Defining performance levels in undergraduate otolaryngology education.

OBJECTIVES: This study seeks the opinions of qualified doctors on what they feel medical students should learn about otolaryngology. It aims to identify both the content deemed relevant and the performance levels for medical students in otolaryngology. METHODS: A national survey developed from a content analysis of undergraduate otolaryngology curricula from the UK was undertaken, accompanied by a review of the literature and input from an expert group. Data were collected from a wide range of doctors. RESULTS: Participants felt that graduating students should be able to: recognise, assess and initiate management for common and life-threatening acute conditions; take an appropriate patient history; and perform an appropriate examination for the majority of otolaryngology clinical conditions but manage only a select few. CONCLUSION: This study reports performance levels for otolaryngology topics at an undergraduate level. Participating doctors felt that a higher level of performance should be expected of students treating life-threatening, acute and common otolaryngology conditions.

[Muscle injuries in professional football : Treatment and rehabilitation]. / Muskelverletzungen im Profifußball : Versorgung und Rehabilitation.

BACKGROUND: Muscle injuries are common in professional sports, especially in football. Recent epidemiological studies showed that muscle injuries account for more than 30% of professional football injuries (1.8-2.2/1000 h exposure); however, even though there are significant differences within a European comparison, a single professional football team diagnosed on average 12 muscle injuries per season, corresponding to more than 300 availability days lost. OBJECTIVE: The aim of this work is to present the diagnosis, general treatment and comprehensive management of muscle injuries in professional football. MATERIAL AND METHODS: The present work is based on current scientific findings, experiences of the authors and examples from routine practice in the management of muscle injuries in a professional sports environment. RESULTS AND CONCLUSION: The authors present a model of gradual progression for the treatment of muscular injuries and their rehabilitation. Due to the time-pressured nature of the professional sports environment, often promoted by coaches and media, this model could help lead players to recover as quickly as possible and return to competitive sports without relapse or sequel injury. This model integrates the player into the treatment plan. The progression sequences in the rehabilitation should be made clear to players and other parties involved, which are crucial for optimal healing. Even if absolute certainty cannot be achieved, i.e. the occurrence of re-injury or secondary injury, this model attempts to minimize the level of risk involved for the returning athlete. Since it is hardly possible to act strictly in line with more conservative guidelines due to the particular circumstances of the professional sport environment, the experiences of the authors are presented in the sense of best practice in order to support future decision-making processes.

An undergraduate Otolaryngology curriculum comparison in the United Kingdom using a curriculum evaluation framework.

OBJECTIVE: To compare undergraduate otolaryngology curricula in the United Kingdom. To develop a tool which would allow undergraduate specialty curricula to be compared. DESIGN: Development of a curriculum evaluation framework (CEF) and survey. SETTING: UK medical schools. PARTICIPANTS: Otolaryngology curricula were requested from all 32 UK medical schools who award a primary medical qualification. Nineteen curricula were received and examined. MAIN OUTCOME MEASURES: Thematic and content analysis of curriculum documents were undertaken. Outcome measures include an examination of curriculum content and methods, type of assessment and alignment of curricula with the General Medical Council's Tomorrow's Doctors document. RESULTS: Learning objectives were listed by 18 of the 19 medical schools who responded. The most commonly included theme was clinical conditions (100%). Psychosocial aspects of otolaryngology was the least covered theme (37%). Examination skills was covered by the majority (74%). Outpatient clinics and theatre attendance were the most commonly utilised teaching methods (47%). Student checklists were the most common form of assessment (32%). Only four medical schools linked their curricula to the GMC's Tomorrow's Doctors document. CONCLUSIONS: The development of a CEF allowed for a systematic comparison of curricula. This study, evaluating otolaryngology curricula, has highlighted the variability of curricula from both a content and methods perspective in the UK. The study provides those involved with curriculum planning an overview of the main themes currently taught in the UK and offers examples of individual topics. It also offers an insight into the way in which otolaryngology is taught in the UK.

Statin prescription initiation and lifestyle behaviour: a primary care cohort study.

BACKGROUND: Statin prescribing and healthy lifestyles contribute to declining cardiovascular disease mortality. Recent guidelines emphasise the importance of giving lifestyle advice in association with prescribing statins but adherence to healthy lifestyle recommendations is sub-optimal. However, little is known about any change in patients' lifestyle behaviours when starting statins or of their recall of receiving advice. This study aimed to examine patients' diet and physical activity (PA) behaviours and their recall of lifestyle advice following initiation of statin prescribing in primary care. METHOD: In 12 general practices, patients with a recent initial prescription of statin therapy, were invited to participate. Those who agreed received a food diary by post, to record food consumed over 4 consecutive days and return to the researcher. We also telephoned participants to administer brief validated questionnaires to assess typical daily diet (DINE) and PA level (Godin). Using the same methods, food diaries and questionnaires were repeated 3 months later. At both times participants were asked if they had changed their behaviour or received advice about their diet or PA. RESULTS: Of 384 invited, 122 (32 %) participated; 109 (89.3 %) completed paired datasets; 50 (45.9 %) were male; their mean age was 64 years. 53.2 % (58/109) recalled receiving lifestyle advice. Of those who did, 69.0 % (40/58) reported having changed their diet or PA, compared to 31.4 % (16/51) of those who did not recall receiving advice. Initial mean daily saturated fat intake (12.9 % (SD3.5) of total energy) was higher than recommended; mean fibre intake (13.8 g/day (SD5.5)), fruit/vegetable consumption (2.7 portions/day (SD1.3)) and PA levels (Godin score 7.1 (SD13.9)) were low. Overall, although some individuals showed evidence of behaviour change, there were no significant changes in the proportions who reported high or medium fat intake (42.2 % v 49.5 %), low fibre (51.4 % v 55.0 %), or insufficient PA (80.7 % v 83.5 %) at 3-month follow-up. CONCLUSION: Whilst approximately half of our cohort recalled receiving lifestyle advice associated with statin prescribing this did not translate into significant changes in diet or PA. Further research is needed to explore gaps between people's knowledge and behaviours and determine how best to provide advice that supports behaviour change.

Medical student rankings of proposed sanction for unprofessional behaviours relating to academic integrity: results from a Scottish medical school.

The General Medical Council emphasizes the cultivation of professional behaviours among medical students from early undergraduate years. Learning professional behaviours, however, is a progression and is constituted of several developmental stages. Behaving with academic integrity may be the first stage. In an educational setting, academic integrity is represented by a collection of diverse behaviours. Although there is consensus within the medical community that the absence of (or lapses in) academic integrity is unacceptable, the level of sanctions recommended for medical students is controversial. In the main, these punitive decisions over students are taken by teachers and clinicians. What sanctions would students suggest for a colleague who is academically unprofessional? This study reports the sanctions recommended by 375/700 (54%) of the students of one Scottish medical school in relation to lapses in academic integrity.

'Pseudo Wine Glass' Radiological Appearance of Intracranial Haemorrhage as a Result of Chemotherapy-Induced Thrombocytopenia and Red Cell Sedimentation.

The radiological features of intracranial haemorrhage are well described in the literature, but atypical appearances can sometimes develop. We report a case of chemotherapy-induced thrombocytopenia resulting in fatal intracranial haemorrhage in a man undergoing autologous peripheral stem cell transplantation. The CT showed an unusual appearance, with separation of blood products and fluid within the haemorrhage leading to a wine-glass-shaped outline in the image. This case draws attention to this uncommon radiological finding and emphasises the risks of allosensitisation following chemotherapy and peripheral stem cell transplantation.

Development and validation of an instrument to measure the postgraduate clinical learning and teaching educational environment for hospital-based junior doctors in the UK.

This paper describes the development and validation of a 40-item inventory, the Postgraduate Hospital Educational Environment Measure (PHEEM), by researchers in Scotland and the West Midlands using a combination of grounded theory and Delphi process. The instrument has since returned an alpha reliability >0.91 in two administrations in England and may be a useful instrument in the quality assurance process for postgraduate medical education and training.

Students' perspectives on the educational environment, Faculty of Medical Sciences, Trinidad

The Dundee Ready Education Environment Measure (DREEM) was administered to 70 final-year medical students and 36 first-year medical interns (pre-registration house officers). The overall total mean DREEM scores for the five subscales--namely, students' perceptions of the atmosphere, students' perceptions of learning, students' social self-perceptions, students' perceptions of teachers and students' academic self-perceptions--was 109.9 and the total mean scores for the subgroups--male students, male interns, female students and female interns--were 103.39, 111.82, 111.33 and 113.15, respectively. The lowest scores were assigned to students' social self-perceptions and students' perceptions of the atmosphere. All of the participants except the male interns recorded the highest scores for the subscale academic self-perceptions.

Selection of neurosurgical trainees.

BACKGROUND: Medical students in Canada must make career choices by their final year of medical school. Selection of students for a career in neurosurgery has traditionally been based on marks, reference letters and personal interviews. Studies have shown that marks alone are not accurate predictors of success in medical practice; personal skills and attributes which can best be assessed by letters of reference and interviews may be more important. This study was an attempt to assess the importance of, and ability to teach, personal skills and attitudes necessary for successful completion of a neurosurgical training program. METHODS: A questionnaire was sent to 185 active members of the Canadian Neurosurgical Society, asking them to give a numerical rating of the importance of 22 personal skills and attributes, and their ability to teach those skills and attributes. They were asked to list any additional skills or attributes considered important, and rate their ability to teach them. RESULTS: Sixty-six (36%) questionnaires were returned. Honesty, motivation, willingness to learn, ability to problem solve, and ability to handle stress were the five most important characteristics identified. Neurosurgeons thought they could teach problem solving, willingness to consult informed sources, critical thinking, manual dexterity, and communication skills, but honesty, motivation, willingness to learn and ability to handle stress were difficult or impossible to teach. CONCLUSIONS: Honesty, motivation, willingness to learn, ability to problem solve and handle stress are important for success in a neurosurgical career. This information should be transmitted to medical students at "Career Day" venues. Structuring letters of reference and interviews to assess personal skills and attributes will be important, as those that can't be taught should be present before the start of training.

Low-grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) of thymus.

This report describes a low-grade B-cell lymphoma of mucosa associated lymphoid tissue (MALT) involving the thymus of a 63-year-old woman with features suggestive of a connective tissue disease. Sections of the thymic lesion and of a lung biopsy performed at the same operation were examined histologically and by immunohistochemistry using the monoclonal antibodies CD45, CD20, CD79a, CD3, CD45RO, and AE1/AE3. Polymerase chain reaction (PCR) for immunoglobulin heavy chain gene rearrangement was also performed. The dense infiltrate of small lymphoid cells intimately admixed with ramifying epithelial elements, some of which had undergone cystic change, closely resembled a thymoma. The lymphoid infiltrate comprised centrocyte-like cells, small lymphocytes, plasma cells, and blasts. Most of the lymphoid cells were immunoreactive with the B-cell markers CD20 and CD79a, and PCR showed clonal immunoglobulin heavy chain gene rearrangement. The lung biopsy showed dense infiltration by small lymphoid cells, morphologically suggestive of lymphoid interstitial pneumonia. However, PCR showed a weak band in the amplification for immunoglobulin heavy chain gene rearrangement, identical to that within the thymus and suggesting either recirculation of cells to accumulated MALT or subhistological lymphoma. MALT lymphoma may rarely involve the thymus, and pathologists should be aware of this to avoid misdiagnosis as a thymoma. Immunohistochemical and/or molecular studies are of value in this regard. MALT lymphomas of the thymus, common with those arising in other organs, may develop in the setting of a connective tissue disease.

Teaching the consultant teachers: identifying the core content.

OBJECTIVES: To determine the key themes for teaching hospital consultants how to teach. DESIGN: 1. In-depth interviews with a total of 19 experts, consultants and junior doctors to identify key topics. 2. Literature review from 1969 to obtain the main themes from the medical educational literature. 3. Analysis of the main themes in 11 'Teaching the teachers' courses. 4. Triangulation of interview data, literature themes and teaching courses content to generate 15 criteria for a questionnaire. 5. Questionnaire study to 593 senior and junior hospital doctors. SETTING: Hospitals in the West Midlands Region in England. SUBJECTS: Consultants and junior hospital doctors. RESULTS: Overall, 441 doctors replied (74% response rate). The top five themes were giving feedback constructively, keeping up to date as a teacher, building a good educational climate, assessing the trainee and assessing the trainee's learning needs. Results showed no statistically significant differences in the order of themes for all groups analysed, including seniority, gender, specialty, origin by medical school and consultants of different ages. CONCLUSIONS: Consultants need teaching in these topics. There are implications for funding and providing these courses for postgraduate deans, Royal Colleges and universities. Further research is needed to evaluate whether such an initiative does produce better teaching and learning, and a better educational climate in hospitals.

Increased expression of the RIalpha subunit of the cAMP-dependent protein kinase A is associated with advanced stage ovarian cancer.

The primary element in the cAMP signal transduction pathway is the cAMP-dependent protein kinase (PKA). Expression of the RIalpha subunit of type I PKA is elevated in a variety of human tumours and cancer cell lines. The purpose of this study was to assess the prognostic importance of RIalpha expression in patients with ovarian cancer. We have evaluated the expression of RIalpha in a panel of human ovarian tumours (n = 40) and five human ovarian cancer cell lines using quantitative reverse transcription polymerase chain reaction (RT-PCR) and Western blot analysis. The human ovarian cell lines OAW42 and OTN14 express high endogenous levels of RIalpha mRNA and protein (at significantly higher mRNA levels than high tissue expressors, P < 0.05). The ovarian cell line A2780 expresses low endogenous levels of RIalpha mRNA and protein (also at higher mRNA levels than low tissue expressors, P < 0.05). Quantitative RT-PCR revealed no significant difference in RIalpha mRNA expression between different ovarian histological subtypes in this study. No associations were found between RIalpha mRNA expression and differentiation state. RIalpha mRNA expression was significantly associated with tumour stage (P = 0.0036), and this remained significant in univariate analysis (P = 0.0002). A trend emerged between RIalpha mRNA expression levels and overall survival in univariate analysis (P = 0.051), however, by multivariate analysis, stage remained the major determinant of overall survival (P = 0.0001). This study indicates that in ovarian epithelial tumours high RIalpha mRNA expression is associated with advanced stage disease. RIalpha expression may be of predictive value in ovarian cancer and may be associated with dysfunctional signalling pathways in this cancer type.

Steady-state clearance rates of warfarin and its enantiomers in therapeutically dosed patients.

Previous studies to identify the pharmacokinetics of R- and S-warfarin have not used steady-state area under the curve (AUC) data during therapeutic doses of racemic warfarin. Instead they have used high single doses of either racemic warfarin or a single enantiomer in volunteers or have taken a single blood sample from anticoagulated patients and assumed full compliance and a steady-state status. In this study, a series of steady-state racemic warfarin, R-warfarin, and S-warfarin serum concentrations, during a 24 h dosage interval, was measured in 10 compliant patients (5 females and 5 males) taking racemic warfarin. The anticoagulation status of all 10 patients according to the International Normalised Ratio (INR) was stable. Their mean (SD) age and weight were 67.0 (9.9) yr and 63.9 (15.4) kg. The mean (SD) clearances derived from steady-state AUC values, following therapeutic dosing, for racemic warfarin, R-warfarin, and S-warfarin were 2.40 (0.82), 2.30 (0.65), and 2.80 (1.17) ml/h/kg, respectively. The mean (SD) ratio of S-warfarin clearance was 1.24 (0.40). Comparison of the clearance measured from the AUC, of these patients, to one point determinations assuming steady state for the samples drawn at either 6, 15, or 20 h after dosage (during the dosing interval) showed some statistical differences. Most single point determinations of warfarin clearance assume that a sample of 12 h postdose is equivalent to that of the steady-state concentration, but in this study the steady-state concentration of only 6 patients occurred between 6 and 15 h postdate. This could explain why these studies demonstrate differences in the clearance of R- and S-warfarin compared to the values we have derived from steady-state AUC data using patients with proven compliance and therapeutic doses.

Measurement of the (R)- and (S)-isomers of warfarin in patients undergoing anticoagulant therapy.

An achiral/chiral high-performance liquid chromatographic system for the analysis of total warfarin together with the (R)- and (S)-enantiomers in clinical samples has been developed. The achiral analysis is achieved using a C8 column, which is coupled to a chiral stationary phase, alpha 1-acid glycoprotein (AGP), thereby allowing for analysis of warfarin isomers without interfering serum peaks. A 0.015 M phosphate buffer mobile phase with 15% v/v propan-2-ol (pH 7.0) was used on the C8/AGP system. UV analysis at 308 nm was used for quantitation of total warfarin on the C8 column and fluorescence (excitation 300 nm, emission 390 nm) detection was employed for isomer quantitation on the AGP. Retention time of total warfarin on the C8 column was 5.95 min, while that of the (S)- and (R)-warfarin on the AGP column was 10.38 and 12.69 min, respectively. Peak resolution of the warfarin isomers was 1.64. All serum samples were subjected to solid-phase extraction. Data from two patients in a single dose study indicate that a two-compartmental model could represent the warfarin concentration-time data with enterohepatic circulation. In some patients studied during steady state therapy, concentrations of (S)-warfarin were greater than (R)-warfarin indicating that the clearance of the former is slower in these patients.