We describe a rare case of aorto-oesophageal fistula and aortic pseudoaneurysm in a middle-aged man, who presented with chest pain and haematemesis 1 week after swallowing a fish bone. Oesophagogastroduodenoscopy and computed tomographic angiography findings were consistent with oesophageal perforation, proximal descending aortic pseudoaneurysm, and aorto-oesophageal fistula. Thoracic endovascular aortic repair was performed. The patient died from severe mediastinal sepsis. Early surgical intervention and broad-spectrum antibiotic therapy are crucial in preventing life-threatening mediastinal infection.
OBJECTIVE: To assess the impact of a structured, clinically integrated evidence-based undergraduate medicine training programme using a validated tool. DESIGN. Before and after study with no control group.
SETTING: A medical school in Malaysia with an affiliated district clinical training hospital.
PARTICIPANTS: Seventy-two medical students in their final 6 months of training (senior clerkship) encountered between March and August 2006.
INTERVENTION: Our educational intervention included two plenary lectures at the beginning of the clerkship, small-group bedside question-generating sessions, and a journal club in the paediatric posting.
MAIN OUTCOME MEASURES: Our primary outcome was evidence-based medicine knowledge, measured using the adapted Fresno test (score range, 0-212) administered before and after the intervention. We evaluated the performance of the whole cohort, as well as the scores of different subgroups that received separate small-group interventions in their paediatric posting. We also measured the correlation between the students' evidence-based medicine test scores and overall academic performances in the senior clerkship.
RESULTS: Fifty-five paired scripts were analysed. Evidence-based medicine knowledge improved significantly post-intervention (means: pre-test, 84 [standard deviation, 24]; post-test, 122 [22]; P<0.001). Post-test scores were significantly correlated with overall senior clerkship performance (r=0.329, P=0.014). Lower post-test scores were observed in subgroups that received their small-group training earlier as opposed to later in the clerkship.
CONCLUSIONS: Clinically integrated undergraduate evidence-based medicine training produced an educationally important improvement in evidence-based medicine knowledge. Student performance in the adapted Fresno test to some extent reflected their overall academic performance in the senior clerkship. Loss of evidence-based medicine knowledge, which might have occurred soon after small-group training, is a concern that warrants future assessment.
Magnetic resonance imaging is gaining importance in the diagnosis of nerve and muscular disorders. The ability of magnetic resonance imaging to delineate the different muscles and the nerve in any plane has made the differentiation between the changes of neuropathy, denervation, and nerve entrapment possible. Although findings on magnetic resonance imaging are non-specific, their use, coupled with clinical symptoms and electromyographic findings, allow an accurate diagnosis to be made without resorting to invasive biopsies.
Rubella is generally a mild and self-limited disease in children. During pregnancy, rubella can have potentially devastating effects on the developing fetus. Postnatal rubella is transmitted primarily by inhalation of virus-laden airborne droplets or direct contact with infected nasopharyngeal secretions. In susceptible pregnant women, the virus may cross the placenta and spread through the vascular system of the developing fetus. Postnatally acquired rubella typically begins with fever and lymphadenopathy, followed by an erythematous, maculopapular rash. The rash classically begins on the face, spreads cephalocaudally, becomes generalised within 24 hours, and disappears within 3 days. Maternal rubella, especially during early pregnancy, may lead to miscarriage, intrauterine fetal death, premature labour, intrauterine growth retardation, and congenital rubella syndrome. Cataracts, congenital heart defects, and sensorineural deafness are the classic triad of congenital rubella syndrome and they typically occur if the fetal infection occurs in the first 11 weeks of gestation. Laboratory confirmation of rubella virus infection can be based on a positive serological test for rubella-specific immunoglobulin M antibody; a four-fold or greater increase in rubella-specific immunoglobulin G titres between acute and convalescent sera; or detection of rubella virus RNA by reverse transcriptase-polymerase chain reaction. Treatment is mainly symptomatic. Universal childhood immunisation and vaccination of all susceptible patients with rubella vaccine to decrease circulation of the virus are cornerstones to prevention of rubella and, more importantly, congenital rubella syndrome.
Measles (rubeola) is a highly contagious vaccine-preventable disease caused by the measles virus-a virus of the Paramyxoviridae family. The illness typically begins with fever, runny nose, cough, and pathognomonic enanthem (Koplik spots) followed by a characteristic erythematous, maculopapular rash. The rash classically begins on the face and becomes more confluent as it spreads cephalocaudally. Laboratory confirmation of measles virus infection can be based on a positive serological test for measles-specific immunoglobulin M antibody, a four-fold or greater increase in measles-specific immunoglobulin G between acute and convalescent sera, isolation of measles virus in culture, or detection of measles virus ribonucleic acid by reverse transcriptase-polymerase chain reaction. Complications occur in 10% to 40% of patients, and treatment is mainly symptomatic. Bacterial superinfections, if present, should be properly treated with antibiotics. To eradicate measles, universal childhood immunisation and vaccination of all susceptible individuals with measles vaccine would be ideal. In developed countries, routine immunisation with measles-containing vaccine is recommended, with the first and second doses at ages 12 to 15 months and 4 to 6 years, respectively. The World Health Organization recommends that the first and second doses of measles-containing vaccine be given at ages 9 months and 15 to 18 months, respectively, in countries with high rates of measles transmission.