Charles Hilton

Black-white contrasts in insulin levels during pubertal development. The Bogalusa Heart Study.

Three hundred and seventy-seven children and adolescents aged 5–17 yr from the biracial (black-white) community of Bogalusa, Louisiana, were evaluated for Tanner stage of sexual development, plasma glucose, and insulin levels during an oral glucose tolerance test. Children of the two races were of similar age, weight, and height at each Tanner stage. Overall insulin response was compared by measuring the area under the insulin curve from the glucose tolerance test. Blacks, especially black females, had significantly higher insulin responses than their white counterparts. The insulin-glucose ratio at the initial t = 0 min baseline did not vary with race or sex throughout the Tanner stages. However, the 30 min postglucose data revealed clear differences between the races with blacks showing a higher insulin-glucose ratio. Ratios increased throughout puberty for both blacks and whites, boys and girls. The trends of racial contrasts seemed to be discernible even at the earliest stage of development. It is concluded that there is a clear difference between blacks and whites in insulin response to a glucose load early in childhood. These findings lead to the hypothesis that the greater prevalence of non-insulindependent diabetes mellitus seen in adult blacks, especially females, may be an expression of a difference in insulin secretion and related insulin resistance in early childhood.

High-fidelity, simulation-based, interdisciplinary operating room team training at the point of care

BACKGROUND The operating room (OR) is a dynamic, high risk setting requiring effective teamwork for the safe delivery of care. Teamwork in the modern OR, however, is less than ideal. High fidelity simulation is an attractive approach to training key teamwork competencies. We have developed a portable simulation platform, the mobile mock OR (MMOR) that permits bringing team training over long distances to the point of care. We examined the effectiveness of this innovative, simulation-based interdisciplinary operating room (OR) team training model on its participants. METHODS All general surgical OR team members at an academic affiliated medical center underwent scenario-based training using a mobile mock OR. Pre- and post-session mean scores were calculated and analyzed for 15 Likert-type items measuring self-efficacy in teamwork competencies using t test. RESULTS The mean gain in pre-post item scores for 38 participants averaged 0.4 units on a 6-point Likert scale. The significance was demonstrated in 4 of the items: role clarity (Delta = 0.6 units, P = .02), anticipatory response (Delta = 0.6 units, P = .01), cross monitoring (Delta = 0.6 units, P < .01), and team cohesion and interaction (Delta = 0.7 units, P < .01). CONCLUSION High-fidelity, simulation-based OR team training at the point of care positively impacts self-efficacy for effective teamwork performance in everyday practice.

Hepatic Insulin Clearance Increases after Weight Loss in Obese Children and Adolescents

BACKGROUND Obesity is a rapidly increasing health problem among US youth. Hyperinsulinemia is associated with obesity and has been found to be a contributory factor for the development of cardiovascular disease in the obese. It has been suggested that hyperinsulinemia of obesity is a result of increased insulin secretion caused by insulin resistance. However, it has been shown in adults that decreased hepatic insulin clearance (HIC) is the primary cause of hyperinsulinemia in this population. METHODS We studied 15 obese children and adolescents (11 F, 4 M; 8.6 to 18.1 years) before and 10 weeks after their enrollment in a multidisciplinary weight reduction program, which included a protein-sparing modified fast, a moderate intensity progressive exercise program, and a behavior-modification intervention. RESULTS All patients lost weight (P < 0.05). Measurements of immunoreactive insulin (IRI) and C-peptide reactivity (CPR) were performed before the program and at 10 weeks. IRI levels dropped significantly, whereas CPR levels did not change. CPR/IRI molar ratios, considered an indirect estimation of HIC, rose significantly after weight loss. CONCLUSIONS Our data suggest that hyperinsulinemia seen in obese children and adolescents is caused by decreased HIC. The cause for this decrease remains unknown, but it is reversible upon weight loss.

Design and effectiveness of a required pre-clinical simulation-based curriculum for fundamental clinical skills and procedures

Abstract Background For more than 20 years, medical literature has increasingly documented the need for students to learn, practice and demonstrate competence in basic clinical knowledge and skills. In 2001, the Louisiana State University Health Science Centers (LSUHSC) School of Medicine – New Orleans replaced its traditional Introduction in to Clinical Medicine (ICM) course with the Science and Practice of Medicine (SPM) course. The main component within the SPM course is the Clinical Skills Lab (CSL). The CSL teaches 30 plus skills to all pre-clinical medical students (Years 1 and 2). Methods Since 2002, an annual longitudinal evaluation questionnaire was distributed to all medical students targeting the skills taught in the CSL. Students were asked to rate their self- confidence (Dreyfus and Likert-type) and estimate the number of times each clinical skill was performed (clinically/non-clinically). Of the 30 plus skills taught, 8 were selected for further evaluation. Results An analysis was performed on the eight skills selected to determine the effectiveness of the CSL. All students that participated in the CSL reported a significant improvement in self-confidence and in number performed in the clinically/non-clinically setting when compared to students that did not experience the CSL. For example, without CSL training, the percentage of students reported at the end of their second year self-perceived expertise as “novice” ranged from 21.4% (CPR) to 84.7% (GU catheterization). Students who completed the two-years CSL, only 7.8% rated their self-perceived expertise at the end of the second year as “novice” and 18.8% for GU catheterization. Conclusion The CSL design is not to replace real clinical patient experiences. Its to provide early exposure, medial knowledge, professionalism and opportunity to practice skills in a patient free environment.

Identification of Cyclo(His-Pro)-Like Immunoreactivity in Human Follicular Fluid Correlation With Steroid and Peptide Hormones

OBJECTIVE: The purpose of this study was to evaluate human follicular fluid (FF) for the presence of cyclo(His-Pro)-like immunoreactivity (CHP-LI). After verifying its presence, we quantitated the levels and investigated correlations with other follicular parameters, including hormone levels. METHODS: Follicular fluid was collected from female volunteers undergoing controlled ovarian hyperstimulation. Fluid was collected by follicular puncture, either transvaginally (in vitro fer tilization) or laparoscopically (gamete intrafallopian transfer) at the time of oocyte retrieval (N = 137). Follicular size was determined ultrasonographically. Assays for steroid and peptide hor mones were determined with commercially available radioimmunoassay kits. CHP-LI was mea sured using a previously reported assay; parallel dilution curves and column chromatography aided in immunoidentity. RESULTS: The mean FF CHP-LI concentration (13.10 ± 1.83 nmol/L; N = 137) was greater than the corresponding serum values (9.42 ± 2.45 nmol/L; N = 21) (P < .05). Large follicles (20 mm or greater; 14.45 ± 1.74 nmol/L) contained significantly more CHP-LI than either medium follicles (16-19 mm; 11.51 ± 1.88 nmol/L) or small follicles (15 mm or smaller; 10.83 ± 2.12 nmol/L) (P < .05). Positive correlations were found between FF CHP-LI values and corresponding FF progesterone and prolactin concentrations (r = 0.67 and 0.62, respectively; P < .05). CONCLUSION: Mean CHP-LI levels in the FF are greater than those in the corresponding serum. We suggest that the neuropeptide may be originating from either peptidase cleavage of precursor peptides or from granulosa cell production. (J Soc Gynecol Invest 1994;1:220-4)

Relationship between Plasma Cyclo (His-Pro), a Neuropeptide Common to Processed Protein-rich Food, and C-Peptide/Insulin Molar Ratio in Obese Women

Cyclo (His-Pro) (CHP) is a gut-brain peptide whose plasma levels in humans are increased after glucose ingestion and preferentially altered by oral glucose ingestion compared to intravenous administration in rats, suggesting a role in the enteroinsular response to nutrient ingestion. We were interested in examining levels of CHP in women of differing weights and comparing these levels to various parameters of insulin secretion. Plasma from 26 fasting, nondiabetic women ranging from 21 to 70 years of age and weighing 43 to 114 kg was assayed for CHP. Insulin and C-peptide levels were measured in 17 of the 26. Fasting CHP levels were elevated in obese compared to nonobese women (2075 ± 144 vs. 905 ± 187 pg/ml; p < 0.001) and were related by regression analysis to weight (r = 0.668, p < 0.001) and body mass index (r = 0.636, p = 0.001). The fasting C peptide/insulin molar ratio, which may be used as an estimate of hepatic insulin clearance (HIC), was inversely related to CHP levels (r=-0.568, p=0.017). We conclude CHP levels are increased in obese women and inversely related to their C-peptide/insulin molar ratio. The elevation of CHP in those with a decrease in this estimate of HIC (obese) is interesting as the greater insulin response seen in normal persons after oral glucose compared to intravenous glucose has been postulated to be due to a decrease in HIC by some gut factor. The presence of such a factor in excess in the obese might explain part of their hyperinsulinemia.

In for the long haul: sustaining and rebuilding educational operations after Hurricane Katrina.

In 2005, Hurricane Katrina and the subsequent levee breaks left 80% of New Orleans under water for weeks. Within 4 short weeks, the Louisiana State University Health Sciences Center at New Orleans had relocated its campus temporarily to Baton Rouge and resumed operations. Many lessons were learned in the first year of recovery and disseminated to the field regarding emergency and disaster preparedness and response. As we approach the second anniversary of the nations most devastating natural disaster, we reflect on the long haul of rebuilding and offer new insights and lessons for sustaining operations and enhancing long-term rebuilding efforts.

Theory and Practice of Developing an Effective Simulation-based Clinical Curriculum

Simulator training and existing technology mutually affect each other: Advances in technology allow more sophisticated methods of teaching whereas educational needs often work as a driving force in new technology development. This process continues ad infinitum and a simulation course must evolve accordingly. Presently, there are two major formats for teaching with a simulator: (i) teacher-focused content-based format, in which the simulator is used solely as a visual aid; and (ii) student-focused simulator-based dynamic methods of teaching with the use of a simulator as an interactive agent. The first method is often used in a form of minilectures where a simulator is used to demonstrate principles or a concept. For example, a teacher presents a lecture on acute bronchial asthma and uses a simulator to demonstrate the manifestations of the disease: wheezing, desaturation, change of inspiration/expiration ratio, bronchial constriction, change in the lung volumes and capacities, etc. A major drawback of this method is its failure to actively engage the learners. The students are observers only. The second method brings a new dimension to traditional clinical education. Here the learners are actively involved in the educational activities, typically in smaller groups. This simulator-based interactive method helps the students develop clinical reasoning and practical skills pertinent to patient care.

Louisiana State University Health Sciences Center School of Medicine at New Orleans.

• Undergraduate medical education (UME) • Graduate medical education (GME) • Office of Medical Education Research and Development (OMERAD) • Learning Center • AHEC Program The assistant dean of undergraduate medical education has responsibility for oversight and management of the undergraduate curriculum under the direction of the associate dean for academic affairs and the dean. The UME office also works closely with the Office of Student Affairs to coordinate schedules and other student activities with the needs of the curriculum. Two courses are administered directly by the OME, but most courses and clerkships are departmentally based. The OMERAD was established in October 2002 as a schoolwide central resource and consultant center for promoting excellence, innovation, research, and scholarship in teaching and education. The OMERAD provides resources and consulting expertise for all courses and faculty members in the school of medicine.

206 DEVELOPMENT OF AN INTERACTIVE LEARNING TOOL FOR IMPLEMENTATION OF THE SAFETY PREPTM IN A CLINICAL ENVIRONMENT.

Introduction The SAFETY PrepTM is a preoperative protocol designed to promote better operating room (OR) team functioning while fulfilling the requirements of the JCAHO Universal Protocol. Its mnemonically driven format uses metacognitive principles to help make OR team members more conscious about their thought processes. In order to ease its implementation into the clinical setting, we attempted to create a user-friendly learning tool about it for OR teams. Methods We established a set of criteria that took into account OR requirements, adult learning theory, and human factors principles in developing the SAFETY PrepTM learning tool. Key components included simplicity in structure, ease of use, acceptability, portability, and interactivity. Results The SAFETY PrepTM learning tool is a CD-based interactive program designed to take an OR team systematically through the five major steps of the SAFETY PrepTM. The tool instructs the OR team in the major requirements of each step and does not proceed until prompted by the team. As a CD-based tool, it is readily portable. Additionally, its interface is very user friendly due to its simple structure. Pilot trials of the tool in our virtual OR demonstrated its adaptability to the clinical setting. Conclusions The SAFETY PrepTM learning tool is a portable, easy to use, interactive program adaptable to an OR environment. We believe that its use will help ease implementation of the SAFETY PrepTM in the clinical setting. We plan to test this hypothesis by using the learning tool in hospitals adopting the SAFETY PrepTM.