Henoch–Schönlein purpura is a systemic vasculitis of unknown etiology usually affecting the pediatric age group and characterized by the clinical triad of non-thrombocytopenic palpable purpura, abdominal pain, and arthritis. There also may be varying degrees of renal involvement. The findings of scrotal involvement are not as well recognized. We describe a case of acute scrotal swelling as part of a 37-year-old male’s presentation of Henoch–Schönlein purpura, a presentation that has not been reported in this age group.

Nepal and Alberta are literally a world apart. Yet they share a common problem of restricted access to health services in remote and rural areas. In Nepal, urban-rural disparities were one of the main issues in the recent civil war, which ended in 2006. In response to the need for improved health equity in Nepal a dedicated group of Nepali physicians began planning the Patan Academy of Health Sciences (PAHS), a new health sciences university dedicated to the education of rural health providers in the early 2000s. Beginning with a medical school the Patan Academy of Health Sciences uses international help to plan, deliver and assess its curriculum. PAHS developed an International Advisory Board (IAB) attracting international help using a model of broad, intentional recruitment and then on individuals' natural attraction to a clear mission of peace-making through health equity. Such a model provides for flexible recruitment of globally diverse experts, though it risks a lack of coordination. Until recently, the PAHS IAB has not enjoyed significant or formal support from any single international institution. However, an increasing number of the international consultants recruited by PAHS to its International Advisory Board are from the University of Alberta in Edmonton, Alberta, Canada (UAlberta). The number of UAlberta Faculty of Medicine and Dentistry members involved in the project has risen to fifteen, providing a critical mass for a coordinated effort to leverage institutional support for this partnership. This paper describes the organic growth of the UAlberta group supporting PAHS, and the ways in which it supports a sister institution in a developing nation.

Takayasu's arteritis (TA) is a rare granulomatous vasculitic disease that affects the aorta and its major branches. Recent studies have suggested that anti-TNFα biological therapies are highly effective in treating TA refractory to conventional immunosuppressive therapy. We describe two patients with TA: one with progressive TA despite management with two different anti-TNFα agents, infliximab and adalimumab, and another who developed TA while treated with infliximab for the management of pre-existing Crohn's disease. From our observations, we believe that a multicentered randomized study should be designed to assess the extent of resistance to these agents when different therapeutic doses are employed for managing TA.

More that 18 years ago, George Miller introduced a framework for the assessment of medical students and residents, “Miller’s Pyramid”1 (Figure 1). In the accompanying address to the Association of American Medical Colleges, he advocated the evaluation of learners for their skills and abilities in the 2 top cells of the pyramid, in the domains of action, or performance, reflecting clinical reality. Miller argued that the demonstration of competence in these higher domains strongly implies that a student has already acquired the prerequisite knowledge, or Knows, and the ability to apply that knowledge, or Knows How, that make up the base of the pyramid. Basic clinical skills (Shows How) are those that can be measured in an examination situation such as an objective structured clinical examination (OSCE). However, the professionalism and motivation required to continuously apply these in the real setting (Does) must be observed during actual patient care. Figure 1. Miller’s pyramid1. From Academic Medicine 1990;65:S63–7; with permission from Wolters Kluwer Health. The component that Miller argued is the most vital aspect of measurement, what the learner does in clinical practice, has been the most difficult to capture. Almost 2 decades later, we are still struggling with the need to develop reliable and valid methods of assessing learners in the clinical setting. In the meantime, there have been many advances in the lower echelons of the pyramid. In the domains of Know and Know How, the Medical Council of Canada2 and the National Board of Medical Examiners3 have made great strides in the art of the multiple choice examination, the Key Feature examination, and computer-based, adaptive examination. In a pair of landmark publications, Tamblyn, et al have provided good evidence of the predictive validity of these assessments … Address reprint requests to Dr. Aaron, Heritage Medical Research Center, 562-107 University Campus NW, Edmonton, AB T6G 2S2.

A 71-year-old previously healthy man, vacationing in Arizona, was admitted for a 1-month history of cough and progressive fatigue limiting his ambulation. With paroxysms of coughing, he described bilateral vision loss for 5 to 10 seconds. His vision grayed and “tunneled down” (i.e., from periphery to center) before blindness. Sometimes, he had transient bilateral blurring with “stars” but no diplopia. He denied presyncope. There was no hemoptysis, dyspnea, or pleurisy. He had no headache, scalp tenderness, jaw claudication, or morning stiffness, but had diffuse bone and muscle pains. He had constitutional symptoms including anorexia, night sweats, and 20-lb weight loss. Other than his Arizona holiday, his infectious contact and medical history was unremarkable. He had low risk of atherosclerosis: he was fit and a nonsmoker, had no family history, and had systolic pressures <135 mm Hg without bruits, low-density lipoprotein–cholesterol of 2.3 mmol/L, hemoglobin A1c of 5.8%, and normal baseline EKG. In hospital he had fevers from 38.7 to 40.4°. There was no lymphadenopathy or temporal artery tenderness. …