Differentiating ischemic stroke patients from healthy subjects using a large-scale, retrospective EEG database and machine learning methods

OBJECTIVES

We set out to develop a machine learning model capable of distinguishing patients presenting with ischemic stroke from a healthy cohort of subjects. The model relies on a 3-min resting electroencephalogram (EEG) recording from which features can be computed.

MATERIALS AND METHODS

Using a large-scale, retrospective database of EEG recordings and matching clinical reports, we were able to construct a dataset of 1385 healthy subjects and 374 stroke patients. With subjects often producing more than one recording per session, the final dataset consisted of 2401 EEG recordings (63% healthy, 37% stroke).

RESULTS

Using a rich set of features encompassing both the spectral and temporal domains, our model yielded an AUC of 0.95, with a sensitivity and specificity of 93% and 86%, respectively. Allowing for multiple recordings per subject in the training set boosted sensitivity by 7%, attributable to a more balanced dataset.

CONCLUSIONS

Our work demonstrates strong potential for the use of EEG in conjunction with machine learning methods to distinguish stroke patients from healthy subjects. Our approach provides a solution that is not only timely (3-minutes recording time) but also highly precise and accurate (AUC: 0.95).

Rhino-Orbital Cerebral Mucormycosis in a Diabetic Patient: An Emergency Medicine Case Report

BACKGROUND

Rhino-orbital cerebral mucormycosis (ROCM) is a rare infection caused by an invasive fungus and found predominantly in immunocompromised patients. The presentation of ROCM ranges from a mild headache, fever, and sinusitis to vision loss, altered mental status, and facial disfigurement secondary to local tissue invasion. ROCM can cause significant morbidity and mortality and requires prompt diagnosis with timely evaluation by surgical and infectious disease specialists. Cases of ROCM have been reported extensively in internal medicine, infectious disease, and otolaryngology literature. However, there are very few reports in emergency medicine literature in the United States.

CASE REPORT

A 72-year-old woman presented to the Emergency Department (ED) with altered mental status, 4 days of left-sided facial numbness and weakness, and sudden facial pain, swelling, and erythema. Laboratory analysis was consistent with diabetic ketoacidosis. Noncontrast computed tomography of the head and magnetic resonance imaging of the brain demonstrated findings indicative of invasive fungal infection of the left sinus and orbit with extension to the cavernous sinus and surrounding cranial nerves. She was initiated on broad-spectrum antifungals, but based on the extent of the infection, was not a surgical candidate. She subsequently transitioned to a comfort-based plan of care and died 6 days after initial ED presentation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early recognition and initiation of treatment can potentially mitigate the devastating outcomes of ROCM, therefore it is critical to be aware of this condition and have a high level of suspicion in susceptible patients.

Remote learning developments in postgraduate medical education in response to the COVID-19 pandemic - A BEME systematic review: BEME Guide No. 71

BACKGROUND

Prior reviews investigated medical education developments in response to COVID-19, identifying the pivot to remote learning as a key area for future investigation. This review synthesized online learning developments aimed at replacing previously face-to-face 'classroom' activities for postgraduate learners.

METHODS

Four online databases (CINAHL, Embase, PsychINFO, and PubMed) and MedEdPublish were searched through 21 December 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction, and assessed risk of bias. The PICRAT technology integration framework was applied to examine how teachers integrated and learners engaged with technology. A descriptive synthesis and outcomes were reported. A thematic analysis explored limitations and lessons learned.

RESULTS

Fifty-one publications were included. Fifteen collaborations were featured, including international partnerships and national networks of program directors. Thirty-nine developments described pivots of existing educational offerings online and twelve described new developments. Most interventions included synchronous activities (n Fif5). Virtual engagement was promoted through chat, virtual whiteboards, polling, and breakouts. Teacher's use of technology largely replaced traditional practice. Student engagement was largely interactive. Underpinning theories were uncommon. Quality assessments revealed moderate to high risk of bias in study reporting and methodology. Forty-five developments assessed reaction; twenty-five attitudes, knowledge or skills; and two behavior. Outcomes were markedly positive. Eighteen publications reported social media or other outcomes, including reach, engagement, and participation. Limitations included loss of social interactions, lack of hands-on experiences, challenges with technology and issues with study design. Lessons learned highlighted the flexibility of online learning, as well as practical advice to optimize the online environment.

CONCLUSIONS

This review offers guidance to educators attempting to optimize learning in a post-pandemic world. Future developments would benefit from leveraging collaborations, considering technology integration frameworks, underpinning developments with theory, exploring additional outcomes, and designing and reporting developments in a manner that supports replication.

Pivot to online learning for adapting or continuing workplace-based clinical learning in medical education following the COVID-19 pandemic: A BEME systematic review: BEME Guide No. 70

BACKGROUND

The novel coronavirus disease was declared a pandemic in March 2020, which necessitated adaptations to medical education. This systematic review synthesises published reports of medical educational developments and innovations that pivot to online learning from workplace-based clinical learning in response to the pandemic. The objectives were to synthesise what adaptations/innovation were implemented (description), their impact (justification), and 'how' and 'why' these were selected (explanation and rationale).

METHODS

The authors systematically searched four online databases up to December 21, 2020. Two authors independently screened titles, abstracts and full-texts, performed data extraction, and assessed the risk of bias. Our findings are reported in alignment with the STORIES (STructured apprOach to the Reporting in healthcare education of Evidence Synthesis) statement and BEME guidance.

RESULTS

Fifty-five articles were included. Most were from North America (n = 40), and nearly 70% focused on undergraduate medical education (UGME). Key developments were rapid shifts from workplace-based learning to virtual spaces, including online electives, telesimulation, telehealth, radiology, and pathology image repositories, live-streaming or pre-recorded videos of surgical procedures, stepping up of medical students to support clinical services, remote adaptations for clinical visits, multidisciplinary team meetings and ward rounds. Challenges included lack of personal interactions, lack of standardised telemedicine curricula and need for faculty time, technical resources, and devices. Assessment of risk of bias revealed poor reporting of underpinning theory, resources, setting, educational methods, and content.

CONCLUSIONS

This review highlights the response of medical educators in deploying adaptations and innovations. Whilst few are new, the complexity, concomitant use of multiple methods and the specific pragmatic choices of educators offers useful insight to clinical teachers who wish to deploy such methods within their own practice. Future works that offer more specific details to allow replication and understanding of conceptual underpinnings are likely to justify an update to this review.

Online learning developments in undergraduate medical education in response to the COVID-19 pandemic: A BEME systematic review: BEME Guide No. 69

BACKGROUND

The COVID-19 pandemic spurred an abrupt transition away from in-person educational activities. This systematic review investigated the pivot to online learning for nonclinical undergraduate medical education (UGME) activities and explored descriptions of educational offerings deployed, their impact, and lessons learned.

METHODS

The authors systematically searched four online databases and conducted a manual electronic search of MedEdPublish up to December 21, 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction and assessed risk of bias. A third author resolved discrepancies. Findings were reported in accordance with the STORIES (STructured apprOach to the Reporting in healthcare education of Evidence Synthesis) statement and BEME guidance.

RESULTS

Fifty-six articles were included. The majority (n = 41) described the rapid transition of existing offerings to online formats, whereas fewer (n = 15) described novel activities. The majority (n = 27) included a combination of synchronous and asynchronous components. Didactics (n = 40) and small groups (n = 26) were the most common instructional methods. Teachers largely integrated technology to replace and amplify rather than transform learning, though learner engagement was often interactive. Thematic analysis revealed unique challenges of online learning, as well as exemplary practices. The quality of study designs and reporting was modest, with underpinning theory at highest risk of bias. Virtually all studies (n = 54) assessed reaction/satisfaction, fewer than half (n = 23) assessed changes in attitudes, knowledge or skills, and none assessed behavioral, organizational or patient outcomes.

CONCLUSIONS

UGME educators successfully transitioned face-to-face instructional methods online and implemented novel solutions during the COVID-19 pandemic. Although technology's potential to transform teaching is not yet fully realized, the use of synchronous and asynchronous formats encouraged virtual engagement, while offering flexible, self-directed learning. As we transition from emergency remote learning to a post-pandemic world, educators must underpin new developments with theory, report additional outcomes and provide details that support replication.

An update on developments in medical education in response to the COVID-19 pandemic: A BEME scoping review: BEME Guide No. 64

BACKGROUND

COVID-19 has fundamentally altered how education is delivered. Gordon et al. previously conducted a review of medical education developments in response to COVID-19; however, the field has rapidly evolved in the ensuing months. This scoping review aims to map the extent, range and nature of subsequent developments, summarizing the expanding evidence base and identifying areas for future research.

METHODS

The authors followed the five stages of a scoping review outlined by Arskey and O'Malley. Four online databases and MedEdPublish were searched. Two authors independently screened titles, abstracts and full texts. Included articles described developments in medical education deployed in response to COVID-19 and reported outcomes. Data extraction was completed by two authors and synthesized into a variety of maps and charts.

RESULTS

One hundred twenty-seven articles were included: 104 were from North America, Asia and Europe; 51 were undergraduate, 41 graduate, 22 continuing medical education, and 13 mixed; 35 were implemented by universities, 75 by academic hospitals, and 17 by organizations or collaborations. The focus of developments included pivoting to online learning (n = 58), simulation (n = 24), assessment (n = 11), well-being (n = 8), telehealth (n = 5), clinical service reconfigurations (n = 4), interviews (n = 4), service provision (n = 2), faculty development (n = 2) and other (n = 9). The most common Kirkpatrick outcome reported was Level 1, however, a number of studies reported 2a or 2b. A few described Levels 3, 4a, 4b or other outcomes (e.g. quality improvement).

CONCLUSIONS

This scoping review mapped the available literature on developments in medical education in response to COVID-19, summarizing developments and outcomes to serve as a guide for future work. The review highlighted areas of relative strength, as well as several gaps. Numerous articles have been written about remote learning and simulation and these areas are ripe for full systematic reviews. Telehealth, interviews and faculty development were lacking and need urgent attention.

Turning Your Educational Work Into Scholarship

This educational download will help readers turn their work into scholarship with 5 straight forward tips. When doing educational work-ask questions. Be sure to have a strong educational foundation for teaching, assessment, and evaluation. Work in teams. Use colleagues to help promote educational work. And finally, manage the work flow to ensure completion.

Succinylcholine Use and Dantrolene Availability for Malignant Hyperthermia Treatment: Database Analyses and Systematic Review

BACKGROUND

Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality.

METHODS

The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given.

RESULTS

Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities.

CONCLUSIONS

Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.

Choosing emergency medicine: Influences on medical students' choice of emergency medicine

Background

Relatively little is understood about which factors influence students’ choice of specialty and when learners ultimately make this decision.

Objective

The objective is to understand how experiences of medical students relate to the timing of selection of Emergency Medicine (EM) as a specialty. Of specific interest were factors such as how earlier and more positive specialty exposure may impact the decision-making process of medical students.

Methods

A cross-sectional survey study of EM bound 4th year US medical students (MD and DO) was performed exploring when and why students choose EM as their specialty. An electronic survey was distributed in March 2015 to all medical students who applied to an EM residency at 4 programs representing different geographical regions. Descriptive analyses and multinomial logistic regressions were performed.

Results

793/1372 (58%) responded. Over half had EM experience prior to medical school. When students selected EM varied: 13.9% prior to, 50.4% during, and 35.7% after their M3 year. Early exposure, presence of an EM residency program, previous employment in the ED, experience as a pre-hospital provider, and completion of an M3 EM clerkship were associated with earlier selection. Delayed exposure to EM was associated with later selection of EM.

Conclusions

Early exposure and prior life experiences were associated with choosing EM earlier in medical school. The third year was identified as the most common time for definitively choosing the specialty.

Modeling Enrollment in the Conservation Reserve Program by Using Agents within Spatial Decision Support Systems: An Example from Southern Illinois

Existing models of agricultural decisionmaking based on economic optimization often fall short of capturing the complex dynamics of land-use choices at both individual parcel and watershed-level scales. The complexity arises from an interplay of several factors, as explained by Herbert Simon's model of bounded rationality, the theory of diffusion of innovations through spatial contagion, the role of personal environmental values and local culture, and simple historical momentum. This complexity can be captured using ‘artificial life agents’ that model land-use choice for individual parcels by considering characteristics and personal beliefs of the owner or operator, physical traits of the land, and information obtained via social networks. Agents are therefore able to consider holistically a large number of factors affecting land-use choice. The creation of agent-based models of human behavior described herein is based upon empirical data on the acceptance of Conservation Reserve Program for the Cache River watershed of southern Illinois (USA). These models are interfaced with a geographic information system to produce a spatial decision support system capable of anticipating the effects of policies that affect land-use decisionmaking on a real landscape and their economic performance.

Initiation and Development of a Toxic and Persistent Pseudo-nitzschia Bloom off the Oregon Coast in Spring/Summer 2015

In spring/summer 2015, a toxic bloom by the diatom Pseudo-nitzschia (PN) occurred along the west coast of the United States which led to closures of the harvest of razor clams and Dungeness crabs. Twice monthly observations of temperature, salinity, nutrients, chlorophyll and phytoplankton species composition allowed us to track oceanographic conditions preceding and during the development of the bloom. PN cells were first detected during late winter 2015. A PN bloom was initiated following the onset of coastal upwelling in mid-April; subsequent peaks in May and June were sustained by episodic upwelling events and reached magnitudes of 10⁵ cells/L and 10⁶ cells/L, 40% and 90% of the total diatom abundance, respectively. The bloom temporarily crashed in July due to a lack of upwelling, but PN cells increased again in August due to a resumption of upwelling, albeit with lower magnitude. Macronutrient conditions prior to this bloom likely played a critical role in triggering the bloom and its toxicity (particularly silicic acid limitation stress). Nutrient stress preceding the toxic bloom was related to two oceanographic events: an anomalously warm and thick water mass that occupied the northern North Pacific from September 2014 through 2015 leading to a highly-stratified water column, and the drawdown of nitrate and silicic acid during an unusually intense winter phytoplankton bloom in February and early March 2015.

MAVEN observations of the response of Mars to an interplanetary coronal mass ejection

Coupling between the lower and upper atmosphere, combined with loss of gas from the upper atmosphere to space, likely contributed to the thin, cold, dry atmosphere of modern Mars. To help understand ongoing ion loss to space, the Mars Atmosphere and Volatile Evolution (MAVEN) spacecraft made comprehensive measurements of the Mars upper atmosphere, ionosphere, and interactions with the Sun and solar wind during an interplanetary coronal mass ejection impact in March 2015. Responses include changes in the bow shock and magnetosheath, formation of widespread diffuse aurora, and enhancement of pick-up ions. Observations and models both show an enhancement in escape rate of ions to space during the event. Ion loss during solar events early in Mars history may have been a major contributor to the long-term evolution of the Mars atmosphere.

Early MAVEN Deep Dip campaign reveals thermosphere and ionosphere variability

The Mars Atmosphere and Volatile Evolution (MAVEN) mission, during the second of its Deep Dip campaigns, made comprehensive measurements of martian thermosphere and ionosphere composition, structure, and variability at altitudes down to ~130 kilometers in the subsolar region. This altitude range contains the diffusively separated upper atmosphere just above the well-mixed atmosphere, the layer of peak extreme ultraviolet heating and primary reservoir for atmospheric escape. In situ measurements of the upper atmosphere reveal previously unmeasured populations of neutral and charged particles, the homopause altitude at approximately 130 kilometers, and an unexpected level of variability both on an orbit-to-orbit basis and within individual orbits. These observations help constrain volatile escape processes controlled by thermosphere and ionosphere structure and variability.

Differential effects of GABA in modulating nociceptive vs. non-nociceptive synapses

GABA (γ-amino-butyric acid) -mediated signaling is normally associated with synaptic inhibition due to ionotropic GABA receptors that gate an inward Cl(-) current, hyperpolarizing the membrane potential. However, there are also situations where ionotropic GABA receptors trigger a Cl(-) efflux that results in depolarization. The well-characterized central nervous system of the medicinal leech was used to study the functional significance of opposing effects of GABA at the synaptic circuit level. Specifically, we focused on synapses made by the nociceptive N cell and the non-nociceptive P (pressure) cell that converge onto a common postsynaptic target. It is already known that GABA hyperpolarizes the P cell, but depolarizes the N cell and that inhibition of ionotropic GABA receptors by bicuculline (BIC) has opposing effects on the synapses made by these two inputs; enhancing P cell synaptic transmission, but depressing N cell synapses. The goal of the present study was to determine whether the opposing effects of GABA were due to differences in Cl(-) homeostasis between the two presynaptic neurons. VU 0240551 (VU), an inhibitor of the Cl(-) exporter K-Cl co-transporter isoform 2 (KCC2), attenuated GABA-mediated hyperpolarization of the non-nociceptive afferent while bumetanide (BUM), an inhibitor of the Cl(-) importer Na-K-Cl co-transporter isoform 1 (NKCC1), reduced GABA-mediated depolarization of the nociceptive neuron. VU treatment also enhanced P cell synaptic signaling, similar to the previously observed effects of BIC and consistent with the idea that GABA inhibits synaptic signaling at the presynaptic level. BUM treatment depressed N cell synapses, again similar to what is observed following BIC treatment and suggests that GABA has an excitatory effect on these synapses. The opposing effects of GABA could also be observed at the behavioral level with BIC and VU increasing responsiveness to non-nociceptive stimulation while BIC and BUM decreased responsiveness to nociceptive stimulation. These findings demonstrate that distinct synaptic inputs within a shared neural circuit can be differentially modulated by GABA in a functionally relevant manner.

A systematic review of the safety of topical therapies for atopic dermatitis

BACKGROUND

The safety of topical therapies for atopic dermatitis (AD), a common and morbid disease, has recently been the focus of increased scrutiny, adding confusion as how best to manage these patients.

OBJECTIVES

The objective of these systematic reviews was to determine the safety of topical therapies for AD.

METHODS

Databases searched included: OVID Medline, Medline In-Process and Other Non-Indexed Citations, Embase, and the Cochrane Central Register of Controlled Trials. In addition to the articles identified by this search, investigators were also referred to a list of links (most recently updated 25 September 2005) to recent Food and Drug Administration (FDA) studies, reports and meetings regarding the topical calcineurin inhibitors for further potential references. Only fully published papers available in English and data obtained from FDA sites were included. Furthermore, the criteria for inclusion and exclusion for each systematic review were further evaluated at a meeting of all of the content and evidence-based medicine experts participating in this process and alteration of the inclusion criteria was done at that time when it was felt necessary to avoid inclusion of lower-quality data in the review. Qualitative review of the abstracted data was performed and reviewed at a meeting of all of the content and evidence-based medicine experts.

RESULTS

While systemic exposure to these topical agents does occur, physiological changes appear to be uncommon and systemic complications rare and have only been found with use of topical corticosteroids.

CONCLUSIONS

Based on the data that are available the overall safety of AD therapies appears to be good with the only documented systemic side-effects of therapy those occasionally seen with use of topical corticosteroids.

Copepod hatching success in marine ecosystems with high diatom concentrations

Diatoms dominate spring bloom phytoplankton assemblages in temperate waters and coastal upwelling regions of the global ocean. Copepods usually dominate the zooplankton in these regions and are the prey of many larval fish species. Recent laboratory studies suggest that diatoms may have a deleterious effect on the success of copepod egg hatching. These findings challenge the classical view of marine food-web energy flow from diatoms to fish by means of copepods. Egg mortality is an important factor in copepod population dynamics, thus, if diatoms have a deleterious in situ effect, paradoxically, high diatom abundance could limit secondary production. Therefore, the current understanding of energy transfer from primary production to fisheries in some of the most productive and economically important marine ecosystems may be seriously flawed. Here we present in situ estimates of copepod egg hatching success from twelve globally distributed areas, where diatoms dominate the phytoplankton assemblage. We did not observe a negative relationship between copepod egg hatching success and either diatom biomass or dominance in the microplankton in any of these regions. The classical model for diatom-dominated system remains valid.

A randomized trial of lansoprazole, amoxycillin, and clarithromycin versus lansoprazole, bismuth, metronidazole and tetracycline in the retreatment of patients failing initial Helicobacter pylori therapy

BACKGROUND/AIM

10-30% of the patients treated for Helicobacter pylori fail to clear the infection after initial therapy. Little is known as to the efficacy of retreatment regimens in these patients. Proton pump inhibitor (PPI) -based triple and quadruple therapies demonstrate efficacies of 80-90% as initial therapy for H. pylori infection, but whether these regimens are as effective when used for retreatment is unknown. The efficacy of a metronidazole-containing regimen in this situation is also unknown. Our aim was to compare the efficacy of a nonmetronidazole-containing PPI-based triple versus a PPI-based quadruple therapy containing metronidazole in patients failing previous H. pylori therapy.

METHODS

48 patients were enrolled in this study at two sites after failure of previous H. pylori therapy as determined by a positive (14)C-urea breath test. Patients were stratified by prior treatment with a metronidazole-containing regimen and were then randomized to either lansoprazole (L) 30 mg twice daily, amoxycillin (A) 1,000 mg twice daily, and clarithromycin (C) 500 mg twice daily for 14 days (LAC) or L 30 mg four times daily, bismuth subsalicylate (B) 2 tablets four times daily, metronidazole (M) 250 mg four times daily and tetracycline (T) 250 mg four times daily for 14 days (LBMT). Side effects and compliance (pill count) were assessed at the completion of therapy. A repeat (14)C-urea breath test was performed 4 or more weeks after completion of therapy, and cure was defined as a negative test result.

RESULTS

48 patients (16 males and 32 females) were enrolled in this study. 20 patients received LAC (18 prior M), and 28 received LBMT (23 prior M). Per protocol and intention-to-treat efficacies were 82% (95% CI 64-100%) and 75% (95% CI 56-94%) for LAC and 80% (96% CI 64-96%) and 71% (95% CI 54-88%) for LBMT (p = 0.85 per protocol and p = 0.78 intention to treat between LAC and LBMT), respectively. The compliance (> or =80% of pills taken) was found to be 89% in both treatment groups. Side effects were noted in 84% for LAC and in 82% for LBMT, but were mild and did not cause discontinuation of therapy.

CONCLUSIONS

PPI-based triple and quadruple therapy with both LAC and LBMT are effective in retreating patients failing initial metronidazole-based H. pylori therapies. LAC was not statistically superior to LBMT as a 'retreatment' regimen in this clinical situation, but the small sample size and wide confidence limits do not preclude the possibility of a smaller but significant difference in efficacy between the regimens. To determine whether LAC or LBMT is as effective for retreating patients failing non-metronidazole-containing regimens requires further study.

Effect of an evidence-based medicine seminar on participants' interpretations of clinical trials: a pilot study

PURPOSE

To evaluate the effect of evidence-based medicine (EBM) education on physicians' short-term and long-term understanding of research methods and statistics.

METHOD

Twenty-four gastroenterology (GI) fellows attended a three-day seminar about evidence-based medicine and the critical appraisal of medical literature. Attendees completed the same 14-item test on this material at the start of the seminar, at the conclusion of the seminar, and six months after the seminar. A student's t-test and chi-square analysis were performed to determine the differences between test scores by testing date and performance on test items.

RESULTS

Seminar attendees improved their test scores between pre-seminar and post-seminar tests (mean test score: 57% +/- 16% versus 82 +/- 14%, respectively; p <.001) and between pre-seminar and six-month post-seminar tests (mean test score: 57% +/- 16% versus 78% +/- 13%, respectively; p <.001). Seminar attendees showed significant improvement in frequency of correct answers with individual questions on concealment of allocation, relative risk reduction, and meta-analysis trial methods.

CONCLUSIONS

In this pilot study, the critical appraisal skills necessary to practice EBM were taught to GI fellows in a seminar format that led to significant improvement in their understanding of research methods and statistics. Data from this pilot study justify a definitive trial examining the educational value of EBM seminars for physicians.

Public policy affecting universal design

The federal government has passed numerous laws that have focused on everything from civil rights legislation to accessibility mandates. This paper looks at the cumulative effects of federal legislation and nonlegislative activities on breaking down the wall of inequality for persons with disabilities and promoting the concept of universal design and universal access.

Two methods of weaning persons with quadriplegia from mechanical ventilators

Two commonly-used methods of weaning individuals with quadriplegia from mechanical ventilators were compared. The medical records were reviewed of 52 patients who were injured at the C3 or C4 levels, were ventilator dependent following their injury, and were treated at the participating facilities. The study subjects had a total of 82 separate wean attempts: 26 utilized intermittent mandatory ventilation, 34 used progressive ventilator-free breathing (T-piece weaning) and 22 used either a combination of these approaches or a different approach. With an overall weaning success rate of 83%, this study demonstrated that individuals with C3 and C4 quadriplegia are indeed candidates for ventilator weaning. Comparing the two weaning methods, progressive ventilator-free breathing was found to be successful more often than intermittent mandatory ventilation (67.6% compared to 34.6%). In addition, progressive ventilator-free breathing appeared superior in its ability to provide a more functional alternative to individuals unable to wean completely.

WiDr is a derivative of another colon adenocarcinoma cell line, HT-29

This paper documents chromosomal and isozymic evidence indicating that WiDr is a derivative of another colon adenocarcinoma cell line, HT-29, which was established in 1964. The phenotypes for seven isozymes studied were identical for all HT-29 and WiDr cell lines. The karyotypes were similar between four HT-29 cultures separated by more than 100 passages and two WiDr cultures that were studied independently in 1979 and 1985. The isozymic and karyotypic data are consistent with that described for the cell line WiDr, originally reported in 1979. Detailed karyotypic comparisons further show that cultures of WiDr possess all nine chromosomal markers found in the initial HT-29 (passage 19) cultures. However, both the higher passaged HT-29 and WiDr differ from the initial HT-29 (passage 19) because it has an additional five to eight constitutive marker chromosomes. An increase or decrease of one copy in several normal chromosomes is also noticed with more normal chromosome gains than losses. The study provides another example demonstrating the remarkable karyotypic stability within a heteroploid cell line with continued passage. It also reemphasizes the critical need for detailed karyotypic and isoenzymic studies on all cell lines in common use.

Clinical pharmacology of etintidine in patients with duodenal ulcer

The gastric antisecretory activity of etintidine, a new histamine H2-receptor antagonist, was evaluated in 5 patients with quiescent duodenal ulcer disease. Meal-stimulated acid secretion was measured after 100 and 300 mg oral doses of etintidine, 100 and 300 mg oral doses of cimetidine, and placebo. Reductions from placebo in four-hour gastric acid secretion were 49, 65, 80, and 94%, with 100 mg cimetidine, 100 mg etintidine, 300 mg cimetidine, and 300 mg etintidine, respectively. Drug concentrations in plasma were determined by HPLC. The pharmacokinetics of the 2 drugs were similar. We analyzed sigmoid-shaped concentration-response curves to both agents; the concentrations causing 50% inhibition of meal-stimulated gastric acid secretion were 0.44 +/- 0.04 and 0.15 +/- 0.04 micrograms/ml for cimetidine and etintidine, respectively. However, characteristics of these curves were such that the potency difference diminished at higher concentrations.

The effect of 15(R)-15-methyl prostaglandin E2 on meal-stimulated gastric acid secretion, serum gastrin, and pancreatic polypeptide in duodenal ulcer patients

The effects of 100-microgram of 15(R)-15-methyl prostaglandin E2 on meal-stimulated acid secretion, serum gastrin, and pancreatic polypeptide concentrations were measured in patients with duodenal ulcer. The drug given in encapsulated or unencapsulated form significantly reduced gastric acid secretion by 59% or 70%, respectively. Rises in serum gastrin and pancreatic polypeptide concentrations after the meal were significantly blunted by 15(R)-15-methyl prostaglandin E2. This dose of prostaglandin led to no side effects and merits clinical evaluation in the treatment of peptic ulcer disease.