Does testing enhance learning in continuing medical education?

BACKGROUND: There has been growing interest in using theory-driven research to develop and evaluate continuing medical education (CME) activities. Within health professions education, testing has been shown to promote learning in a variety of different contexts, an effect referred to as test-enhanced learning (TEL). However, the extent to which TEL generalizes to CME remains unclear. The purpose of this study was to investigate whether physicians who received two intervening tests following a CME event would experience a TEL effect relative to physicians who received additional study material to review without testing. METHODS: Forty-nine physicians were recruited during a local CME activity. Physicians were randomized to either a) the test group (n=26), where participants completed two 20 multiple-choice question (MCQ) quizzes related to the lecture content or b) the study group (n=23), where participants studied the same information without testing. Testing and studying occurred independently during the CME activity, and then four weeks later online. At eight weeks, participants completed a final 20-item MCQ online test. A between-subjects t-test was used to compare performance on the final test as a function of the initial educational activity (test group vs. study group). RESULTS: Performance on the final MCQ test was equivalent for both test (Mean (SD): 75% (9.9)) and study-only (77% (7.3)) conditions (t(47) = 0.94, p=0.35). CONCLUSION: The null findings in the present study are contrary to previous findings demonstrating TEL among novice learner populations. The lack of TEL highlights several programmatic considerations that should be factored in before implementing TEL as a part of CME.

Getting fit for hip and knee replacement: a protocol for the Fit-Joints pilot randomized controlled trial of a multi-modal intervention in frail patients with osteoarthritis.

BACKGROUND: Joint replacement provides significant improvements in pain, physical function, and quality of life in patients with osteoarthritis. With a growing body of evidence indicating that frailty can be treated, it is important to determine whether targeting frailty reduction in hip and knee replacement patients improves post-operative outcomes. OBJECTIVES: The primary objective is to examine the feasibility of a parallel group RCT comparing a preoperative multi-modal frailty intervention to usual care in pre-frail/frail older adults undergoing elective unilateral hip or knee replacements. The secondary objectives areTo explore potential efficacy of the multi-modal frailty intervention in improving frailty and mobility between baseline and 6 weeks post-surgery using Fried frailty phenotype and short performance physical battery (SPPB) respectively.To explore potential efficacy of the multi-modal frailty intervention on post-operative healthcare services use. METHODS/DESIGN: In a parallel group pilot RCT, participants will be recruited from the Regional Joint Assessment Program in Hamilton, Canada. Participants who are (1) ≥ 60 years old; (2) pre-frail (score of 1 or 2) or frail (score of 3-5; Fried frailty phenotype); (3) having elective unilateral hip or knee replacement; and (4) having surgery wait times between 3 and 10 months will be recruited and randomized to either the intervention or usual care group. The multi-modal frailty intervention components will include (1) tailored exercise program (center-based and/or home-based) with education and cognitive behavioral change strategies; (2) protein supplementation; (3) vitamin D supplementation; and (4) medication review. The main comparative analysis will take place at 6 weeks post-operative. The outcome assessors, data entry personnel, and data analysts are blinded to treatment allocation. Assessments: feasibility will be assessed by recruitment rate, retention rate, and data collection completion. Frailty and healthcare use and other clinical outcomes will be assessed. The study outcomes will be collected at the baseline, 1 week pre-operative, and 6 weeks and 6 months post-operative. DISCUSSION: This is the first study to examine the feasibility of multi-modal frailty intervention in pre-frail/frail older adults undergoing hip or knee replacement. This study will inform the planning and designing of multi-modal frailty interventional studies in hip and knee replacement patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT02885337.

A remote metastatic giant cell tumour to the skull.

This case discusses an unusual presentation of remote metastatic giant cell tumour presenting as a seizure.

Management of Central Poststroke Pain: Systematic Review of Randomized Controlled Trials.

BACKGROUND AND PURPOSE: Central poststroke pain is a chronic neuropathic disorder that follows a stroke. Current research on its management is limited, and no review has evaluated all therapies for central poststroke pain. METHODS: We conducted a systematic review of randomized controlled trials to evaluate therapies for central poststroke pain. We identified eligible trials, in any language, by systematic searches of AMED, CENTRAL, CINAHL, DARE, EMBASE, HealthSTAR, MEDLINE, and PsychINFO. Eligible trials (1) enrolled ≥10 patients with central poststroke pain; (2) randomly assigned them to an active therapy or a control arm; and (3) collected outcome data≥14 days after treatment. Pairs of reviewers, independently and in duplicate, screened titles and abstracts of identified citations, reviewed full texts of potentially eligible trials, and extracted information from eligible studies. We used a modified Cochrane tool to evaluate risk of bias of eligible studies, and collected patient-important outcomes according to recommendations by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials. We conducted, when possible, random effects meta-analyses, and evaluated our certainty in treatment effects using the Grading of Recommendations Assessment, Development, and Evaluation System. RESULTS: Eight eligible English language randomized controlled trials (459 patients) tested anticonvulsants, an antidepressant, an opioid antagonist, repetitive transcranial magnetic stimulation, and acupuncture. Results suggested that all therapies had little to no effect on pain and other patient-important outcomes. Our certainty in the treatment estimates ranged from very low to low. CONCLUSIONS: Our findings are inconsistent with major clinical practice guidelines; the available evidence suggests no beneficial effects of any therapies that researchers have evaluated in randomized controlled trials.

Effectiveness of test-enhanced learning in continuing health sciences education: a randomized controlled trial.

BACKGROUND: Increasing concerns over the effectiveness and quality of continuing medical education (CME) programs has encouraged educators to use theoretically driven empirical research to improve the educational value of these activities. Within cognitive psychology, theories of learning and knowledge acquisition, such as test-enhanced learning (TEL), may be used to enhance the effectiveness of CME protocols and delivery. The present study examined whether the pedagogical benefits of testing can be observed in practicing physicians. METHODS: A total of 83 physicians were recruited following an education session on constipation management and were randomized to either (a) the test condition (n = 43), where learners wrote a short test consisting of 10 short-answer questions (SAQs), or (b) the study condition (n = 40), where learners studied the same information. Four weeks later, 56 (68%) physicians completed a final test with 10 new SAQs, with 27 being from the initial test condition and 29 belonging to the initial study condition. RESULTS: Performance on the final SAQ test was equivalent for both test (42.5%) and study-only (41.2%) conditions (p = .71). DISCUSSION: The null findings in the present study are inconsistent with previous research showing the pedagogical benefits of testing relative to studying. Given that most TEL research focuses on novice learners, who lack strong associative memory networks, it is possible that TEL is specific to novices and not generalizable to experts. Alternative explanations focus on the importance of repeated, distributed testing with feedback.

Management of chronic neuropathic pain: a protocol for a multiple treatment comparison meta-analysis of randomised controlled trials.

INTRODUCTION: Chronic neuropathic pain is associated with reduced health-related quality of life and substantial socioeconomic costs. Current research addressing management of chronic neuropathic pain is limited. No review has evaluated all interventional studies for chronic neuropathic pain, which limits attempts to make inferences regarding the relative effectiveness of treatments. METHODS AND ANALYSIS: We will conduct a systematic review of all randomised controlled trials evaluating therapies for chronic neuropathic pain. We will identify eligible trials, in any language, by a systematic search of CINAHL, EMBASE, MEDLINE, AMED, HealthSTAR, DARE, PsychINFO and the Cochrane Central Registry of Controlled Trials. Eligible trials will be: (1) enrol patients presenting with chronic neuropathic pain, and (2) randomise patients to alternative interventions (pharmacological or non-pharmacological) or an intervention and a control arm. Pairs of reviewers will, independently and in duplicate, screen titles and abstracts of identified citations, review the full texts of potentially eligible trials and extract information from eligible trials. We will use a modified Cochrane instrument to evaluate risk of bias of eligible studies, recommendations from the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) to inform the outcomes we will collect, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to evaluate our confidence in treatment effects. When possible, we will conduct: (1) in direct comparisons, a random-effects meta-analysis to establish the effect of reported therapies on patient-important outcomes; and (2) a multiple treatment comparison meta-analysis within a Bayesian framework to assess the relative effects of treatments. We will define a priori hypotheses to explain heterogeneity between studies, and conduct meta-regression and subgroup analyses consistent with the current best practices. ETHICS AND DISSEMINATION: We do not require ethics approval for our proposed review. We will disseminate our findings through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: PROSPERO (CRD42014009212).

Chronic pain syndromes after ischemic stroke: PRoFESS trial.

BACKGROUND AND PURPOSE: Chronic pain syndromes are reported to be common after stroke, but most previous epidemiological studies have generally included small cohorts of patients with relatively short-term follow-up. In a large cohort with ischemic stroke (Prevention Regimen for Effectively avoiding Second Stroke [PRoFESS] trial), we determined the prevalence, risk factors, and clinical consequence of new poststroke pain syndromes. METHODS: Within the PRoFESS trial (mean follow-up 2.5 years), a standardized chronic pain questionnaire was administered (at the penultimate follow-up visit) to all participants who reported chronic pain since their stroke and did not have a history of chronic pain before their index stroke. Multivariable logistic regression analyses were used to determine risk factors for poststroke pain (and pain subtypes), and the association between poststroke pain and cognitive (≥ 3 reduction in Mini-Mental State Examination score) and functional decline (≥ 1 increase in m-Rankin). RESULTS: In total, 15 754 participants were included; of which 1665 participants (10.6%) reported new chronic poststroke pain, and included 431 participants (2.7%) with central poststroke pain, 238 (1.5%) with peripheral neuropathic pain, 208 (1.3%) with pain from spasticity, and 136 participants (0.9%) with pain from shoulder subluxation. More than 1 pain subtype was reported in 86 participants (0.6%). Predictors of poststroke pain included increased stroke severity, female sex, alcohol intake, statin use, depressive symptoms, diabetes mellitus, antithrombotic regimen, and peripheral vascular disease. A new chronic pain syndrome was associated with greater dependence (odds ratio, 2.16; 95% confidence interval, 1.82-2.56). Peripheral neuropathy and pain from spasticity/shoulder subluxation were associated with cognitive decline. CONCLUSIONS: Chronic pain syndromes are common after ischemic stroke and are associated with increased functional dependence and cognitive decline.

Does this patient with diabetes have large-fiber peripheral neuropathy?

CONTEXT: Diabetic peripheral neuropathy predisposes patients to foot ulceration that heals poorly and too often leads to amputation. Large-fiber peripheral neuropathy (LFPN), one common form of diabetic neuropathy, when detected early prompts aggressive measures to prevent progression to foot ulceration and its associated morbidity and mortality. OBJECTIVE: To systematically review the literature to determine the clinical examination findings predictive of asymptomatic LFPN before foot ulceration develops. DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION: MEDLINE (January 1966-November 2009) and EMBASE (1980-2009 [week 50]) databases were searched for articles on bedside diagnosis of diabetic peripheral neuropathy. Included studies compared elements of history or physical examination with nerve conduction testing as the reference standard. DATA SYNTHESIS: Of 1388 articles, 9 on diagnostic accuracy and 3 on precision met inclusion criteria. The prevalence of diabetic LFPN ranged from 23% to 79%. A score greater than 4 on a symptom questionnaire developed by the Italian Society of Diabetology increases the likelihood of LFPN (likelihood ratio [LR], 4.0; 95% confidence interval [CI], 2.9-5.6; negative LR, 0.19; 95% CI, 0.10-0.38). The most useful examination findings were vibration perception with a 128-Hz tuning fork (LR range, 16-35) and pressure sensation with a 5.07 Semmes-Weinstein monofilament (LR range, 11-16). Normal results on vibration testing (LR range, 0.33-0.51) or monofilament (LR range, 0.09-0.54) make LFPN less likely. Combinations of signs did not perform better than these 2 individual findings. CONCLUSIONS: Physical examination is most useful in evaluating for LFPN in patients with diabetes. Abnormal results on monofilament testing and vibratory perception (alone or in combination with the appearance of the feet, ulceration, and ankle reflexes) are the most helpful signs.

Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients in Canada.

BACKGROUND: Venous thromboembolism (VTE) prophylaxis in acutely ill medical patients has been shown to be safe and effective. Underutilization of this patient safety practice may result in avoidable mortality and morbidity. OBJECTIVES: We aimed to determine the proportion of hospitalized, acutely ill medical patients across Canada who were eligible to receive thromboprophylaxis and to evaluate the frequency, determinants and appropriateness of its use. PATIENTS/METHODS: CURVE is a national, multicenter chart audit of 29 Canadian hospitals. Data were collected on consecutive patients admitted to hospital for an acute medical illness during a defined 3-week study period. Information on demographic and clinical characteristics, risk factors for VTE and bleeding and use of VTE prophylaxis were recorded. The indications for and appropriateness of VTE prophylaxis were assessed using pre-specified criteria based on international consensus guidelines. Multivariable analyses were performed to identify determinants of prophylaxis use. RESULTS: Of the 4124 medical admissions screened over the study period, 1894 patients (46%) were eligible for study inclusion. The most common specified admitting diagnoses were severe infection (28%), COPD exacerbation or respiratory failure (12%), malignancy (9%) and congestive heart failure (8%). Thromboprophylaxis was indicated in 1702 (90%) study patients. Overall, some form of prophylaxis was administered to 23% of all patients. However, only 16% received appropriate thromboprophylaxis. Factors independently associated with greater use of prophylaxis included internist (vs. other specialty) as attending physician (OR 1.33, 95% confidence interval (CI) [1.03, 1.71]), university-associated (vs. community) hospital (OR 1.46, 95% CI [1.03, 2.07]), immobilization (per day) (OR 1.60, 95% CI [1.45, 1.77]), presence of >or=1 VTE risk factors (OR=1.78, 95% CI [1.35, 2.34]) and duration of hospitalization (per day of stay) (OR 1.05, 95% CI [1.03, 1.07]), however, use of prophylaxis was unacceptably low in all groups. Patients with cancer had a significantly reduced likelihood of receiving prophylaxis (OR=0.40, 95% CI [0.24, 0.68]). Presence of risk factors for bleeding did not influence the use or choice of prophylaxis. CONCLUSION: Most patients hospitalized for medical illness had indications for thromboprophylaxis, yet only 16% received appropriate prophylaxis. Efforts should be made to elucidate the reasons that underlie the very low rate of thromboprophylaxis in medical patients and to develop and test strategies to improve implementation of this patient safety practice.

Does the clinical examination predict lower extremity peripheral arterial disease?

CONTEXT: Lower extremity peripheral arterial disease (PAD) is common and associated with significant increases in morbidity and mortality. Physicians typically depend on the clinical examination to identify patients who need further diagnostic testing. OBJECTIVE: To systematically review the accuracy and precision of the clinical examination for PAD. DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION: MEDLINE (January 1966 to March 2005) and Cochrane databases were searched for articles on the diagnosis of PAD based on physical examination published in the English language. Included studies compared an element of the history or physical examination with a reference standard of ankle-brachial index, duplex sonography, or angiogram. Seventeen of the 51 potential articles identified met inclusion criteria. Two of the authors independently extracted data, performed quality review, and used consensus to resolve any discrepancies. DATA SYNTHESIS: For asymptomatic patients, the most useful clinical findings to diagnose PAD are the presence of claudication (likelihood ratio [LR], 3.30; 95% confidence interval [CI], 2.30-4.80), femoral bruit (LR, 4.80; 95% CI, 2.40-9.50), or any pulse abnormality (LR, 3.10; 95% CI, 1.40-6.60). While none of the clinical examination features help to lower the likelihood of any degree of PAD, the absence of claudication or the presence of normal pulses decreases the likelihood of moderate to severe disease. When considering patients who are symptomatic with leg complaints, the most useful clinical findings are the presence of cool skin (LR, 5.90; 95% CI, 4.10-8.60), the presence of at least 1 bruit (LR, 5.60; 95% CI, 4.70-6.70), or any palpable pulse abnormality (LR, 4.70; 95% CI, 2.20-9.90). The absence of any bruits (iliac, femoral, or popliteal) (LR, 0.39; 95% CI, 0.34-0.45) or pulse abnormality (LR, 0.38; 95% CI, 0.23-0.64) reduces the likelihood of PAD. Combinations of physical examination findings do not increase the likelihood of PAD beyond that of individual clinical findings. However, when combinations of clinical findings are all normal, the likelihood of disease is lower than when individual symptoms or signs are normal. A PAD scoring system, which includes auscultation of arterial components by handheld Doppler, provides greater diagnostic accuracy. CONCLUSIONS: Clinical examination findings must be used in the context of the pretest probability because they are not independently sufficient to include or exclude a diagnosis of PAD with certainty. The PAD screening score using the hand-held Doppler has the greatest diagnostic accuracy.

Can troponin I measurement predict short-term serious cardiac outcomes in patients presenting to the emergency department with possible acute coronary syndrome?

OBJECTIVE: To determine the ability of troponin I (TnI) measurement to predict the likelihood of a serious cardiac outcome over the subsequent 72 hours in patients presenting to the emergency department (ED) with symptoms suggestive of an acute coronary syndrome. METHODS: This prospective observational study enrolled consecutive patients presenting to 2 urban tertiary care hospital EDs over a 5-week period. Eligible patients included those for whom a TnI test was ordered within 24 hours of arrival and in whom no serious cardiac outcome occurred before the test result was available. Patients were followed for 72 hours and serious cardiac outcomes documented; these included cardiovascular death, myocardial infarction, congestive heart failure, serious arrhythmia and refractory pain. We calculated likelihood ratios (LRs) to describe the association of the TnI result with serious cardiac outcomes. RESULTS: Of the 352 enrolled patients, 20 had a serious cardiac outcome within 72 hours of ED presentation. The derived LRs (and 95% confidence interval [CI]) were 0.5 (0.3-0.9) for TnI values <0.5 microg/L, 1.6 (0.4-6.5) for TnI values from 0.5 to 2.0 microg/L, 5.8 (1.7-19.5) for TnI values from >2.0 to 10.0 microg/L and 14.4 (4.8-42.9) for TnI values >10.0 microg/L. CONCLUSIONS: TnI values >2.0 microg/L are associated with an increased probability of serious cardiac outcomes within 72 hours. TnI values between 0.5 and 2.0 microg/L are weakly positive predictors. TnI values <0.5 microg/L have LRs in the range of 0.5 and thus are weakly negative predictors, not substantially decreasing the likelihood of serious cardiac outcomes, particularly in patients with a moderate or high pretest probability.

Does this patient have pulmonary embolism?

CONTEXT: Experienced clinicians' gestalt is useful in estimating the pretest probability for pulmonary embolism and is complementary to diagnostic testing, such as lung scanning. However, it is unclear whether recently developed clinical prediction rules, using explicit features of clinical examination, are comparable with clinicians' gestalt. If so, clinical prediction rules would be powerful tools because they could be used by less-experienced health care professionals to simplify the diagnosis of pulmonary embolism. Recent studies have shown that the combination of a low pretest probability (using a clinical prediction rule) and a normal result of a D-dimer test reliably excludes pulmonary embolism without the need for further testing. OBJECTIVE: To evaluate and demonstrate the accuracy of pretest probability assessment for pulmonary embolism using clinical gestalt vs clinical prediction rules. DATA SOURCES: The MEDLINE database was searched for relevant articles published between 1966 and March 2003. Bibliographies of pertinent articles also were scanned for suitable articles. STUDY SELECTION: To be included in the analysis, studies were required to have consecutive, unselected patients enrolled; participating physicians in the studies, blinded to the results of diagnostic testing, had to estimate pretest probability of pulmonary embolism; and validated diagnostic methods had to be used to confirm or exclude pulmonary embolism. DATA EXTRACTION: Three reviewers independently scanned titles and abstracts for inclusion of studies. An initial MEDLINE search identified 1709 studies, of which 16 involving 8306 patients were included in the final analysis. DATA SYNTHESIS: A clinical gestalt strategy was used in 7 studies, and in the low, moderate, and high pretest categories, the rates of pulmonary embolism ranged from 8% to 19%, 26% to 47%, and 46% to 91%, respectively. Clinical prediction rules were used in 10 studies, and 3% to 28%, 16% to 46%, and 38% to 98% in the low, moderate, and high pretest probability groups, respectively, had pulmonary embolism. CONCLUSIONS: The clinical gestalt of experienced clinicians and the clinical prediction rules used by physicians of varying experience have shown similar accuracy in discriminating among patients who have a low, moderate, or high pretest probability of pulmonary embolism. We advocate the use of a clinical prediction rule because it has shown to be accurate and can be used by less-experienced clinicians.

Venous thromboembolism prophylaxis in medical inpatients: a retrospective chart review.

BACKGROUND: Venous thromboembolic disease (VTE) is a major cause of morbidity and mortality in hospitalized patients. Most hospitalized patients with a fatal pulmonary embolism are medical patients who do not have a history of recent surgery [BMJ 302 (1991) 709; J. R. Soc. Med. 82 (1989) 198]. There is evidence suggesting that VTE prophylaxis is indicated in many high risk medical patients [Chest 119 (2001) 132S; NEJM 341 (1999) 793]. However, previous studies have shown that only about one third of high risk medical patients receive VTE prophylaxis [Ann. Intern. Med. 115 (1991) 591; Chest 106 (1994) 13; Chest 107 (1995) 296]. The objective of this study was to determine the frequency of use of VTE prophylaxis in medical inpatients at two teaching hospitals in Hamilton, Ontario. METHODS: A retrospective chart review of consecutive patients admitted to medical wards at two acute care sites of McMaster University affiliated teaching hospitals between October 10, 2001 and December 11, 2001 was performed. For each patient, demographic data, risk factors for VTE, method of VTE prophylaxis and contraindications to VTE prophylaxis were recorded. RESULTS: 756 patient charts were reviewed and 310 (41%) were excluded because the primary diagnosis required anticoagulation, the patients were being treated with anticoagulation (warfarin or heparin) before admission or the patient was admitted to the intensive care unit. Of the remaining 446 patients, 146 (33%) received some form of VTE prophylaxis. Of the patients receiving prophylaxis, 4% had early ambulation, 9% wore anti-embolic stockings (AES), 1% used intermittent pneumatic compression, 23% used unfractionated heparin and 3% used low molecular weight heparin. Two hundred five (46%) patients had one identifiable VTE risk factor and 63 (14%) had two or more risk factors. Patients with more VTE risk factors were more likely to receive prophylaxis. INTERPRETATION: One third of medical inpatients at two teaching hospitals in Hamilton received some form of VTE prophylaxis.