Teaching cardiac auscultation to trainees in internal medicine and family practice: does it work?

BACKGROUND: The general proficiency in physical diagnostic skills seems to be declining in relation to the development of new technologies. The few studies that have examined this question have invariably used recordings of cardiac events obtained from patients. However, this type of evaluation may not correlate particularly well with bedside skills. Our objectives were 1) To compare the cardiac auscultatory skills of physicians in training with those of experienced cardiologists by using real patients to test bedside diagnostic skills. 2) To evaluate the impact of a five-month bedside cardiac auscultation training program. METHODS: 1) In an academic primary care center, 20 physicians (trainees in internal medicine and family practice) and two skilled academic cardiologists listened to 33 cardiac events in 13 patients directly at bedside and identified the cardiac events by completing an open questionnaire. Heart sounds, murmurs and diagnosis were determined beforehand by an independent skilled cardiologist and were validated by echocardiography. Thirteen primary cardiologic diagnoses were possible.2) Ten of the physicians agreed to participate in a course of 45-minute sessions once a week for 5 months. After the course they listened again to the same patients (pre/post-interventional study). RESULTS: 1) The experts were the most skillful, achieving 69% recognition of heart sounds and murmurs and correct diagnoses in 62% of cases. They also heard all of the diastolic murmurs. The residents heard only 40% of the extra heart sounds and made a correct diagnosis in 24% of cases. 2) After the weekly training sessions, their mean percentage for correct diagnosis was 35% [an increase of 66% (p < 0.05)]. CONCLUSIONS: The level of bedside diagnostic skills in this relatively small group of physicians in training is indeed low, but can be improved by a course focusing on realistic bedside teaching.

A new order, a new family and a new genus of Paleozoic Radiolaria: Latentifistularia, Cauletellidae and Cauletella

Since the genus Deflandrella De Wever and Caridroit 1984 is a homonym of Deflandrella Loeblich and Tappan 1961, the new name Cauletella is :herein proposed, and the genus is redefined. Consequently, the family name Deflandrellidae De Wever and Caridroit, previously erected, becomes Cauletellidae, and its definiton is emended. This important radiolarian group, typical of the Permian times, is closely related to the families Ruzhencevispongidae Kozur 1980 and Latentifistulidae Nazarov and Ormiston 1983. These Paleozoic radiolarians are characterized by an initial skeleton quite different from that of the other radiolarian orders and are assigned to the new order Latentifistularia, which is herein defined and briefly discussed. ((C) 1999 Academie des sciences/ Editions scientifiques et medicales Elsevier SAS.).

A-1 Monthly Public Assistance Statistical Report Family Investment Program, November 2007

A-1 - Monthly Public Assistance Statistical Report Family Investment Program - Nov 2007

Audit report on the Iowa Federal Family Education Loan Program Division, a Division of the Iowa College Student Aid Commission, for the year ended June 30, 2007

Audit report on the Iowa Federal Family Education Loan Program Division, a Division of the Iowa College Student Aid Commission, for the year ended June 30, 2007

Coparenting and Toddler's Interactive Styles in Family Coalitions

The current study examined the coparenting and toddler's interactive styles in family coalitions. According to structural family theory, boundaries between generations are clear in alliances, but disturbed in coalitions: the parents look to the child to regulate their conflictual relationship and the child attempts to meet this need. In a normative sample studied longitudinally during the Lausanne Trilogue Play situation (LTP, N=38), 15 coalition cases were detected. Styles of coparenting and of child's interactions were determined and compared in coalition and alliance cases at 18 months. Findings confirm the structural family model by showing the specific ways in which the coparenting and the toddler's interactive styles are associated in 3 different patterns of coalitions: binding, detouring, and triangulation. They illustrate how the child's triangular capacity, or her ability to simultaneously communicate with both parents, is used to regulate the parents' relationship. They suggest that the LTP observational paradigm is a promising assessment method of early family interactions. They point to the importance of assessing early the child's contribution to family coalitions.

Mutations leading to X-linked hypohidrotic ectodermal dysplasia affect three major functional domains in the tumor necrosis factor family member ectodysplasin-A.

Mutations in the epithelial morphogen ectodysplasin-A (EDA), a member of the tumor necrosis factor (TNF) family, are responsible for the human disorder X-linked hypohidrotic ectodermal dysplasia (XLHED) characterized by impaired development of hair, eccrine sweat glands, and teeth. EDA-A1 and EDA-A2 are two splice variants of EDA, which bind distinct EDA-A1 and X-linked EDA-A2 receptors. We identified a series of novel EDA mutations in families with XLHED, allowing the identification of the following three functionally important regions in EDA: a C-terminal TNF homology domain, a collagen domain, and a furin protease recognition sequence. Mutations in the TNF homology domain impair binding of both splice variants to their receptors. Mutations in the collagen domain can inhibit multimerization of the TNF homology region, whereas those in the consensus furin recognition sequence prevent proteolytic cleavage of EDA. Finally, a mutation affecting an intron splice donor site is predicted to eliminate specifically the EDA-A1 but not the EDA-A2 splice variant. Thus a proteolytically processed, oligomeric form of EDA-A1 is required in vivo for proper morphogenesis.

A member of the PLEIOTROPIC DRUG RESISTANCE family of ATP binding cassette transporters is required for the formation of a functional cuticle in Arabidopsis.

Although the multilayered structure of the plant cuticle was discovered many years ago, the molecular basis of its formation and the functional relevance of the layers are not understood. Here, we present the permeable cuticle1 (pec1) mutant of Arabidopsis thaliana, which displays features associated with a highly permeable cuticle in several organs. In pec1 flowers, typical cutin monomers, such as ω-hydroxylated fatty acids and 10,16-dihydroxypalmitate, are reduced to 40% of wild-type levels and are accompanied by the appearance of lipidic inclusions within the epidermal cell. The cuticular layer of the cell wall, rather than the cuticle proper, is structurally altered in pec1 petals. Therefore, a significant role for the formation of the diffusion barrier in petals can be attributed to this layer. Thus, pec1 defines a new class of mutants. The phenotypes of the pec1 mutant are caused by the knockout of ATP BINDING CASSETTEG32 (ABCG32), an ABC transporter from the PLEIOTROPIC DRUG RESISTANCE family that is localized at the plasma membrane of epidermal cells in a polar manner toward the surface of the organs. Our results suggest that ABCG32 is involved in the formation of the cuticular layer of the cell wall, most likely by exporting particular cutin precursors from the epidermal cell.

Wage structures and family economies in the Catalan textile industry in an age of nascent capitalism

This paper deals with changes in managerial practices in Catalonia in anage of nascent capitalism (1830-1925) and adaptive family strategies inorder to face the absence of state welfare. During the 19 t h Century andin the absence of recorded labor contracts, human resources of the firmwere organized by means of implicit contracts and informal labor markets.With the advent of scientific organization of labor, wage per hour workedbegan to be recorded. This is why in the 1920s the perfect competitionmodel applies to our case. On the other hand, in the same period, and inthe absence of state welfare, ideas stemming from cooperative game theoryapply to the pattern of household income formation. Kin related networkswere used to improve the living standards of the household. In thisparticular direction we also show that there was a demonstration effectby means of which migrant s living standards were higher than those ofnatives.

Study of a Swiss dopa-responsive dystonia family with a deletion in GCH1: redefining DYT14 as DYT5.

OBJECTIVE: To report the study of a multigenerational Swiss family with dopa-responsive dystonia (DRD). METHODS: Clinical investigation was made of available family members, including historical and chart reviews. Subject examinations were video recorded. Genetic analysis included a genome-wide linkage study with microsatellite markers (STR), GTP cyclohydrolase I (GCH1) gene sequencing, and dosage analysis. RESULTS: We evaluated 32 individuals, of whom 6 were clinically diagnosed with DRD, with childhood-onset progressive foot dystonia, later generalizing, followed by parkinsonism in the two older patients. The response to levodopa was very good. Two additional patients had late onset dopa-responsive parkinsonism. Three other subjects had DRD symptoms on historical grounds. We found suggestive linkage to the previously reported DYT14 locus, which excluded GCH1. However, further study with more stringent criteria for disease status attribution showed linkage to a larger region, which included GCH1. No mutation was found in GCH1 by gene sequencing but dosage methods identified a novel heterozygous deletion of exons 3 to 6 of GCH1. The mutation was found in seven subjects. One of the patients with dystonia represented a phenocopy. CONCLUSIONS: This study rules out the previously reported DYT14 locus as a cause of disease, as a novel multiexonic deletion was identified in GCH1. This work highlights the necessity of an accurate clinical diagnosis in linkage studies as well as the need for appropriate allele frequencies, penetrance, and phenocopy estimates. Comprehensive sequencing and dosage analysis of known genes is recommended prior to genome-wide linkage analysis.

A-1 Monthly Public Assistance Statistical Report Family Investment Program, January 2008

A-1 - Monthly Public Assistance Statistical Report Family Investment Program

A-1 Monthly Public Assistance Statistical Report Family Investment Program, Februray 2008

A-1 - Monthly Public Assistance Statistical Report Family Investment Program

A-1 Monthly Public Assistance Statistical Report Family Investment Program, March 2008

A-1 - Monthly Public Assistance Statistical Report Family Investment Program

Understanding triadic and family group interactions during infancy and toddlerhood.

This paper outlines recent conceptual and methodological developments in the assessment of triadic and family group process during infancy and toddlerhood. Foundations of the emerging family group process are identified, and conditions specific to the assessment of the family during the early phases of family formation are summarized. Both microanalytic and global approaches to evaluating mother-father-child interactions are discussed. We highlight both similarities and differences in the strategies and methods employed by several different investigators who have been studying the group dynamics of families with infant and toddler children, and underscore several important family patterns and emerging themes that appear to be cutting across these different methods and measurement strategies. Preliminary evidence for the validity and clinical significance of family-level assessments is summarized, and directions currently being pursued by researchers engaged in studies of the family triad are outlined. We close by identifying several conceptual and clinical issues that remain to be addressed by subsequent work.

A-1 Monthly Public Assistance Statistical Report Family Investment Program, April 2008

A-1 - Monthly Public Assistance Statistical Report Family Investment Program

The sustainable debts of Philip II: A reconstruction of Castile's fiscal position, 1566-1596

The defaults of Philip II have attained mythical status as the origin of sovereigndebt crises. We reassess the fiscal position of Habsburg Castile, derivingcomprehensive estimates of revenue, debt, and expenditure from new archivaldata. The king s debts were sustainable. Primary surpluses were large and rising.Debt-to-revenue ratios remained broadly unchanged during Philip s reign.Castilian finances in the sixteenth century compare favorably with those of otherearly modern fiscal states at the height of their imperial ambitions, includingBritain. The defaults of Philip II therefore reflected short-term liquidity crises,and were not a sign of unsustainable debts.