Putting the Heme Back in Heme-Onc: an Evaluation of the Redesigned Hematology Track within the Dana Farber/Mass General Brigham Hematology-Oncology Fellowship

In 2019, the Dana Farber/Mass General Brigham Hematology-Oncology Fellowship redesigned the 6-month Hematology training track/curriculum required for all fellows seeking to double board in hematology and oncology. Responding to both national and local trends suggesting a future shortage of hematologists, the goal of the redesign was to create a new curriculum that would increase fellow interest in hematology, improve fellows' clinical knowledge of hematology, and serve as an example to other Hematology-Oncology programs across the country. The revised track has now been in place for four years, and, in this paper, the authors present the fellow experience with the first four years of the redesigned curriculum. Based on the number of fellows who chose to complete the new curriculum, as well as the fellow evaluations and performance on the Hematology In-Training Exam, the authors conclude that the new curriculum has successfully increased both fellow interest in and knowledge of hematology.

Nurse-doctor co-teaching: A path towards interprofessional collaboration

BACKGROUND

Nurse-doctor collaborations are essential for team-based patient care. Although there are increasing calls for interprofessional education, teaching and learning together is rare. In 2019, we designed a Nurse-Doctor Co-Teaching pilot programme to provide an opportunity for nurses and doctors to co-teach junior doctors and nurses. We aimed to explore the experiences of the co-teachers and understand their perceptions of teaching together. The study was conducted through the lens of positioning theory.

METHODS

We held an hour-long focus group discussion and follow-up one-on-one interviews with nurses and doctors who participated as co-teachers. Conversations were audio-video recorded, transcribed, and thematically analysed. The Partners Institutional Review Board approved this study.

RESULTS

Three nurses and four doctors participated in the focus group conversation, and four nurses and two doctors participated in individual interviews. Participant narratives provided insight into shifts in hospital culture that would be necessary to promote effective interprofessional learning and collaboration: (1) break down professional silos, (2) invite the nursing perspective, (3) flatten professional hierarchies, and (4) recognise nurses as clinical teachers.

CONCLUSION

Nurses and doctors felt they shared a collegial and equal partnership as co-teachers. But this relationship was not typical of their daily clinical roles. Institutional barriers presented challenges to collaboration on the hospital floor and nursing participation in teaching. Successful interprofessional education may require culture and policy shifts that formally recognise nurses as valuable clinical teachers.

Impact of Extended Duty Hours on Perceptions of Care and Objective Patient Outcomes

OBJECTIVE

In 2017, interns were permitted to work continuously for up to 28 hours at a time, a reversal from the previously mandated 16-hour limit. Our objective was to evaluate perceptions of care and patient outcomes on an extended (28-hour) compared with a limited (16-hour) duty-hour system on identical interdisciplinary teams.

METHODS

Sixty-two interns, 27 residents, 28 attendings, and 449 patients participated. Patients completed surveys assessing their satisfaction. Anonymous weekly surveys were obtained from interns, residents, and attendings evaluating perceptions of intern tiredness, overall satisfaction, and performance. Nursing surveys evaluated intern and medical team performance. Objective outcome measures, including intensive care unit transfers, length of stay, readmissions, mortality, and complications, were assessed through a retrospective, blinded chart review.

RESULTS

Patients reported similar satisfaction in care. Extended duty-hour interns reported significantly decreased familiarity with their patients, decreased ability to conduct physical exams on new patients, increased tiredness, and decreased overall satisfaction. Residents overseeing extended-duty interns reported significantly decreased quality in intern presentations and overall quality of teaching, and increased perception of intern tiredness and increased incorrect orders. Attending physicians reported significantly improved quality of new patient presentations by extended duty-hour interns. No significant differences in patient objective outcome measures were noted.

CONCLUSIONS

Extended intern duty hours do not affect patient's satisfaction with their care. Although interns in the extended duty-hour system reported significantly increased fatigue and decreased overall satisfaction and residents' perceived increases in incorrect intern orders in the extended duty-hour system, there were no detrimental effects on patient safety.

Agreement of Nurses' and Physicians' Attitudes on Collaboration During the Covid-19 Pandemic Using the Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration

BACKGROUND

Collaboration between physicians and nurses has been shown to lead to better patient outcomes. However, studies have shown differing physicians' and nurses' responses to survey questions about physician-nurse collaboration. We surveyed physicians and nurses during the Covid-19 pandemic for their attitudes toward collaboration.

METHODS

In August 2021, during the Covid-19 pandemic, we surveyed physicians and nurses throughout an urban, academic teaching hospital over a consecutive twenty-day period using the validated Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration. Anonymous surveys were obtained from nurses and physicians on duty at the hospital. Demographic data from each survey included gender, age, profession of nurse or physician, degree, and specialization.

RESULTS

Four hundred and fifteen (415) unique paper surveys were collected from 308 nurses and 107 physicians over the twenty-day period. Five nurses and two physicians declined to complete the survey (1.6%). Using the Independent t-test of Means, total score and sub-scores were analyzed. Physicians and nurses scored the paper surveys in a similar manner. No statistically significant differences between the scores of physicians and nurses were found for any of the fifteen Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration questions, except for the youngest age group (20-29-year-old) having a significantly more positive response to doctors being the dominant authority on all health matters (p-value=0.011). Gender and nursing degree did not make a significant difference. Surgical Specialties (167), Medical Specialties (196), Intensive Care Unit (21), and the Emergency Department (43) survey responses did not differ significantly from each other.

CONCLUSION

One and a half years into the Covid-19 pandemic, physicians and nurses at an urban, academic teaching hospital were in agreement with their responses on the validated Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration. Our data may reflect a catalytic and positive effect of the Covid-19 pandemic on physician and nurse attitudes toward collaboration.

Nurse-Doctor Co-Teaching: A Pilot Study of the Design, Development, and Implementation of Structured Interprofessional Co-Teaching Sessions

INTRODUCTION

High levels of interprofessional collaboration are beneficial for patients and healthcare providers. Co-teaching may be one method for creating a collaborative environment. This pilot study designed, developed, and implemented Nurse-Doctor Co-Teaching on an inpatient medicine service.

METHODS

Ten Nurse-Doctor Co-Teaching pairs designed 30-minute, structured co-teaching sessions with learning objectives, evidence-based content, interactive teaching strategies and a Take-Away of key content with the help of a coaching team. Each session was presented by a nurse and senior doctor to nurse and resident learners. Our assessment blueprint included: 1. Anonymous surveys assessing the overall rating of each session and 2. Pre- and post-anonymous surveys assessing measures of interprofessional collaboration and communication between nurses and residents before and after the series of ten co-teaching sessions.

RESULTS

Data from ten post-session surveys included 121 of 156 participants (77.6%). Attendance at each session ranged from 13-19 participants with 8-17 participants completing a survey per session for an average of 12.1 surveys analyzed. All Nurse-Doctor Co-Teaching sessions scored in the excellent range between 1.00 and 1.43 on a Likert scale (1 is excellent and 5 is poor). In response to the question "What did you like best?", interactive teaching strategies was the most frequent spontaneous answer. A significant correlation between the number of interactive teaching strategies and enjoyability of the session (p-value=0.01) was observed. Measures of interprofessional collaboration and communication did not change significantly in the pre-intervention compared to post-intervention period.

CONCLUSION

We created a unique model of interprofessional co-teaching on an inpatient service. The overall excellent ratings of our interactive sessions indicate that Nurse-Doctor Co-Teaching is a valued form of learning. Our structured format is adaptable to various medical settings and could be expanded to include additional allied health professionals. We plan further studies to assess if Nurse-Doctor Co-Teaching improves measures of interprofessional collaboration.

Optimizing Multidisciplinary Simulation in Medical School for Larger Groups: Role Assignment by Lottery and Guided Learning

PURPOSE

Medical school simulations are often designed for a limited number of students to maximize engagement and learning. To ensure that all first-year medical students who wished to join had an opportunity to participate, we designed a novel method for larger groups.

PATIENTS AND METHODS

We devised a low technology "Orchestra Leader's" chart approach to prominently display students' roles, chosen by lottery. During simulation, the chart was mounted on an intravenous pole and served as a group organizational tool. A course instructor prompted students using the chart to accomplish the course objectives in a logical order. Real-life cardiologists and gastroenterologists provided the students with expert subspecialty consultation. We analyzed 125 anonymous student evaluation ratings for 3 years (2017-2019) with a range of 8 to 19 students per laboratory session.

RESULTS

Our 2017-2019 larger group sessions were all rated as excellent (1.26, Mean, SD ±.510) on the Likert scale where 1.0 is excellent and 5.0 is poor. There were no statistically significant differences in overall ratings among the 2017, 2018 and 2019 sessions. The subspecialists were uniformly rated as excellent. Verbatim free-text responses demonstrated resounding student appreciation for the role assignment by lottery method.

CONCLUSION

We designed a novel, "Orchestra Leader's" chart approach for accommodating larger groups in a multidisciplinary simulation laboratory using role assignment by lottery, roles depicted on an organizational chart, and expert instructor prompting. Our consistently excellent ratings suggest that our methods are useful for achieving well-rated larger group simulation laboratories.

Is Asking Questions on Rounds a Teachable Skill? A Randomized Controlled Trial to Increase Attendings' Asking Questions

BACKGROUND

Morning bedside rounds remain an essential part of Internal Medicine residency education, but rounds vary widely in terms of educational value and learner engagement.

OBJECTIVE

To evaluate the efficacy of an intervention to increase the number and variety of questions asked by attendings at the bedside and assess its impact.

DESIGN

We conducted a randomized, controlled trial to evaluate the efficacy of our intervention.

PARTICIPANTS

Hospitalist attendings on the general medicine service were invited to participate. Twelve hospitalists were randomized to the experimental group and ten hospitalists to the control group.

INTERVENTION

A one-hour interactive session which teaches and models the method of asking questions using a non-medical case, followed by practice using role plays with medical cases.

MAIN MEASURES

Our primary outcome was the number of questions asked by attendings during rounds. We used audio-video recordings of rounds evaluated by blinded reviewers to quantify the number of questions asked, and we also recorded the type of question and the person asked. We assessed whether learners found rounds worthwhile using anonymous surveys of residents, patients, and nurses.

KEY RESULTS

Blinded analysis of the audio-video recordings demonstrated significantly more questions asked by attendings in the experimental group compared to the control group (mean number of questions 23.5 versus 10.8, p< 0.001) with significantly more questions asked of the residents (p<0.003). Residents rated morning bedside rounds with the experimental attendings as significantly more worthwhile compared to rounds with the control group attendings (p=0.009).

CONCLUSION

Our study findings highlight the benefits of a one-hour intervention to teach faculty a method of asking questions during bedside rounds. This educational strategy had the positive outcome of including significantly more resident voices at the bedside. Residents who rounded with attendings in the experimental group were more likely to "strongly agree" that bedside rounds were "worthwhile".

Case-Based Curriculum With Integrated Smartphone Applications Improves Internal Medicine Resident Knowledge Of Contraceptive Care

BACKGROUND

Contraception is an essential preventive service for all women. However, the literature suggests that internal medicine residents have low levels of confidence and knowledge of contraceptive care.

OBJECTIVE

We designed and implemented a novel contraception curriculum promoting active, collaborative learning. We sought to evaluate whether this curriculum improved internal medicine resident knowledge of and comfort with contraceptive care through the administration of pre-/post-surveys.

METHODS

Our curriculum was delivered in a two-hour session as part of the mandatory ambulatory curriculum for internal medicine interns at our institution in the academic year 2017-2018. Interns were provided with select online resources and two smartphone applications at the beginning of the session, which they then used in case-based small group work. Small group work was followed by a large group case review, co-facilitated by OB/GYN and internal medicine faculty.

RESULTS

Thirty-eight participants completed surveys assessing knowledge of and comfort with contraceptive care immediately before and after the curriculum; 20 participants completed surveys assessing the same domains 4-6 months after the curriculum. Data from surveys administered immediately post-curriculum demonstrated significant improvements in knowledge about and comfort with counseling about, assessing medical eligibility for, and initiating multiple forms of contraception. Many of these improvements in knowledge and comfort were maintained on follow-up surveys 4-6 months following the curriculum.

CONCLUSION

Our case-based curriculum with integrated smartphone applications resulted in significant improvements in internal medicine resident knowledge of and comfort with the key skills of contraceptive care. In contrast to active, collaborative learning methodologies such as the flipped classroom, our methodology supports active, collaborative learning without requiring advance learner preparation, and is thus well suited to the time constraints of the graduate medical education setting. Our methodology is readily translatable to other clinical topics and residency curricula.

Health Care Use by Muslim Patients During Ramadan

PURPOSE

Health care utilization during Ramadan has not been examined in the United States.

METHODS

A retrospective review of billing and electronic health record data for Muslims (n = 2,919) and non-Muslims (n = 184,803) in primary care practices in Eastern Massachusetts.

RESULTS

Muslim patients were younger, less educated, less often commercially insured, more likely to have Medicare, and less likely to be primary English speakers (p &lt; .0001 for all comparisons). In multivariate models, during Ramadan, Muslims, compared with non-Muslims, had a higher rate of primary care visits (incidence rate ratio [IRR], 1.06; 95% confidence interval [CI], 1.01-1.11), emergency department visits (IRR, 1.60; 95% CI, 1.34-1.91), and hospitalizations (IRR, 1.18; 95% CI, 1.03-1.34).

CONCLUSIONS

Important demographic differences exist between Muslim and non-Muslim patients. Muslims, compared with non-Muslims, had higher health care utilization during Ramadan.

Scope of Burnout Among Young Gastroenterologists and Practical Solutions from Gastroenterology and Other Disciplines

Burnout is a critical issue among physicians, including gastroenterologists. Up to 50% of gastroenterologists have reported symptoms of burnout in national assessments, leading to increased recognition of the burden of burnout among subspecialty societies. Particularly alarming in these assessments of burnout is the suggestion of increased rates of burnout among trainees and early career gastroenterologists. In this article, we describe the scope of burnout among young gastroenterologists and the risk factors that contribute. In addition, we will offer practical solutions to reduce burnout based on insights developed from multidisciplinary approaches, including relevant burnout literature, organizational approaches within academic medical centers, and training programs, as well as interviews with successful private practice gastroenterologists, and leaders in the fields of business and education.

Teaching methods used by internal medicine residents on rounds: what works?

BACKGROUND

The specific teaching methods used by internal medicine residents on walk rounds are unknown.

OBJECTIVES

1) To characterize in real time the specific teaching methods used by internal medicine residents on rounds and 2) to identify attributes of successful resident teaching on rounds.

MATERIALS AND METHODS

We conducted a prospective mixed-methods study on inpatient medical services at a single academic medical center from September 2016 to January 2017. Participants were internal medicine residents (postgraduate year [PGY]-1, PGY-2, and PGY-3) and attending physicians. Teachers were PGY-2 and PGY-3 residents, and learners were PGY-1 residents. Residents' teaching on rounds was observed and characterized according to resident demographics, specific teaching methods, and length of time. Participants completed a survey with Likert scale and free-text questions.

RESULTS AND CONCLUSION

Among 136 surveys across 28 separate teaching encounters, we noted that PGY-3 residents' teaching was rated significantly better than PGY-2 residents' teaching. Teaching lasting >1 minute was rated significantly better than teaching lasting <1 minute. Free-text responses emphasized the value of immediate clinical relevance, citing published evidence, conciseness, clarity, and pertinence to the patient. Our findings may help guide internal medicine residents aiming to teach better on rounds and inform further research into specific resident teaching methods.

Asking what do residents value most: a recent overview of internal medicine residents' learning preferences

BACKGROUND

Little is known about the preferred learning experiences of today's internal medicine residents. We conducted a survey of the educational experiences in an internal medicine residency to determine the learning opportunities internal medicine residents value most and why.

METHODS

An online, anonymous survey of 182 internal medicine residents was performed, with each resident receiving a survey each day over nine days. Participants were asked to state their most valuable learning experience over the past day, describe why it was valuable, and rank it on a 5-point Likert-type scale. Resident free-text responses were coded and grouped into themes. The location of and participants in the experience were also examined.

RESULTS

The 182 residents completed a total of 303 surveys. Of the 303 surveys, 92% (N=277) of the responses noted their chosen learning experience was useful. An attending was involved in 50% (N=152) of experiences; the patient was noted as a participant in 8% (N=25) of experiences. Free-text responses were coded into five thematic groups descriptive of why residents found their learning experiences to be valuable: Repetition in Learning, Effective Pedagogy, Clinical Problem Solving as an Individual or Collaboratively, Opportunity for Active Engagement, and Bedside Learning.

CONCLUSION

Our data provide a broader framework for designing and implementing future faculty development and resident curricula that emphasize interprofessional education and the patient as a key educational figure.

Volunteer patients and small groups contribute to abdominal examination's success

BACKGROUND

Prior to 2007, we taught the abdominal examination in a hospital based group to 40 students, at one hospital. We used volunteer patients, small groups, repetition, and required faculty development sessions. In 2007, our medical school changed its "Introduction to Physical Examination" session so that the entire class was to be taught in a geographically central session. Our hospital was selected to lead the abdominal examination portion of the session.

AIM

Our aim was to answer three questions. First, could we quadruple the recruitment of volunteer patients, and faculty? Second, was it volunteer patients, small groups, repetition, or faculty training that was most valued by the students? Third, would volunteer patients and/or faculty agree to participate a second time?

METHODS

A total of 43-46 patients and 43-46 faculty were recruited and 43-46 examining rooms were obtained for each of the 5 years of this study. Teachers were required to attend a 1-hour faculty development session. The class of about 170 students was divided into 43-46 groups each year. The teacher demonstrated the abdominal examination and each student practiced the examination on another student. Each student then repeated the full abdominal examination on a volunteer patient.

RESULTS

Over the 5-year time period (2008-2012), the abdominal examination ranked first among all organ systems' "Introductory Sessions". The abdominal examination ratings had the best mean score (1.35) on a Likert scale where 1 is excellent and 5 is poor. The students gave the most positive spontaneous comments to having volunteer patients, with small groups coming in as the second most appreciated educational element.

CONCLUSION

We successfully quadrupled the number of faculty, patients, and examining rooms and created a highly rated educational program as measured by anonymous student evaluations, patient and faculty participation, and the medical school's selecting the abdominal examination methods as an "Advanced Examination" for the Pathways Curriculum.

The Effect of Rubric-Guided, Focused, Personalized Coaching Sessions and Video-Recorded Presentations on Teaching Skills Among Fourth-Year Medical Students: A Pilot Study

PROBLEM

As medical students become residents, teaching becomes an expected and integral responsibility. Yet, training-for-teaching opportunities are lacking. In 2014, the authors designed a pilot study using rubric-guided, focused, personalized coaching sessions and video-recorded presentations to improve student teaching skills among fourth-year students at Harvard Medical School.

APPROACH

In 2014-2015, the authors recruited students from an elective on how to tutor preclinical students for the pilot, which consisted of four phases: a precoaching teaching presentation, a 30- to 45-minute coaching session, a postcoaching teaching presentation, and blinded reviewer ratings. Students' pre- and postcoaching presentations were video recorded. Using a scoring rubric for 15 teaching skills, students rated their pre- and postcoaching videos. Blinded reviewers also rated the pre- and postcoaching presentations using the same rubric with an additional category to gauge their overall impression.

OUTCOMES

Fourteen students completed all four phases of the pilot. Students' ratings demonstrated statistically significant improvement in several teaching skills, including presentation content (P < .001), rate of speech (P = .001), and opening statement and learning objectives (P = .004). Blinded reviewers' ratings demonstrated statistically significant improvements in several teaching skills, including opening statement and learning objectives (P < .001), overall impression (P = .001), and conclusion and summary of learning objectives (P = .004). Students provided largely positive comments on the interventions.

NEXT STEPS

The authors will work toward addressing limitations in the rubric, using coaching in different teaching settings, addressing the interventions' generalizability, training coaches, and performing additional evaluations.

An active learning curriculum improves fellows' knowledge and faculty teaching skills

OBJECTIVES

Traditional didactic lectures are the mainstay of teaching for graduate medical education, although this method may not be the most effective way to transmit information. We created an active learning curriculum for Brigham and Women's Hospital (BWH) gastroenterology fellows to maximize learning. We evaluated whether this new curriculum improved perceived knowledge acquisition and knowledge base. In addition, our study assessed whether coaching faculty members in specific methods to enhance active learning improved their perceived teaching and presentation skills.

METHODS

We compared the Gastroenterology Training Exam (GTE) scores before and after the implementation of this curriculum to assess whether an improved knowledge base was documented. In addition, fellows and faculty members were asked to complete anonymous evaluations regarding their learning and teaching experiences.

RESULTS

Fifteen fellows were invited to 12 lectures over a 2-year period. GTE scores improved in the areas of stomach (p<0.001), general gastroenterology (p=0.005), esophagus (p<0.001), and small bowel (p=0.001), and the total score (p=0.001) between pre- and postimplementation of the active learning curriculum. Scores in hepatology, as well as biliary and pancreatic study, showed a trend toward improvement (p>0.05). All fellows believed the lectures were helpful, felt more prepared to take the GTE, and preferred the interactive format to traditional didactic lectures. All lecturers agreed that they acquired new teaching skills, improved teaching and presentation skills, and learned new tools that could help them teach better in the future.

CONCLUSION

An active learning curriculum is preferred by GI fellows and may be helpful for improving transmission of information in any specialty in medical education. Individualized faculty coaching sessions demonstrating new ways to transmit information may be important for an individual faculty member's teaching excellence.

Innovative curriculum for second-year Harvard-MIT medical students: practicing communication skills with volunteer patients giving immediate feedback

PURPOSE

Medical students are expected to develop excellent communication skills. The purpose of our study was to create an innovative communication skills exercise using real volunteer patients and physician co-teachers for students to practice communication skills while receiving immediate feedback.

METHOD

This is a mixed methods study where second-year medical students participated in the communication skills exercise with real patients and physician co-teachers giving immediate feedback. Clinical scenarios reflected the patients' actual experiences. Students acted out roles as physicians. Physicians co-taught with the patients and gave immediate feedback to students. Students completed an anonymous written survey at the end of the exercise. Qualitative and quantitative responses were recorded. Student feedback from the 2014 surveys was used to modify the teaching designs to increase active role play opportunities by having only two students in each group and doubling the number of stations with real patients.

RESULTS

Students rated the overall exercise and the utility of patient volunteers in learning how to communicate on a Likert scale of 1-5, where in this medical school traditionally 1 is excellent and 5 is poor. In 2014, the exercises were rated with a mean score of 1.47 (SD 0.621). In 2015, the exercises were rated with a mean score of 1.03 (SD 0.62). In 2016, the exercises were rated with a mean score of 1.27 (SD 0.52). ANOVA analysis (p=0.002) and Bonferroni corrections indicate a statistically significant difference between combined mean scores of the exercise in 2014 and 2015 (p=0.001). No difference was shown between 2014 and 2016 or 2015 and 2016.

CONCLUSIONS

Medical students rated practicing communication skills with real patient volunteers and physician co-teachers giving immediate feedback in their preclinical years very highly. Student feedback indicated that they preferred active roles and increased opportunities to practice their communication skills.

Working up rectal bleeding in adult primary care practices

RATIONALE, AIMS AND OBJECTIVES

Variation in the workup of rectal bleeding may result in guideline-discordant care and delayed diagnosis of colorectal cancer. Accordingly, we undertook this study to characterize primary care clinicians' initial rectal bleeding evaluation.

METHODS

We studied 438 patients at 10 adult primary care practices affiliated with three Boston, Massachusetts, academic medical centres and a multispecialty group practice, performing medical record reviews of subjects with visit codes for rectal bleeding, haemorrhoids or bloody stool. Nurse reviewers abstracted patients' sociodemographic characteristics, rectal bleeding-related symptoms and components of the rectal bleeding workup. Bivariate and multivariable logistic regression models examined factors associated with guideline-discordant workups.

RESULTS

Clinicians documented a family history of colorectal cancer or polyps at the index visit in 27% of cases and failed to document an abdominal or rectal examination in 21% and 29%. Failure to order imaging or a diagnostic procedure occurred in 32% of cases and was the only component of the workup associated with guideline-discordant care, which occurred in 27% of cases. Compared with patients at hospital-based teaching sites, patients at urban clinics or community health centres had 2.9 (95% confidence interval 1.3-6.3) times the odds of having had an incomplete workup. Network affiliation was also associated with guideline concordance.

CONCLUSION

Workup of rectal bleeding was inconsistent, incomplete and discordant with guidelines in one-quarter of cases. Research and improvements strategies are needed to understand and manage practice and provider variation.

Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures

BACKGROUND

Although delayed colorectal cancer diagnoses figure prominently in medical malpractice claims, little is known about the quality of primary care clinicians' workup of rectal bleeding.

METHODS

In this study, 438 patients were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for rectal bleeding, hemorrhoids, and blood in the stool at 10 Boston adult primary care practices. Following nurse chart abstraction, physician reviewers assessed the overall quality of care and key care processes. Subjects' characteristics and physician reviewers' processes-of-care assessments were tabulated, and logistic regression models were used to examine the association of process failures with overall quality and guideline concordance.

RESULTS

Although reviewers judged the overall quality of care to be good or excellent in 337 (77%) of 438 cases, 312 (71%) patients experienced at least one process-of-care failure in the workup of rectal bleeding. Clinicians failed to obtain an adequate family history in 38% of cases, complete a pertinent physical exam in 23%, and order laboratory tests in 16%. Failure to order or perform tests, or to make follow-up plans were associated with increased odds of poor or fair care. Guideline concordance bore little relationship with quality judgments. Reviewers judged that 128 delays could have been reduced or prevented.

CONCLUSION

Process-of-care failures among adult primary care patients with rectal bleeding were frequent and associated with fair or poor quality. Educating practitioners and creating systems to ensure adequate history taking, physical examination, and processes for ordering, performing, and interpreting diagnostic tests may improve performance.

A faculty development program integrating cross-cultural care into a gastrointestinal pathophysiology tutorial benefits students, tutors, and the course

A specific faculty development program for tutors to teach cross-cultural care in a preclinical gastrointestinal pathophysiology course with weekly longitudinal followup sessions was designed in 2007 and conducted in the same manner over a 6-yr period. Anonymous student evaluations of how "frequently" the course and the tutor were actively teaching cross-cultural care were performed. The statements "This tutor actively teaches culturally competent care" and "Issues of culture and ethnicity were addressed" were significantly improved over baseline 2004 data. These increases were sustained over the 6-yr period. A tutor's overall rating as a teacher was moderately correlated with his/her "frequently" actively teaching cross-cultural care (r = 0.385, P < 0. 001). Course evaluation scores were excellent and put the course into the group of preclinical courses with the top ratings. Students in the Race in Curriculum Group asked that the program be expanded to other preclinical courses. In conclusion, from 2007 to 2012, a faculty development program for teaching cross-cultural care consistently increased the discussion of cross-cultural care in the tutorial and course over each year beginning with 2007 compared with the baseline year of 2004. Our data suggest that cross-cultural care can be effectively integrated into pathophysiology tutorials and helps improve students' satisfaction and tutors' ratings. Teaching cross-cultural care in a pathophysiology tutorial did not detract from the course's overall evaluations, which remained in the top group over the 6-yr period.

A division of medical communications in an academic medical center's department of medicine

Excellent physician communication skills (physician-to-patient and patient-to-physician) have been found to have a positive impact on patient satisfaction and may positively affect patient health behaviors and health outcomes. Such skills are also essential for accurate, succinct, and clear peer-to-peer (physician-to-physician), physician-to-lay-public, and physician-to-media communications. These skills are not innate, however; they must be learned and practiced repeatedly. The Division of Medical Communications (DMC) was created within the Department of Medicine at Brigham and Women's Hospital as an intellectual home for physicians who desire to learn and teach the wide variety of skills needed for effective communication.In this Perspective, the authors provide an overview of the key types of medical communications and share the DMC model as an innovative approach to providing expert guidance to physicians and physicians-in-training as they develop, practice, and refine their communication skills. Current DMC projects and programs include a Volunteer Patient Teaching Corps, which provides feedback to medical students, residents, and faculty on communication skills; a controlled trial of a modified team-based learning method for attending rounds; expert coaching in preparation for presentations of all types (e.g., grand rounds; oral presentations or poster presentations on basic science, clinical, or medical education research); sessions on speaking to the media and running a meeting well; and courses on writing for publication. Objective assessment of the impact of each of these interventions is planned.

Disparities in evaluation of patients with rectal bleeding 40 years and older

BACKGROUND & AIMS

Rectal bleeding is associated with colorectal cancer. We characterized the evaluation of patients aged 40 years and older with rectal bleeding and identified characteristics associated with inadequate evaluation.

METHODS

We conducted a retrospective review of records of outpatient visits that contained reports of rectal bleeding for patients aged 40 years and older (N = 480). We studied whether patient characteristics affected whether or not they received a colonoscopy examination within 90 days of presentation with rectal bleeding. Patient characteristics included demographics; family history of colon cancer and polyps; and histories of screening colonoscopies, physical examinations, referrals to specialists at the index visit, and communication of laboratory results. Data were collected from medical records, and patient income levels were estimated based on Zip codes.

RESULTS

Nearly half of the patients presenting with rectal bleeding received colonoscopies (48.1%); 81.7% received the procedure within 90 days. A history of a colonoscopy examination was more likely to be reported in white patients compared with Hispanic or Asian patients (P = .012 and P = .006, respectively), and in high-income compared with low-income patients (P = .022). A family history was more likely to be documented among patients with private insurance than those with Medicaid or Medicare (P = .004). A rectal examination was performed more often for patients who were white or Asian, male, and with high or middle incomes, compared with those who were black, Hispanic, female, or with low incomes (P = .027). White patients were more likely to have their laboratory results communicated to them than black patients (P = .001).

CONCLUSIONS

Sex, race, ethnicity, patient income, and insurance status were associated with disparities in evaluation of rectal bleeding. There is a need to standardize the evaluation of patients with rectal bleeding.

The impact of cross-cultural interactions on medical students' preparedness to care for diverse patients

PURPOSE

Medical students who graduate from schools with diverse student populations are more likely to rate themselves as prepared to care for diverse patients compared with students who graduate from more homogenous schools. This study aimed to identify the types of cross-cultural interactions associated with students' self-rated preparedness.

METHOD

In 2010, the authors developed and administered a Web-based survey that queried Harvard Medical School students about their voluntary interethnic interactions (studying, socializing), participation in diversity-related extracurricular activities, and self-rated preparedness to care for diverse patients. The authors separated students' responses regarding interethnic interactions and participation in diversity-related extracurricular activities into high and low participation, then determined the association between these responses and those to questions about students' self-rated preparedness to care for diverse patients. They used ANOVA and Z tests of proportion to analyze their data.

RESULTS

Of 724 eligible students, 460 completed the survey (64%). Seventy-five percent (324/433) believed they were prepared to care for patients from backgrounds different from their own. Students who spent >75% of their study time with students from different backgrounds or who participated in a greater number of diversity-related extracurricular activities were more likely to rate themselves as prepared to care for diverse patients overall and to perform seven other skills.

CONCLUSIONS

Voluntary cross-cultural interactions, both studying and socializing, are associated with higher self-rated preparedness to care for patients from diverse backgrounds. Medical schools should continue to support multicultural pursuits to prepare students to become physicians sensitive to the needs of diverse patients.

Barrett's esophagus: endoscopic treatments II

The following on endoscopic treatments of Barrett's esophagus includes commentaries on animal experiments on cryotherapy; indications for cryotherapy, choice of dosimetry, number of sessions, and role in Barrett's esophagus and adenocarcinoma; recent technical developments of RFA technology and long-term effects; the comparative effects of diverse ablation procedures and the rate of recurrence following treatment; and the indications for treatment of dysplasia and the role of radiofrequency ablation.

Using medical students to enhance curricular integration of cross-cultural content

We hypothesized that an interested medical student group would be helpful in reviewing tutorial cases and giving relevant feedback on the curricular integration of cross-cultural content using case triggers in a preclinical gastrointestinal pathophysiology course. Self-selected student leaders (n = 9) reviewed pre-existing problem-based learning tutorial cases (n = 3) with cross-cultural triggers, and provided narrative feedback to course faculty. The cases were modified and used for the entire class in the following 2 years. Participating course students' comments and teaching faculty feedback were also noted. Outcomes were a change in case content, student global evaluations of the course, and self-reported faculty comfort with teaching the cases. All three tutorial cases were reviewed by a separate group of 2-3 students. Major and minor revisions were made to each case based on the student feedback. These cases were used in 2007 and 2008 and were the major change to the course during that time. Overall course evaluation scores improved significantly from 2006 to 2008 (p = 0.000). Tutors (n = 22 in 2007; n = 23 in 2008) expressed relief during tutor meetings that students had reviewed the cases. A general framework for eliciting student feedback on problem-based cases was developed. Student feedback, consisting of self-selected students' case reviews and solicited course and tutor comments, added value to a curricular reform to improve the integration of cross-cultural content into a problem-based learning curriculum. Our study underscores the fundamental link between teachers and students as partners in curricular development.

Exposure to both radiation and chemotherapy increases the risk of Barrett's and multilayered epithelium

The relationship between radiation and/or chemotherapy and the development of Barrett's and/or multilayered epithelium has not been investigated before. We ascertained a group of patients exposed to radiation and/or chemotherapy and an unexposed group to compare the prevalence rates of Barrett's epithelium and multilayered epithelium at the time of endoscopy in these two groups. Barrett's epithelium was found in ten of the 19 (53%) exposed patients, compared to eight of 38 (21%) unexposed subjects (P = 0.02). Six of 19 (32%) exposed patients had multilayered epithelium, compared to four of 38 (11%) unexposed subjects (P = 0.06). Twelve of the 19 exposed patients (63%) had either Barrett's or multilayered epithelium, in contrast to ten of 38 (26%) unexposed subjects (P = 0.01). Those with exposure to both chemotherapy and radiation had a significant increase in the risk for Barrett's and/or multilayered epithelium (P = 0.003). This study suggests a relationship between exposure to a combination of radiation and chemotherapy and the development of Barrett's and/or multilayered epithelium.

Integration of racial, cultural, ethnic, and socioeconomic factors into a gastrointestinal pathophysiology course

BACKGROUND & AIMS

Our study describes a faculty development program to encourage the integration of racial, cultural, ethnic, and socioeconomic factors such as obesity, inability to pay for essential medications, the use of alternative medicine, dietary preferences, and alcoholism in a gastrointestinal pathophysiology course.

METHODS

We designed a 1-hour faculty development session with longitudinal reinforcement of concepts. The session focused on showing the relevance of racial, ethnic, cultural, and socioeconomic factors to gastrointestinal diseases, and encouraged tutors to take an active and pivotal role in discussion of these factors. The study outcome was student responses to course evaluation questions concerning the teaching of cultural and ethnic issues in the course as a whole and by individual tutorials in 2004 (pre-faculty development) and in 2006 to 2008 (post-faculty development).

RESULTS

Between 2004 and 2008, the proportion of students reporting that "Issues of culture and ethnicity as they affect topics in this course were addressed" increased significantly (P = .000). From 2006 to 2008, compared with 2004, there was a significant increase in the number of tutors who "frequently" taught culturally competent care according to 60% or greater of their tutorial students (P = .003). The tutor's age, gender, prior tutor experience, rank, and specialty did not significantly impact results.

CONCLUSIONS

An innovative faculty development session that encourages tutors to discuss racial, cultural, ethnic, and socioeconomic issues relevant to both care of the whole patient and to the pathophysiology of illness is both effective and applicable to other preclinical and clinical courses.

Gastrointestinal manifestations of dermatologic disorders

The skin and the gastrointestinal tract may be affected concurrently by the same diseases. Pathogenetically, these conditions may be primarily dermatologic diseases involving the gastrointestinal (GI) tract or systemic diseases involving the skin, GI tract, and liver simultaneously. The correct diagnosis of such conditions relies on the ability of the gastroenterologist to recognize the underlying dermatologic disorder. The goal of this clinical review article is to increase gastroenterologists' awareness and understanding of some of these conditions. Case vignettes are presented and the relevant literature reviewed for epidermolysis bullosa, mastocytosis, hereditary hemorrhagic telangiectasia, and melanoma. This review focuses on increasing gastroenterologists' ability to recognize, diagnose, comprehend, and manage patients with these dermatologic conditions who have GI manifestations. Advances in molecular genetics that provide insight into the underlying pathophysiology and histopathology of these lesions are highlighted.

A faculty development program to train tutors to be discussion leaders rather than facilitators

PURPOSE

During 2003, 2004, and 2005, the role of 70 tutors was changed from that of facilitator to discussion leader, in a preclinical PBL learning course, Gastrointestinal Pathophysiology, by use of three key business school teaching strategies: questions, summaries, and schematics. The purpose of this study was to learn what difference this new approach made.

METHOD

During each of the three study years, 171 (2003), 167 (2004), and 170 (2005) students were given Likert-scale attitudinal questionnaires to rate whether their tutors encouraged student direction of the tutorials and whether the summaries and closure schematics benefited their learning. Students' overall course evaluations and mean USMLE scores were quantitatively analyzed, pre- and postintervention. A variety of statistical tests were used to assess the statistical significance of means at the confidence level of .05.

RESULTS

In the third year of the program, student ratings indicated that their tutors were significantly better at encouraging student direction of the tutorials than in the first year (P < .05). The students reported that the tutorial made a more important contribution to their learning (P < .05), and the course objectives were better stated (P = .038) and better met (P = .007). Overall satisfaction with the course also improved significantly (P = .006). Part I gastrointestinal system mean scores of the USMLE showed a statistically significant increase in 2005 compared with 2001 or 2002.

CONCLUSIONS

The tutor as a discussion leader who questions, summarizes, and uses schematics to illustrate concepts had a significant and positive impact on learning in tutorials, achieving course objectives, improving overall course satisfaction, and increasing a standardized national exam's mean score.

Multilayered epithelium may be found in patients with Barrett's epithelium and dysplasia or adenocarcinoma

To determine if multilayered epithelium (MLE) is a useful prognostic indicator for a benign natural history of Barrett's epithelium, we evaluated endoscopic biopsies from patients with Barrett's epithelium without and with dysplasia and/or adenocarcinoma and from non-Barrett's controls for the presence of MLE. MLE was found in 6% of non-Barrett's controls, 30% of Barrett's patients with no dysplasia, and 14% of Barrett's patients with dysplasia and/or adenocarcinoma. MLE was significantly associated with shorter lengths of Barrett's epithelium in both Barrett's groups. Three of 5 photodynamic therapy patients were noted to develop MLE after therapy. MLE may be found in patients with dysplasia and/or adenocarcinoma and after photodynamic therapy; its presence is not useful as a prognostic indicator for a more benign course of Barrett's. This study confirms that MLE is significantly associated with shorter lengths of Barrett's epithelium.

Prospective evaluation of multilayered epithelium in Barrett's esophagus

OBJECTIVE

We recently identified a distinctive type of multilayered epithelium in two patients with Barrett's esophagus, which shows morphological characteristics of both squamous and columnar epithelium. This study was performed to prospectively evaluate the prevalence of multilayered epithelium in patients with Barrett's esophagus.

METHODS

Mucosal biopsies were obtained from the squamocolumnar junction (Z-line) of 58 patients with endoscopic evidence of esophageal columnar epithelium and from the gastroesophageal junction in 21 patients without endoscopic evidence of esophageal columnar epithelium. Specimens were evaluated for the presence of multilayered epithelium and goblet cells.

RESULTS

Twenty-four of 58 (41%) of the patients with endoscopic evidence of esophageal columnar epithelium had multilayered epithelium compared with only one of 21 patients (5%) in the control group (p = 0.005). Of the 58 patients in the study group, 43 had goblet cell metaplasia and 15 did not (p < 0.001). Only patients with goblet cell metaplasia had multilayered epithelium. Shorter lengths of columnar epithelium were noted in the 24 patients with goblet cells and multilayered epithelium compared with the 19 patients with goblet cells and no multilayered epithelium (p < 0.05).

CONCLUSIONS

Multilayered epithelium is strongly associated with goblet cell metaplasia in patients with endoscopic evidence of esophageal columnar epithelium. These data support the hypothesis that multilayered epithelium may represent a transitional stage in the development of Barrett's esophagus.

Factors that influence the decision to do an adequate evaluation of a patient with a positive stool for occult blood

OBJECTIVE

The factors that influence the decision to do an adequate evaluation for a positive test for fecal occult blood in a middle-aged or elderly patient are largely unknown. Our study was undertaken to determine whether factors such as the number of positive Hemoccult II card windows, age, gender, family history of colon cancer, the patient's concern that he or she might have colon cancer, or history of rectal bleeding influence the evaluation performed.

METHOD

A mass screening program for colon cancer was performed using unrehydrated Hemoccult II cards in the Boston area.

RESULTS

Among the 23,593 Hemoccult II cards returned to Beth Israel Deaconess Medical Center, cards from 1,112 patients (4.7%) were found to be positive for one or more of the six possible card windows. Ninety percent, or 940 patients, over 40 yr of age had follow-up information available. As the number of positive windows increased from one to four, there was a significant trend (p < 0.001) for the adequacy of the evaluation to increase. Family history (p = 0.044) and a patient's worry that he or she might have colon cancer (p = 0.003) significantly improved a patient's chance for an adequate evaluation.

CONCLUSIONS

Hemoccult testing is not followed by an adequate evaluation in a significant proportion of patients. Our study points out for the first time that the number of positive Hemoccult windows significantly influences the decision-making.

Distribution of cytokeratin markers in Barrett's specialized columnar epithelium

BACKGROUND & AIMS

The cell of origin for Barrett's epithelium is unknown. A multilayered epithelium within Barrett's epithelium has been noted recently. To investigate the hypothesis that this multilayered epithelium may be a transitional stage between squamous and Barrett's epithelium, cytokeratin immunocytochemistry was used to examine normal squamous, Barrett's, and multilayered epithelium.

METHODS

Seventeen endoscopic biopsy specimens taken from the squamo-Barrett's junction of 8 patients with Barrett's epithelium and 3 biopsy specimens from the gastroesophageal junction of 3 patients without Barrett's epithelium were investigated. Antibodies to cytokeratins 4 and 13 were used as markers for squamous differentiation, and antibodies to cytokeratins 8 and 19 were used as markers for glandular differentiation. Coded samples were evaluated by immunocytochemistry.

RESULTS

In patients with Barrett's epithelium and control patients, staining with columnar markers was confined to either the Barrett's or the gastric columnar epithelium. Staining with squamous markers was confined to the adjacent squamous epithelium. In contrast, focal areas of multilayered epithelium amidst Barrett's epithelium stained with cytokeratin antibodies for both squamous and columnar epithelium.

CONCLUSIONS

A focal multilayered epithelium within Barrett's epithelium that expresses concurrently both squamous and glandular cytokeratin markers is described. These findings suggest a multipotential cell as the cell of origin of Barrett's epithelium.

Morphological characterization of the squamocolumnar junction of the esophagus in patients with and without Barrett's epithelium

Barrett's esophagus is a metaplastic condition in which the normal stratified squamous epithelium of the distal esophagus is replaced by columnar epithelium. Our group has previously characterized a unique surface cell (the "distinctive cell") at the junction of squamous and Barrett's epithelium. This cell is notable for the simultaneous presence on its surface of both squamous and columnar cell features. The aims of our present study were, first, to evaluate prospectively the frequency with which Barrett's patients have the distinctive cell at the squamo-Barrett's junction; second, to further elucidate the characteristics of the distinctive cell; and third, to perform a combined morphological study of the squamo-Barrett's junction using scanning electron microscopy followed by transmission and light microscopy. We divided study patients into two groups: Group I consisted of Barrett's patients and group II of non-Barrett's control patients. Of eight group I Barrett's patients with junctional biopsies, three were noted to have the distinctive cell (37.5%). In contrast, this cell was not observed in any of the group II control patients. Biopsies in control patients as well as Barrett's patients without the distinctive cell revealed abrupt squamogastric or squamo-Barrett's junctions by scanning electron microscopy and light microscopy. In contrast, biopsies from the Barrett's patients with the distinctive cell revealed junctions that were not abrupt and had the distinctive cells overlying normal squamous epithelium. By scanning electron microscopy, the distinctive cells were flattened, polygonal cells with surface microvilli (a columnar cell feature) and were demarcated from one another by shallow depressions, or by intercellular ridges (a squamous cell feature). By transmission electron microscopy, the distinctive cells were cuboidal in shape with abundant apical microvilli and secretory vesicles. We have confirmed that distinctive cells are present in some Barrett's patients. This cell is a morphologic hybrid, sharing features of both squamous and columnar cells, and may be analogous to hybrid cells identified in other locations that undergo metaplasia (eg, the human cervix). Its origin may be the result of transformation of multipotential basal cells of squamous epithelial origin. We hypothesize that the distinctive cells may represent an intermediate stage in the development of Barrett's epithelium.

Scanning electron microscopy of the human esophagus: application to Barrett's esophagus, a precancerous lesion

In Barrett's esophagus, metaplastic columnar epithelium replaces the normal squamous epithelium. The importance of this lesion lies in the increased incidence of adenocarcinoma of the esophagus occurring in patients with Barrett's esophagus. We characterized the surface epithelial cells of Barrett's esophagus using quantitative scanning electron microscopy. Three distinct surface cell types, in addition to the globlet cell, were recognized in Barrett's epithelium: the gastric-like cell and the intestinal-like cell, both of which were similar to normal gastric and small intestinal surface cells, respectively, by quantitative scanning electron microscopy, and the variant cell which had a range of surface features. In four biopsy specimens from the squamo-Barrett's junction in three patients, we found the distinctive cell that had features intermediate between those of squamous and columnar epithelium. On the distinctive cell's surface there are two disparate structures not normally present on the same cell in the gastrointestinal tract: microvilli (a scanning electron microscopy feature of glandular epithelium) and intercellular ridges (a scanning electron microscopy feature of squamous epithelium). The surface characteristics of this cell were almost identical to those of cells found in the transformation zone of the uterine cervix, an area in which squamous epithelium physiologically replaces columnar epithelium. Scanning electron microscopy of Barrett's esophagus has increased our understanding of this precancerous lesion by showing striking cellular heterogeneity. It has also identified the distinctive cell which may represent an intermediate step in the development of Barrett's epithelium during which the surface characteristics of two different cell types, columnar and squamous, coexist in the same cell.

Detection by scanning electron microscopy of a distinctive esophageal surface cell at the junction of squamous and Barrett's epithelium

Metaplastic columnar epithelium replaces the normal squamous epithelium in Barrett's esophagus. We characterized the surface epithelial cells of the junction between squamous and Barrett's epithelium using scanning electron microscopy and light microscopy. In four biopsy specimens from the squamous-Barrett's junction in three patients, we found a distinctive cell type having features intermediate between those of squamous and columnar epithelium. Its distinguishing characteristic is the presence on its surface of two disparate structures not normally present on the same cell in the gastrointestinal tract: microvilli (a scanning electron microscopy feature of glandular epithelium) and intercellular ridges (a scanning electron microscopy feature of squamous mucosa). The surface characteristics of this newly recognized cell were strikingly similar to those of cells found in the transformation zone of the uterine cervix, an area in which squamous epithelium physiologically replaces columnar epithelium. We also examined 28 biopsies of the gastroesophageal junction area from 14 patients with and without a history of heartburn but with no evidence of Barrett's esophagus. None of these biopsies showed the distinctive cell. We hypothesize that this distinctive cell represents an intermediate step in either the development or the healing of Barrett's epithelium, during which surface characteristics of two different cell types, columnar and squamous, coexist on the same cell.

Light microscopic immunocytochemical localization of hepatic and intestinal types of fatty acid-binding proteins in rat small intestine

Monospecific antisera to purified hepatic fatty acid-binding protein (hFABP) and gut fatty acid-binding protein (gFABP) have been used to localize these two proteins in the small intestine of fed rats at the light microscopic level. Pieces of duodenum, jejunum, and ileum were removed from 4-, 10-, 20-, 22-, and 60-day-old Sprague-Dawley rats. Both cryostat and paraffin sections were studied for the presence of hFABP or gFABP by the avidin-biotin immunoperoxidase method. Slides were graded blind for the intensity of staining. Despite the structural and immunological differences between these two proteins, we showed no major differences between their staining patterns or their staining intensity throughout the intestine during postnatal development. The staining for both fatty acid-binding proteins was cytoplasmic. No brush border staining was found. Staining was more intense in the proximal rather than distal intestine, in the villus rather than crypt cells, and in the apex rather than the base of intestinal cells. Shifts in staining patterns, and staining intensity occurring during development may be related to variations in dietary fat intake, rates of cell proliferation, intestinal anatomy, and mechanisms for fat absorption.

Scanning electron microscopic appearance of chronic ulcerative colitis with and without dysplasia

This study was conducted to determine whether scanning electron microscopy of colonic mucosal biopsy specimens can help to detect dysplasia in patients with chronic ulcerative colitis. In the first phase of the study, using light microscopy as the standard for the diagnosis, the scanning electron microscopic appearance of specimens from patients with chronic ulcerative colitis and control patients was examined. Descriptive criteria were established to identify normal, atrophic, and dysplastic colonic mucosa. In the second phase, quantitative techniques were used to develop more objective criteria for the diagnosis of dysplasia in ulcerative colitis. Twenty-one coded colonic specimens from 11 patients were sequentially examined by scanning electron microscopy and by light microscopy. The three morphometric analyses performed on the surface epithelial cells were number of cells per unit area, number of microvilli per unit area, and percentage of microvilli with a normal width. The cell count and percentage of microvilli with a normal width were significantly reduced in the seven specimens with colonic dysplasia as compared with non-dysplastic tissues. Scanning electron microscopy may serve as an adjunct to light microscopy in the diagnosis of colonic dysplasia.

Distribution of immunoreactive alkaline phosphatase in the adult rat ileum by immunoperoxidase staining at the light microscopic level

Our prior immunocytochemical studies using monospecific antibody to alkaline phosphatase, Bouin's fixation, and paraffin sections demonstrated a decreasing gradient of villus brush border staining from the proximal to the distal rat small intestine. In addition, we noted an unusual pattern of staining in the terminal centimeter of the adult rat ileum: the villus brush border staining was less intense than crypt brush border staining. To determine whether this pattern of staining was present throughout the entire ileum, we examined alkaline phosphatase staining in two separate jejunal sites and the entire lowest third of the intestine of adult Wistar rats. With Bouin's fixation and paraffin embedding, both conventional and germ-free rats showed the same unusual staining pattern throughout the entire ileum. This pattern suggested that bacterial proteases were not responsible for the diminished ileal brush border alkaline phosphatase. However, when acetone fixation and cryostat sections were used with the avidin-biotin-peroxidase complex system, the previously noted reversed gradient of staining between the ileal villus and crypt areas was no longer present. Rather, ileal crypt brush border staining was less than ileal villus brush border staining. With either methodology, jejunal villus brush border staining was significantly more intense than ileal brush border staining, whereas the deep crypt brush border staining was not significantly different between the two regions. The present study reinforces the need for a combination of methodologies in order to best and most accurately localize certain antigens with immunocytochemistry. It also confirms a decreasing proximal to distal gradient for villus brush border alkaline phosphatase despite similar deep crypt brush border staining throughout the small intestine.

Esophageal dysplasia. Assessment by light microscopy and scanning electron microscopy

This study was performed to determine the characteristics of esophageal dysplasia by scanning electron microscopy. A total of 82 esophageal biopsy specimens were taken from 30 patients who were divided into three groups. Group 1 patients had no known esophageal disease. Group 2 patients had squamous cell cancer. Group 3 patients had esophagitis. Mucosal biopsy specimens that had been diagnosed by light microscopy as normal, esophagitis, or dysplastic mucosa were examined by scanning electron microscopy. A characteristic appearance for each type of mucosa was recognized by scanning electron microscopy. A quantitative analysis of the scanning electron microscopy feature of microridge density showed a statistically significant difference not only between normal and dysplastic mucosa, but also between esophagitis and dysplastic mucosa. The addition of scanning electron microscopy to light microscopy may prove helpful in the diagnosis of dysplasia as well as in the understanding of the biologic behavior of dysplastic cells and possibly their relationship to esophageal carcinoma.

The identification and management of patients with a high risk for cardiac arrhythmias during modified ECT

The authors describe the cardiovascular complications of ECT in 42 patients undergoing this procedure during a one year period at a psychiatric referral center. Twenty-eight percent of the entire group of patients developed ischemic and/or arrhythmic complications following ECT. Seventy percent of the patients who had a history, physical or EKG evidence of cardiac disease developed cardiac complications. On the basis of this data, a high risk category for ECT is defined more precisely than previously. Recommendations are made for managing this high risk category of depressed patients in order to treat them with maximum safety and effectiveness.

Localization of immunoreactive alkaline phosphatase in the rat small intestine at the light microscopic level by immunocytochemistry

Monospecific antibody to purified alkaline phosphatase hs been used to localize alkaline phosphatase in the rat small intestine at the light microscopic level. Pieces of duodenum, jejunum, and ileum were removed from 2-, 9-, 12-, 18-, 21-, 26-day-old and adult wistar rats. They were fixed in Bouin's fluid and examined for the presence of alkaline phosphatase by th immunoperoxidase method. Slides were graded blindly for the intensity of staining. The localization of alkaline phosphatase by the immunoperoxidase method extends previous histochemical observations in several ways. First, diffuse cytoplasmic staining is present particularly in the opical portion of the villus and crypt epithelium. Second, staining for alkaline phosphatase is present on the brush border and in the apical portion of the deep crypt cells throughout the duodenum, jejunum, and ileum at the various ages tested. Third, in the adult rat distal ileum there is more staining on the brush border of the deep crypt epithelial cells than on the villus absorptive cells. These observations are consistent with the presence of a non-brush border alkaline phosphatase in all intestinal cells and with fan enzymatically inactive form of alkaline phosphatase in the deep crypt epithelium.