Medical School Teaching Hospital Research Articles

Health Professionals Organizing for Climate Action: A Novel Community Organizing Fellowship.

Climate change is a public health and health equity crisis. Health professionals are well positioned to advance solutions but may lack the training and self-efficacy needed to achieve them. The Center for Health Equity Education and Advocacy at Cambridge Health Alliance, a Harvard Medical School Teaching Hospital, developed a novel, longitudinal fellowship that taught health professionals about health and health equity effects of climate change, as well as community organizing practices that may help them mitigate these effects. The fellowship cohort included 40 fellows organized into 12 teams and was conducted from January to June 2022. Each team developed a project to address climate change and received coaching from an experienced community organizer coach. Effects of the fellowship on participants' knowledge, skills, and attitudes were evaluated using pre- and postfellowship surveys. Surveys were analyzed for 38 of 40 (95%) participants who consented to the evaluation and completed both surveys. Surveys used a 7-point Likert scale for item responses. McNemar's test for paired data was used to assess changes in the proportion of respondents who agreed ("somewhat agree"/"agree"/"strongly agree") with statements in pre- vs postfellowship surveys. Statistically significant improvements were found for 11 of the 17 items assessing knowledge, skills, and attitudes. Participants' views of the fellowship and its effects were assessed through additional items in the postfellowship survey. Most respondents agreed that the fellowship increased their knowledge of the connections between climate change and health equity (32/38, 84.2%) and prepared them to effectively participate in a community organizing campaign (37/38, 94.7%). Each of the 12 groups developed climate health projects by the fellowship's end. This novel fellowship was well received and effective in teaching community organizing to health professionals concerned about climate change. Future studies are needed to assess longer-term effects of the fellowship.

Critical Review Two-Years Thereafter of the Effectiveness of the Revolutionary Changes in a Gastroenterology Division at A Medical School Teaching Hospital in Response to the COVID-19 Pandemic: Medical School, Residency, and Gastrointestinal Fellowship Education and Clinical Practice of Gastroenterology Attendings and Gastrointestinal Endoscopy.

Profound and pervasive GI divisional changes maximized clinical resources devoted to COVID-19-infected patients and minimized risks of transmitting infection. Academic changes degraded by massive cost-cutting while offering institution to about 100 hospital systems and eventually "selling" institution to Spectrum Health, without faculty input.

A Critical Review from the Perspective of 2 Years Thereafter of the Effectiveness of Revolutionary Changes in a Gastroenterology Division at a Medical School Teaching Hospital due to the Coronavirus Disease-2019 Pandemic: Gastrointestinal Physician Clinical Practice and Emotional Stresses, Gastrointestinal Graduate Medical Education, Gastrointestinal Professional Societies, and Pandemic Control.

Critically review approximately 2 years afterward the effectiveness of revolutionary changes at an academic gastroenterology division from coronavirus disease-2019 (COVID-19) pandemic surge at the metropolitan Detroit epicenter from 0 infected patients on March 9, 2020, to>300 infected patients (one-quarter of) in-hospital census in April 2020 and>200 infected patients in April 2021. GI Division, William Beaumont Hospital which had 36 GI clinical faculty who used to perform>23,000 endoscopies annually with a massive plunge in endoscopy volume during the past 2 years; fully accredited GI fellowship since 1973; employs>400 house staff annually since 1995; predominantly voluntary attendings; and primary teaching hospital, Oakland-University-Medical-School. Expert opinion, based on: Hospital GI chief>14years until September 2019; GI fellowship program director, at several hospitals for>20years; author of 320 publications in peer-reviewed GI journals; and committee-member Food-and-Drug-Administration-GI-Advisory Committee for>5years. Original study exempted by Hospital Institutional Review Board (IRB), April 14, 2020. IRB approval is not required for the present study because this opinion is based on previously published data. Advantageous changes: Division reorganized patient care to add clinical capacity and minimize risks to staff of contracting COVID-19. Affiliated medical school changes included: changing "live" to virtual lectures, meetings, and conferences. Initially, virtual meetings usually used telephone conferencing which proved cumbersome until meetings were changed to completely computerized virtual meetings using Microsoft Teams or Google Zoom, which performed superbly. Some clinical electives were canceled for medical students and residents because of the need to prioritize car for COVID-19 infection during the pandemic, and medical students graduated on time despite partly missing electives. Division reorganized by changing "live" GI lectures to virtual lectures; by four GI fellows temporarily reassigned as medical attendings supervising COVID-19-infected patients; postponing elective GI endoscopies; and drastically reducing an average number of endoscopies from 100/weekday to a small fraction long-term! GI clinic visits were reduced by half by postponing nonurgent visits, and physical visits were replaced by virtual visits. Economic pandemic impact included a temporary, hospital deficit initially relieved by federal grants and hospital employee terminations. GI program director contacted GI fellows twice weekly to monitor pandemic-induced stress. Applicants for GI fellowship were interviewed virtually. Graduate medical education changes included weekly committee meetings to monitor pandemic-induced changes; program managers working from home; canceling annual ACGME fellowship survey, ACGME site visits, and national GI conventions changed from physical to virtual. Dubious changes: Temporarily mandated intubation of COVID-19-infected patients for EGD; temporarily exempted GI fellows from endoscopy duties during surge; fired highly respected anesthesiology group employed for 20years during pandemic leading to anesthesiology shortages, and abruptly firing without warning or cause numerous senior respected faculty who greatly contributed to research, academics, and reputation. Profound and pervasive GI divisional changes maximized clinical resources devoted to COVID-19-infected patients and minimized risks of transmitting infection. Academic changes were degraded by massive cost-cutting while offering institutions to about 100 hospital systems and eventually "selling" institutions to Spectrum Health, without faculty input.

Is AST/ALT Ratio a Predictor of In-hospital Mortality in Pulmonary Embolism Patients?

To document the association between serum transaminases and in-hospital mortality in pulmonary embolism (PE) patients. Analytical study. Patients treated with acute PE in hospital between January 2011 and December 2019 from Sakarya University Medical School Research and Teaching Hospital, Sakarya, Turkey. Patients with PE were included. Receiver operating characteristics (ROC) analysis was conducted to define a cut-off value for AST/ALT ratio to predict in-hospital death. Simplified pulmonary embolism severity index (sPESI) scores were calculated and the AST/ALT ratio were entered into binary logistic regression analysis with components of sPESI score to document the prognostic significance of as an independent predictor of in-hospital mortality. 164 acute PE patients were included; of those, 33 (20%) died in hospital. Deceased patients had higher AST/ALT ratio (median, 1.4; 25th-75th percentile, 1.1-1.8) comparing to patients with discharged home (median, 1.1; 25th-75th percentile, 0.84-1.4) (p=0.006). ROC analysis showed that AST/ALT ratio was an indicator of in-hospital mortality, and the calculated area under the curve was 0.655 (95% CI, 0.547-0.764). The cut-off value of 1.3 was associated with a prognostic sensitivity of 61% and specificity of 65%. Binary logistic regression analysis failed to show AST/ALT ratio as an independent predictor of in-hospital mortality. AST/ALT ratio predicts in-hospital mortality with acceptable sensitivity and specificity in patients with acute PE and might be used as a biomarker for risk stratification. Key Words: Pulmonary embolism, In-hospital mortality, Transaminases.

Very Low Rates of Ureteral Injury in Laparoscopic Hysterectomy Performed by Fellowship-Trained Minimally Invasive Gynecologic Surgeons

<h3>Study Objective</h3> The incidence of ureteral injury with laparoscopic hysterectomy reported in the literature is 0.78%. The objective of this study was to evaluate the rates of ureteral injury at the time of laparoscopic hysterectomy among high-volume fellowship-trained surgeons. <h3>Design</h3> We performed a retrospective chart review, evaluating gynecologic surgery cases between January 2009 and May 2019 performed exclusively by fellowship-trained surgeons in the Minimally Invasive Gynecologic Surgery (MIGS) Department at Harvard Medical School teaching hospitals in Boston. The rate of ureteral injury was assessed. <h3>Setting</h3> Patients were positioned in dorsal lithotomy with legs in Allen stirrups. A central (typically umbilical) camera port was placed along with bilateral lower quadrant ports and a third ipsilateral port to the left of the umbilicus. <h3>Patients or Participants</h3> A total of 5,160 cases were performed by MIGS surgeons between 2009-2019 at Brigham & Women's Hospital and Brigham & Women's Faulkner Hospital. Patients undergoing laparoscopic hysterectomy were selected for this review. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> Out of the 5,160 MIGS cases, 2,396 laparoscopic hysterectomies were performed. Only 1 ureteral injury was noted intraoperatively (0.04%). No additional delayed ureteral injuries were observed. <h3>Conclusion</h3> Ureteral injury is associated with significant patient morbidity and high economic burden. Despite taking on medically and surgically complex cases at our tertiary referral center, we observed very low rates of ureteral injury at the time of laparoscopic hysterectomy. Putting this into context given that approximately 600,000 hysterectomies are performed annually in the US; the literature-reported ureteral injury rate would result in approximately 4,680 injuries versus an estimated 240 injuries in a high-volume center. This study highlights the benefits of fellowship-training and high-volume practice on patient outcomes.

Poor Learning In Operation Theatres Causing Brain Drain

This article was migrated. The article was not marked as recommended. Introduction: In interior Sindh, most of the hospitals including teaching hospitals of Hyderabad, Larkana, Sukkur and Nawabshah lack specialists so the attitude of available specialists as supervisors is important for learning in operation theatre like need good mentorship, observation and hands-on skills. Limited research has been conducted in Pakistan while none of the study has been done considering specifically the hospitals of interior Sindh. Objective: To identify the perception of residents towards learning environment in surgical theatre of a medical school teaching hospital of interior Sindh. Method : A cross-sectional study was conducted at Peoples Medical College, Nawabshah, from May 2018 to October 2018. STEEM questionnaire of 40 statements was used and was validated after pilot study. The participants' responses were calculated using a five-point Likert scale. Randomized sampling technique was used. The reliability was assessed using Cronbach's alpha for the whole questionnaire. Mann-Whitney and the one-way analysis of variance (ANOVA) tests were used as nonparametric methods for comparative statistics for assessing gender differences. We also conducted the factor analysis by using a varimax rotation. Kaiser-Mayer-Olkin (KMO) and Bartlett's tests were applied. Results :Of the 88 participants, 71.6% (n=63) were females and 28.4% (n=25) were males. Majority of participants 43% belong to gynaecology department. The reliability of the scale was 0.822, calculated using Cronbach alpha. The mean overall STEEM score was 108.81 whereas, mean score of males was 115.44 and females was 106.17 which shows there the difference between scores based on gender. Male perceived the educational environment more positive than females in each subscale. Conclusion : Under current circumstances and condition of interior Sindh postgraduate trainees are deprived from good mentorship, observation and hands on skills due to lack and non-serious attitude of consultants/supervisors. The current study concluded that overall learning environment of operating theatre was perceived to be inadequate for learning.

Using the Syndrome Model of Addiction: a Preliminary Consideration of Psychological States and Traits

This article describes a collaborative research project between the Division on Addiction, Cambridge Health Alliance, a Harvard Medical School Teaching Hospital, and the Integrated Centre on Addiction Prevention and Treatment (ICAPT) of the Tung Wah Group of Hospitals (TWGHs) in Hong Kong. The goal of this research is to better understand the syndrome model of addiction by establishing an epidemiology of addiction treatment seekers across various expressions of addiction (e.g., alcohol and other psychoactive drugs, gambling, sexual behaviors, online gaming). This paper presents initial findings about the demographic and psychological characteristics of three groups of treatment seekers in TWGHs in Hong Kong: (1) a group seeking treatment for chemical expressions of addiction (n = 35); (2) a group seeking treatment for behavioral expressions of addiction (n = 125); and (3) a comparison group seeking services (n = 18) unrelated to addiction. The initial findings identified various common psychological vulnerabilities (i.e., trait anxiety, state anxiety, depression, using emotional support and venting as psychological coping, higher levels of attentional impulsiveness) shared among both the behavioral expression and chemical expression groups, and possible unique psychological characteristics associated with each expression of addiction (e.g., coping mechanisms). These findings provide support for conceptualizing addiction as a syndrome.

Locally advanced laryngeal cancer: Total laryngectomy or primary non-surgical treatment?

Between January 1997 and December 2013, the Charles University 3rd Medical School and Royal Vinohrady Teaching Hospital Ear, Nose and Throat oncology team treated 185 patients with advanced laryngeal cancer, which, from a surgical perspective, required a total laryngectomy. Overall, ~70% of these patients (n=129) underwent conventional treatment (i.e., total laryngectomy with post-operative radiotherapy), and ~30% (n=56) were treated with larynx preservation protocols (including primary radiotherapy, neoadjuvant chemotherapy followed by radiotherapy or chemoradiotherapy, or primary chemoradiotherapy). Patients treated with laryngeal preservation protocols had a 5-year survival probability of 48%, whereas those treated with total laryngectomy and post-operative radiotherapy had a 5-year survival probability of 63%. This difference was not statistically significant. However, patients who underwent primary surgical treatment survived for a significantly longer period (P<0.010). The sex of the patient did not have a statistically significant impact on patient survival probability. More extensive local disease and more advanced disease stages conferred a lower survival probability, but were not statistically significant; however, a lower survival probability in patients >70 years was identified to be statistically significant (P<0.010). Local disease recurrence and recurrent cervical nodal metastases had a statistically significant impact on the 5-year survival probability (P<0.001). A step wise Cox regression analysis was used to compare the parameters of sex, patient age, tumor extent, disease stage, choice of primary surgery, local recurrence and cervical nodal recurrence. In the first step, local recurrence was selected as the parameter having the greatest effect on survival (P<0.001); patient age >70 years (P<0.001) was selected in the second step; cervical nodal recurrence (P<0.001) in the third step; and disease stage (P<0.010) in the fourth step. Other parameters did not significantly affect survival. The results of the present study confirmed that primary non-surgical treatment is an alternative approach to total laryngectomy, and that an informed patient should determine the treatment approach. The decreased overall survival observed in more extensive tumors suggests that surgical treatment may be a better selection in these cases. Due to increased overall survival, primary non-surgical treatment may be recommended for younger patients. If the patient chooses primary non-surgical treatment, concomitant chemoradiotherapy is recommended. If the patient cannot tolerate cytostatic chemotherapy, radiotherapy alone is recommended.

A Historical Perspective on Disparities as Context for Our Work Ahead

BAYLOR HEALTH CARE System's laudable accomplishments in promoting care equity and Dr. Joseph Betancourt's analysis in this same issue illustrate how far we have come toward reducing disparities in care-and how far we still must go. For hospitals and health systems, historical context is important here, as the roots of disparities in the US healthcare system run deep and merit consideration as we push forward to improve how we serve society's most vulnerable people.HISTORICAL BACKDROP TO CURRENT EQUITY EFFORTSThat Baylor, a system situated in the once rigidly segregated South, has emerged as a leader in reducing care disparities is particularly noteworthy when we consider the long and troubled history of healthcare for minorities and other vulnerable populations in the United States.As with most aspects of life, medical care in the United States, and especially in the American South, was segregated by race prior to the civil rights era. Across much of the South, and even in northern cities with significant populations of African Americans, a separate system of hospitals served black patients and provided training and practice opportunities for black physicians. African Americans in the South largely received care at only hospitals, and even those requiring emergency care often were turned away by white institutions (Zheng and Zhou 2008).That hospitals for black patients existed at all owes in part to the reaction of African American physicians to the terrible consequences that the lack of hospital care had on sick and injured blacks. Black physicians spearheaded efforts to establish these facilities after the Civil War and through the first half of the twentieth century-from about 40 in 1900 to about 370 by the early 1960s (Zheng and Zhou 2008). But in terms of health outcomes, progress was slow-especially in the South, where hospital care for African Americans was scarce. In Mississippi, for example, black lay midwives delivered more than 80 percent of African American babies well into the 1940s, and overall, the health status of blacks changed little between the slavery era and the start of the Great Depression (Smith 2005).Ultimately, the 1964 Civil Rights Act and the application of its antidiscrimination safeguards to Medicare ended sanctioned separation of races in hospitals. As important were the urban health departments and public hospitals, especially in the North, that stepped in to fill the void of care for blacks and other minorities well before civil rights reforms took hold. The New York City Health Department, for example, worked with the Urban League in 1916 to reduce high infant mortality rates among blacks, lowering deaths from diarrheal and respiratory diseases from 71 and 80, respectively, of every 1,000 black infants to 48 and 50 in one year (Beardsley 1990). Prominent public institutions that in the latter half of the 1900s coalesced into the nation's healthcare safety net trace their beginnings as historically black hospitals-the Civil War-era Freedmen's Hospital in Washington, D.C., which later became Howard University Medical School's teaching hospital, among the first.That legacy of providing access to society's most vulnerable reverberates strongly today among those essential hospitals and health systems committed to keeping their doors open to the uninsured, the underinsured, and other disadvantaged patients. Against the historical backdrop of this nation's profound care inequities, the efforts today of Baylor and other systems like it are all the more remarkable and deserving of recognition.But clearly, we need to do much more, as Betancourt shows us. All hospitals-not just those that historically have championed the cause of the vulnerable-must recognize the urgent need to ensure that all patients receive the highest quality of care possible. More to the point, they need to follow Baylor's lead and emulate the work of the many other essential hospitals that make understanding and meeting the particular needs of minorities a priority. …

Partners HealthCare Center for Connected Health

This article reviews the history, current status, and future plans of the Partners HealthCare Center for Connected Health (the Center). Established in 1995 by Harvard Medical School teaching hospitals, the Center develops strategies to move healthcare from the hospital and doctor's office into the day-to-day lives of patients. It leverages information technology to help manage chronic conditions, maintain health and wellness, and improve adherence to prescribed regimen, patient engagement, and clinical outcomes. Since inception, it has served over 30,000 patients. The Center's core functions include videoconference-based real-time virtual visits, home vital sign monitoring, store-and-forward online consultations, social media, mobile technology, and other novel methods of providing care and enabling health and wellness remotely and independently of traditional time and geographic constraints. It offers a wide range of services, programs, and research activities. The Center comprises over 40 professionals with various technical and professional skills. Internally within Partners HealthCare, the role of the Center is to collaborate, guide, advise, and support the experimentation with and the deployment and growth of connected health technologies, programs, and services. Annually, the Center engages in a deliberative planning process to guide its annual research and operational agenda. The Center enjoys a diversified revenue stream. Funding sources include institutional operating budget/research funds from Partners HealthCare, public and private competitive grants and contracts, philanthropic contributions, ad hoc funding arrangements, and longer-term contractual arrangements with third parties.

Relaxation Response–Based Yoga Improves Functioning in Young Children with Autism: A Pilot Study

The study objectives were to develop and objectively assess the therapeutic effect of a novel movement-based complementary and alternative medicine approach for children with an autism-spectrum disorder (ASD). A within-subject analysis comparing pre- to post-treatment scores on two standard measures of childhood behavioral problems was used. SETTINGS AND LOCATION: The intervention and data analysis occurred at a tertiary care, medical school teaching hospital. Twenty-four (24) children aged 3-16 years with a diagnosis of an ASD comprised the study group. The efficacy of an 8-week multimodal yoga, dance, and music therapy program based on the relaxation response (RR) was developed and examined. The study outcome was measured using The Behavioral Assessment System for Children, Second Edition (BASC-2) and the Aberrant Behavioral Checklist (ABC). Robust changes were found on the BASC-2, primarily for 5-12-year-old children. Unexpectedly, the post-treatment scores on the Atypicality scale of the BASC-2, which measures some of the core features of autism, changed significantly (p=0.003). A movement-based, modified RR program, involving yoga and dance, showed efficacy in treating behavioral and some core features of autism, particularly for latency-age children.

CLINICAL AND EPIDEMIOLOGICAL FEATURES OF ORAL CANCER IN A MEDICAL SCHOOL TEACHING HOSPITAL FROM 1994 TO 2002: INCREASING INCIDENCE IN WOMEN, PREDOMINANCE OF ADVANCED LOCAL DISEASE, AND LOW INCIDENCE OF NECK METASTASES

Description of clinical and epidemiological characteristics of patients who underwent surgery for oral cancer in a Medical School Teaching Hospital, and determination of differences with respect to other institutions and/or periods of time. The charts of patients undergoing surgery for oral cancer from 1994 to 2002 were reviewed. Data were collected in a spreadsheet in order to analyze clinical and epidemiological features.. A total of 374 patients having undergone 406 operations was identified. Their ages varied from 14 to 94 years (mean = 57.4 years), with 255 men (68.2%), and 295 out 366 Caucasian (80.6%). A majority had tumors of the tongue and/or floor of mouth (55.6%), while 20.3% had lip cancer. Squamous cell carcinoma was found in 90.3%, and glandular carcinoma in 4%. T4 tumors in 39.6%, Tis or T1 lesions in 15.2% of all patients. Nearly 62% had no regional metastases, and the relative incidence in young patients (40 years or younger) reached 8.6%. In spite of the predominance of locally advanced tumors, a majority of patients had no neck metastases. The 31.8% incidence in females indicates an increasing incidence of oral cavity cancer among women when compared to previous periods at the same institution.

What motivates senior clinicians to teach medical students?

BackgroundThis study was designed to assess the motivations of senior medical clinicians to teach medical students. This understanding could improve the recruitment and retention of important clinical teachers.MethodsThe study group was 101 senior medical clinicians registered on a teaching list for a medical school teaching hospital (The Canberra Hospital, ACT, Australia). Their motivations to teach medical students were assessed applying Q methodology.ResultsOf the 75 participants, 18 (24%) were female and 57 (76%) were male. The age distribution was as follows: 30–40 years = 16 participants (21.3%), 41–55 years = 46 participants (61.3%) and >55 years = 13 participants (17.3%). Most participants (n = 48, 64%) were staff specialists and 27 (36%) were visiting medical officers. Half of the participants were internists (n = 39, 52%), 12 (16%) were surgeons, and 24 (32%) were other sub-specialists. Of the 26 senior clinicians that did not participate, two were women; 15 were visiting medical officers and 11 were staff specialists; 16 were internists, 9 were surgeons and there was one other sub-specialist. The majority of these non-participating clinicians fell in the 41–55 year age group. The participating clinicians were moderately homogenous in their responses. Factor analysis produced 4 factors: one summarising positive motivations for teaching and three capturing impediments for teaching. The main factors influencing motivation to teach medical students were intrinsic issues such as altruism, intellectual satisfaction, personal skills and truth seeking. The reasons for not teaching included no strong involvement in course design, a heavy clinical load or feeling it was a waste of time.ConclusionThis study provides some insights into factors that may be utilised in the design of teaching programs that meet teacher motivations and ultimately enhance the effectiveness of the medical teaching workforce.

Responsibly Managing the Medical School???Teaching Hospital Power Relationship

The relationship between medical schools and their teaching hospitals involves a complex and variable mixture of monopoly and monopsony power, which has not been previously been ethically analyzed. As a consequence, there is currently no ethical framework to guide leaders of both institutions in the responsible management of this complex power relationship. The authors define these two forms of power and, using economic concepts, analyze the nature of such power in the medical school-teaching hospital relationship, emphasizing the potential for exploitation. Using concepts from both business ethics and medical ethics, the authors analyze the nature of transparency and co-fiduciary responsibility in this relationship. On the basis of both rational self-interest, drawn from business ethics, and co-fiduciary responsibility, drawn from medical ethics, they argue for the centrality of transparency in the medical school-teaching hospital relationship. Understanding the ethics of monopoly and monopsony power is essential for the responsible management of the complex relationship between medical schools and their teaching hospitals and can assist the leadership of academic health centers in carrying out one of their major responsibilities: to prevent the exploitation of monopoly power and monopsony power in this relationship.

Significance of methicillin-resistant Staphylococcus aureus (MRSA) survey in a university teaching hospital.

We experienced a methicillin-resistant Staphylococcus aureus (MRSA) outbreak in two wards at our medical school teaching hospital during the period of July-September 1997. To determine whether these MRSA clinical isolates were associated with environmental factors, we conducted two sequential MRSA surveys of the hospital staff and surroundings in wards with outbreaks (wards 1 and 2) and in one ward without an outbreak (ward 3) in April 1998 (ward 1 only) and in March 1999 (wards 1, 2, and 3). In the two sequential surveys, MRSA strains were detected mainly from white coats. MRSA strains isolated from fingers in the first survey were decreased in the second survey. The pulsed-field gel electrophoresis (PFGE) patterns of the strains isolated in the two surveys were classified into five types (A-E). Type D, including the outbreak pattern of the MRSA in ward 1 in 1997, was reduced between the first and second surveys by managing microbiological hygiene, suggesting that the outbreak was controlled in ward 1. On the other hand, the strains isolated in the second survey in ward 2 were mainly type E, which was also common among clinical isolates from ward 2 during the latter half of 1998 to 1999. This suggested a high probability of cross-infection between the patients and the hospital staff in the ward. Our observations suggest that doctors and nurses should be cautious that their coats might be contaminated with the prevailing strains of MRSA. We also concluded that the surveys were very useful for the successful management of MRSA infections.

An efficient and effective teaching model for ambulatory education.

Teaching and learning in the ambulatory setting have been described as inefficient, variable, and unpredictable. A model of ambulatory teaching that was piloted in three settings (1973-1981 in a university-affiliated outpatient clinic in Portland, Oregon, 1996-2000 in a community outpatient clinic, and 2000-2001 in an outpatient clinic serving Dartmouth Medical School's teaching hospital) that combines a system of education and a system of patient care is presented. Fully integrating learners into the office practice using creative scheduling, pre-rotation learning, and learner competence certification enabled the learners to provide care in roles traditionally fulfilled by physicians and nurses. Practice redesign made learners active members of the patient care team by involving them in such tasks as patient intake, histories and physicals, patient education, and monitoring of patient progress between visits. So that learners can be active members of the patient care team on the first day of clinic, pre-training is provided by the clerkship or residency so that they are able to competently provide care in the time available. To assure effective education, teaching and learning times are explicitly scheduled by parallel booking of patients for the learner and the preceptor at the same time. In the pilot settings this teaching model maintained or improved preceptor productivity and on-time efficiency compared with these outcomes of traditional scheduling. The time spent alone with patients, in direct observation by preceptors, and for scheduled case discussion was appreciated by learners. Increased satisfaction was enjoyed by learners, teachers, clinic staff, and patients. Barriers to implementation include too few examining rooms, inability to manipulate patient appointment schedules, and learners' not being present in a teaching clinic all the time.

Beneficial effect of microinjected trehalose on the cryosurvival of human oocytes

Objective: To determine the effectiveness of trehalose as an intracellular cryoprotectant for the cryopreservation of human oocytes. Design: In vitro comparative study. Setting: Clinical and academic research environment at a medical school teaching hospital. Patient(s): Women undergoing in vitro fertilization (IVF). Intervention(s): Discarded human oocytes, obtained from IVF patients, were randomly distributed into three groups: control group (no trehalose), extracellular trehalose group (0.5 M extracellular trehalose), and intracellular trehalose group (0.15 M intra- and 0.5 M extracellular trehalose). Trehalose was introduced into oocytes by microinjection. The oocytes in each group were cooled to different temperatures (i.e., −15°C, −30°C, and −60°C) at rate of 1°C/minute and thawed at ambient air temperature. Survival was examined after overnight culture. Main Outcome Measure(s): Survival of human oocytes cryopreserved in the presence and absence of trehalose. Result(s): The majority of oocytes in the intracellular trehalose group survived cooling to −15°C (63%), −30°C (53%), and −60°C (66%). In contrast, only a small number of oocytes in both the control (13%) and extracellular trehalose group (22%) survived cooling to −15°C, while all oocytes degenerated when cooled to −30°C and −60°C. Conclusion(s): Small amounts of intracellular trehalose in the absence of any other cryoprotectant provide a significant protection against freeze-associated stresses. Our results suggest that sugars such as trehalose should be considered as intracellular cryoprotectants for cryopreservation of human oocytes.

Herniated blastomere following chemically assisted hatching may result in monozygotic twins

Objective: To explore a possible mechanism of the increasing incidence of monozygotic twins following assisted hatching of human embryos. Design: Case report. Setting: Clinical research center in a medical school teaching hospital. Patient(s): A 37-year-old infertile woman with repeated IVF failures. Intervention(s): Assisted hatching of the day 3 embryos using acidic Tyrode’s solution. Main Outcome Measure(s): The morphology of the zona-drilled embryos and the pregnancy outcome. Result(s): After assisted hatching, a herniated blastomere through an oversized opening in the zona pellucida was found in one embryo. The transfer of two zona-drilled embryos resulted in a triplet pregnancy. Conclusion(s): Large openings in the zona pellucida following chemically assisted hatching may cause premature hatching of the blastomeres and may be implicated in the occurrence of monozygotic twins.

Gynecomastia-like lesions in the female breast.

Gynecomastia is an abnormal enlargement of the male breast, but the histopathologic abnormalities could theoretically be present in female breasts as well. To my knowledge, however, there have been no reports in the literature to date that have attributed a clinically or radiologically detectable mass in a female breast exclusively to the histopathologic findings seen in gynecomastia. The clinical, radiologic, and histopathologic findings of 4 patients with lesions composed exclusively of the findings of gynecomastia, herein termed gynecomastia-like lesions, are presented and compared with those of 3 patients with lesser degrees of these changes, herein termed gynecomastia-like areas, which were incidental accompaniments to other lesions. During a 26-month interval, 1242 breast excisions (excluding needle biopsies or aspirates) were examined in a 170-bed, acute-care, community-medical school teaching hospital. Four patients had gynecomastia-like lesions varying from 1 to 3 cm in greatest dimension with histopathologic features showing the changes of gynecomastia exclusively. Two patients had clinically palpable masses. Two other patients had masses detected only by mammography. One postmenopausal patient was taking estrogen/progesterone replacement medication. Two of the 3 others were not taking birth control pills, and none had a clinical endocrinopathy. Thus far, none of the lesions have recurred. The 3 patients with gynecomastia-like areas were diagnosed separately with infiltrating ductal carcinoma, fibroadenoma, and lipoma. Pathologists should be aware that clinically palpable or radiologically detected masses in female breasts may be composed exclusively of the histopathologic findings of gynecomastia.

Gynecomastia-like lesions in the female breast.

Abstract Context.—Gynecomastia is an abnormal enlargement of the male breast, but the histopathologic abnormalities could theoretically be present in female breasts as well. To my knowledge, however, there have been no reports in the literature to date that have attributed a clinically or radiologically detectable mass in a female breast exclusively to the histopathologic findings seen in gynecomastia. Objective.—The clinical, radiologic, and histopathologic findings of 4 patients with lesions composed exclusively of the findings of gynecomastia, herein termed gynecomastia-like lesions, are presented and compared with those of 3 patients with lesser degrees of these changes, herein termed gynecomastia-like areas, which were incidental accompaniments to other lesions. Setting.—During a 26-month interval, 1242 breast excisions (excluding needle biopsies or aspirates) were examined in a 170-bed, acute-care, community–medical school teaching hospital. Results.—Four patients had gynecomastia-like lesions varyi...