Randolph B. Schiffer

What makes a good clinical teacher in medicine? A review of the literature.

Purpose The authors perform a review of the literature pertinent to the question, “What makes a good clinical teacher in medicine?” Method After framing the question, based on discussions of their own experiences with clinical teachers, the authors performed a search of the literature pertinent to the question, “What are the qualities of a good clinical teacher in medicine?” Between July and December, 2006, they reviewed titles from Index Medicus (1909–1966), PubMed (1966 to the present), PubMed Related Articles, and referenced articles. The initial selections were chosen by scanning pre-1966 Index Medicus title lists and post-1966 abstracts. Chosen articles were then read in their entirety, and those which described specific characteristics of clinical teachers were selected for inclusion. Qualitative analysis was used to identify themes. Results From 4,914 titles, 68 articles were selected for analysis—26 published before 1966, and 42 published after 1966. Four hundred eighty descriptors were identified and grouped into 49 themes, which were clustered into three main categories: physician, teacher, and human characteristics. Echoing the authors’ intuitive descriptions, noncognitive characteristics dominated the descriptions and themes. Conclusions Excellent clinical teaching, although multifactorial, transcends ordinary teaching and is characterized by inspiring, supporting, actively involving, and communicating with students. Faculty development programs and future research should focus on development of the noncognitive attributes of clinical teachers, as well as the knowledge and skills associated with effective teaching.

The Goldman Consensus statement on depression in multiple sclerosis

Background. In January 2002 the New York City Chapter of the National Multiple Sclerosis Society convened a panel of experts to review the issue of depressive affective disorders associated with multiple sclerosis (MS). This Consensus Conference was supported by a grant from the Goldman family of New York City. Results. The panel reviewed summaries of current epidemiologic, neurobiologic, and therapeutic studies having to do with depressive disorders among MS patient populations. Depressive disorders occur at high rates among patients with MS, and there is reason to believe that the immunopathology of the disease is involved in the clinical expression of affective disorders. The depressive syndromes of MS have a major, negative impact on quality of life for MS sufferers, but are treatable. At the present time, most MS patients with depression do not receive adequate recognition and treatment. Conclusions. The Goldman Consensus Conference Study Group provides recommendations for improved screening, diagnosis, and clinical management for depressive affective disorders among patients suffering from MS.

Treatment of Pathologic Laughing and Weeping with Amitriptyline

Patients with bilateral forebrain disease may commonly manifest the syndrome of pathologic laughing and weeping. We investigated the efficacy of low-dose amitriptyline in 12 patients in whom this syndrome was a consequence of multiple sclerosis. In a double-blind crossover study comparing amitriptyline with placebo, eight patients experienced dramatic and significant improvement with amitriptyline (P = 0.02). The mean dose of amitriptyline was 57.8 mg per day and did not exceed 75 mg per day in any patient. Concurrent measurements of depression showed no change during the study. We conclude that amitriptyline is effective in the treatment of this disturbance of affective expression, and that this effect is distinct from the antidepressant effect of the medication.

Psychiatric features in diffuse Lewy body disease A clinicopathologic study using Alzheimer's disease and Parkinson's disease comparison groups

We conducted a retrospective study to determine the frequency of depression, hallucinations, and delusions in patients with diffuse Lewy body disease (DLBD) and to compare these findings with those in Alzheimers disease (AD) and Parkinsons disease (PD).One hundred twelve subjects were included in the study. Of these, 28 subjects were diagnosed with DLBD, 58 with AD, and 26 with PD at autopsy. Main outcome measures included the percentages of subjects in each of the three categories in whom depression, hallucinations, or delusions were reported at any time during the course of the illness. Hallucinations and delusions were further classified by type. We found that depression was more common in DLBD (50.0%) than in AD (13.8%) (chi squared = 13.00, p = 0.0003). There was no difference in the frequency of depression in DLBD and PD (57.7%) (chi squared = 0.32, p = 0.57). Hallucinations were reported more frequently in DLBD (60.7%) than in AD (34.5%) (chi squared = 5.30, p = 0.021). There was no difference in the frequency of hallucinations in DLBD and PD (53.8%) (chi squared = 0.26, p = 0.61). Delusions were more common in DLBD (57.1%) than in PD (15.4%) (chi squared = 10.08, p = 0.0015). There was no difference in the frequency of delusions in DLBD and AD (53.4%) (chi squared = 0.10, p = 0.75). There was a male predominance of DLBD cases and PD cases; AD cases were predominantly women. We conclude that psychiatric features are very common in DLBD and should be a central diagnostic criterion for the disease. NEUROLOGY 1996;47: 1148-1152

Utility of the RBANS in detecting cognitive impairment associated with Alzheimer's disease : Sensitivity, specificity, and positive and negative predictive powers

Although initially developed as a brief dementia battery, the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) has not yet demonstrated its sensitivity, specificity, and positive and negative predictive powers in detecting cognitive impairment in patients with Alzheimers disease (AD). Therefore, the current study examined the clinical utility of the RBANS by comparing two age-, education-, and gender-matched groups: patients with AD (n=69) and comparators (n=69). Significant differences (p<0.001) were observed on the RBANS Total score, all 5 Indexes, and all 12 subtests, with patients performing worse than the comparison participants. An optimal balance between sensitivity and specificity on RBANS scores was obtained when cutoffs of one and one and a half standard deviations below the mean of the comparison sample were implemented. Areas under the Receiver Operating Characteristic curves for all RBANS Indexes were impressive though Immediate and Delayed Memory Indexes were excellent (0.96 and 0.98, respectively). Results suggest that RBANS scores yield excellent estimates of diagnostic accuracy and that the RBANS is a useful screening tool in detection of cognitive deficits associated with AD.

Dextromethorphan plus ultra low-dose quinidine reduces pseudobulbar affect.

To evaluate dextromethorphan combined with ultra low‐dose quinidine (DMq) for treating pseudobulbar affect (PBA) in patients with amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS).

The Differential Diagnosis of Pseudobulbar Affect (PBA): Distinguishing PBA Among Disorders of Mood and Affect

This monograph summarizes the proceedings of a roundtable meeting convened to discuss pseudobulbar affect (PBA). Two didactic lectures were presented followed by a moderated discussion among 11 participants. Post-meeting manuscript development synthesized didactic- and discussion-based content ad incorporated additional material from the neuroscience literature. A conceptual framework with which to distinguish between disorders of mood and affect is presented first, and disorders of affect regulation are then reviewed briefly. A detailed description of the most common of these disorders, PBA, is the focus of the remainder of the monograph. The prevalence, putative neuranatomic and neurochemical bases of PBA are reviewed, and current and emerging methods of evaluation and treatment of persons with PBA are discussed. The material presented in this monograph will help clinicians better recognize, diagnose, and treat PBA, and will form a foundation for understanding and interpreting future studies of this condition.

The interaction between depressive affective disorder and neuropsychological test performance in multiple sclerosis patients.

Cognitive impairment of mild-to-moderate severity is known to occur among a large proportion of patients with multiple sclerosis (MS). Depressive affective disturbances are also known to occur commonly among these patients. In order to determine the degree of interaction between mood disturbance and cognitive impairment, we conducted a test-retest neuropsychological study of 11 MS patients with current major depression diagnosed by Research Diagnostic Criteria. Patients were tested while depressed and at another point while euthymic. Nine patients were assessed first in a depressed state, followed by a reevaluation in the euthymic state, and two were assessed first in the euthymic state. The mean time interval between assessments was 7 months. When cognitive performance in the depressed condition was compared with cognitive performance in the euthymic condition, no significant differences were found. There was evidence for a pattern of improvement in verbal memory tests that fell short of statistical significance. Some language-related cognitive functions actually deteriorated during the 6-month course of this study.

EEG Patterns in Mild Cognitive Impairment (MCI) Patients

An emerging clinical priority for the treatment of Alzheimer’s disease (AD) is the implementation of therapies at the earliest stages of disease onset. All AD patients pass through an intermediary stage of the disorder known as Mild Cognitive Impairment (MCI), but not all patients with MCI develop AD. By applying computer based signal processing and pattern recognition techniques to the electroencephalogram (EEG), we were able to classify AD patients versus controls with an accuracy rate of greater than 80%. We were also able to categorize MCI patients into two subgroups: those with EEG Beta power profiles resembling AD patients and those more like controls. We then used this brain-based classification to make predictions regarding those MCI patients most likely to progress to AD versus those who would not. Our classification algorithm correctly predicted the clinical status of 4 out of 6 MCI patients returning for 2 year clinical follow-up. While preliminary in nature, our results suggest that automated pattern recognition techniques applied to the EEG may be a useful clinical tool not only for classification of AD patients versus controls, but also for identifying those MCI patients most likely to progress to AD.

Chrysin, a natural flavonoid enhances steroidogenesis and steroidogenic acute regulatory protein gene expression in mouse Leydig cells

During the aging process of males, testosterone biosynthesis declines in testicular Leydig cells resulting in decreases in various physiological functions. To explore the possibility of delaying the decline using food supplements, we have studied steroidogenic effects of a natural flavonoid, chrysin, in mouse Leydig cells. Chrysin dramatically increased cyclic AMP (cAMP)-induced steroidogenesis in MA-10 mouse Leydig tumor cells. This result was confirmed using Leydig cells isolated from mouse testes. The steroidogenic effect of chrysin is not associated with an increase in expression of the P450 side-chain cleavage enzyme, required for the conversion of cholesterol to pregnenolone. In addition, when 22(R)hydroxylcholesterol was used as a substrate, chrysin induced a non-significant increase in steroid hormone, suggesting that the majority of the observed increase in steroidogenesis was due to the increased supply of substrate cholesterol. These observations were corroborated by showing that chrysin induced a marked increase in the expression of steroidogenic acute regulatory (StAR) protein, the factor that controls mitochondrial cholesterol transfer. Also, chrysin significantly increased StAR promoter activity and StAR mRNA level. Further studies indicated that this compound depressed expression of DAX-1, a repressor in StAR gene transcription. In the absence of cAMP, chrysin did not increase steroidogenesis. However, when a sub-threshold level of cAMP was used, StAR protein and steroid hormone were increased by chrysin to the levels seen with maximal stimulation of cAMP. These results suggest that while chrysin itself is unable to induce StAR gene expression and steroidogenesis, it appears to function by increasing the sensitivity of Leydig cells to cAMP stimulation.