament fibroblasts were approximately half of that by medial collateral ligament fibroblasts. The increase was mostly in type-I collagen. Treatment of anterior cruciate ligament fibroblasts with epidermal growth factor increased collagen synthesis by approximately 25% but had little effect on medial collateral ligament fibroblasts. Neither basic nor acidic fibroblast growth factor increased either collagen or noncollagenous protein synthesis. These findings suggest that topical application of transforming growth factor beta 1, alone or in combination with epidermal growth factor, may have the potential to strengthen the ligament by increasing matrix synthesis during its remodeling and healing processes.

The optimal treatment for concurrent injuries to the medial collateral and anterior cruciate ligaments has not been determined, despite numerous clinical and laboratory studies. The objective of this study was to examine the effect of surgical repair of the medial collateral ligament on its biomechanical and biochemical properties 52 weeks after such injuries. In the left knee of 12 skeletally mature New Zealand White rabbits, the medial collateral ligament was torn and the anterior cruciate ligament was transected and then reconstructed. This is an experimental model previously developed in our laboratory. In six rabbits, the torn ends of the medial collateral ligament were repaired, and in the remaining six rabbits, the ligament was not repaired. Fifty-two weeks after injury, we examined varus-valgus and anterior-posterior knee stability; structural properties of the femur-medial collateral ligament-tibia complex; and mechanical properties, collagen content, and mature collagen crosslinking of the medial collateral ligament. We could not detect significant differences between repair and nonrepair groups for any biomechanical or biochemical property. Our data support clinical findings that when the medial collateral and anterior cruciate ligaments are injured concurrently and the anterior cruciate ligament is reconstructed, conservative treatment of the ruptured medial collateral ligament can result in successful healing.

Since its inception, scholars have struggled with the concept of CBSs. This struggle is reflected in the continuing use of a term that is confusing and inaccurate. Most authors would agree that the term "culture-bound syndrome" was intended to describe forms of otherwise common mental illness that are rendered unusual because of the pathoplastic influence of culture. It was intended not only to describe specific syndromes, but also meanings of illness and non-Western notions of disease causation. The term has become an anachronism, for the word, "syndrome," implies specific disease entities, not illnesses of attribution of idioms of distress. Furthermore, the word "bound" implies that the entities described are restricted to a single culture. Close examination reveals that many of the so-called "culture-bound" syndromes are found in multiple cultures that have in common only that they are "non-Western." It may be unreasonable to expect one term to describe these different concepts. The most accurate of the designations offered might be "folk diagnostic categories." Perhaps the most difficult question remaining is "How can we understand (and classify) these phenomena in such a way that highlights their uniqueness but does not dismiss them as too rare and exotic to warrant attention?" The first step is to recognize that the CBSs are a heterogeneous group of conditions. We must next acknowledge that the concepts represented may be difficult for the average Western clinician to recognize but, in their respective cultures, are neither rare nor unusual. With 80% of our increasingly shrinking world coming from "non-Western" cultures, a familiarity with non-Western notions of disease causation is particularly important for modern clinicians. Many authors have recommended that those CBSs that are "true" syndromes be classified together with their Western counterparts. In order to do this, the folk labels need to be put aside and the fundamental components of each disorder examined. Each entity would have to be placed in the body of the classificatory manual, and defined by its symptoms, not by the fact that its form is highly influenced by culture.(ABSTRACT TRUNCATED AT 400 WORDS)

The optimal treatment for a combined injury of the medial collateral and anterior cruciate ligaments is controversial, and the question remains as to whether repair of the medial collateral ligament and reconstruction of the anterior cruciate ligament improves healing of the medial collateral ligament. We compared reconstruction of the anterior cruciate ligament with and without repair of the medial collateral ligament in a rabbit model of a combined injury of these two ligaments. The anterior-posterior translation and varus-valgus rotation of the knee, the structural properties of the femur-medial collateral ligament-tibia complex, and the mechanical properties of the midsubstance of the medial collateral ligament were evaluated immediately after surgery and at 6 and 12 weeks postoperatively. Repair of the medial collateral ligament led to significantly less varus-valgus rotation of the knee than did no repair, but the anterior-posterior translation of the knees in the repair and nonrepair groups were not significantly different at any study time. At 12 weeks, the cross-sectional area and ultimate load in the repair group were 60 and 53% greater, respectively, than in the nonrepair group. Among 12 specimens that were repaired (six specimens at 6 weeks and six specimens at 12 weeks), failure occurred within the midsubstance in four (two at each time period); in all of the specimens that were not repaired, failure occurred at the tibial insertion site. There was no significant difference between the modulus of the modulus of the midsubstance in the repaired and the nonrepaired medial collateral ligaments.(ABSTRACT TRUNCATED AT 250 WORDS)

The tensile and viscoelastic properties of fresh-frozen, nonirradiated human patellar tendon were investigated in two groups of 15 specimens: one group was from individuals 29-50 years old and the other group was from individuals 64-93 years old. The central portion of each patella-patellar tendon-tibia complex was subjected to cyclic preconditioning, stress-relaxation, cyclic stress-relaxation, and load to failure tests. For each age group, stress-relaxation and stress-strain curves were obtained, from which percentage relaxation, ultimate tensile strength, strain at failure, modulus, and strain energy density were determined. Viscoelastic behavior was described with use of quasilinear viscoelasticity. The younger group showed a 46 +/- 9% (mean +/- SD) decrease in stress after 15 minutes, whereas the older group exhibited a 50 +/- 6% decrease. The values for ultimate tensile strength and strain at failure, respectively, were 64.7 +/- 15.0 MPa and 14 +/- 6% for the younger group and 53.6 +/- 10.0 MPa and 15 +/- 5% for the older group. Modulus values were 660 +/- 266 MPa for the younger group and 504 +/- 222 MPa for the older group. Except for ultimate tensile strength, which was 17% less for the older group than for the younger one, no statistically significant differences were found in tensile or viscoelastic properties. This study indicated that there were minimal differences in biomechanical properties of the substance of the patellar tendon between younger and older age groups.

Investigated the adverse sexual effects of two antihypertensive drugs, atenolol and slow-release nifedipine, in a placebo-controlled, randomized, crossover study. Subjects were 16 older men (mean age = 66.6 years, SEM = 1.4) with mild to moderate hypertension. Subjects completed daily self-reports on 13 measures of sexuality: frequency of desire, coitus, noncoital partner sex, masturbation, morning erections, spontaneous erections, orgasms in coitus and masturbation, firmness of morning, masturbatory and coital erections, and subjective pleasure in coitus and masturbation. Except for a significant decrease in masturbatory erectile firmness with nifedipine therapy, variables did not differ between the two drug treatments or between either drug and placebo. Although the sample was relatively small, small differences between treatment means suggest that these antihypertensive agents are fairly benign relative to sexual function in men.