Peer review: an effective approach to cultivating lecturing virtuosity.

BACKGROUND: Most university faculty members are expected to teach. Many would benefit from instruction designed to improve lecturing. AIMS: To explore the impact of a program in which video-recorded lectures were critiqued by peers. METHOD: Sixteen lecturers participated in this qualitative study. Four agreed to have an undergraduate lecture video-recorded for peer review. Twelve participated in review sessions wherein the lecturer and three peers viewed and critiqued the recorded lecture. All discussions were recorded and transcribed for thematic analysis. Subsequently, semi-structured interviews were conducted with each lecturer and all 12 peer reviewers. Three pairs of research team members independently conducted thematic analyses of the discussion transcripts and the interviews; then all members met to develop consensus on major emergent themes. RESULTS: Six themes were identified: (1) the benefits of peer review; (2) the components of successful peer review; (3) the value of reflection on teaching experiences; (4) the inherent stress in peer evaluations; (5) the elements of successful lecturing; (6) lecturing as performance. CONCLUSIONS: The benefits of peer assessment of lecturing (PAL) were enthusiastically endorsed by all 16 participants. The PAL program is now supported by the McGill Faculty Development Committee and plans to implement regular PAL sessions in place.

Assessing the cumulative effects of exposure to selected benzodiazepines on the risk of fall-related injuries in the elderly.

BACKGROUND: The use of benzodiazepines is associated with increased risk of fall-related injuries in the elderly. However, it is unclear if the risks vary across the products and how they depend on the pattern of use and dosage. Specifically, the possibility of cumulative effects of past benzodiazepine use has not been thoroughly investigated. METHODS: We used the administrative database for a cohort of 23,765 new users of benzodiazepines, aged 65 years and older, in Quebec, Canada, between 1990 and 1994. The associations between the use of seven benzodiazepines and the risk of fall-related injuries were assessed using several statistical models, including a novel weighted cumulative exposure model. That model assigns to each dose taken in the past a weight that represents the importance of that dose in explaining the current risk of fall. RESULTS: For flurazepam, the best-fitting model indicated a cumulative effect of doses taken in the last two weeks. Uninterrupted use of flurazepam in the past months was associated with a highly significant increase in the risk of fall-related injuries (HR = 2.83, 95% CI: 1.45-4.34). The cumulative effect of a 30-day exposure to alprazolam was 1.27 (1.13-1.42). For temazepam, the results suggested a potential withdrawal effect. CONCLUSIONS: Mechanisms affecting the risk of falls differ across benzodiazepines, and may include cumulative effects of use in the previous few weeks. Thus, benzodiazepine-specific analyses that account for individual patterns of use should be preferred over simpler analyses that group different benzodiazepines together and limit exposure to current use or current dose.

Antidepressant use and cognitive functioning in older medical patients with major or minor depression: a prospective cohort study with database linkage.

OBJECTIVE: The long-term cognitive effect of antidepressant medications in older persons is not well understood, especially in those with minor depression and complex medical conditions. The objective of this study is to examine this relationship in older medical patients with different depression diagnoses. METHODS: 281 medical inpatients aged 65 years and older from 2 acute care hospitals in Montreal, Canada, were diagnosed as with major or minor depression or without depression according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. They were followed up with the Mini-Mental State Examination for cognitive function and the Hamilton Depression Rating Scale for depressive symptoms at baseline and 3, 6, and 12 months after discharge. Antidepressant medication was ascertained from a provincial prescription database and quantified as cumulative exposures over each follow-up interval. RESULTS: During the 12-month follow-up period, 1027 antidepressant prescriptions were filled. The most frequently prescribed antidepressant agents were citalopram (0.81 prescriptions per person), sertraline (0.76), and paroxetine (0.66). Antidepressant use was not associated with cognitive changes among patients with major depression or without depression but was associated with an increased Mini-Mental State Examination score in patients with minor depression (1.4 points; 95% confidence interval, 0.1-2.6), independent of change in the severity of depression symptoms, concomitant benzodiazepine or psychotropic drug use, and other potentially important confounders. CONCLUSIONS: In this cohort of older medical patients, antidepressant use for 12 months did not lead to significant cognitive impairment. The small cognitive improvement among minor depression associated with antidepressant use deserves further investigation.

12-month cognitive outcomes of major and minor depression in older medical patients.

OBJECTIVE: To examine the temporal relationship between depression diagnoses and cognitive function in older medical patients. DESIGN: Prospective cohort study with repeated follow-up assessments at 3, 6, and 12 months after hospitalization. SETTING: The medical services of two acute care hospitals in Montreal, Quebec, Canada. PARTICIPANTS: Two hundred eighty-one medical inpatients aged 65 and older without apparent cognitive impairment at study entry. MEASUREMENTS: Diagnostic Interview Schedule for depression and Mini-Mental State Examination (MMSE) for cognitive function. RESULTS: At study entry, 121 (43.1%) and 51 (18.1%) patients, respectively, met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for major or minor depression. Based on a mixed effects regression model, depression diagnoses were associated with poorer cognitive function, independent of age, education, baseline cognitive and physical function, cardiovascular diseases and other comorbidities, previous history of depression and antidepressant treatment, and fluctuation in the severity of depression symptoms over time. On average across three follow-up assessments, patients with major or minor depression, respectively, had a 0.8 (95% confidence interval: 0.1-1.5) and 1.0 (0.3-1.8) point lower performance on the MMSE than those without depression. In contrast, there was no significant association when depression diagnoses and cognitive function were assessed over shorter intervals or cross-sectionally. A general linear regression model yielded consistent results, with adjusted effect estimates of 0.9 (0.03-0.8) for major and 1.5 (0.5-2.5) for minor depression over 12 months. CONCLUSION: A diagnosis of major or minor depression at hospital admission is an independent risk factor for poorer cognitive function during the subsequent 12 months in older medical patients.

The temporal relationship between depression symptoms and cognitive functioning in older medical patients--prospective or concurrent?

BACKGROUND: Epidemiological studies remain inconclusive as to whether old age depression is an independent risk factor, a prodrome, or a clinical concomitant of cognitive impairment. The objective of this study, using repeated measures over a 12-month period, was to examine the short-term temporal relationship between depressive symptoms and cognitive impairment. METHODS: Two hundred eighty-one medical inpatients 65 years old or older were followed up with the Hamilton Depression Rating Scale (HDRS) and Mini-Mental State Examination (MMSE) at enrollment and 3, 6, and 12 months later. A repeated-measures mixed linear regression model was used to evaluate the association between HDRS scores and MMSE changes over time and to test competing hypotheses about their temporal sequence. RESULTS: After adjusting for age, cardiovascular risk, illness severity, baseline physical and cognitive function, and other covariates, a one-point increase in HDRS score (baseline mean +/- standard deviation: 14.4 +/- 7.4) was associated with a lower MMSE score (-0.03, 95% confidence interval, -0.07 to 0.00) at the same time points, but not with the MMSE at subsequent time points (all p values >.40). There were no statistically significant interactions detected between follow-up time and HDRS scores measured at baseline or during follow-up. These results were confirmed in alternative models using dynamic measures of both HDRS and MMSE changes over each successive follow-up interval. CONCLUSIONS: These findings suggest that the short-term relationship between depression symptoms and cognitive functioning may be concurrent or temporary, rather than prospective or protracted, consistent with the clinical concomitant hypothesis.

Longitudinal patterns of new Benzodiazepine use in the elderly.

PURPOSE: To characterize longitudinal patterns of Benzodiazepine use in the elderly. METHODS: Prospective cohort of 78 367 community-dwelling Quebec residents aged 66 years or more who were new Benzodiazepine users, was followed for 5 years, 1989-1994. Data acquired from four population-based, provincial administrative databases were used to create time-dependent measures of change in dosage, switching or adding Benzodiazepines for 11 drugs listed in the provincial formulary. Subject-specific Spearman's rank correlation coefficients between dose and time were used to measure the tendency of increasing dose with consecutive periods of use. Multiple logistic regression and generalized estimating equations (GEE) models evaluated subject characteristics associated with increasing dose. RESULTS: The mean duration of uninterrupted Benzodiazepine use was 75.5 days. The mean daily dose was about half the recommended adult daily dose but 8.6% of subjects exceeded the recommended adult dose. Some of them (28.8%) switched medications at least once and 8.2% filled two or more prescriptions concurrently. For women, older age at date of first prescription was associated with increasing dose over time (odds ratio (OR) for 10 year age increase = 1.23, p < 0.001). CONCLUSION: Long periods of Benzodiazepine use are frequent among Quebec elderly. The evidence of increasing dose, particularly for older women, and long-duration of use has important implications for clinicians.