Teaching the teachers--a needs assessment of tutors for a new clinical skills course

There is an increasing trend in undergraduate education towards teaching clinical skills from a community base. A new clinical curriculum was introduced in Newcastle upon Tyne in 1995, beginning with an integrated clinical skills course. Although the attitudes and views of general practitioners (GPs) towards community-based clinical teaching have previously been reported, their perceived training needs have not been formally identified. The aims of this study were to identify the competencies needed by GPs for community-based clinical skills teaching, to compare and contrast these needs with their hospital colleagues, and to use the results to develop a teaching programme for the clinical tutors involved in the new course. In order of priority, the GPs and hospital tutors expressed similar needs: small-group teaching skills, assessing student needs, giving effective feedback and assessment of student performance, with a preference for the teaching to be organized within local teaching units. Most GPs and hospital tutors (73 and 69%, respectively) requested a distance-learning pack to complement the teaching. General practitioners rated resources for improving their individual clinical skills more highly than their hospital colleagues: for example, videotapes demonstrating examination techniques. Forty-six per cent of GP tutors had received some formal training in teaching methods compared to 29% of hospital tutors. The implications of the results for developing a 'Teaching the Teachers' course for clinical tutors are discussed.

c-myc antisense oligodeoxyribonucleotides inhibit proliferation of non-small cell lung cancer

BACKGROUND

Mutation or deregulation of certain cellular genes (protooncogenes) results in expression of proteins that appear to promote malignant transformation. Human non-small cell lung cancer has been documented to express many such oncogenes including c-myc, bcl-2, and mutant p53. Antisense oligodeoxyribonucleotides (ASODN) complementary to these oncogenes were tested on three non-small cell lung cancer cell lines for their efficacy in inhibiting cellular proliferation and oncoprotein expression.

METHODS

Established non-small cell lung cancer cell lines A427, SKMES-1, and A549 were grown in the presence of ASODNs complementary to messenger RNA of c-myc, bcl-2, p53, or controls at 1 mumol/L or 10 mumol/L concentrations for 4 or 10 days. Cellular proliferation was measured by tritiated thymidine uptake. Flow cytometry was used to quantitate oncoprotein expression. Intranuclear ASODN uptake was documented by fluoresceine-tagged ASODNs.

RESULTS

Fluoresceine-tagged ASODNs were readily taken up by all cell lines. c-myc, as well as bcl-2 and p53 ASODNs, were found to inhibit proliferation of all cell lines significantly compared with controls, most notably in line A549 (40.1% +/- 7.1% of control, p = 0.000 with c-myc ASODN). Antisense c-myc reduced c-myc protein by as much as 71.3% in A427, although protein levels were only minimally reduced in the viable cells of the other lines.

CONCLUSIONS

c-myc ASODNs inhibit proliferation of non-small cell lung cancer cell lines as well as reduce c-myc protein expression. Antisense bcl-2 and p53 also cause similar growth inhibition. These results suggest a critical role for activation of these oncogenes in the growth of cultured lung cancer cells. Furthermore, the efficacy and rapid cellular uptake of ASODNs support the potential role of antisense targeting of oncogene expression for pharmacologic control of non-small cell lung cancer.

Escherichia coli verotoxin binding to human paediatric glomerular mesangial cells

Haemolytic uraemic syndrome (HUS) remains the leading cause of acute renal failure in children. Although an Escherichia coli-produced verotoxin (VT) has been implicated in the pathogenesis of HUS, the precise mechanisms of disease are not well defined. We hypothesise that the pathogenesis of renal failure in HUS includes the binding of E. coli VT to the glomerular mesangial cell, with consequent effects on renal function. Using human paediatric mesangial cells, we studied the binding and biological effects of the purified verotoxin VT-1. We isolated, purified and characterised paediatric glomerular mesangial cells. The mesangial cells were characterised by their immunoreactivity with both smooth muscle actin and vimentin antibodies, and lack of immunoreactivity with cytokeratin or factor VIII antibodies. Using an fluorescein isothiocyanate-conjugated VT (10(-7)-10(-8) M), we demonstrated specific binding to the mesangial cell membrane by immunofluorescence microscopy. We also demonstrated a dose-dependent inhibition of mesangial cell mitogenesis at concentrations from 10(-9) to 10(-17) M. Our data demonstrate that VT-1 binds to paediatric human glomerular mesangial cells and this binding results in specific biological actions, including an inhibition of cell mitogenesis.

Analysis of the practice of nutrition support pharmacy specialists

In 1988 the Board of Pharmaceutical Specialities (BPS) recognized nutrition support pharmacy practice (NSPP) as one of four specialty areas in pharmacy. The BPS appointed a specialty council to develop and manage the process for board certification of qualified specialists. One step was to identify and validate activities performed by the specialists. This was accomplished by conducting a study that delineated the role of these practitioners and also provided information for developing a blueprint for a certification examination. The results revealed the types of practice settings, education, and training for specialists, and the distribution of professional time devoted to nutrition support activities.

Fallibility of transthoracic needle biopsy of anterior mediastinal masses

Percutaneous transthoracic core needle biopsy has been advocated as a highly accurate technique for the diagnosis of anterior mediastinal masses. A patient is described with a large anterior mediastinal mass in whom the diagnosis of mediastinal carcinoid tumour was made by transthoracic core needle biopsy. At definitive surgical resection the tumour proved to be a B cell lymphoma. This case illustrates one of the important limitations of needle biopsy with its potential for sampling error.

Use facilitated case discussions for significant event auditing

An important type of review undertaken routinely in health care teams is analysis of individual cases. This informal process can be turned into a structured and effective form of audit by using an adaptation of the "critical incident" technique in facilitated case discussions. Participants are asked to recall personal situations that they feel represent either effective or ineffective practice. From such review of individual cases arise general standards to improve the quality of care. On the basis of a study of audit of deaths in general practice, we describe how to implement such a system, including forming and maintaining the discussion group, methodology, and guidelines for facilitators. Problems that may arise during the case discussions are outlined and their management discussed, including problems within the team and with the process of the discussions.

Temperature control of the development of frost hardiness in two populations of Leptospermum scoparium

Seedlings of Leptospermum scoparium J.R. et G. Forst (manuka) originating from seed from a low altitude coastal site (Auckland) and from a high altitude inland site (Desert Road) were grown for 96 days in four controlled environments to compare the relationship between growth temperature and frost hardening. Day/night temperature treatments were 12/6, 12/3, 12/0 and 12/-3 degrees C. Frost hardiness was determined at 14-day intervals by exposing whole seedlings to temperatures ranging from -2 to -8 degrees C. Frost damage differed significantly between the two populations: Desert Road seedlings were less affected than Auckland seedlings. At all growth temperatures, the time courses of frost hardiness of both populations followed curvilinear relationships reaching a maximum hardiness at about Day 50, after which the seedlings spontaneously dehardened. The rate of frost hardening increased linearly with decreasing temperature from 6 to 0 degrees C, but thereafter, no further increase occurred with decreasing temperature to -3 degrees C. The frost hardening process was more sensitive to temperature in the Desert Road seedlings than in the Auckland seedlings, and this difference may account for the intraspecific variation in frost hardening capacity of this species. Comparisons with Pinus radiata D. Don and Lolium perenne L. indicated that interspecific variation in frost hardening capacity can also be accounted for by differences in the sensitivity of the hardening process to temperature.

Pulmonary resection for invasive Aspergillus infections in immunocompromised patients

Standard antifungal medical therapy of invasive pulmonary aspergillosis that occurs in immunocompromised patients with hematologic diseases with neutropenia or in liver transplant recipients results in less than a 5% survival. In view of these dismal mortality rates, we adopted an aggressive approach with resection of the involved area of lung along with systemic antifungal therapy when localized invasive pulmonary aspergillosis developed in these patients. Between January 1987 and December 1993, 14 patients with hematologic diseases and 2 liver transplant recipients underwent resection of acute localized pulmonary masses suggestive of invasive pulmonary aspergillosis a median of 7.5 days (range 1 to 45 days) after the diagnosis was clinically suggested and confirmed by chest computed tomographic scans. Operative procedures done included two pneumonectomies, one bilobectomy with limited thoracoplasty, nine lobectomies, and five wedge resections (one patient with hematologic disease had two procedures). All patients were treated before and after the operation with antifungal agents. Nine (64%) of 14 patients with hematologic disease and 2 (100%) of 2 liver transplant recipients survived the hospitalization with no evidence of recurrent Aspergillus infection after a median 8 months of follow-up (range 3 to 82 months). The five hospital deaths (all patients with hematologic diseases) occurred a median of 20 days after operation from diffuse alveolar hemorrhage in three, graft-versus-host disease in one, and multiple organ system failure with presumed disseminated Aspergillus infection in one. Four of the five deaths were in patients with allogeneic bone marrow transplants. Two of the three patients requiring resection of multiple foci of infection died, as did the only patient who was preoperatively ventilator dependent. In immunocompromised patients with hematologic diseases or liver transplantation with invasive pulmonary aspergillosis, early pulmonary resection should be strongly considered when the characteristic clinical and radiographic pictures appear.

Myocardial protection for acquired heart disease surgery: results of a national survey

To study current myocardial protection practices, all 4,393 United States board-certified thoracic surgeons were surveyed in 1992. Of the 1,413 respondents (32% total response), 936 are in active practice dealing with acquired heart disease. Based on their frequency of cases, respondents perform approximately 32% of all acquired heart disease operations in the United States yearly and individually average 157 patients/year. For myocardial protection, 98% of respondents routinely use cardioplegic arrest. The primary method of cardioplegia delivery is antegrade 36%, retrograde 4%, and a combination of antegrade and retrograde 60%. The types of cardioplegic solutions used are blood 72%, crystalloid 22%, and oxygenated crystalloid 6%. Continuous warm blood cardioplegia is used by 10% of respondents, whereas most (75%) have adopted a skeptical "wait and see" attitude or have abandoned it (6%). Overall, most surgeons (78%) report that they are very satisfied with their present methods of myocardial protection, whereas only 2% are dissatisfied. Still, the three areas believed most important for future research are reperfusion injury (74%), acutely infarcting myocardium (61%), and metabolic enhancers in cardioplegia (58%).

Techniques to simplify esophagogastric circular stapled anastomoses

Stapling devices for end-to-end anastomoses (EEA) have facilitated more rapid and reliable reestablishment of esophagogastric continuity following esophageal resections. Despite their ease of use, various intraoperative problems can arise, especially with the esophageal pursestring or the insertion of the anvil into the fragile, commonly contracted lumen. This paper describes various technical details that are useful adjuncts to allow creation of rapid, consistently successful EEA stapled esophagogastric anastomoses. These techniques are of particular value in the resident teaching setting.

Localized pleural mesothelioma. The clinical spectrum

Localized pleural mesotheliomas are rare tumors that have a variety of clinical presentations, from an asymptomatic solitary nodule to a massive, highly symptomatic neoplasm filling most of the pleural cavity. Two cases are reported which show the clinical spectrum of the more common benign variant. The clinical differentiation between the benign tumor as well as the less frequent malignant neoplasms of localized mesotheliomas has been disappointing. Complete surgical resection is the preferred treatment for both types and is usually curative with the benign mesothelioma.

Contribution of academic departments of general practice to undergraduate teaching, and their plans for curriculum development

BACKGROUND

In 1991, the General Medical Council suggested the development of a new undergraduate curriculum, on a 'core plus electives' basis. The combination of National Health Service reforms and the rising profile of academic departments of general practice had led to a consideration of general practice as an alternative teaching environment. These departments now face escalating expectations from their medical schools of their ability to provide additional community based teaching.

AIM

The aim of this study was to investigate the present contribution of academic departments of general practice to undergraduate teaching and their plans for curriculum development, including the introduction of community-based clinical skills teaching.

METHOD

A questionnaire was circulated in June 1993 to all academic departments of general practice in the United Kingdom and Eire.

RESULTS

Twenty seven out of 28 questionnaires were returned. Twenty two departments provided pre-clinical teaching and all provided a clinical practice attachment. Eight medical schools were organizing community-based clinical skills teaching, and in two this formed the basis for a community-based medical attachment. Eight planned to reduce the factual content of their curricula and introduce problem-based learning while nine were contemplating a 'core plus electives' option. Fourteen medical schools had primary care input in teaching basic clinical skills and an additional seven planned to introduce this. Problems encountered by the general practitioner tutors in teaching clinical skills included insufficient time and resources and poor self-esteem; they identified a need for good central and peripheral organization.

CONCLUSION

Compared with a 1988 study, academic departments of general practice are increasingly involved in teaching both general practice and general medical skills at undergraduate level. Curriculum change is occurring rapidly, with an increasing trend towards community teaching; the implications for both academic departments and general practitioner tutors are discussed.

Benign mediastinal teratoma masquerading as a large multiloculated effusion

Benign mediastinal teratomas are uncommon germ cell tumors often discovered while still asymptomatic. Almost all arise in the anterosuperior mediastinal compartment, and most symptoms, when present, result from compression of adjacent structures. We report a case of a large teratoma arising from the anterior mediastinum that presented a confusing clinical picture of a multiloculated pleural effusion. It was successfully treated by surgical excision, with no long-term recurrence.

Defibrillator twiddler's syndrome

Long-term complications of internal cardioverter defibrillators have generally involved inappropriate shocks or hardware malfunctions. The present case documents a new problem of internal cardioverter defibrillator lead disruption resulting from patient-induced rotation of the generator in its pocket, similar to the previously reported pacemaker twiddler's syndrome. However, unlike the usual early symptoms of pacemaker nonfunction, the first symptomatic manifestation of the defibrillator twiddler's syndrome may be an inappropriate internal cardioverter defibrillator discharge or more importantly, unrescued sudden death. Careful attention to patient complaints about the internal cardioverter defibrillator generator and being alert to subtle lead changes on chest radiographs may allow the clinician to recognize this syndrome before a major, possibly fatal event.

Options in managing the patient with high defibrillation thresholds

The desired defibrillation threshold (DFT) obtained during intraoperative testing of an implantable cardioverter defibrillator (ICD) should be 10 J lower than the maximal energy delivered by the ICD generator. Of the 206 patients undergoing ICD implantation since December 1986, 8 (3.9%) have had initial DFTs with less than the 10-J safety margin using the standard large patch-large patch configuration. Patches were implanted by left thoracotomy in 6 and sternotomy in 1, and 1 had implantation of a transvenous defibrillation lead and subcutaneous patch. Of note, 6 (75%) of the 8 patients with high DFTs had prior open heart operations, half were on a regimen of long-term amiodarone therapy, and the mean left ventricular mass index was quite large but not significantly greater than that of patients with low DFTs. Multiple techniques was tried to improve the DFTs in this group. Satisfactory DFTs were eventually obtained in 7 (88%); the threshold was lowered from a mean of 41.4 +/- 3.8 J to 26.9 +/- 8.8 J (p = 0.002). The most effective techniques were addition of a superior vena cava lead attached by a Y connector to one of the large patch leads in some patients and conversion to a biphasic-waveform generator in 2 others. Adding a third epicardial lead did not lower the DFTs. There were no major postoperative complications or deaths attributable to these supplemental procedures. Using these techniques, satisfactory DFTs were obtained in almost all patients with an ICD.(ABSTRACT TRUNCATED AT 250 WORDS)

Trends in the stage of cancer at the time of diagnosis

The stage of cancers at the time of diagnosis for 10 major sites of disease from patients treated at two Medical College of Wisconsin teaching hospitals was analyzed from tumor registry data and compared from the years 1983, 1987, and 1991. A trend toward earlier stages of cancer of major sites was noted, with patients having in situ or localized disease increasing from 35% in 1983 to 48% in 1991. Patients with breast cancer demonstrated the strongest trend, with 44% of the cases representing in situ or localized disease in 1983 compared to 61% in 1991 (p = 0.03). A shift toward earlier stage of cancer at diagnosis was also noted for other major sites including: lung, trachea and bronchus; colon and rectum; and prostate cancers. Trends toward an earlier stage of cancer may result from patient and physician education, local practice patterns, as well as proper use of screening programs. Information on such trends from hospital tumor registries may be helpful in the appropriate and efficient allocation of local health care resources.

Intrapleural fibrinolytic treatment of multiloculated thoracic empyemas

Acute multiloculated thoracic empyemas incompletely drained by tube thoracostomy alone usually require operation. To avoid a thoracotomy yet treat this difficult problem, intrapleural fibrinolytic agents were employed. Between April 1, 1990, and April 1, 1993, 13 consecutive patients presenting with a fibrinopurulent empyema were demonstrated to have incomplete drainage. To facilitate drainage, streptokinase, 250,000 units in 100 mL 0.9% saline solution (3 patients), or urokinase, 100,000 units in 100 mL 0.9% saline solution (10 patients), was instilled daily into the chest tube, and the tube was clamped for 6 to 12 hours followed by suction. This routine was continued daily for a mean of 6.8 +/- 3.7 days (range, 1 to 14 days) until resolution of the pleural fluid collection was demonstrated by computed chest tomography and clinical indications. This regimen was completely successful in 10 of 13 patients (77%), who had resolution of the empyema, eventual withdrawal of chest tubes, and no recurrence. Two patients, both pediatric liver transplant patients, had an initial good response but eventually required decortication. One patient with a good radiographic response became increasingly febrile during streptokinase therapy and underwent a thoracotomy, but no significant undrained fluid was found. This patient's continued fever was believed to be a streptokinase reaction. Urokinase was used subsequently. No treatment-related mortalities or complications occurred. Intrapleural fibrinolytic agents, especially urokinase, are safe, cost-effective means of facilitating complete chest tube drainage, thereby avoiding the morbidity of a major thoracotomy for 77% of a group of multiloculated empyema patients who traditionally would have required open surgical therapy.

Intrapleural doxycycline control of malignant pleural effusions

The intrapleural instillation of agents for pleural sclerosis has proved effective in preventing the reaccumulation of symptomatic malignant pleural effusions. Because manufacture of the most popular agent, tetracycline, was recently discontinued, a preliminary study was undertaken to evaluate an alternative agent, doxycycline, for treating symptomatic malignant pleural effusions. From November 1991 to September 1992, 21 patients with symptomatic malignant pleural effusions have undergone overnight chest tube drainage followed by intrapleural instillation of 10 mL 1% lidocaine and then doxycycline, 500 mg in 30 mL 0.9% saline solution. The chest tube was clamped 2 hours with patient repositioning every 15 minutes. Tubes were removed when drainage was less than 50 mL/8 h. Of surviving patients, a complete objective response at 1 month was obtained in 88% (15/17), who were free of a symptomatic or radiographic recurrence of the effusion. Complications included mild pain in 23% (5/21), moderate pain requiring analgesics in 19% (4/21), and mild fever in 5% (1/21). There were no treatment-related deaths. The mean time for chest tube removal was 1.7 +/- 0.7 days after the last treatment. Based on this preliminary study, we conclude that doxycycline is a highly effective agent for the palliative treatment of symptomatic malignant pleural effusions. Its safety profile and efficacy compare favorably with those of tetracycline and other agents used for pleural sclerosis.

Operationalizing the Corbin & Strauss Trajectory Model for elderly clients with chronic illness

A research team of six nursing faculty at Thomas Jefferson University College of Allied Health Sciences collaborated to develop a research proposal to provide nursing care to a selected population of chronically ill elderly persons. The Corbin and Strauss Nursing Model for Chronic Illness Management (1991) was selected as the organizing framework to guide research and care delivery. While conceptual models offer direction for nursing practice, specific guidelines for providing care can only be identified when major concepts of the model are operationalized (Fawcett, 1989). This article describes the first step in operationalizing the Corbin and Strauss Trajectory Model undertaken by the research team which resulted in the development of eight "Phase-specific protocols." Two of the eight phase-specific protocols are presented.

Infection control of parenteral nutrition solutions

Microbial contamination of parenteral nutrition solutions is a preventable cause of in patients receiving nutrition support. The components of the parenteral nutrition solutions have variable microbial growth potential. Crystalline amino acid and dextrose solutions are poor growth media for bacteria but may support fungal growth. Lipid emulsions provide an excellent medium for growth of bacteria and fungal species. Total nutrient admixtures will support microbial growth better than standard parenteral nutrition solutions will but less well than will lipid emulsion alone. Control of infection related to contaminated infusate depends on compounding procedure, quality control, appropriate storage, and procedures to prevent in-use contamination. Guidelines are presented for the preparation and administration of parenteral nutrition infusates that will minimize microbial contamination.