How well prepared are graduates for the role of pre-registration house officer? A comparison of the perceptions of new graduates and educational supervisors

OBJECTIVE

The principal aim of undergraduate medical education is to produce competent pre-registration house officers (PRHOs). We examined and compared the perceptions of graduates and educational supervisors concerning how well prepared graduates were for their first post.

METHODS

A postal questionnaire was sent to house officers who had graduated from Manchester 3 months earlier and also to educational supervisors of PRHOs in the North-west Region. The questionnaires were based on the competencies set out by the General Medical Council of the United Kingdom.

RESULTS

The response rates were 66% from the graduates and 76% from the supervisors. Of the 18 broad areas of competence listed, only four were rated more than 'quite well prepared' by at least 50% of the graduates ('understanding disease processes', 'communicating effectively', 'awareness of limitations' and 'working in a team'). Similarly, more than half of educational supervisors rated graduates as more than quite competent in only three areas ('awareness of limitations', 'keeping accurate records' and 'working in a team'). Within the competencies surveyed, there were differences between the perceptions of graduates and educational supervisors on the preparedness of graduates for the skills they may require as a pre-registration house officer.

CONCLUSION

Overall, given that most graduates and supervisors perceived the preparedness as 'quite well' or less, the undergraduate course had only partially met its objectives. A mismatch in ratings could be attributed to either inappropriate expectations on the part of the educational supervisors or the graduates or an inaccurate assessment by either group of respondents.

Use of a new finger-mounted device to compare mechanical nociceptive thresholds in cats given pethidine or no medication after castration

Mechanical nociceptive thresholds are regularly used to determine the efficacy of analgesic agents both experimentally and clinically in a variety of species. The 'pressure of palpation device' (PPD) was developed for use in cats and is a small battery operated device with a finger-mounted force sensing resistor (FSR, Interlink Electronics, Northumberland. UK). The PPD was used in a study assessing the analgesic efficacy of pethidine after castration in cats. Pethidine was demonstrated to prevent the development of post-operative scrotal hypersensitivity for up to 2 hours after castration, whereas cats given no analgesics showed marked hyperalgesia immediately after surgery. Visual Analogue Scale (VAS) pain scores after castration showed a similar analgesic effect of pethidine. These results suggest that the PPD could become a useful research tool to assess the effectiveness of analgesic agents in the cat.

Role of radionuclide imaging in hyperthyroid patients with no clinical suspicion of nodules

The purpose of the study was to assess the role of radionuclide imaging of hyperthyroid patients with no suspicion of nodules. (99)Tc(m) radionuclide scans performed on all 190 patients referred over a 2-year period with symptoms and thyroid function tests compatible with thyrotoxicosis were retrospectively reviewed. 73% of patients were referred by a hospital clinician and 27% were referred direct from the general practitioner. Referral letters and, where applicable, the clinical notes were reviewed and patients with suspected thyroid nodules were excluded. The results of (99)Tc(m) thyroid scans of the 190 patients (age range 23-93 years, mean 48 years) were reviewed. 152 (80%) patients had Graves' disease, 10 (5.3%) had Graves' disease with nodules, 6 (3.2%) had Graves' disease with non-functioning nodules, 5 (2.6%) had viral thyroiditis, 5 (2.6%) had autonomously functioning nodules and 12 (6.3%) were normal studies. Therefore, 20% of patients had a diagnosis other than solely Graves' disease. These diagnoses are important with respect to clinical management. In conclusion, routine radionuclide imaging is worthwhile, as a significant proportion of patients with clinical "Graves' disease" in this study would have received incorrect treatment without the result of this scan.

Publication rates of scientific papers presented at the Otorhinolarygological Research Society meetings

The aim of this study was to determine the publication rate of scientific papers in peer review journals presented at the Otorhinolarygological Research Society (ORS) meetings from 1978 to 1995 inclusive. The abstracts of the presentations at ORS meetings are published in Clinical Otolaryngology. A MEDLINE search was performed on abstracts presented at ORS meetings from 1978 to 1995 using both authors and key words within the text of the abstract. The publication rate, journal of publication, time to publication, change in contents, change in authors and change in conclusions of abstracts were tabulated. The publication rate for papers presented at ORS meetings from 1978 to 1995 was 69.09%. The average time to publication was 22.5 months. Papers derived from the ORS abstracts were most commonly published in Clinical Otolaryngology (34%) and Journal of Laryngology and Otology (18.64%). The results indicate that nearly 69% of presented material at the biannual ORS meetings eventually get published in peer reviewed journals. This compares favourably with publication rate of other specialities.

Protein assays for diagnosis of Wiskott-Aldrich syndrome and X-linked thrombocytopenia

Mutations in the gene encoding the Wiskott-Aldrich syndrome protein (WASp) give rise to Wiskott-Aldrich syndrome (WAS), a condition that exhibits a wide spectrum of clinical severity. Patients may develop mild thrombocytopenia or suffer from a wide range of associated disorders including eczema, immune dysfunction, autoimmune disease and malignancy. The clinical diagnosis of Wiskott-Aldrich syndrome (WAS) can be difficult and is usually supported by the detection of WASp gene mutations using genetic analysis. Recently, protein-based assays have been used to demonstrate the absence of WASp in patients known to have WASp gene mutations. We have now reversed this approach and report on the use of immunoblot assays to rapidly diagnose WAS in 13 patients. There was a complete absence of WASp in 10 out of 13 patients and an abnormal protein form was detected in the remaining three patients. In all cases, subsequent genetic analysis confirmed the presence of a WASp gene mutation. We believe that protein-based assays should be employed as the first line of investigation in the diagnosis of WAS spectrum disorders.

A novel family of chitin-binding proteins from insect type 2 peritrophic matrix. cDNA sequences, chitin binding activity, and cellular localization

The peritrophic matrix is a prominent feature of the digestive tract of most insects, but its function, formation, and even its composition remain contentious. This matrix is a molecular sieve whose toughness and elasticity are generated by glycoproteins, proteoglycans, and chitin fibrils. We now describe a small, highly conserved protein, peritrophin-15, which is an abundant component of the larval peritrophic matrices of the Old World screwworm fly, Chrysomya bezziana, and sheep blowfly, Lucilia cuprina. Their deduced amino acid sequences code for a 8-kDa secreted protein characterized by a highly conserved and novel register of six cysteines. Two Drosophila homologues have also been identified from unannotated genomic sequences. Recombinant peritrophin-15 binds strongly and specifically to chitin; however, the stoichiometry of binding is low (1:10,000 N-acetyl glucosamine). We propose that peritrophin-15 caps the ends of the chitin polymer. Immunogold studies localized peritrophin-15 to the peritrophic matrix and specific vesicles in cells of the cardia, the small organ of the foregut responsible for peritrophic matrix synthesis. The vesicular contents are disgorged at the base of microvilli underlying the newly formed peritrophic matrix. This is the first time that the process of synthesis and integration of a peritrophic matrix protein into the nascent peritrophic matrix has been observed.

The influence of professional roles on clinical supervision

Clinical supervision involves establishing professional relationships that, notwithstanding other benefits, are concerned with safe and effective nursing practice. It is important that supervisors and supervisees are able to work together constructively. Supervisors and supervisees should, therefore, consider their roles and responsibilities outside supervision and how these might influence the supervision relationship. This article draws on the author's personal experiences in the roles of supervisor and supervisee, as well as using ideas from counselling, social work and nursing. Issues related to safe professional practice are also explored. Protocols could be devised offering guidance regarding who should undertake the role of supervisor.

Relation of vascular endothelial growth factor production to expression and regulation of hypoxia-inducible factor-1 alpha and hypoxia-inducible factor-2 alpha in human bladder tumors and cell lines

Hypoxia is an important regulator of vascular endothelial growth factor (VEGF) expression, and VEGF is associated with poor prognosis in bladder cancer. To investigate further the mechanisms of VEGF regulation, we examined VEGF expression by mRNA and protein analysis in four human bladder cancer cell lines, showing a progression from well to poorly differentiated phenotypes under varying conditions of confluence and hypoxia (0.1% O(2)) and with chemical mimics of hypoxia. Hypoxia significantly increased VEGF protein expression in all cell lines, although this effect was dependent on the degree of confluence. The superficial bladder cancer cell line RT4 lost hypoxia inducibility at confluence, whereas inducibility was maintained in the invasive cell lines 253J and EJ28. This pattern of VEGF expression in the invasive cell lines correlated with the expression of the transcription factor hypoxia inducible factor-1 alpha (HIF-1 alpha) and with hypoxia-inducible factor-2 alpha (HIF-2 alpha) and in RT4 correlated with a marked reduction in HIF-1 alpha inducibility at confluence. Using the phosphatidylinositol 3-kinase (PI 3-kinase) inhibitor LY 294002, we show that this VEGF hypoxia-inducible pathway regulated by HIF-1 alpha is distinct from a PI 3-kinase-dependent pathway, which regulates basal amounts of VEGF, but does not affect inducibility. Both HIF-1 alpha and HIF-2 alpha protein and mRNA were up-regulated in primary human bladder tumors (n = 12) compared with normal bladder specimens (n = 4), with significant intertumor variation. These results suggest that components of the hypoxia response pathway, including HIF-1 alpha and HIF-2 alpha, are important cofactors in the regulation of VEGF in bladder cancer and are therapeutic targets in this disease.

Detection of widespread fluids in the Tibetan crust by magnetotelluric studies

Magnetotelluric exploration has shown that the middle and lower crust is anomalously conductive across most of the north-to-south width of the Tibetan plateau. The integrated conductivity (conductance) of the Tibetan crust ranges from 3000 to greater than 20,000 siemens. In contrast, stable continental regions typically exhibit conductances from 20 to 1000 siemens, averaging 100 siemens. Such pervasively high conductance suggests that partial melt and/or aqueous fluids are widespread within the Tibetan crust. In southern Tibet, the high-conductivity layer is at a depth of 15 to 20 kilometers and is probably due to partial melt and aqueous fluids in the crust. In northern Tibet, the conductive layer is at 30 to 40 kilometers and is due to partial melting. Zones of fluid may represent weaker areas that could accommodate deformation and lower crustal flow.

Out of Africa: origins of the Taenia tapeworms in humans

Phylogenetic and divergence date analyses indicate that the occurrence of Taenia tapeworms in humans pre-dates the development of agriculture, animal husbandry and domestication of cattle (Bos spp.) or swine (Sus scrofa). Taeniid tapeworms in Africa twice independently colonized hominids and the genus Homo prior to the origin of modern humans. Dietary and behavioural shifts, from herbivory to scavenging and carnivory, as early Homo entered the carnivore guild in the Pliocene/Pleistocene, were drivers for host switching by tapeworms to hominids from carnivores including hyaenids and felids. Parasitological data provide a unique means of elucidating the historical ecology, foraging behaviour and food habits of hominids during the diversification of Homo spp.

Use of the CONSORT statement and quality of reports of randomized trials: a comparative before-and-after evaluation

CONTEXT

The Consolidated Standards for Reporting of Trials (CONSORT) statement was developed to help improve the quality of reports of randomized controlled trials (RCTs). To date, a paucity of data exists regarding whether it has achieved this goal.

OBJECTIVE

To determine whether use of the CONSORT statement is associated with improvement in the quality of reports of RCTs.

DESIGN AND SETTING

Comparative before-and-after evaluation in which reports of RCTs published in 1994 (pre-CONSORT) were compared with RCT reports from the same journals published in 1998 (post-CONSORT). We included 211 reports from BMJ, JAMA, and The Lancet (journals that adopted CONSORT) as well as The New England Journal of Medicine (a journal that did not adopt CONSORT and was used as a comparator).

MAIN OUTCOME MEASURES

Number of CONSORT items included in a report, frequency of unclear reporting of allocation concealment, and overall trial quality score based on the Jadad scale, a 5-point quality assessment instrument.

RESULTS

Compared with 1994, the number of CONSORT checklist items in reports of RCTs increased in all 4 journals in 1998, and this increase was statistically significant for the 3 adopter journals (pre-CONSORT, 23.4; mean change, 3.7; 95% confidence interval [CI], 2.1-5.3). The frequency of unclear reporting of allocation concealment decreased for each of the 4 journals, and this change was statistically significant for adopters (pre-CONSORT, 61%; mean change, -22%; 95% CI, -38% to -6%). Similarly, 3 of the 4 journals showed an improvement in the quality score for reports of RCTs, and this increase was statistically significant for adopter journals overall (pre-CONSORT, 2.7; mean change, 0.4; 95% CI, 0.1-0.8).

CONCLUSION

Use of the CONSORT statement is associated with improvements in the quality of reports of RCTs.

Effect of counter-anion concentration on retention in high-performance liquid chromatography of protonated basic analytes

The influence of acid and salt concentration in the mobile phase on the retention of basic analytes has been studied. An increase in the retention of fully protonated analytes with increasing the concentration of inorganic additives was found. The addition of salt, such as perchlorate, trifluoroacetate, and phosphate, leads to the increase of retention for fully protonated analytes while mobile phase pH remains constant. The observed effect was attributed to the interaction of protonated analytes with the counter-anion of acid or salt, which leads to the disruption of the analyte solvation shell and the increase of its hydrophobicity and corresponding increase of retention. A mathematical model for the description of the influence of counter-anion concentration on analyte retention is proposed.

Effect of the eluent pH and acidic modifiers in high-performance liquid chromatography retention of basic analytes

The retention of ionogenic bases in liquid chromatography is strongly dependent upon the pH of the mobile phase. Chromatographic behavior of a series of substituted aniline and pyridine basic compounds has been studied on C18 bonded silica using acetonitrile-water (10:90) as the eluent with different pHs and at various concentrations of the acidic modifier counter anions. The effect of different acidic modifiers on solute retention over a pH range from 1.3 to 8.6 was studied. Ionized basic compounds showed increased retention with a decrease of the mobile phase pH. This increase in retention was attributed to the interaction with counter anions of the acidic modifiers. The increase in retention is dependent on the nature of the counter anion and its concentration in the mobile phase. It was shown that altering the concentration of counter anion of the acidic modifier allows the optimization of the selectivity between basic compounds as well as for neutral and acidic compounds.

Elite swimmers and the D allele of the ACE I/D polymorphism

A polymorphism of the human angiotensin-1-converting enzyme (ACE) gene has been identified in which the presence (insertion, I allele) of a 287-bp fragment rather than the absence (deletion, D allele) is associated with lower ACE activity. Several recent studies have shown an association of the I allele with endurance performance, it being found with excess frequency in elite distance runners, rowers and mountaineers. Other workers using heterogeneous cohorts of athletes from mixed sporting disciplines have found no such association. An increasing linear trend of I allele frequency with the distance run amongst Olympic runners and an excess of the D allele amongst sprinters led us to examine whether the ratio of I and D alleles in swimmers competing over different distances would also vary. Swimmers (n=120) from the European and Commonwealth championships and an American college team had their ACE genotype determined and their gene and allele frequencies compared with several control groups, the most closely age-matched of which were 1,248 military recruits. Of the 103 Caucasians, there was a significant excess of the D allele compared with this control group only in the truly elite swimmers of the European and Commonwealth championships (P=0.004). This association remained in those competing over shorter distances (P=0.005 for 400 m and below) but not in the longer events. These findings were confirmed in three further large control groups. A population association study testing whether a genetic marker (the ACE I/D polymorphism) occurs more frequently in cases (elite athletes) than in controls therefore requires a homogeneous cohort of subjects from the same sporting discipline.

Rapid protein-based assays for the diagnosis of T-B+ severe combined immunodeficiency

The severe combined immunodeficiencies (SCID) are a heterogeneous group of conditions arising from a variety of molecular defects. The X-linked form of SCID (X-SCID) is caused by defects in the common gamma chain (gammac), and is characterized by a T-B+NK- immunophenotype. This lymphocyte profile is seen in an autosomal recessive form of SCID caused by mutations in the JAK3 molecule. Thus, X-SCID and JAK3-deficient SCID are clinically and immunologically indistinguishable. Knowledge of the precise molecular defect is essential for antenatal diagnosis, carrier testing and for treatment using somatic gene therapy. To identify the molecular defect in children presenting with a T-B+NK- form of SCID, we have developed rapid assays based on flow cytometric analysis of gammac, immunoblotting for JAK3 and gammac, and detection of interleukin-2 (IL-2)-induced tyrosine phosphorylation of JAK3. Sixteen T-B+NK- SCID patients from 15 families were examined. Nine had no detectable gammac, four had abnormal gammac expression and no IL-2-induced JAK3 tyrosine phosphorylation, and one had normal gammac expression but no IL-2-induced JAK3 tyrosine phosphorylation, although JAK3 was present. All these patients had mutations identified in their gammac gene. Two patients exhibited normal gammac expression, but JAK3 was not detected by immunoblotting and these patients were confirmed as having JAK3 gene mutations. Thus, these protein-based assays have led to rapid molecular diagnoses in T-B+ SCID that have subsequently been confirmed by genetic analysis.

Some experiences of professional practice and beneficial changes derived from clinical supervision by community Macmillan nurses

This is a report of an interpretative study that explored some 'lived experiences' of community Macmillan nurses as they recounted them during clinical supervision meetings. This discussion is concerned with serious illness, dying and bereavement and the potential of supervision to reach the 'life-world' of professional practice but also potential benefits for Macmillan nurses. Accounts of professional practice are considered in the context of clinical supervision meetings. Five nurses--four women and one man--undertook individual clinical supervision with the researcher for 6 months over three phases for 18 months in total. Meetings took place in the clinics and health centres in which the Macmillan nurses worked. The method of clinical supervision drew on and developed established ideas from the health science literatures to guide supervisory practice. A synthesis of psychoanalytic ways of thinking and existential phenomenology provided a framework for understanding the data. Five salient themes were identified as emerging from accounts of professional practice: Biographical Determinants, Compulsion, Existential Concerns, Empathic Insufficiency in the Organisation of Palliative Care and Empathic Attainment in the Organisation of Palliative Care. The study shows a need to consider structuring environments that both help and protect community Macmillan nurses and fellow workers. Methods of clinical supervision should be informed by and complement lived experiences of working with serious illness, dying and bereavement.

Mercury contamination incident

BACKGROUND

The aim of this paper is to describe an incident where elemental mercury led to widespread contamination and the exposure of 225 individuals and confirmed toxicity in 19 individuals. The paper describes the incident and difficulties found in trying to assess the risk to individuals and to identify and decontaminate the residences involved.

METHODS

All individuals exposed to elemental mercury in the incident were followed up for 15 months.

RESULTS

Thirty-seven individuals were found to be 'at risk' and 13 were symptomatic of mercury poisoning. Five patients required chelation therapy. The incident was closed when the risk of poisoning and re-exposure was minimized.

CONCLUSION

Incident management depends on early effective communication and collaboration between all agencies involved.

A multicentre phase II pilot study of epirubicin and Taxol (paclitaxel) in patients with advanced breast cancer

Anthracyclines are the gold standard monotherapy for metastatic breast cancer. Higher response rates are seen with drug combinations, especially with newer agents such as taxanes. The purpose of this study was to evaluate the toxicity and activity of the combination of paclitaxel and epirubicin in patients with advanced breast cancer. Thirty-five women with locally advanced or metastatic breast cancer (first and second relapse) were treated with epirubicin 75 mg/m2 and paclitaxel 200 mg/m2 3-weekly. Six centres recruited 35 patients; 34 (97%) were assessable for response. Eighteen had undergone prior chemotherapy, including six (17%) with anthracycline-containing regimens. Grade 4 neutropenia was found in 33 patients (94%), which was of 4 days' average duration; however, infective complications were rare, with only nine cycles (6%) complicated by neutropenic sepsis. There were two sepsis-related deaths. Symptomatic cardiotoxicity was infrequent, although a >15% decline in cardiac function was recorded in five patients (14%). Grade 3 peripheral neuropathy occurred in three patients (9%). The overall response rate was 50% (95% confidence interval 33-67) (complete response 12%; partial response 38%), with a median duration of response of 31 weeks. The median time to progression was 27 weeks, with a median survival of 48 weeks. This regimen appears to be a relatively safe, tolerable and effective treatment for advanced breast cancer. A United Kingdom Co-ordinating Committee for Cancer Research Phase III trial (AB-01) comparing this combination of epirubicin and paclitaxel with cyclophosphamide and paclitaxel completed accrual in November 1999.