Kathleen V. Watson

Vascular complications of essential thrombocythaemia : a link to cardiovascular risk factors

Essential thrombocythaemia (ET) is a myeloproliferative disorder characterized by absolute thrombocytosis and increased incidence of thrombosis and haemorrhage. We report higher morbidity in patients with ET due to arterial ischaemic complications when cardiovascular risk factors are present. In this retrospective analysis of 46 patients, arterial complications occurred in 20/46 patients (43.4%); patients with cardiovascular risk factors, especially cigarette smoking, had more than twice as many arterial complications than patients without risk factors (62.5%v 22.7%, P<0.05). Neither age, gender nor degree of thrombocytosis were linked to the number of complications. In contrast, we observed no association between cardiovascular risk factors and venous thrombosis or haemorrhagic complications of ET.

Lupus anticoagulant induces a selective defect in thrombin‐mediated endothelial prostacyclin release and platelet aggregation

Summary A patient with microvascular thrombosis and thrombocytopenia was found to have a high‐titre lupus anticoagulant. The biological effects of the patients lupus anticoagulant were studied using whole patient serum and plasma, Staph Protein A eluate, and affinity‐purified lupus anticoagulant. The latter was isolated by immunoadsorption of serum onto cardiolipin/phosphatidylserine/cholesterol liposomes. Each source of lupus anticoagulant demonstrated‘anticoagulant’activity, defined as prolongation of a modified kaolin clotting time, and contained antibody which bound to endothelial monolayers. Each interfered with thrombin‐mediated prostacyclin release from endothelial cells, but had no effect on arachidonate‐induced prostacyclin release. In addition, the lupus anticoagulant selectively blocked platelet aggregation in response to thrombin, but not in response to arachidonate, ADP or epinephrine. Lupus anticoagulant also reduced thrombin‐stimulated shifts in cytosolic calcium. Thrombin‐mediated membrane inositol metabolism and total thrombin binding to endothelium were unaffected by lupus anticoagulant, and another endothelial anticoagulant function related thrombin binding, Protein C activation by thrombomodulin, was not altered. We conclude that the binding of lupus anticoagulant to endothelial cells and platelets does not prevent all thrombin signalling events, but does interrupt prostacyclin production.

Lupus anticoagulant inhibition of in vitro prostacyclin release is associated with a thrombosis-prone subset of patients.

PURPOSE The effect of lupus anticoagulant-containing sera on endothelial prostacyclin generation (both basal and after thrombin stimulation) was determined. Subsets of patients who had experienced arterial, venous, or no thrombosis were compared with respect to the quantitation of antiphospholipid antibody and effects on prostacyclin production. PATIENTS AND METHODS Serum antiphospholipid antibodies were detected in 26 patients by immunologic (enzyme-linked immunosorbent assay) and kinetic (anticoagulant) assays. Cultured human endothelial cells were exposed to patient or normal serum, and the release of prostacyclin was determined by radioimmunoassay of supernatants. Release was determined in the absence and presence of the secretagogue, thrombin (1 U/mL), corrected for interassay variation, and correlated with other clinical and laboratory variables. RESULTS The normal prostacyclin response was a 2.5-fold increase after thrombin (1 U/mL) compared to basal production. Patients with a history of arterial thrombosis (Group 1, n = 10) had the highest IgG anticardiolipin antibody titers (449 +/- 115 [OD x 1,000]), most prolonged kaolin clotting times (140 +/- 15 seconds), and the least prostacyclin response to thrombin (1.36-fold). Patients with venous thrombosis (Group 2, n = 6) had lower titers (329 +/- 120), intermediate clotting times (125 +/- 19 seconds), and slightly impaired prostacyclin responses (2.18-fold). Patients with no history of thrombosis (Group 3, n = 10) had low antibody titers (220 +/- 20), mildly prolonged clotting times (108 +/- 6 seconds), and normal prostacyclin responses (2.33-fold). Patient serum did not alter basal or arachidonate-induced prostacyclin production. Group 1 had significantly lower platelet counts (99 +/- 19) compared to Group 2 (167 +/- 35) or Group 3 (167 +/- 34), but were similar in age and associated diagnoses. CONCLUSIONS Inhibition of prostacyclin responses is commonly found in serum from patients with lupus anticoagulants, and is likely to be present in patients with high IgG anticardiolipin antibodies, strong lupus anticoagulants, low platelet counts, and a recent arterial thrombosis.

A communication assessment and skill-building exercise (CASE) for first-year residents.

OBJECTIVE Good communication skills are essential for residents entering postgraduate education programs. However, these skills vary widely among medical school graduates. This pilot program was designed to create opportunities for (1) teaching essential interviewing and communication skills to trainees at the beginning of residency, (2) assessing resident skills and confidence with specific types of interview situations, (3) developing faculty teaching and assessment skills, (4) encouraging collegial interaction between faculty and new trainees, and (5) guiding residency curricular development. DESCRIPTION During residency orientation, all first-year internal medicine residents (n = 26) at the University of Minnesota participated in the communication assessment and skill-building exercise (CASE). CASE consisted of four ten-minute stations in which residents demonstrated their communication skills in encounters with standardized patients (SPs) while faculty members observed for specific skills. Faculty and SPs were oriented to the educational purposes and goals of their stations, and received instructions on methods of providing feedback to residents. With each station, residents were provided one and a half minutes of direct feedback by the faculty observer and the SP. The residents were asked to deal with an angry family member, to counsel for smoking cessation, to set a patient-encounter agenda, and to deliver bad news. A residents performance was analyzed for each station, and individual profiles were created. All residents and faculty completed evaluations of the exercise, assessing the benefits and areas for improvement. DISCUSSION Evaluations and feedback from residents and faculty showed that most of our objectives were accomplished. Residents reported learning important skills, receiving valuable feedback, and increasing their confidence in dealing with certain types of stressful communication situations in residency. The activity was also perceived as an excellent way to meet and interact with faculty. Evaluators found the experience rewarding, an effective method for assessing and teaching clinical skills, a faculty development experience for themselves in learning about structured practical skills exercises, and a good way to meet new interns. The residency program director found individual resident performance profiles valuable for identifying learning issues and for guiding curricular development. Time constraints were the most frequently cited area for improvement. The exercise became feasible by collaborating with the medical school Office of Education-Educational Development and Research, whose mission is to collaborate with faculty across the continuum of medical education to improve the quality of instruction and evaluation. The residency program saved considerable time, effort, and expense by using portions of the medical schools existing student skills-assessment programs and by using chief residents and faculty as evaluators. We plan to use CASE next year with a wider variety of physician-patient scenarios for interns, and to expand the program to include beginning second- and third-year residents. Also, since this type of exercise creates powerful feedback and assessment opportunities for instructors and course directors, and because feedback was so favorable from evaluators, we will encourage participation in CASE as part of our faculty educational development program.

Development and Implementation of a Web-based Evaluation System for an Internal Medicine Residency Program

Evaluation and feedback are fundamental components of graduate medical education. Paper-based evaluation systems are inefficient and costly and the evaluation data they provide are difficult to retrieve and analyze. In view of these problems, in 1996-1997, the authors developed and implemented a World Wide Web-based electronic evaluation system for the internal medicine residency program at the University of Minnesota. Residents were evaluated using the American Board of Internal Medicine Resident Evaluation Form. Custom evaluations were created for the assessment of sites, rotations, and faculty. The evaluations were completed by accessing an evaluation Web site from any location using standard computers and Web browsers. The evaluations were submitted electronically and automatically entered into a database. The system tracked compliance and automatically sent out reminders. Other features of the system included extensive reporting capabilities, automatic notification of substandard performance, and the ability to send confidential information to the program director. The total compliance rate ranged between 81% and 92% during the first 12 months of operation, with no significant difference in compliance observed between faculty and residents. The system was easy to use and could quickly and confidentially identify performance problems of residents and faculty from large numbers of evaluations.

The Rise of Learning Communities in Medical Education: A Socio-Structural Analysis

ong burdened with the descriptor “reform without change”,1 medical education is entering an era of appreciable reconceptualization and restructuring. The numerous social and economic forces buffeting delivery of health care services (including those of commercialization, commodification, and corporatization) are forcing medical educators to rethink the process, structure, and content of a pedagogical enterprise that has remained fundamentally unchanged since the Flexnerian revolution. One consequence of these forces has been the inadvertent tendency for medical schools to marginalize their traditional core mission—the education of future clinicians.2-8 In its place, research and clinical care enterprises have swept to the forefront of organizational consciousness, driven by the dual mandates of revenue enhancement and national rankings. For some, this realignment of organizational priorities obscures a more fundamental problem. Medical education, as traditionally constituted, embodies a profound paradox. On the one hand, it appears painstakingly crafted, a detailed collage of rigorously organized and sequenced educational emersions. On the other hand, this cornucopia of basic science and clinical experiences is undergirded by a Balkanized learning structure as students with faculty, other health professionals, patients, and most importantly, each other in a largely ephemeral manner. Because of these structural disconnects, and as brilliantly captured by Christakis and Feudtner’s “Temporary matters: The ethical consequences of transient social relationships in medical training,”9 student learning is “evanescent” in nature and thus is “ambiguous, baffling, cagey, deceitful, deceptive, elusory, equivocal...” all synonyms for the root concept (see http://thesaurus.reference.com/browse/evanescent). How then do we counter these problems of educational compartmentalization and disjointedness? Phrased differently, how can we better reconcile the inconsistencies and conflicts that spring up between basic science and clinical education, along with the countervailing lessons that emerge within medicine’s formal, informal, and hidden curricula? One emerging and remedial effort has been to promote organizational structures that bolster “relating” and “relationships,” both among students and between student and faculty. Within medicine, these structures have been variously labeled “learning communities” “academic societies,” or “docent units.”

Teaching and evaluating awareness of cultural and ethnic diversity in the medical encounter

No abstract available.

Children asking questions: speech interface reformulations and personification preferences

The pervasive availability of voice assistants may support children in finding answers to informational queries by removing the literacy requirements of text search (e.g., typing, spelling). However, most such systems are not designed for the specific needs and preferences of children and may struggle with understanding the intent of their questions. In our investigation, we observed 87 children and 27 adults interacting with three Wizard-of-Oz speech interfaces to arrive at answers to questions that required reformulation. We found that many children and some adults required help to reach an effective question reformulation. We report the common types of reformulations (both effective and ineffective ones). We also compared three versions of speech interfaces with different approaches to referring to itself (personification) and to the participant (naming personalization). We found that children preferred personified interfaces, but naming personalization did not affect preference. We connect our findings to implications for design of speech systems for families.