The quality of questions and use of resources in self-directed learning: personal learning projects in the maintenance of certification

INTRODUCTION

To engage effectively and efficiently in self-directed learning and knowledge-seeking practices, it is important that physicians construct well-formulated questions; yet, little is known about the quality of good questions and their relationship to self-directed learning or to change in practice behavior.

METHODS

Personal learning projects (PLPs) submitted to the Canadian Maintenance of Certification program were examined to include underlying characteristics, quality of therapeutic questions (population, intervention, comparator, outcome [PICO] mnemonic), and relationships between stage of change and level of evidence used to resolve questions.

RESULTS

We assessed 1989 submissions (from 559 Fellows of the Royal College of Physicians and Surgeons of Canada [RCPSC]). The majority of submissions were by males (69.2%) aged 40-59 (59.4%) with an average of 24.3 (range 6-58, SD 11.1) years since graduation. The most frequent submissions were treatment (36.6%) and diagnosis (22.3%) questions. Half of all questions described > or =2 components (PICO), and only 3.7% of questions included all 4 components. Cross tabulations indicated only 1 significant trend for the use of narrative reviews and the outcome "integrating new knowledge' (P < .000).

DISCUSSION

Self-directed learning skills comprise an important strategy for specialists maintaining or expanding their expertise in patient care, but an important obstacle to answering patient care questions is the ability to formulate good ones. Engagement in most major learning activities is stimulated by management of a single patient: formal accredited group learning events are of limited value in starting episodes of self-directed learning. Low levels of evidence used to address learning projects. Future research should determine how best to improve the quality of questions submitted and whether or not these changes result in increased efficiencies, more appropriate uses of evidence, and increased changes in practice behaviors.

MRI of impingement syndromes of the shoulder

The diagnosis of shoulder impingement is primarily a clinical one. Imaging has a role in assisting clinicians in developing a treatment strategy by identifying and characterizing the cause of shoulder impingement. In this review, the relevant anatomy, cause/pathomechanics, clinical features, and magnetic resonance imaging (MRI) findings of the different types of impingement syndromes are presented.

The association between multifocal electroretinograms and OCT retinal thickness in retinitis pigmentosa patients with good visual acuity

AIMS

To investigate relationships between retinal morphology and retinal function in patients with retinitis pigmentosa (RP) using optical coherence tomography (OCT) and multifocal electroretinography (mfERG).

METHODS

In all, 14 patients with RP who had visual acuities of 0.2 logMAR or better and Humphrey central fields of 10 degrees or larger participated in the study along with 16 normal control subjects. The amplitudes and timings of the mfERG responses were compared with spatially corresponding measures of retinal layer thickness from OCT within the macula region (central 12 degrees ).

RESULTS

Eyes with RP showed thinning of the photoreceptor retinal (PR) layer and thickening of mid-inner retinal (MIR) layers beyond the fovea. mfERG amplitude was reduced in all regions, whereas mfERG timing was only significantly delayed at a retinal eccentricity of 6-12 degrees and was otherwise preserved within the foveal and parafoveal retina (0-6 degrees). PR layer thickness was correlated with mfERG amplitude across the macula region. mfERG timing was correlated with the total change in retinal thickness (combined PR thinning and MIR thickening) at an eccentricity of 6-12 degrees.

CONCLUSIONS

The relationship between mfERG timing and retinal thickness in RP is dependent on the retinal eccentricity. Preserved timing in the central retina (0-6 degrees ), despite significant disruption to retinal laminar structure, could be suggestive of inner retinal remodelling or functional redundancy. Cone system activity derived from mfERG amplitude appears to be related to the thickness of the photoreceptor layer in the macula region.

Quantitative, small bore, 1 Tesla, magnetic resonance imaging of the hands of patients with rheumatoid arthritis

OBJECTIVE

To determine if quantitative hand images obtained from an office-based MRI extremity scanner reliably distinguish patients with rheumatoid arthritis from controls.

METHODS

The hands of 39 patients suffering from rheumatoid arthritis were imaged using a small bore, 1.0 Tesla Magnetic Resonance Imager. Non-contrast images of the metacarpophalangeal joints and wrist joints were evaluated using a method based on the validated rheumatoid arthritis magnetic resonance imaging system (RAMRIS). The extent and degree of synovitis, bone edema and bone erosions was assessed. Derived scores were compared with the corresponding scores for groups of younger (n=14) and older (n=27) controls with no signs or symptoms of joint disease.

RESULTS

The mean (+/-standard error) total joint scores were 0.3+/-0.2 for young controls, 11.5+/-2.4 for older controls and 34.1+/-6.0 for the patients with rheumatoid arthritis. The greatest difference between rheumatoid patients and older controls was observed for synovitis with scores that were greater by a factor of almost 6.5. Scores for erosions and edema were factors of 2.9 and 2.3 greater in rheumatoid arthritis than in controls. The relationship between scores for the same joints on the dominant and non-dominant sides was generally stronger than the relationship between the metacarpophalangeal and wrist joints of the same hand.

CONCLUSION

These observations indicate that scoring of hand images obtained from a small bore, office based, 1.0 Tesla MR imager have clinical validity and may be used to distinguish patients with rheumatoid arthritis from aged matched controls.

Redo transanal endorectal pull-through: a preliminary study

The aim of this study is to evaluate the safety and efficacy of the redo transanal endorectal pull-through (TEPT) for patients with persistent symptoms after pull-through for Hirschsprung's disease (HD). Seven children were included in the study, their ages ranged from 2.5 to 6 years (four males and three females). They presented with persistent obstructive symptoms after pull-through for HD, which was remediated with redo TEPT. Indications were persistent constipation, anastomotic stricture unresponsive to dilatation with or without attacks of enterocolitis. Mean follow-up period was 12 months (ranged from 8 to 16 months). Obstructive symptoms were relieved in all patients with no soiling throughout the period of follow-up. Enterocolitis developed once in two patients who responded to conservative management after hospitalization. There were no deaths and anastomotic leakage, persistent stricture and cuff abscess did not develop in our series. EMG mapping of the external anal sphincter showed a good resting and powerful squeezing pressure curve. Redo TEPT is a useful alternative procedure for persistent symptoms of HD, and it appears to be safe and effective.

Tuning fork (128 Hz) versus neurothesiometer: a comparison of methods of assessing vibration sensation in patients with diabetes mellitus

The current study compared the effectiveness of the graduated tuning fork (128 Hz) and the neurothesiometer in assessing vibration sensation perception in patients presenting with type II diabetes mellitus. A quota sample of patients (n = 21; age range 43-73 years) were assessed using the neurothesiometer and tuning fork by two investigators at five sites on both feet. There was a positive correlation between the results for the two methods of assessment for both investigators, and also between the results for both tools at three individual sites. Overall, there was 66.2% agreement between the results obtained from the two investigators using the tuning fork at each site; however, Kappa values only reached statistical significance at one site, indicating variability between the results from the two tools. This study suggests that assessment of vibration sensation with the tuning fork may be unreliable. These preliminary findings are based on a small sample size; thus further research is warranted.

The relationships between bone mineral density in the spine, hip, distal femur and proximal tibia and medial minimum joint space width in the knees of healthy females

OBJECTIVE

To investigate the relationships between bone mineral density (BMD) in the hip, spine, distal femur and proximal tibia and minimum joint space width (mJSW) in the knees of healthy women.

METHODS

Women 22-68 years old without a history of knee pain, bone or joint disease or injury underwent a single, fixed-flexion knee X-ray. Radiographs were graded according to the Kellgren-Lawrence scale and analyzed for mJSW using a computer algorithm. Dual X-ray absorptiometry scans of the spine, hip, distal femur and proximal tibia were also acquired for each participant. Femur and tibia scans were acquired and analyzed using a modified version of the lumbar spine software.

RESULTS

Forty-five females, mean [standard deviation (SD)] age and body mass index (BMI) of 40.1 (13.9) years and 24.6 (4.5)kg/m(2), respectively, participated. The mean (SD) mJSW was 4.64 (0.68)mm. Linear regression analyses controlling for age and BMI revealed that BMD in the femoral trochanter and the central two regions of the tibia (T2 and T3) was significantly related to mJSW in the knee. A backwards regression analysis performed to determine which region of interest is most significantly related to mJSW revealed that femoral trochanter BMD (beta-value=0.416) is the most significant.

CONCLUSIONS

In contrast to the suggestion that BMD is negatively correlated with mJSW in the knees of osteoarthritic individuals, these results suggest that increasing BMD in the femoral trochanter and tibia is significantly associated with increasing mJSW in healthy females. Further investigation of this relationship is warranted.

Reduced medial temporal lobe N-acetylaspartate in cognitively impaired but nondemented patients

BACKGROUND

N-acetylaspartate (NAA) in the medial temporal lobe (MTL) and parietal lobe gray matter (GM) is diminished in Alzheimer disease (AD). Because NAA is considered a marker of neuronal integrity, reduced medial temporal and parietal lobe NAA could be an early indication of dementia-related pathology in elderly individuals.

OBJECTIVES

1) To determine whether cognitively impaired but nondemented (CIND) elderly individuals exhibit a similar pattern of reduced medial temporal and parietal lobe NAA as AD patients. 2) To compare regional NAA patterns, hippocampal and neocortical gray matter (GM) volumes in CIND patients who remained cognitively stable and those who became demented over 3.6 years of follow-up. 3) To examine the relationship between memory performance, medial temporal lobe NAA, and hippocampal volume.

METHODS

Seventeen CIND, 24 AD, and 24 cognitively normal subjects were studied using MRSI and MRI.

RESULTS

Relative to controls, CIND patients had reduced MTL NAA (19 to 21%, p = 0.005), hippocampal (11 to 14%, p < or = 0.04), and neocortical GM (5%, p = 0.05) volumes. CIND patients who later became demented had less MTL NAA (26%, p = 0.01), hippocampal (17 to 23%, p < or = 0.05), and neocortical GM (13%, p = 0.02) volumes than controls, but there were no significant differences between stable CIND patients and controls. MTL NAA in combination with hippocampal volume improved discrimination of CIND and controls over hippocampal volume alone. In AD and CIND patients, decreased MTL NAA correlated significantly with impaired memory performance.

CONCLUSION

Reduced medial temporal lobe N-acetylaspartate, together with reduced hippocampal and neocortical gray matter volumes, may be early indications of dementia-related pathology in subjects at high risk for developing dementia.

Abnormalities identified in the knees of asymptomatic volunteers using peripheral magnetic resonance imaging

OBJECTIVE

To estimate the prevalence of bone and soft tissue abnormalities in asymptomatic knees using peripheral magnetic resonance imaging (pMRI) and to examine the relationship between these abnormalities and Kellgren-Lawrence (K-L) graded X-rays.

METHOD

Volunteers (20-68 years) with no history of knee pain, injury or bone or joint disease were recruited. Individuals underwent a single MRI scan and radiograph of their non-dominant knee. pMR images were acquired in sagittal plane using a 3-D gradient-echo protocol. Two radiologists graded the presence and severity of cartilage degeneration, osteophytosis, meniscal and ligamentous abnormalities, bone marrow edema and subchondral cysts. X-rays were acquired using a fixed-flexion technique and graded using the K-L scale.

RESULTS

Forty-four individuals, mean age (SD) 41.1 (14.2) years, participated. K-L grading of X-rays revealed 29 individuals were grade 0, 12 were grade 1 and 3 were grade 2. Five individuals showed evidence of cartilage lesions, the femoral trochlea, medial femur and patella being those regions most commonly affected. Twelve individuals (27.3%) showed evidence of osteophytosis, nine of whom did not show evidence on X-ray. Forty-three individuals showed evidence of at least one meniscal abnormality while 27 individuals (61.4%) had abnormalities in at least three of the four regions of the knee.

CONCLUSION

Our results suggest that osteophytes may be more prevalent in this population than radiographic data suggests due to the limitations of two-dimensional imaging. Meniscal degeneration or tears, a risk factor for knee osteoarthritis, are highly prevalent in asymptomatic individuals with the medial anterior and posterior horns being the most commonly affected regions.

Women's experiences of information, psychological distress and worry after treatment for gynaecological cancer

Sensitive, appropriate patient information is considered to be an important element in the psychological support of patients. Specialist nurses are seen to have a key responsibility for this work. With regard to gynaecological cancer, evidence suggests that women do not get optimum psychological care. This study set out to explore women's experiences of information, psychological distress and worry after treatment for gynaecological cancer. The study was a survey (not an RCT) and 70 patients from two specialist gynaecological oncology centres were interviewed at the time of diagnosis/initial treatment and again at 6 months. The semi-structured schedule included recognised instruments to assess; sources of information, concerns, and psychological distress. Both initially and at 6 months there was evidence of a considerable burden of worry; over half the women had four or more significant concerns related to their illness experience. However, women who had initial support from a clinical nurse specialist at the time of diagnosis experienced a clinically significant reduction in their level of psychological distress 6 months from diagnosis. Hospital linked professional sources of information were well used at the time of diagnosis, but by 6 months many patients were using non-professional sources such as television, magazines and newspapers. This study suggests that support from a clinical nurse specialist may be able to assist psychological recovery. However, to be effective in this area nurses should be skilled and willing to assess the individual's need for help with information, and managing their worry.

Effect of the introduction of helical CT on radiation dose in the investigation of pulmonary embolism

The aim of this study was to assess the change in patient radiation dose in the radiological investigation of pulmonary embolism since the introduction of helical CT pulmonary angiography (CTPA) in a large teaching hospital. All radiological investigations performed as an integral part of the imaging protocol in the investigation of clinically suspected pulmonary embolism (PE) were retrospectively reviewed. The protocol for the investigation of PE changed in our institution after the introduction of CTPA. Protocols 1 and 2 were the protocols in place before and after the introduction of CTPA, respectively. An in-depth evaluation was made of the imaging records and radiation dose for 30 consecutive patients investigated for clinically suspected PE in 1995 (protocol 1) and 2002 (protocol 2). Radiation doses were then extrapolated for the total number of patients investigated in each year. The number of radiological investigations performed per patient decreased from a mean of 1.17 in protocol 1 to 1.06 in protocol 2. There was a 44% increase in the total number of patients investigated. The effective dose per patient increased from 1.30 mSv to 1.35 mSv with the introduction of CTPA into the imaging protocol, an increase of only 4%. First line investigations showed a significant decrease in indeterminate examinations from 25.7% to 8.5%. Two different imaging protocols are reviewed with respect to type and number of procedures required for the investigation of PE and the resulting patient effective dose incurred. Results demonstrate an increase in the number of patients being investigated for suspected PE and a small increase in effective dose per patient since the introduction of helical CTPA. Although CTPA in itself incurs a higher effective dose, this is offset by the significant decrease in the number of non-diagnostic and total number of investigations per patient. In addition the ventilation component of lung scintigraphy was not required in protocol 2, thus reducing the dose further. We believe this small increase in effective dose is justified by the decrease in non-diagnostic studies and the reduction in total number of investigations per patient. We hope this paper will serve as a stimulus for the radiology community to examine current protocols in all areas of diagnostic imaging. We stress the importance of assessing new and established imaging investigative protocols to maximize the benefit and reduce any risk to patients.

Mycorrhizal diversity in photosynthetic terrestrial orchids

•  Specific orchid-fungal associations are known for nonphotosynthetic orchids but fungal diversity in photosynthetic orchids is thought to be quite broad. Specific fungal associations will figure prominently in conservation efforts, while diverse associations may require less attention. We combined culture techniques with ITS and mtLSU sequences and phylogenetic analysis to determine the genetic diversity of mycorrhizal fungi associated with an evergreen, a spring-green, and a winter-green orchid and compared this diversity with that published for a nonphotosynthetic orchid. •  Mycorrhizal diversity in two of the three photosynthetic orchids was lower than for the nonphotosynthetic orchid. Mycorrhizal diversity in protocorms of the third species was also equal to, or less than, the fungal diversity associated with the nonphotosynthetic species, but adult fungal diversity was greater. •  We found that photosynthetic orchids do not necessarily have more diverse mycorrhizal associations than nonphotosynthetic orchids. Similarly, evergreen orchids do not necessarily have greater mycorrhizal diversity than seasonally green orchids. Thus, orchid mycorrhizal diversity may not be determined by adult photosynthetic capacity.

Effects of estrogen and raloxifene on neuroglia number and morphology in the hippocampus of aged female mice

Hormone replacement therapy with the gonadal steroid estrogen or synthetic agents such as raloxifene, a selective estrogen receptor modulator, may affect cellular function in brains of postmenopausal women. In vitro studies suggest that 17beta estradiol and raloxifene can alter the microglial and astrocyte expression of immuno-neuronal modulators, such as cytokines, complement factors, chemokines, and other molecules involved in neuroinflammation and neurodegeneration. To directly test whether exogenous 17beta estradiol and raloxifene affect the number of glial cells in brain, C57BL/6NIA female mice aged 20-24 months received bilateral ovariectomy followed by s.c. placement of a 60-day release pellet containing 17beta estradiol (1.7 mg), raloxifene (10 mg), or placebo (cholesterol). After 60 days, numbers of microglia and astrocytes were quantified in dentate gyrus and CA1 regions of the hippocampal formation using immunocytochemistry and design-based stereology. The results show that long-term 17beta estradiol treatment in aged female mice significantly lowered the numbers of astrocytes and microglial cells in dentate gyrus and CA1 regions compared with placebo. After long-term treatment with raloxifene, a similar reduction was observed in numbers of astrocytes and microglial cells in the hippocampal formation. These findings indicate that estrogen and selective estrogen receptor modulators can influence glial-mediated inflammatory pathways and possibly protect against age- and disease-related neuropathology.

Doctor-patient communication in a musculoskeletal unit: relationship between an observer-rated structured scoring system and patient opinion

OBJECTIVES

To investigate the ability of consultant rheumatologists and orthopaedic surgeons to communicate well with patients and to determine the validity of a structured proforma used to assess medical students' communication skills.

METHODS

Seventy new patient appointments with consultant rheumatologists and orthopaedic surgeons were assessed for communication skills exhibited by the consultants and patient satisfaction. Communication skills were assessed using a proforma previously used to examine medical students, and patient ratings were obtained using visual analogue scales.

RESULTS

Median scores attained using the structured proforma for rheumatology, elective orthopaedic and fracture clinic consultations were 17, 15 and 14 out of 20 (P < 0.05). Patient satisfaction scores were high in all three domains measured. Scores were statistically significantly higher for rheumatology appointments than in fracture clinic (median scores 29.5, 29.5 and 28 out of 30). Consultation durations varied, with a median of 23 min for rheumatology and 10.5 and 4 min for orthopaedic surgeons in clinic and fracture clinic, respectively.

CONCLUSIONS

Consultant rheumatologists and orthopaedic surgeons demonstrate good communication skills, according to a tool used to assess medical students. These scores correlate with patient views, suggesting that teaching and assessment of communication skills at medical schools may address concerns of patients. Scores and satisfaction correlate with the duration of the consultation.

Different patterns of N-acetylaspartate loss in subcortical ischemic vascular dementia and AD

OBJECTIVES

1) To determine the regional pattern of reduced N-acetylaspartate (NAA) in subcortical ischemic vascular dementia (SIVD); 2) to explore the relationship between NAA reduction and subcortical vascular disease; and 3) to test if MR spectroscopic imaging (MRSI) in combination with structural MRI improves differentiation between SIVD and Alzheimer disease (AD).

METHODS

Thirteen patients with SIVD (71 +/- 8 years old) and 43 patients with AD of comparable age and dementia severity were studied using MRSI and MRI. Patients were compared to 52 cognitively normal subjects with and without lacunes.

RESULTS

Compared to controls, patients with SIVD had lower NAA by 18% (p < 0.001) in frontal cortex and by 27% (p < 0.003) in parietal cortex, but no significant NAA reduction in white matter and medial temporal lobe. Compared to patients with AD, patients with SIVD had lower NAA by 13% (p < 0.02) in frontal cortex and by 20% (p < 0.002) in left parietal cortex. Cortical NAA decreased in SIVD with increasing white matter lesions (r = 0.54, p < 0.02) and number of lacunes (r = 0.59, p < 0.02). Thalamic lacunes were associated with greater NAA reduction in frontal cortex than were lacunes outside the thalamus (p < 0.02) across groups, after adjusting for cognitive impairments. Adding parietal NAA to MRI-derived hippocampal atrophy improved separation between SIVD and AD (p = 0.02) from 79 to 89%.

CONCLUSIONS

These results emphasize the importance of cortical dysfunction as a factor in SIVD and indicate a characteristic pattern of metabolite change that might serve as a basis for improved diagnosis.

Comparative antistreptococcal activity of photobactericidal agents

In order to establish a comparative order of efficacy among established photosensitising compounds currently under investigation, the in vitro photobactericidal activities of six commercially available photosensitisers were investigated at equal concentration against Streptococcus sanguis using a Helium Neon (HeNe) laser (632.8 nm). Of the photosensitisers used, the four phenothiazinium compounds were efficient photobactericidal agents as was the protoporphyrin IX salt. However, the zinc phthalocyaninetetrasulfonate was less effective. Of the active agents, 1,9-dimethyl Methylene Blue (DMMB) was notable in achieving complete bacterial kill when used at a concentration of 40.85 microM in conjunction with a light energy dose of 21.8 J cm(-2), although there was inherent dark activity associated with this compound. Since each of the photosensitisers is well known to produce singlet oxygen, the relative activities exhibited are thought to be due to differences in bacterial cell uptake, which in turn are related to the physicochemical properties of the photosensitisers, in particular, to the combination of lipophilicity and ionic character.

Patients presenting with acute myocardial infarction to a district general hospital: baseline results and effect of audit

The Cardiovascular Health Strategy recommended that patients presenting with acute myocardial infarction receive thrombolysis within ninety minutes of alerting medical or ambulance services. The aim of this prospective study was to describe the management of patients with acute myocardial infarction (AMI) presenting to a district general hospital in Donegal. All patients with a confirmed diagnosis of acute myocardial infarction, excluding those from the Donegal Area Rapid Treatment Study (DARTS) practices, admitted to Letterkenny General Hospital (LGH) from 31.08.99 to 31.08.01 were included in the study. 349 patients were included in the study; average age of 68 ranging from 30 to 96 years and 69% were male. Of the 349 patients, 101 (29%) were located more than 30 miles from LGH at the time of onset of symptoms. The median time taken from the onset of symptoms to calling for help was 119 minutes. The median time from hospital arrival to patients being admitted to CCU was 90 minutes. Thrombolytic therapy was administered in 31% of patients; for these patients the median call to needle time was 200 minutes. Call to needle times differed significantly between rural (median 227.5 minutes n = 64) and urban patients (median 175 minutes n = 37, p < 0.05, Mann-Whitney). Hospital delay times decreased throughout the study period (p > 0.05, Mann-Whitney). The study extends the findings from previous research by investigating the individual time delay components from onset of symptoms to treatment in AMI patients. Delay times exceed the recommended call to needle and door to needle times suggesting the need for interventions to reduce these times.

Varicella and paediatric staff: current practice and vaccine cost-effectiveness

This study was undertaken to audit staff varicella policy for UK paediatric centres, and to estimate the cost-effectiveness of implementing a staff varicella vaccine policy. A telephone survey of 22 hospitals was performed to determine the policy regarding varicella immune status among healthcare workers (HCWs). All hospitals surveyed except one recorded immune status of informed HCWs, and had a policy of exclusion from work if they developed chickenpox. The total cost of vaccine implementation for nurses at the John Radcliffe Hospital neonatal unit over 5 years was estimated at 1601 pounds sterling versus 2474 pounds sterling for the estimated total cost of varicella exposure. Therefore it is likely that vaccination represents a cost-effective intervention.

Comparison of novel and existing methods for detection of linkage disequilibrium using parent-child trios in the GAW12 genetic isolate simulated data

A novel method for joint detection of association caused by linkage disequilibrium (LD) and estimation of both recombination fraction and linkage disequilibrium parameters was compared to several existing implementations of the transmission/disequilibrium test (TDT) and modifications of the TDT in the simulated genetic isolate data from Genetic Analysis Workshop 12. The first completely genotyped trio of affected child and parents was selected from each family in each replicate so that the TDT tests are valid tests of linkage and association, rather than being only valid as tests for linkage. In general, power to detect LD using the genome-wide scan markers was inadequate in the individual replicate samples, but the power was better when analyzing several SNP markers in candidate gene 1.