Educational effectiveness of gynaecological teaching associates: a multi-centre randomised controlled trial.

OBJECTIVE: To evaluate, among medical students learning the female pelvic examination, the added benefits of training by gynaecological teaching associates compared with training involving a manikin only. DESIGN: Randomised controlled trial. SETTING: Nine university teaching hospitals. POPULATION: Ninety-four medical students recruited prior to commencing a 4-week obstetrics and gynaecology rotation. METHODS: The control training consisted of lectures, demonstration of the pelvic examination on a manikin, and opportunities to practise on this low-fidelity simulation (n = 40). The experimental group received additional gynaecological teaching associate training, delivered by pairs of experienced associates to groups of four medical students (n = 54). MAIN OUTCOME MEASURES: Outcomes measured at the end of the rotation included knowledge of the correct order of examination components (Yes/No), and student comfort [Likert scales anchored between 1 (very uncomfortable) and 4 (very comfortable) on four items] and confidence [Likert scales anchored between 1 (No) and 3 (Yes) on six items]. The primary outcome, measured at the end of the academic year, was the objective structured clinical examination of a female pelvis (score range 0-54). RESULTS: At baseline, the groups were similar in age, gender, and ethnicity. At the end of the clinical rotation, when compared with the control intervention, the experimental intervention had a moderate effect on student knowledge [difference 29.9% (95% CI 11.2-48.6%); P = 0.002] and confidence [difference 1 (95% CI 0-2); P < 0.001], and a large effect on student comfort [difference 1.8 (95% CI 0.6-3.0); P = 0.004]. At the end of the academic year, the experimental intervention had no impact on skills compared with the control [difference 2 (95% CI-1 to 4); P = 0.26]. CONCLUSIONS: Among medical students taught the female pelvic examination by low-fidelity simulation, additional training by gynaecology teaching associates improved knowledge, comfort, and confidence at the end of the clinical rotation but did not improve examination skills at end of the academic year.

Enzyme immunoassays for the estimation of adenosine 3',5' cyclic monophosphate and guanosine 3',5' cyclic monophosphate in biological fluids.

Simple, rapid and sensitive competitive enzyme immunoassays for the estimation of adenosine 3',5' cyclic monophosphate (cAMP) and guanosine 3',5' cyclic monophosphate (cGMP) in human plasma and urine are described. Specific antisera to each nucleotide were raised in rabbits by immunization with succinyl cyclic nucleotide--human serum albumin conjugates. For the assay, specific antibodies were incubated with a mixture of succinyl cyclic nucleotide labelled with horseradish peroxidase together with unlabelled standard or sample. The antibody-bound enzyme conjugate was separated from free hapten by anti-rabbit (IgG) sera immobilized to a microtitre plate. Activity of the bound enzyme conjugate was determined with tetramethylbenzidine. The assays were capable of detecting levels as low as 2 fmol of cAMP and cGMP. Good correlations were obtained between values generated by enzyme immunoassay and radioimmunoassay.

Rhizopus osteomyelitis. A case report and review.

Mucormycosis osteomyelitis has previously been described exclusively in association with contiguous infections of rhinocerebral mucormycosis. In a patient with corticosteroid-dependent neutropenia and anemia osteomyelitis of the femur developed caused by the Mucoraceae Rhizopus. Although a primary focus was not identified, we believe this infection was hematogenous in origin. Mitogen stimulation to phytohemagglutinin (PHA) of the patient's lymphocytes revealed depressed cellullar immunity; however, there was specific response to Rhizopus extract. Treatment with systemic amphotericin B prevented further progression of the infection. A review of mucormycosis osteomyelitis is presented.

Necrotizing enterocolitis with Escherichia coli heat-labile enterotoxin.

Twenty-one babies occupied a newborn intensive care unit during two separate clusters of necrotizing enterocolitis (NEC). Seven babies had suspected NEC, seven had proved NEC, two had diarrhea only, and five were unaffected. Of affected babies, 15 had toxigenic Escherichia coli or heat-labile E coli toxin in feces detected by enzyme-linked immunosorbent assay. One of five unaffected babies had fecal toxin (P = .01). Four of 12 affected babies had a fourfold immunoglobulin M (Igm) antitoxin titer rise within 3 weeks of the fecal studies. None of five unaffected infants had a serologic immune response. The clinical disease seen in the babies was not characteristic of previously described E coli heat-labile toxin-associated diarrhea.

Diarrhea in breast-fed and non-breast-fed infants.

During the first year of life a group of babies was prospectively observed for diarrhea and for fecal carriage of heat-labile toxigenic bacteria, with or without colonization factor, and rotavirus. Approximately half of the babies were breast-fed for the first six months of life. There was no difference between groups (breast-fed vs non-breast-fed) in number of babies who had diarrhea during any two-month period. Nor was there any difference between groups in the number of babies who had diarrhea while carrying toxigenic bacteria, with or without colonization factor. Secretory antibody to toxin was found in 37% of colostrum and milk samples. There was a small but insignificant difference in the number of babies who had diarrhea when they carried toxigenic bacteria depending on the presence of antibody in the breast milk they received.

Pediatric plague.

The large reservoir of animal plague in the American West led to 121 cases of human plague from 1970 to 1980. The majority (55%) of recent cases have occurred in children 16 years of age and younger. In New Mexico 38 pediatric plague cases were reviewed to determine the epidemiologic, clinical, and laboratory feature of this disease. Thirty-one patients (82%) had bubonic plague and seven (18%) had primary septicemic disease. Primary septicemic plague had a significantly higher case-fatality ratio (71% vs 3%; P = .0002) and an increased risk of plague pneumonia (57% vs 6%; P = .01) compared with bubonic disease. Symptoms at onset, physical examination, and laboratory data at hospitalization (mean of three days after onset) were consistent with an acute, systemic febrile illness. Recovery from plague was slow, requiring an average of 5.9 days from initiation of effective antibiotics until fever lysis. Only a minority of plague patients were initially suspected to have plague, even by the time of hospitalization. Whereas clinical evidence, particularly in bubonic disease, should suggest plague, residing in or visiting a rural are of the West (especially from June through September) during the week prior to illness may be the only useful epidemiologic clue for the majority of patients who lack a history suggestive of exposure to animals or fleas. The importance of pediatric plague stems from the recent increase in cases, the significant increase in the proportion of all cases occurring in children, the public health implications of plague pneumonia (16% of cases), and the demonstrated potential for plague patients to travel to areas of the country unfamiliar with the disease and its sylvatic home in the American West.

Analogs of Manduca adipokinetic hormone tested in a bioassay and in a receptor-binding assay.

Single amino acid replacement analogs of Manduca adipokinetic hormone (M-AKH) pGlu-Leu-Thr-Phe-Thr-Ser-Ser-Trp-GlyNH2 were tested for activity in bioassays as well as receptor binding assays. Amino acids were replaced by Ala and by D-analogs. In addition an extended M-AKH and analogs containing photo affinity labels were tested. All analogs had reduced activity. All the peptides which had enough activity to allow a full dose response curve reached the same maximal activity as native M-AKH. The use of analogs, in which L-Phe4 was replaced by Ala or by D-Phe and of L-Thr3 replaced by D-Thr, as competitors led to improved binding of M-AKH in our competitive receptor binding assay. In the bioassay an inactive concentration of Ala4 M-AKH increased the activity of a half optimal concentration of native M-AKH.

Measurement of calcium flux through ionotropic glutamate receptors using Cytostar-T scintillating microplates.

Human embryonic kidney cells (HEK293), expressing the human GluR4 receptor sub-unit of 2-amino-3-hydroxy-methylisoxazol-4-ylpropionic acid (AMPA) type non-NMDA receptors were used, in combination with Cytostar-T scintillating microplates, to develop an assay system for the screening of novel compounds with potential AMPA antagonistic characteristics. Agonist dose responses were measured using the agonists: AMPA; quisqualic acid; L-glutamic acid and kainic acid (KA), and EC50 values of 40, 10, 100 and 100 microM were estimated for each of the agonists, respectively. The AMPA receptor antagonists LY293558 and GYK152466 were tested and shown to inhibit agonist induced [45Ca] influx into the cells. An IC50 value of 600 microM was estimated for the competitive antagonist LY293558 and a value of 100 microM estimated for the non-competitive antagonist GYK152466. The developed assay system is homogeneous, allowing increased assay precision and speed. This allows the potential for automation of the assay and it may be used for screening large numbers of novel compounds.

Rapid noninvasive techniques for determining etiology of bronchitis and pneumonia in infants and children.

Table 2 lists the names, abbreviations, and principle underlying most of the rapid diagnostic techniques we have described. Table 3 lists the pathogens most likely to cause lower respiratory tract infections in pediatric patients, the specimens needed for each rapid diagnostic test now generally available, and the approximate time required for its actual performance. For maximal cost-effectiveness, it is recommended that laboratory diagnosis be pursued in a stepwise manner: 1) The usual patient with acute respiratory illness who is to be managed as an outpatient may need little if any laboratory evaluation. 2) For the child for whom hospital admission is being considered, serum C-reactive protein screen, urine bacterial antigen tests, and a cold agglutinin test (at the appropriate age) will help to classify the etiology of the infection as likely or unlikely to be bacterial. If antibiotic therapy is to be given, a blood culture should be obtained before starting. 3) For the child admitted to the hospital with a possible chlamydial or viral lower respiratory infection for whom specific therapy is considered, nasopharyngeal secretions should be examined for Chlamydia and for antigens of respiratory syncytial, parainfluenza, and influenza viruses to help select the appropriate antimicrobial. Serum for IgM level may be helpful. 4) For the child who has been intubated for respiratory support, a specimen of deep respiratory secretions should be sent for Gram stain, bacterial culture, for Chlamydia, and viral antigens and culture. 5) For patients presenting with atypical symptoms, signs, or clinical course additional diagnostic possibilities should be considered and appropriate tests done even if results may not be available within 48 hours.

Suppression of rabbit peritoneal macrophage migration by heat-labile E. coli toxin.

Migration of rabbit peritoneal macrophages toward casein-serum was inhibited by preincubation of the cells with heat-labile toxin of Escherichia coli in direct relationship to the concentration of toxin in the incubation mixture. Cells preincubated with heated toxin or with toxin-antiserum migrated the same as those which had been incubated in toxin-free media. Toxin-preincubated cells had levels of cyclic AMP which were increased in direct relationship to the concentration of toxin in the preincubation mixture. Heated toxin failed to induce increased levels of cAMP in the cells at the highest concentration tested.

Secretory IgA in cervical mucus.

PURPOSE: Sexually active adolescent girls are uniquely vulnerable to sexually transmitted disease, including cervical cancer and AIDS. Little is known about the development of genital immunity in adolescents. Secretory IgA (sIgA) in cervical mucus is an important component of genital immunity. We studied sIgA levels in cervical mucus samples for both adolescent and adult females. METHODS: Samples were collected in a university-based adolescent medicine clinic and a university student health center. Participants consisted of 13 sexually active adolescent girls and fourteen adult controls. Samples were collected in the course of routine pelvic exams. All subjects were at least two years post menarche. Mucus was aspirated directly from the cervical os. Diluted samples were liquefied with a proteolytic enzyme (bromelain). Secretory IgA levels were measured by radial immunodiffusion using IgA2 from pooled human plasma as a standard. RESULTS: Secretory IgA levels for the adolescent group (mean 0.157 g/L SD 0.080) were slightly lower than for the adult group mean (0.199 g/L SD 0.130) although not statistically significant. CONCLUSIONS: Cervical sIgA levels were comparable between sexually active adolescents and adults.

Clinical effect of converting antidepressant therapy from fluoxetine to sertraline.

The effect of replacing fluoxetine with sertraline at two dosage-conversion ratios was studied. Outpatients at a Veterans Affairs mental health clinic who were being treated with fluoxetine were randomly assigned to receive either 50 or 75 mg of sertraline hydrochloride for every 20 mg of fluoxetine (as the hydrochloride salt) or to continue to receive their current dosage of fluoxetine. The subjects were given the Hamilton Depression Rating Scale (HDRS) and the Beck Depression Inventory (BDI) at baseline and were re-examined at one-month intervals for three months with the HDRS and BDI and the Clinical Global Impression of Change. Each patient was re-evaluated by the same blinded investigator. A total of 45 patients (42 men and 3 women) completed the study. The final overall response did not differ significantly among the three groups. There were also no significant differences among the groups in the proportions of patients with HDRS and BDI scores classified as improving, worsening, or not changing. Improvement was more common in patients receiving the higher dosage of sertraline. Few adverse effects were reported. Outpatients receiving fluoxetine were switched to sertraline therapy without a loss of control of depression and without substantial adverse effects.

Dental attendance and dental status.

This article examines the relationship between differences in dental attendance patterns and variations in dental status. A sample of 336 dentate men and 110 dentate women were selected at random from employees of two industrial plants in N.W. England in 1980. They were given a dental examination and asked about visits to the dentist. Regression analysis showed that while the more frequent the dental visits, the lower the rate of tooth loss and the fewer the number of teeth with active decay, the higher, however, the average number of fillings. There were significant differences, moreover, between manual and non-manual workers, the former being more likely to lose their teeth and the latter to have their teeth filled, at each given age and frequency of dental visit. Though the more frequent dental attenders had the advantage over the less frequent of having, on average, a higher number of functioning teeth, restored or otherwise sound, they also had the disadvantage of having higher levels of treated disease and thus of disease experience. The results suggest that while frequent dental visits help to postpone tooth loss and to maintain dental function, they do not apparently help to prevent the onset of further disease.

Early decortication for anaerobic empyema in children.

Nine children underwent early decortication for empyema. Three had posttraumatic empyema and six had postpneumonic empyema. The decision for decortication was made 3-5 days after diagnosis of empyema, when it was judged that conventional treatment by antibiotics and intercostal catheter drainage was failing. Such failure was manifested by: loculated effusions (9), persistent fever (8), persistent respiratory distress (3), pulmonary air leak (3), and worsening parenchymal disease (1). The decortication procedure consisted of a standard posterolateral thoracotomy, removal of the fibrinous peel from the visceral and parietal pleurae, debridement or resection of necrotic lung tissue, irrigation of the pleural space, and drainage by intercostal catheters. In the 9 children who underwent this procedure, there were no deaths and a single complication, suppurative thrombophlebitis. Recovery was rapid in 6 out of 9 children, who were discharged within 10 days of operation. The remaining 3 out of 9 children had associated injuries or illnesses that necessitated a longer hospital stay. Bacteriologic studies confirmed anaerobic bacteria in the infected pleural contents of 5 out of 9 children. Bacteroides and anaerobic streptococci were the commonest isolates. Anaerobic infection of the pleural space cannot be cured without aggressive surgical drainage, in addition to antibiotics. Our experience suggests that early decortication is an efficacious procedure for selected children with empyema. The presence of anaerobic bacteria in the empyema may constitute an unequivocal indication for early decortication.

Cellulitis and necrotizing fasciitis of the abdominal wall in pediatric patients.

Soft tissue infections of the abdominal wall in 14 children were classified as cellulitis (8), necrotizing fasciitis (5), or myositis/myonecrosis (1). These 3 categories were characterized by increasing anatomic depth of infection, clinical severity, and need for more radical surgical treatment. Ten of the 14 children were neonates. The most frequent associations were omphalitis (5), necrotizing enterocolitis (4), and urachal anomalies (3). The severest infections were usually polymicrobial and contained both aerobic and anaerobic bacteria. Important clinical findings in children with necrotizing fasciitis and myositis/myonecrosis were tachycardia, systemic toxicity, severe edema, and, in older children, pain out of proportion to the apparent degree of infection. None of the children had fever or crepitation of the wound. An ominous sign, indicative of the need for immediate, radical debridement was the appearance of a patch of dusky or gangrenous skin. There were two deaths associated with delayed diagnosis of necrotizing fasciitis. One child did not receive radical debridement, and the other received it too late to be of benefit. Although these infections are rare in children, their lethal potential and early diagnostic signs must be recognized.

Nitrogen dioxide and respiratory illness in children. Part I: Health outcomes.

We have carried out a prospective cohort study to test the hypothesis that exposure to nitrogen dioxide increases the incidence and severity of respiratory infections during the first 18 months of life. Between January 1988 and June 1990, 1,315 infants were enrolled into the study at birth and followed with prospective surveillance for the occurrence of respiratory infections and monitoring of nitrogen dioxide concentrations in their homes. The subjects were healthy infants from homes without smokers; they were selected with stratification by type of cooking stove at a ratio of four to one for gas and electric stoves. Illness experience was monitored by a daily diary of symptoms completed by the mother and a telephone interview conducted every two weeks. Illnesses with wheezing or wet cough were classified as involving the lower respiratory tract; all other respiratory illnesses were designated as involving the upper respiratory tract. Exposure to nitrogen dioxide was estimated by two-week average concentrations measured in the subjects' bedrooms with passive samplers. This analysis is limited to the 1,205 subjects completing at least one month of observation; of these, 823 completed the full protocol, contributing 82.8% of the total number of days during which the subjects were under observation. Incidence rates for all respiratory illnesses, all upper respiratory illness, all lower respiratory illnesses, and lower respiratory illness further divided into those with any wheezing, or wet cough without wheezing, were examined within strata of nitrogen dioxide exposure at the time of the illness, nitrogen dioxide exposure during the prior month, and type of cooking stove. Consistent trends of increasing illness incidence rates with increasing exposure to nitrogen dioxide were not evident for either the lagged or unlagged exposure variables. The effect of nitrogen dioxide exposure on illness occurrence during at-risk intervals of two weeks' duration was examined using the generalized estimating equation approach. In these multivariate analyses, none of the odds ratios was significantly elevated for unlagged nitrogen dioxide exposures, lagged nitrogen dioxide exposures, or stove type. Duration of illness was assessed in relation to the same exposure variables; illness duration and nitrogen dioxide exposure were not associated. We have found that indoor exposure to nitrogen dioxide is associated with neither the incidence nor the duration of respiratory illnesses. The study was designed to have sufficient power to detect effects of nitrogen dioxide exposure of magnitudes previously reported and in a range relevant to public health concern; the lack of association cannot be attributed to potential bias from misclassification of outcome or exposure.(ABSTRACT TRUNCATED AT 400 WORDS)

Nitrogen dioxide and respiratory illness in children. Part III: Quality assurance in an epidemiologic study.

This report describes the quality assurance and quality control program developed for the previously reported epidemiologic study of nitrogen dioxide (NO2) and respiratory illness in children (Health Effects Institute Research Report 58, Parts I and II). The specific aims of the program were to make certain that data were sufficiently accurate, complete, verifiable, and retrievable. The quality assurance and quality control program consisted of: a written protocol, standard operating procedures, written records, a project management system, appropriate data processing, data verification, and data analysis planning, and was staffed by qualified and appropriately trained personnel. Within the activities of the overall program, two focused quality assurance studies were conducted. During the first of these focused studies, parents maintained a calendar-diary of their child's daily respiratory symptoms. Telephone interviews were conducted at intervals of two weeks, and parents used the calendars to report on symptom occurrence since the previous call. To assess the comparability of illness events based on symptom reports from the parents with usual clinical diagnostic methods, nurse practitioners examined children during illness, and office and clinic records of outpatient visits were reviewed. Using the parent reports, respiratory illnesses were defined as symptom episodes of at least two consecutive days; lower respiratory illnesses included at least one day of either wet cough or wheeze. Runny or stuffy nose was reported for 93% of illnesses; and wet cough for 33% and wheeze for 6% of illnesses. In comparison with the diagnoses made by a nurse practitioner, parent reports of wet cough or wheeze were sensitive (93.4%) for detecting lower respiratory illnesses, but nonspecific (with specificity of only 24.2%). The majority of the false-positive lower respiratory illnesses had the symptom of wet cough. The comparison of parent reports with outpatient records provided similar findings. These findings indicate that standardized reporting of respiratory illnesses can be achieved with regular telephone interviews, but the classification of specific illnesses from the observations of parents' information may differ from diagnoses made by clinicians. The second focused quality assurance study evaluated the measurement error associated with the parents' use of passive diffusion samplers for NO2. Midway through the study, technicians conducted home visits to assess compliance with stated procedures, and to make independent measurements of NO2. Based on criteria for placement and use of the samplers, conditions of noncompliance were observed on about 40% of visits.(ABSTRACT TRUNCATED AT 400 WORDS)

Assessment of the need for education and/or training in the dental care of people with handicaps.

A survey questionnaire was sent to members of the British Society of Dentistry for the Handicapped to investigate their opinions about the need for education and training of dentists in the delivery of oral care to people with handicaps. Their educational experience was explored. Views on education and training were investigated in relation to timing, content and methods. Three hundred and sixty five questionnaires were sent and the total response rate was 67.4 per cent. There was a higher percentage of females than males and a higher percentage of 30 to 39 year old subjects in the sample. The data were analysed using the 'Survey Plus' program. A high proportion of respondents thought there was a need for education and training of dentists in the delivery of care to people with handicaps (70 per cent). Their views on training provided information on three main issues: the type of training course, and the content and methods of training or education. In-service training, observation of other dentists and continuing education courses were opportunities that people considered would have helped them. Although views varied, there was a notable desire for contact with experienced clinicians, particularly the observation of them carrying out treatment, the opportunity for participating in teaching methods, discussions and problem-solving aids. The involvement of carers and of people with handicaps themselves was suggested. Undergraduate and postgraduate education were both considered important, although postgraduate training was the more highly favoured. In relation to the content of training, behaviour management, communication skills and appropriate treatment planning were most commonly identified. This information will be useful for those wishing to establish courses.

The concept of need in dental care.

The most commonly used methods of assessing need for treatment are based solely on clinical criteria. Recently, it has been recognized that a wider interpretation than that provided by clinically assessed need is required. Measures of need should include the impact of ill health upon individuals, the degrees of dysfunction and the perceptions and attitudes of patients. Although there is no generally agreed definition of need, the taxonomy suggested by Bradshaw (1972) is recommended. He divides need into normative, felt, expressed and comparative types. One of the major shortcomings of all methods of assessing need is that they do not assess the need and propensity for preventive care and health education. A more realistic assessment of treatment needs should include the functional and social dimensions of dental disease and an assessment of the social and motivational factors which predispose people towards dental ill health and influence the effectiveness of treatment and health education. Some dental needs are not very well assessed. In particular, the assessment of the need for treatment of malocclusion, whilst claiming to be objective, does not incorporate measures of lay perception or impact of the condition. Instead of relying only upon purely clinical methods of assessing needs, the development of sociodental indicators is required. This will encourage a shift in emphasis away from the mechanical to the behavioural aspects of treatment and the development of a health-orientated model of care in preference to the sickness model that dominates current dental services.

An innovation in the assessment of future dentists.

'The assessment of students is a serious and often tragic enterprise.' The central question in assessment is 'What is one trying to assess?'. Is it factual knowledge, ability to apply and problem solve, clinical competencies or indeed other attributes? The domain being assessed requires appropriate methods. Professionals involved in examination development have identified three characteristics which all assessment methods demand: reliability, validity and feasibility. This article sets out to describe these features.