Outcomes of trimodality bladder-sparing therapy for muscle-invasive bladder cancer.

INTRODUCTION: Although radical cystectomy is considered the standard of care for muscle-invasive bladder cancer (MIBC), recent data has suggested comparable survival outcomes for bladder-sparing trimodality therapy (TMT). We conducted a retrospective, single-institution analysis of MIBC patients to evaluate the efficacy of TMT as an alternative, curative approach to surgical intervention. METHODS: We conducted a retrospective analysis of MIBC patients assessed by a multidisciplinary team at the Juravinski Cancer Centre from 2010-2016. Patients underwent transurethral resection of bladder tumor (TURBT) followed by radiotherapy with or without concurrent chemotherapy. Patients could receive neoadjuvant treatment. Clinical data and response rates were summarized, and overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method. RESULTS: Our analytic cohort included 115 patients, of whom 53 underwent TMT and 62 underwent radiotherapy alone following TURBT. Median age at diagnosis was 79 years and median followup was 21 months. Complete response rates in those receiving TMT and radiation without chemotherapy were 84.4% and 66.7%, respectively. For TMT patients, three-year OS and DFS were 68.5% and 49.6%, respectively. Patients who received TMT had reduction in risk of mortality (hazard ratio [HR] 0.49; p=0.026) and disease recurrence (HR 0.55; p=0.017) compared to those who had radiation without chemotherapy. Overall, four patients had grade 3 or higher late toxicity. CONCLUSIONS: In this single-institution analysis, TMT appears to be a safe and effective approach in the short-term management of MIBC in appropriately selected patients. Extended followup and analysis are necessary to validate these results.

McMaster at 50: lessons learned from five decades of PBL.

Although educators frequently act as if curricula are as standardized as drug doses (300 mg of PBL t.i.d.), such is not the case. As a case in point, at its inception, Problem Based Learning was hailed as a major curriculum innovation, with the promise of enormous gains in learning outcomes. Very quickly, ecclesiastical debates arose as what was true PBL and what was "modified PBL". Ironically, systematic reviews conducted fairly early in its evolution showed that the gains in learning outcome from PBL were neither large nor uniform (Vernon and Blake in Acad Med 68:550-563, 1993), and the most consistent finding was greater student satisfaction. In this paper, we review five decades of experience with the first PBL curriculum at McMaster. We point out how the curriculum has evolved, both theoretically and practically, in response to external influences, based both on empirical evidence and practical demands. We describe these changes in four broad domains-theoretical rationale, the curriculum, assessment and admissions.

Contexts, concepts and cognition: principles for the transfer of basic science knowledge.

CONTEXT: Transfer of basic science aids novices in the development of clinical reasoning. The literature suggests that although transfer is often difficult for novices, it can be optimised by two complementary strategies: (i) focusing learners on conceptual knowledge of basic science or (ii) exposing learners to multiple contexts in which the basic science concepts may apply. The relative efficacy of each strategy as well as the mechanisms that facilitate transfer are unknown. In two sequential experiments, we compared both strategies and explored mechanistic changes in how learners address new transfer problems. METHODS: Experiment 1 was a 2 × 3 design in which participants were randomised to learn three physiology concepts with or without emphasis on the conceptual structure of basic science via illustrative analogies and by means of one, two or three contexts during practice (operationalised as organ systems). Transfer of these concepts to explain pathologies in familiar organ systems (near transfer) and unfamiliar organ systems (far transfer) was evaluated during immediate and delayed testing. Experiment 2 examined whether exposure to conceptual analogies and multiple contexts changed how learners classified new problems. RESULTS: Experiment 1 showed that increasing context variation significantly improved far transfer performance but there was no difference between two and three contexts during practice. Similarly, the increased conceptual analogies led to higher performance for far transfer. Both interventions had independent but additive effects on overall performance. Experiment 2 showed that such analogies and context variation caused learners to shift to using structural characteristics to classify new problems even when there was superficial similarity to previous examples. CONCLUSIONS: Understanding problems based on conceptual structural characteristics is necessary for successful transfer. Transfer of basic science can be optimised by using multiple strategies that collectively emphasise conceptual structure. This means teaching must focus on conserved basic science knowledge and de-emphasise superficial features.

The Impact of Emotion on Learners' Application of Basic Science Principles to Novel Problems.

PURPOSE: Training to become a physician is an emotionally laden experience. Research in cognitive psychology indicates that emotions can influence learning and performance, but the materials used in such research (e.g., word lists) rarely reflect the complexity of material presented in medical school. The present study examined whether emotions influence learning of basic science principles. METHOD: Fifty-five undergraduate psychology students were randomly assigned to write about positive, negative, or neutral life events for nine minutes. Participants were then taught three physiological concepts, each in the context of a single organ system. Testing consisted of 13 clinical cases, 7 presented with the same concept/organ system pairing used during training ("near transfer") and 6 with novel pairings ("far transfer"). Testing was repeated after one week with 13 additional cases. RESULTS: Forty-nine students provided complete data. Higher test scores were found when the concept/organ system pairing was held constant (near transfer = 51% correct vs. far = 33%; P < .001). Emotion condition influenced participants' overall performance, with individuals in the neutral condition (50.1%) performing better than those in the positive (38.2%, P < .05) and negative (37.7%, P < .001) emotion conditions. CONCLUSIONS: These data suggest that regardless of whether the emotion is positive or negative, mild affective states can impair learning of basic science concepts by novices. Demands on working memory and subsequent cognitive load provide a potential explanation. Future work will examine the extent to which these findings generalize to medical trainees.

The mediating effect of context variation in mixed practice for transfer of basic science.

Applying a previously learned concept to a novel problem is an important but difficult process called transfer. Practicing multiple concepts together (mixed practice mode) has been shown superior to practicing concepts separately (blocked practice mode) for transfer. This study examined the effect of single and multiple practice contexts for both mixed and blocked practice modalities on transfer performance. We looked at performance on near transfer (familiar contexts) cases and far transfer (unfamiliar contexts) cases. First year psychology students (n = 42) learned three physiological concepts in a 2 × 2 factorial study (one or two practice contexts and blocked or mixed practice). Each concept was practiced with two clinical cases; practice context was defined as the number of organ systems used (one system per concept vs. two systems). In blocked practice, two practice cases followed each concept; in mixed practice, students learned all concepts before seeing six practice cases. Transfer testing consisted of correctly classifying and explaining 15 clinical cases involving near and far transfer. The outcome was ratings of quality of explanations on a 0-3 scale. The repeated measures analysis showed a significant near versus far by organ system interaction [F(1,38) = 3.4, p < 0.002] with practice with a single context showing lower far transfer scores than near transfer [0.58 (0.37)-0.83 (0.37)] compared to the two contexts which had similar far and near transfer scores [1.19 (0.50)-1.01 (0.38)]. Practicing with two organ contexts had a significant benefit for far transfer regardless of mixed or blocked practice; the single context mixed practice group had the lowest far transfer performance; this was a large effect size (Cohen's d = 0.81). Using only one practice context during practice significantly lowers performance even with the usually superior mixed practice mode. Novices should be exposed to multiple contexts and mixed practice to facilitate transfer.

The use of triangulation in qualitative research.

Triangulation refers to the use of multiple methods or data sources in qualitative research to develop a comprehensive understanding of phenomena (Patton, 1999). Triangulation also has been viewed as a qualitative research strategy to test validity through the convergence of information from different sources. Denzin (1978) and Patton (1999) identified four types of triangulation: (a) method triangulation, (b) investigator triangulation, (c) theory triangulation, and (d) data source triangulation. The current article will present the four types of triangulation followed by a discussion of the use of focus groups (FGs) and in-depth individual (IDI) interviews as an example of data source triangulation in qualitative inquiry.

Integration and timing of basic and clinical sciences education.

BACKGROUND: Medical education has traditionally been compartmentalized into basic and clinical sciences, with the latter being viewed as the skillful application of the former. Over time, the relevance of basic sciences has become defined by their role in supporting clinical problem solving rather than being, of themselves, a defining knowledge base of physicians. METHODS: As part of the national Future of Medical Education in Canada (FMEC MD) project, a comprehensive empirical environmental scan identified the timing and integration of basic sciences as a key pressing issue for medical education. Using the literature review, key informant interviews, stakeholder meetings, and subsequent consultation forums from the FMEC project, this paper details the empirical basis for focusing on the role of basic science, the evidentiary foundations for current practices, and the implications for medical education. FINDINGS: Despite a dearth of definitive relevant studies, opinions about how best to integrate the sciences remain strong. Resource allocation, political power, educational philosophy, and the shift from a knowledge-based to a problem-solving profession all influence the debate. There was little disagreement that both sciences are important, that many traditional models emphasized deep understanding of limited basic science disciplines at the expense of other relevant content such as social sciences, or that teaching the sciences contemporaneously rather than sequentially has theoretical and practical merit. Innovations in integrated curriculum design have occurred internationally. Less clear are the appropriate balance of the sciences, the best integration model, and solutions to the political and practical challenges of integrated curricula. DISCUSSION: New curricula tend to emphasize integration, development of more diverse physician competencies, and preparation of physicians to adapt to evolving technology and patients' expectations. Refocusing the basic/clinical dichotomy to a foundational/applied model may yield benefits in training widely competent future physicians.

How good is good? Students and assessors' perceptions of qualitative markers of performance.

BACKGROUND: Qualitative markers of performance are routinely used for medical student assessment, though the extent to which such markers can be readily translated to actionable pieces of information remains uncertain. PURPOSE: To explore (a) the perceived value to be indicated by descriptor phrases commonly used for describing student performance, (b) the perceived weight of the different performance domains (e.g. communication skills, work ethic, knowledge base, etc), and (c) whether or not the perceived value of the descriptors changes as a function of the performance domains. METHODS: Five domains of performance were identified from the thematic coding of past medical student transcripts (N = 156). From the transcripts, 91 distinct descriptors indicating the language commonly used by assessors were also identified. From the list of 91 descriptors, Thurstone's method of equal-appearing intervals was used to extract 10 descriptors that were representative of the continuum of student performance. A modified paired comparisons method was then used to enable the relative ranking of each of 10 descriptors combined with each of 5 different domains of performance. A web-based survey was used to collect responses from participants (N = 209), which consisted of medical students and faculty members who were previously involved in student assessment. RESULTS: Results demonstrated that respondents did not simply sum positive and negative descriptors in a uniform manner. Rather, comments on some domains (e.g., "ability to apply patient centred medicine") were seen as particularly positive when associated with positive descriptors but not particularly negative when associated with negative descriptors. For others (e.g., "receptivity and responsiveness to feedback") the reverse was true. Comments on "knowledge-base" elicited a relatively muted perception at both ends of the scale. Finally, the results also revealed moderate misalignment in the perceptions of assessors and students. CONCLUSIONS: The findings from this study suggest that the use of any given descriptor conveys slightly different meaning dependent on the context in which it is used. This helps to address some key issues surrounding the application of qualitative markers to performance assessment in medical education.

The effect of conceptual and contextual familiarity on transfer performance.

Applying a previously learned concept to a novel problem is an important but difficult process called transfer. It is suggested that a commonsense analogy aids in transfer by linking novel concepts to familiar ones. How the context of practice affects transfer when learning using analogies is still unclear. This study investigated the effect of a commonsense analogy and context familiarity for transfer of physiological concepts. First year psychology students (n = 24) learned three concepts: Starling's law, Laplace's law, and laminar-turbulent flow. The control group saw standard explanations while the intervention group saw an additional commonsense analogy. The context of learning was the organ system used for two practice clinical cases which differed for all concepts. Testing consisted of 12 new clinical cases. Starling's law cases used the organ system from practice while the other concepts presented in both novel and familiar organ systems. Half of the sample repeated testing after 1 week delay. The outcome was ratings of explanations of cases on a 0-3 scale. The effect of analogy was significant (Mean = 1.24 with, 0.86 without, F(1,22) = 4.26, p < 0.05) but not after delay (means of 1.08 and 0.75 respectively, F = (1,10), p = 0.06) There was significant effect for familiar context (Same = 1.23 (Starling), different = 0.68 (Laplace) and 0.73 (laminar-turbulent flow) (F(2,44) = 5.14, p < 0.01). Laplace's law and laminar turbulent flow cases in the familiar organ system had means of 1.65 and 1.77 respectively compared to novel cases with means of 0.74 and 0.68 (F(1,22) = 35.64, p < 0.0001). Similar effects were observed after delay. There was significant decay in performance after delay for all participants (immediate = 1.17, delayed = 0.91, F = 11.9 (1,10) p < 0.01). Common analogies aid conceptual understanding necessary for transfer. Despite conceptual aids, solving transfer problems is difficult.

The supportive care needs of men with advanced prostate cancer.

PURPOSE/OBJECTIVES: To better understand the priority supportive care needs of men with advanced prostate cancer. RESEARCH APPROACH: Qualitative, descriptive study. SETTING: Outpatient cancer center and urology clinics in central western Ontario, Canada. PARTICIPANTS: 12 men with hormone-sensitive prostate cancer and 17 men with hormone-refractory prostate cancer. METHODOLOGIC APPROACH: Patients participated in focus groups and interviews that examined their supportive care needs, their priority needs, and suggestions for improvements to the delivery of care. Tape-recorded focus group discussions and interviews were organized using NVivo software. MAIN RESEARCH VARIABLES: Patients' supportive care needs. FINDINGS: Participants identified prostate cancer-specific information and support to maintain their ability "to do what they want to do" as priority needs. Both hormone-sensitive and hormone-refractory groups cited problems with urinary function, the side effects of treatment, fatigue, and sexual concerns as major functional issues. Participants experienced emotional distress related to diagnosis and treatment. CONCLUSIONS: A priority health need for men with advanced prostate cancer is to improve or maintain functional abilities. In addition, men require support to meet their stage-specific information needs and to address concerns about the diagnosis and ambivalent feelings about past treatment decisions. INTERPRETATION: Nurses could play an important role in addressing men's information needs and providing emotional support. The complex care needs of men with advanced prostate cancer provide opportunity for the development of advanced practice nurse roles that would use the clinical and nonclinical aspects of the role.

The supportive care needs of family members of men with advanced prostate cancer.

This exploratory study identified the supportive care needs of family members of men with advanced hormone-sensitive (HS) and hormone-refractory (HR) prostate cancer. In focus groups and individual interviews, we asked eight family members of men with HS disease and 11 family members of men with HR disease to identify their supportive care needs and recommend strategies for improving care to meet these needs. Unmet needs common to both groups were lack of information and uncertainty about the future. Unmet needs specific to family members affected by HR prostate cancer related to caregiver burden, practical assistance, and isolation. Implications for practice to improve supportive care services for families affected by APC are provided.

Assessment steers learning down the right road: impact of progress testing on licensing examination performance.

Although it is generally accepted that assessment steers learning, this is generally viewed as an undesirable side effect. Recent evidence suggests otherwise. Experimental studies have shown that periodic formative assessments can enhance learning over equivalent time spent in study (Roediger & Karpicke 2006). However, positive effects of assessment at a curriculum level have not been demonstrated. Progress tests are a periodic formative assessment designed to enhance learning by providing objective and cumulative feedback, and by identifying a subgroup of students who require additional remediation. McMaster adopted the progress test methods in 1992-1993, as a consequence of poor performance on a national licensing examination. This article shows the positive effect of this innovation, which amounts to an immediate increase of about one-half standard deviation in examination scores, and a consistent upward trend in performance. The immediate effect of introducing objective tests was a reduction in failure rate on the licensing examination from 19% to 4.5%. Various reasons for this improvement in performance are discussed.

Evaluating health-related quality of life and priority health problems in patients with prostate cancer: a strategy for defining the role of the advanced practice nurse.

A framework for the introduction and evaluation of APN roles emphasizes the importance of a systematic approach to role development based on the assessment of patient health needs. This study determined the health-related quality of life (HRQL) of patients with prostate cancer. The most frequent and severe patient health problems and their perceptions of priority health problems were identified and compared across five patient groups as a strategy to inform the supportive care role of the advanced oncology nurse for patients with advanced prostate cancer. The study found that the majority of men with early stage and advanced hormone sensitive prostate cancer can expect to enjoy good quality of life for several years following diagnosis. These two patient groups have common priority needs for improving their health related to sexual function, urinary frequency, urinary incontinence, and physical activity. Both groups may benefit from an advanced practice nursing (APN) role that can provide episodic supportive care for health problems occurring at different treatment stages. Conversely, it was found that men with advanced hormone refractory prostate cancer experience significantly poorer HRQL and have multiple severe health problems. These patients also have different priority needs including problems related to pain, fatigue, and decreased physical activity. Because of this, the focus of supportive care programs and interventions in advanced prostate cancer will differ for those with hormone refractory disease. They may benefit more from an APN role that can provide ongoing rather than episodic supportive care to assess and manage the multiple, new, and worsening health problems associated with progressive disease.

Lung cancer.

INTRODUCTION: Lung cancer is the leading cause of cancer deaths in both men and women, with 80% to 90% of cases caused by smoking. Small cell lung cancer accounts for 20% of all cases, and is usually treated with chemotherapy. Adenocarcinoma is the main non-small cell pathology, and is treated initially with surgery. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for resectable and unresectable non-small cell lung cancer? What are the effects of treatments for small cell lung cancer? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations, such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 96 systematic reviews and RCTs. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: chemotherapy (postoperative or preoperative, dose intensification), continuous hyperfractionated accelerated radiotherapy (CHART), first-line platinum (or non-platinum)-based chemotherapy, molecular-targeted therapy, non-CHART hyperfractionated radiotherapy, prophylactic cranial irradiation, second-line chemotherapy (with single agent), second-line molecular-targeted therapy (with gefitinib or erlotinib), and thoracic irradiation (with or without chemotherapy).

Lung cancer.

INTRODUCTION: Lung cancer is the leading cause of cancer deaths in both men and women, with 80-90% of cases caused by smoking. Small cell lung cancer accounts for 20% of all cases, and is usually treated with chemotherapy. Adenocarcinoma is the main non-small cell pathology, and is treated initially with surgery. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for resectable and unresectable non-small cell lung cancer? What are the effects of treatments for small cell lung cancer? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations, such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 86 systematic reviews and RCTs. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: chemotherapy (postoperative or preoperative, dose intensification), continuous hyperfractionated accelerated radiotherapy (CHART), different single-agent chemotherapy regimens, first-line palliative chemotherapy (single or multiple agents), first-line platinum (or non-platinum)-based chemotherapy, molecular-targeted therapy, non-CHART hyperfractionated radiotherapy, palliative care, prophylactic cranial irradiation, second-line chemotherapy (with single or multiple agents), second-line molecular-targeted therapy (with gefitinib or erlotinib), second-line palliative chemotherapy, and thoracic irradiation (with or without chemotherapy).

Bisphosphonate associated osteonecrosis of the jaw.

In 2003, the first reports describing osteonecrosis of the jaw (ONJ) in patients receiving bisphosphonates (BP) were published. These cases occurred in patients with cancer receiving high-dose intravenous BP; however, 5% of the cases were in patients with osteoporosis receiving low-dose bisphosphonate therapy. We present the results of a systematic review of the incidence, risk factors, diagnosis, prevention, and treatment of BP associated ONJ. We conducted a comprehensive literature search for relevant studies on BP associated ONJ in oncology and osteoporosis patients published before February 2008.All selected relevant articles were sorted by area of focus. Data for each area were abstracted by 2 independent reviewers. The results showed that the diagnosis is made clinically. Prospective data evaluating the incidence and etiologic factors are very limited. In oncology patients receiving high-dose intravenous BP, ONJ appears to be dependent on the dose and duration of therapy, with an estimated incidence of 1%-12% at 36 months of exposure. In osteoporosis patients, it is rare, with an estimated incidence < 1 case per 100,000 person-years of exposure. The incidence of ONJ in the general population is not known. Currently, there is insufficient evidence to confirm a causal link between low-dose BP use in the osteoporosis patient population and ONJ. We concluded BP associated ONJ is associated with high-dose BP therapy primarily in the oncology patient population. Prevention and treatment strategies are currently based on expert opinion and focus on maintaining good oral hygiene and conservative surgical intervention.

Problem-based learning and medical education forty years on. A review of its effects on knowledge and clinical performance.

Problem-based learning (PBL) has swept the world of medical education since its introduction 40 years ago, leaving a trail of unanswered or partially answered questions about its benefits. The literature is replete with systematic reviews and meta-analyses, all of which have identified some common themes; however, heterogeneity in the definition of a 'problem-based learning curriculum' and its delivery, coupled with different outcome measurements, has produced divergent opinions. Proponents and detractors continue to dispute the merits of the cognitive foundation of a PBL approach, but, despite this, there is evidence that graduates of PBL curricula demonstrate equivalent or superior professional competencies compared with graduates of more traditional curricula.

Canadian consensus practice guidelines for bisphosphonate associated osteonecrosis of the jaw.

OBJECTIVE: Following publication of the first reports of osteonecrosis of the jaw (ONJ) in patients receiving bisphosphonates in 2003, a call for national multidisciplinary guidelines based upon a systematic review of the current evidence was made by the Canadian Association of Oral and Maxillofacial Surgeons (CAOMS) in association with national and international societies concerned with ONJ. The purpose of the guidelines is to provide recommendations regarding diagnosis, identification of at-risk patients, and prevention and management strategies, based on current evidence and consensus. These guidelines were developed for medical and dental practitioners as well as for oral pathologists and related specialists. METHODS: The multidisciplinary task force established by the CAOMS reviewed all relevant areas of research relating to ONJ associated with bisphosphonate use and completed a systematic review of current literature. These evidence-based guidelines were developed utilizing a structured development methodology. A modified Delphi consensus process enabled consensus among the multidisciplinary task force members. These guidelines have since been reviewed by external experts and endorsed by national and international medical, dental, oral surgery, and oral pathology societies. RESULTS: RECOMMENDATIONS regarding diagnosis, prevention, and management of ONJ were made following analysis of all current data pertaining to this condition. ONJ has many etiologic factors including head and neck irradiation, trauma, periodontal disease, local malignancy, chemotherapy, and glucocorticoid therapy. High-dose intravenous bisphosphonates have been identified as a risk factor for ONJ in the oncology patient population. Low-dose bisphosphonate use in patients with osteoporosis or other metabolic bone disease has not been causally linked to the development of ONJ. Prevention, staging, and treatment recommendations are based upon collective expert opinion and current data, which has been limited to case reports, case series, surveys, retrospective studies, and 2 prospective observational studies. RECOMMENDATIONS: In all oncology patients, a thorough dental examination including radiographs should be completed prior to the initiation of intravenous bisphosphonate therapy. In this population, any invasive dental procedure is ideally completed prior to the initiation of high-dose bisphosphonate therapy. Non-urgent procedures are preferably delayed for 3 to 6 months following interruption of bisphosphonate therapy. Osteoporosis patients receiving oral or intravenous bisphosphonates do not require a dental examination prior to initiating therapy in the presence of appropriate dental care and good oral hygiene. Stopping smoking, limiting alcohol intake, and maintaining good oral hygiene should be emphasized for all patients receiving bisphosphonate therapy. Individuals with established ONJ are most appropriately managed with supportive care including pain control, treatment of secondary infection, removal of necrotic debris, and mobile sequestrate. Aggressive debridement is contraindicated. CONCLUSION: Our multidisciplinary guidelines, which provide a rational evidence-based approach to the diagnosis, prevention, and management of bisphosphonate-associated ONJ in Canada, are based on the best available published data and the opinion of national and international experts involved in the prevention and management of ONJ.