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The current standard of care for many patients with HER2-positive breast cancer is neoadjuvant chemotherapy in combination with anti-HER2 agents, based on HER2 amplification as detected by in situ hybridization (ISH) or protein immunohistochemistry (IHC). However, hematoxylin & eosin (H&E) tumor stains are more commonly available, and accurate prediction of HER2 status and anti-HER2 treatment response from H&E would reduce costs and increase the speed of treatment selection. Computational algorithms for H&E have been effective in predicting a variety of cancer features and clinical outcomes, including moderate success in predicting HER2 status. In this work, we present a novel convolutional neural network (CNN) approach able to predict HER2 status with increased accuracy over prior methods. We trained a CNN classifier on 188 H&E whole slide images (WSIs) manually annotated for tumor regions of interest (ROIs) by our pathology team. Our classifier achieved an area under the curve (AUC) of 0.90 in cross-validation of slide-level HER2 status and 0.81 on an independent TCGA test set. Within slides, we observed strong agreement between pathologist annotated ROIs and blinded computational predictions of tumor regions / HER2 status. Moreover, we trained our classifier on pre-treatment samples from 187 HER2+ patients that subsequently received trastuzumab therapy. Our classifier achieved an AUC of 0.80 in a five-fold cross validation. Our work provides an H&E-based algorithm that can predict HER2 status and trastuzumab response in breast cancer at an accuracy that is better than IHC and may benefit clinical evaluations.

Distance learning is expanding and replacing the traditional academic medical settings. Managing trauma patients seems to be a prerequisite skill for medical students. This study has been done to evaluate the efficiency of distance learning on performing the initial assessment and management in trauma patients, compared with the traditional learning among senior medical students. One hundred and twenty senior medical students enrolled in this single-blind quasi-experimental study and were equally divided into the experimental (distance learning) and control group (traditional learning). All participants did a written MCQ before the study. The control group attended a workshop with a 50-minute lecture on initial management of trauma patients and a case simulation scenario followed by a hands-on session. On the other hand, the experimental group was given a DVD with a similar 50-minute lecture and a case simulation scenario, and they also attended a hands-on session to practice the skills. Both groups were evaluated by a trauma station in an objective structured clinical examination (OSCE) after a month. The performance in the experimental group was statistically better (P=0.001) in OSCE. Distance learning seems to be an appropriate adjunct to traditional learning.

Emergency medicine is a relatively new specialty in Iran. Therefore, the general public and the medical community do not have enough information on its duties, capabilities, its nature, and its work schedule or its degree of occupational difficulty compared to other specialties. Hence, an insight from the early group of residents who selected this specialty can help identify the strengths and weaknesses of this field in order to promote the scientific quality of this field, and attract medical students. It can also help to alleviate deficiencies and strengthen positive aspects of emergency medicine. The aim of this study was to identify the reasons behind choosing emergency medicine as a specialty. A qualitative study was conducted using semi-structured interviews. Maximum variation opportunistic sampling was done, and face-to-face interviews were held with 23 emergency medicine residents and fellows (4 faculty members and 19 residents). Data were analyzed through thematic analysis, and categories and themes were extracted. The main levels extracted were: 1) Individual priorities, 2) the nature of work and the field of study, and 3) professional future. The themes of each main level were extracted and encoded. This study showed that the majority of residents choose emergency medicine specialty to achieve a better social and professional status in one of the most challenging fields of medicine.

Moving toward establishing more student center educational environment to meet the ever-changing learning expectations in a challenging climate like emergency department for under graduates is an intimidating task. In our newly founded academic emergency department, every step toward scoring as a dynamic and modern educational environment for both undergraduates and postgraduates would be a great success. The last 18 months of undergraduate medical education in Iran is considered as an internship. Interns have two months mandatory emergency department rotation during that period. This study has design to evaluate the medical students' conception about the educational environment using the Dundee Ready Education Environment Measure (DREEM) questionnaire. 156 undergraduate interns during their two months emergency medicine rotation from October 2009 to March 2010 enrolled into a cross sectional observational study to anonymously fill up the DREEM questionnaire on the last week of the course. The overall mean score of DREEM questionnaire was 134.79 out of 200 for the emergency department. The mean scores are 135.37 in female (n=87) group and 131.56 in male (n=69) group. There was not any significant difference between two genders (P>0.05). A score of 134.79 is compatible with the modern universities. Scores of 100 or less indicate serious problems and scores above 170 is compatible with ultimate student centered and modern educational environment. Such an achievement in the start of the new installed Emergency Medicine program is admirable, hence great effort must be put to pinpoint problems and fix them. DREEM questionnaire helped us moving toward a more student center environment in the emergency department.

Arterial blood gas (ABG) sampling is a painful procedure with no perfect technique for quelling the discomfort. An ideal local anesthesia should be rapid, easy to learn, inexpensive, and noninvasive. This study was aimed to compare pain levels from ABG sampling performed with vapocoolant spray in comparison to placebo. We hypothesized that pretreatment with the vapocoolant would reduce the pain of arterial puncture by at least 1 point on a 10 point verbal numeric scale. We have evaluated the effectiveness of a vapocoolant spray in achieving satisfactory pain control in patients undergoing ABG sampling in this randomized placebo controlled trial. Eighty patients were randomized to 2 groups: group A, who received vapocoolant spray, and group B, who received water spray as placebo (Control group). Puncture and spray application pain was assessed with numerical rating scale (0, the absence of pain; 10, greatest imaginable pain) and number of attempts was recorded. The pain score during ABG sampling was not lower in group A compared with group B significantly (4.78±1.761 vs. 4.90±1.837; P:0.945). This study showed that while the spray exerts more application pain, the number of attempts required for ABG sampling was not significantly lower in group A compared with group B (1.38±0.54 vs. 1.53±0.68; P=0.372). Vapocoolant spray was not effective in ABG pain reduction, had milder application pain compared to placebo (P

We aim to assess serum sodium and potassium levels in patients with different types of cerebro-vascular accidents (CVA) in comparison to control group.A comparative cross-sectional study conducted on patients admitted to the emergency department from January to August 2012. Control group consisted of patients admitted to emergency department due to common cold, urinary tract infection, low back pain, cluster, and tension headache or migraine. Serum sodium and potassium levels were measured via standard laboratory methods.There were 77 patients in control group and 78 in CVA group. Forty nine patients from the CVA group had ischemic CVA, 11 had hemorrhagic CVA and 18 suffered a transient ischemic attack (TIA). Serum sodium level in control group was significantly lower than in patients with TIA, ischemic CVA, and hemorrhagic CVA (P0.001). Serum potassium level in control group was higher than patients with TIA, ischemic CVA, and hemorrhagic CVA (P0.001). Patients with hemorrhagic CVA showed significantly lower serum potassium level than patients with TIA and ischemic CVA (P0.001). Correspondingly, it was observed that serum sodium to potassium ratio was higher in patients with TIA, ischemic CVA, and hemorrhagic CVA (P0.001). In patients with hemorrhagic CVA serum sodium to potassium ratio was higher when compared to patients with TIA and ischemic CVA (P0.001).This study shows that higher serum sodium and lower serum potassium level may be associated with higher incidence of CVA. Further studies are paramount to elucidate the role of serum electrolyte levels in vascular events.

Background: Simulation can be used for educating, evaluating and assessing psychometric properties of an instrument. The aim of this study was to contextualize and assess the validity and reliability of the Interprofessional Collaborative Assessment tool (ICAR) in an Iranian context using simulation. Methods: In this descriptive study, contextualization of the ICAR was assessed through several steps. Firstly, validity assessment was approved through expert panels and Delphi rounds. Secondly, reliability assessment was done by arranging a simulation video and assessing reproducibility, test-retest (ICC), internal consistency (Cronbach's Alpha) and inter-rater reliability (Kappa).The participants included 26 experts, 27 students and 6 staff of the Standardized Simulation Office of Teheran University of Medical Sciences. Results: Contextualization and validity of the ICAR were approved in an Iranian context. The reliability of the tool was computed to be 0.71 according to Cronbach´s Alpha. The test-retest was calculated to be 0.76. Conclusion: The Iranian ICAR can be a useful tool for evaluating interprofessional collaborative competencies. The development of the instrument through a simulation scenario has been a positive prospect for researchers.