Competence assessment of senior vascular trainees using a carotid endarterectomy bench model.

BACKGROUND: Competency-based assessment is being introduced to surgical training. The value of bench-top technical skills assessment using a synthetic carotid endarterectomy (CEA) model was evaluated in vascular trainees and consultants. METHODS: Forty-one surgeons (13 junior trainees, 15 senior trainees and 13 experienced consultants with experience of more than 50 CEAs) performed a three-throw knot-tying exercise on a jig and a CEA on the bench model. A composite score for knot-tying was calculated, incorporating electromagnetic motion analysis. CEA technical skill was assessed using validated rating scales by blinded video analysis. RESULTS: Senior trainees performed better than junior trainees in knot-tying (P = 0.025) as well as generic (P < 0.001) and procedural (P < 0.001) skills on CEA model assessment. There was no difference between senior trainees and consultants on any of these measures. The CEA model interobserver reliability was high for all rating scales (generic alpha = 0.974, procedural alpha = 0.952, end-product alpha = 0.976). CONCLUSION: Senior trainees achieved the same score as consultants, suggesting a similar level of basic technical skill and knowledge required to perform CEA, and were significantly better than junior trainees. Performance on the bench model could provide an early assessment for suitability to proceed to operative training in a competency-based training and assessment programme.

A mitotically stable marker chromosome negative for whole chromosome libraries, centromere probes and chromosome specific telomere regions: a novel class of supernumerary marker chromosome?

A two year-old child presented with mild developmental delay. On karyotype analysis, a supernumerary small marker chromosome (SMC) was found in all cells examined. This SMC was approximately the size of an isochromosome 18p, being symmetrical with a central constriction. C-banding and silver staining were negative and FISH with all chromosome-specific paints, centromere probes and telomere probes showed no hybridization to the SMC; telomere repeat sequences were however present on both arms. Comparative genomic hybridization showed no amplification of any chromosome region. Flow sorting of the SMC and reverse painting onto normal metaphase spreads showed no hybridization to any chromosome, whereas reverse painting onto the patient's own metaphases showed hybridization to the SMC only. This SMC may thus represent either a complex amplicon of different genomic regions, or a multifold amplification of a very small region, with a neocentromere comprising an active kinetochore but no alphoid DNA. Prognostic implications for the proband were difficult to assess due to the absence of reports of similar marker chromosomes in the literature.

Lack of cell cycle checkpoints in human cleavage stage embryos revealed by a clonal pattern of chromosomal mosaicism analysed by sequential multicolour FISH.

Multicolour fluorescence in situ hybridisation (FISH) analysis of interphase nuclei in cleavage stage human embryos has highlighted a high incidence of postzygotic chromosomal mosaicism, including both aneuploid and ploidy mosaicism. Indeed, some embryos appear to have a chaotic chromosomal complement in a majority of nuclei, suggesting that cell cycle checkpoints may not operate in early cleavage. Most of these studies, however, have only analysed a limited number of chromosomes (3-5), making it difficult to distinguish FISH artefacts from true aneuploidy. We now report analysis of 11 chromosomes in five sequential hybridisations with standard combinations of two or three probes and minimal loss of hybridisation efficiency. Analysis of a series of arrested human embryos revealed a generally consistent pattern of hybridisation on which was superimposed frequent deletion of one or both chromosomes of a specific pair in two or more nuclei indicating a clonal origin and continued cleavage following chromosome loss. With a binucleate cell in a predominantly triploid XXX embryo, the two nuclei remained attached during preparation and the chaotic diploid/triphoid status of every chromosome analysed was the same for each nucleus. Furthermore, in each hybridisation the signals were distributed as a mirror-image about the plane of attachment, indicating premature decondensation during anaphase consistent with a lack of checkpoint control.

Maternal depressive symptoms affect infant cognitive development in Barbados.

This longitudinal study is part of a series examining the relationships between maternal mood, feeding practices, and infant growth and development during the first 6 months of life in 226 well-nourished mother-infant dyads in Barbados. In this report, we assessed maternal moods (General Adjustment and Morale Scale and Zung Depression and Anxiety Scales), feeding practices (scales describing breast-feeding and other practices associated with infant feeding in this setting), and infant cognitive development (Griffiths Mental Development Scales). Multivariate analyses, with and without controlling for background variables, established significant relationships between maternal moods and infant cognitive development. Infants of mothers with mild moderate depression had lower Griffiths scores than infants of mothers without depression. Maternal depressive symptoms and lack of trust at 7 weeks predicted lower infant social and performance scores at 3 months. Maternal moods at 6 months were associated with lower scores in motor development at the same age. Although no independent relationships emerged between feeding practices and infant cognitive development, the combination of diminished infant feeding intensity and maternal depression predicted delays in infant social development. These findings demonstrate the need to carefully monitor maternal moods during the postpartum period, in order to maximize the benefits of breast-feeding and related health programs to infant cognitive development.

Tuberculosis surveillance in immigrants through health undertakings in Western Australia.

SETTING: Tuberculosis Control Program, Western Australia. OBJECTIVE: To assess the effectiveness and efficiency of tuberculosis (TB) surveillance in immigrants. DESIGN: Retrospective descriptive analysis of records of immigrants who first registered with the Tuberculosis Program from January 1994 to December 1995, having entered Western Australia on health undertakings (nonlegal contracts signed by those determined during premigration screening to require post-arrival evaluation). RESULTS: Of 1,344 immigrants on health undertakings for TB in the period, 587 (44%) had findings directly related to TB through pre-migration screening, 69 of whom required treatment for active disease. Another 443 (33%) had chest X-ray changes for which TB could not be excluded. Of the remaining 314 (23%), 172 had poor quality X-rays. Post-arrival assessment and follow-up of the whole group detected four of seven additional cases of active TB, 373 persons (28%) requiring on-going surveillance, 667 (50%) with non-TB conditions and 280 (21%) with normal chest X-rays. CONCLUSIONS: Migrant surveillance for TB in Australia is effective in detecting active disease and identifying a high-risk subgroup requiring further evaluation. Efficiency can be improved and high compliance achieved with simple administrative changes. Routine pre-migration Mantoux testing is inappropriate, and its inclusion in post-arrival assessments should be a national policy decision.

Maternal moods predict breastfeeding in Barbados.

This study was designed to identify psychosocial variables affecting early infant feeding practices in Barbados. The sample included 93 healthy women and infants born at the Queen Elizabeth Hospital who were extensively evaluated 7 weeks, 3 months, and 6 months after birth. Maternal moods were assessed with the Zung Depression and Anxiety Scales and the General Adjustment and Morale Scale. Feeding practices were evaluated using a questionnaire developed for this population. The prevalence of mild depression in this population was 16% at 7 weeks and increased to 19% at 6 months, whereas there were very few cases of moderate-to-severe depression. Disadvantaged environmental conditions, including less information-seeking by the mother, lower family income, and poor maternal health, were closely associated with increased symptoms of depression and anxiety in all women. However, significant predictive relationships between mood and feeding practices remained even when the effects of the home environment were controlled. Specifically, depressive symptoms at 7 weeks postpartum predicted a reduced preference for breastfeeding at current and later infant ages. Conversely, feeding practices did not predict maternal moods at later ages. These findings have important implications for public policy dealing with programs promoting breastfeeding. Early interventions designed to treat mild postnatal depression should be instituted early in the postpartum period to improve the chances for successful breastfeeding.

Preventive therapy for tuberculosis in Western Australia.

SETTING: State Tuberculosis Control Programme, Western Australia. OBJECTIVE: To ascertain baseline information, applicability and efficacy of preventive therapy for tuberculosis (TB) under indirectly supervised treatment in Western Australia. DESIGN: Retrospective analyses of records of persons with TB infection who were prescribed preventive therapy for the period 1993-1996 inclusive, using simple descriptive statistics. RESULTS: Preventive therapy was given to 411 persons after screening for TB due to on-arrival migrant surveillance (269), contact tracing (59), tuberculin surveys (59) and other reasons (24). Six-month isoniazid monotherapy (HMT) was prescribed for 403 and multidrug regimens for the remaining eight. Excepting 34 whose compliance was unknown, varying degrees of treatment non-adherence were found in 90 (24%) of the remaining 369 persons given HMT, including 36 (10%) with under five months of total medication. Minor adverse drug effects occurred in 32 (9%) subjects and contributed to the non-adherence in 23 of these. One person has since developed active TB. CONCLUSIONS: Preventive therapy in Western Australia conformed to generally accepted guidelines. Varying degrees of non-adherence to HMT occurred in 24% of persons, but 90% completed adequate therapy under indirect supervision. Non-adherence is significantly related to adverse drug effects.

Infant feeding practices in Barbados predict later growth.

This longitudinal study was designed to examine reciprocal relationships between feeding practices and infant growth over the first 6 mo of life. The following three hypotheses were tested: 1) early feeding practices predict later infant growth; 2) early infant growth predicts later feeding practices; and 3) these relationships occur after controlling for related background variables. The sample included 226 healthy, well-nourished infants born at the Queen Elizabeth Hospital, Bridgetown, Barbados. Assessments were made at birth, 7 wk, and 3 and 6 mo of age. Factor analysis of a feeding practices questionnaire for those mothers who attended all three postnatal visits yielded five uncorrelated factors. Three of these factors, preference for breast-feeding, feeding intensity and feeding difficulty, declined with infant age. Two of these factors, father helps and relatives help, increased with infant age. Several background variables, including maternal age, anthropometry and reproductive history, and reliance on outside sources of information were correlated with infant growth. Multivariate analyses confirmed all three hypotheses. The group of feeding practices (particularly the preference for breast-feeding) at 7 wk predicted increases in infant lengths at subsequent ages. Conversely, infant weights at 3 and 6 mo predicted subsequent feeding practices, especially feeding intensity. These reciprocal relationships remained even after statistically controlling for the influence of the background variables. Implications for public policy include the need for comprehensive programs advocating breast-feeding and supporting the general health of mothers and infants.

Comparative effects of schizophrenia and temporal lobe epilepsy on memory.

The goal of this study was to further characterize episodic memory functioning in schizophrenia. This study compared verbal and visual learning and memory performance in (1) patients with schizophrenia (N = 35), (2) patients with temporal lobe epilepsy (TLE; N = 30), and (3) normal controls (N = 25). Results indicated significant memory impairments in patients with schizophrenia and TLE. "Savings" score measures of memory decay showed that the loss of information in schizophrenia and TLE was approximately equal, and quantitatively mild compared to that found in most neurologic groups with memory disorders. The severe difficulty shown by the schizophrenia group on a task of incidental recall suggested that the absence of instructional set added to a vulnerability to memory deficit. In contrast, relatively mildly impaired performance on paired associate learning suggested that patients with schizophrenia benefited from retrieval cues, multiple trials, and short (nonsupraspan) informational loads. Because patients with schizophrenia consisted of a relatively nonchronic sample with a mean IQ of 99.7, their memory disorder could not be attributed to schizophrenic dementia, nor was it accounted for by other potential confounds. Patients with schizophrenia, even those relatively early in the course of illness, have a mild episodic memory disorder.

Factor structure of the Wisconsin Card Sorting Test: dimensions of deficit in schizophrenia.

The aim of this study was to explore the factorial structure of the Wisconsin Card Sorting Test (WCST) and to identify the dimensions of deficit in schizophrenia. WCST scores in patients with schizophrenia and schizophrenia-related psychosis (n = 292), 1st degree relatives of schizophrenic patients (n = 91), and normal controls (n = 141) were subjected to a principal factor analysis followed by orthogonal rotation. This led to 3 factors, perseveration, failure to maintain set, and idiosyncratic sorting. The detected factor structure was found to be invariant across the schizophrenic and control subsamples. Moreover, it replicated previous findings from 2 smaller samples. Only perseverations and, to a lesser degree, idiosyncratic sorting appeared to differentiate schizophrenic patients from comparisons. Only perseveration had good sensitivity and specificity, as well as the most robust significant correlations with estimates of IQ, attention, and other measures of executive functioning. Thus, perseveration appears to be the most diagnostically useful and characteristic WCST feature of schizophrenia.

A new approach to the elucidation of complex chromosome rearrangements illustrated by a case of Rieger syndrome.

A patient with a complex chromosome rearrangement and unilateral Rieger syndrome is presented. This rearrangement involves four chromosomes and six breakpoints, one of which is at 4q25, the candidate region for Rieger syndrome. We discuss a novel approach to the elucidation of this case using a multiprobe fluorescence in situ hybridisation method to show rearrangements unpredictable from G banded analysis, and the clear and unambiguous presentation of the karyotype using computer generated colour ideograms.