Virtual trauma patient simulation design using the McGill Simulation Complexity Score (MSCS): a breakthrough in trauma education.

BACKGROUND: Virtual patient simulations are interactive, computer-based cases. We designed scenarios based on the McGill Simulation Complexity Score (MSCS), a previously described objective complexity score. We aimed to establish validity of the MSCS and introduce a novel learning tool in trauma education at our institution. METHODS: After design of an easy and difficult patient scenario, we randomized medical students and residents to each perform 1 of the 2 scenarios. We conducted a 2-way analysis of variance of training level (medical student, resident) and scenario complexity (easy, difficult) to assess their effects on virtual time, the number of steps taken in the scenario, beneficial and harmful actions, and the ratio of beneficial over harmful actions. RESULTS: Virtual patient scenarios were successfully designed using the MSCS. Twenty-four medical students and 12 residents participated in the easy scenario (MSCS = 3), and 27 medical students and 12 residents did the difficult scenario (MSCS = 18). Though beneficial actions were similar between students and residents, sudents performed more harmful actions, particularly when the scenario was difficult. One virtual patient died in the easy scenario and 3 died in the difficult one (all medical students). Performance varied with level of complexity and there was significant interaction between level of training and number of steps, as well as with number of harmful actions. Decreasing performance with increasing level of complexity, as defined by the MSCS, suggests this score can accurately quantify difficulty. CONCLUSION: We established validity of the MSCS and showed its successful application on virtual patient scenario design.

A retrospective study comparing postoperative opioid prescribing practices in an academic medical centre.

Background: In the midst of the North American opioid crisis, identifying and intervening on drivers of high-risk opioid prescriptions is an important step towards reducing iatrogenic harm. Objectives: We aimed to identify factors associated with variations in high-risk opioid discharge prescriptions, following select surgical procedures, to guide future quality improvement initiatives. Methods: This retrospective cohort study analyzed 1322 patients who underwent select open pelvic and open abdominal surgeries between January 1 and December 31, 2017, in a tertiary health care centre in Montreal. Results: Patients who underwent open abdominal surgeries were prescribed significantly higher daily doses of morphine milligram equivalents (MME) (45 mg; interquartile range, 30-60), than patients who underwent either a caesarean delivery (20 mg, 20-20) or a hysterectomy (30 mg, 22-30). After adjustment for multiple potential confounders, abdominal surgery was associated with 4 times the odds of receiving more than 50 MME at hospital discharge compared with pelvic surgeries (odds ratio, 3.96; 95% confidence interval, 1.31-11.97). The availability of postoperative preprinted order sets with fixed high doses of opioids was also highly associated with the outcome. Conclusion: In our institution, some surgeries were more likely to receive high-risk opioid prescriptions at discharge. Efforts to optimize safer prescribing practices should address the creation and/or updating of preprinted order sets to reflect current best practice guidelines. This initiative could be overseen by hospital pharmacy and therapeutics committees.

Twelve tips to support the development of clinical reasoning skills using virtual patient cases.

Clinical reasoning is a critical core competency in medical education. Strategies to support the development of clinical reasoning skills have focused on methodologies used in traditional settings, including lectures, small groups, activities within Simulation Centers and the clinical arena. However, the evolving role and growing utilization of virtual patients (VPs) in undergraduate medical education; as well as an increased emphasis on blended learning, multi-modal models that include VPs in core curricula; suggest a growing requirement for strategies or guidelines that directly focus on VPs. The authors have developed 12 practical tips that can be used in VP cases to support the development of clinical reasoning. These are based on teaching strategies and principles of instructional design and pedagogy, already used to teach and assess clinical reasoning in other settings. Their application within VPs will support educators who author or use VP cases that promote the development of clinical reasoning.

Universal Genetic Testing for Newly Diagnosed Invasive Breast Cancer.

Importance: Between 5% and 10% of breast cancer cases are associated with an inherited germline pathogenic or likely pathogenic variant (GPV) in a breast cancer susceptibility gene (BCSG), which could alter local and systemic therapy recommendations. Traditional genetic testing criteria misses a proportion of these cases. Objective: To evaluate the prevalence and clinicopathological associations of GPVs in 2 groups of BCSGs among an ethnically diverse cohort of women with newly diagnosed breast cancer. Design, Setting, and Participants: This cross-sectional study, conducted at 3 Montreal hospitals between September 2019 and April 2022, offered universal genetic counseling and testing to all women with a first diagnosis of invasive breast cancer. Women were offered an obligatory primary panel of BRCA1, BRCA2, and PALB2 (B1B2P2) and an optional secondary panel of 14 additional BCSGs. Eligible participants were women 18 years of age or older who received a diagnosis of a first primary invasive breast cancer not more than 6 months before the time of referral to the study. Data were analyzed from November 2023 to June 2024. Results: Of 1017 referred patients, 805 were eligible and offered genetic counseling and testing, and 729 of those 805 (90.6%) consented to be tested. The median age at breast cancer diagnosis was 53 years (range, 23-91 years), and 65.4% were White and of European ancestry. Fifty-four GPVs were identified in 53 patients (7.3%), including 39 patients (5.3%) with B1B2P2 and 15 patients (2.1%) with 6 of the 14 secondary panel BCSGs (ATM, BARD1, BRIP1, CHEK2, RAD51D, and STK11). On multivariable analysis, clinical factors independently associated with B1B2P2-positive status included being younger than 40 years of age at diagnosis (odds ratio [OR], 6.83; 95% CI, 2.22-20.90), triple-negative breast cancer (OR, 3.19; 95% CI, 1.20-8.43), high grade disease (OR, 1.68; 95% CI, 1.05-2.70), and family history of ovarian cancer (OR, 9.75; 95% CI, 2.65-35.85). Of 39 B1B2P2-positive patients, 13 (33.3%) were eligible for poly(adenosine diphosphate-ribose) polymerase (PARP) inhibitors. Conclusions and Relevance: In this cross-sectional universal genetic testing study of women with newly diagnosed invasive breast cancer, the prevalence of GPVs was 7.3%, with 5.3% of patients testing positive for B1B2P2. Among B1B2P2-women women, one-third were eligible for PARP inhibitors.

Single pre-operative radiation therapy (SPORT-CK) trial for low-risk breast cancer: Early results of a phase 2 study.

BACKGROUND AND PURPOSE: Preoperative partial breast irradiation (PBI) is a novel technique that can be used in patients with early-stage breast cancer with the goal of limiting the irradiated breast volume, toxicity and number of fractions. The aim of this trial is to assess the toxicity, surgical, oncologic and cosmetic outcomes of preoperative PBI. MATERIALS AND METHODS: In this single-arm phase II trial, we enrolled women ≥ 60 years, with unifocal low-risk breast invasive ductal carcinoma (cT1N0, grade 1-2, ER+, Her2-). Patients were treated with a single fraction of 20 Gy of preoperative PBI using volumetric modulated arc therapy (VMAT). Patients then underwent breast-conserving surgery (BCS) +/- sentinel lymph node biopsy within 72 h of radiation. Primary outcomes were rate of surgical complications and early toxicity. Secondary outcomes were cosmesis at 12 months, chronic toxicity and ipsilateral breast tumor recurrence. RESULTS: Twenty-five patients were recruited with a median age of 67 years, and a median follow-up of 60 months. Sentinel biopsy was positive in 1 out of 24 patients (4 %). Two patients received adjuvant RT for close margins or positive lymph nodes. Within the first 90 days, none of the patients had surgical complications; almost all had grade 0 to 1 acute and late RTOG skin toxicity. The cosmetic outcome was rated between good and excellent in all cases by physicians and patients, except for one patient who self-rated her cosmesis as fair as of the third year. There were no recurrences. CONCLUSION: Preoperative single-fraction PBI is a safe and feasible treatment for elderly patients with low-risk early-stage breast cancer, with no surgical complications, very low rates of acute and late radiation toxicity, and excellent cosmetic outcomes. Randomized controlled trials are needed to compare preoperative to adjuvant PBI in this patient population.

Targeted Intraoperative Radiation Therapy during Breast-Conserving Surgery for Patients with Early Stage Breast Cancer: A Phase II Single Center Prospective Trial.

Purpose: Patients with early stage breast cancer (ESBC) are conventionally treated with breast-conserving surgery (BCS) followed by whole-breast external beam radiation therapy (EBRT). The emergence of targeted intraoperative radiation therapy (TARGIT) with Intrabeam has been used as a therapeutic alternative for patients with risk-adapted ESBC. Here we present our radiation therapy toxicities (RTT), postoperative complications (PC), and short-term outcomes of the prospective phase II trial at the McGill University Health Center. Methods and Materials: Patients aged ≥50 years with biopsy-proven hormone receptor-positive, grade 1 or 2, invasive ductal carcinoma of the breast, cT1N0, were eligible for the study. Enrolled patients underwent BCS followed by immediate TARGIT of 20 Gy in 1 fraction. Upon final pathology, patients with low-risk breast cancer (LRBC) received no further EBRT, and those with high-risk breast cancer (HRBC) received further 15 to 16 fractions of whole breast EBRT. HRBC criteria included pathologic tumor size >2 cm, grade 3, positive lympho-vascular invasion, multifocal disease, close margins (<2 mm), or positive nodal disease. Results: A total of 61 patients with ESBC were enrolled in the study; upon final pathology, 40 (65.6%) had LRBC, and 21 (34.4%) had HRBC. The median follow-up was 3.9 years. The most common HRBC criteria were close margins in 66.6% (n = 14) and lymphovascular invasion in 28.6% (n = 6). No grade 4 RTT were observed in either group. The most common PC were seroma and cellulitis for both groups. The rate of locoregional recurrence was 0% in both groups. The overall survival in LRBC was 97.5% and in HRBC 95.2% with no significant differences. Deaths were nonbreast cancer related. Conclusions: In patients with ESBC undergoing BCS, the use of TARGIT shows low rates of RTT and PC complications. Moreover, our short-term outcomes show no significant difference at 3.9 years median follow-up for locoregional recurrence or overall survival between groups of patients receiving TARGIT alone or TARGIT followed by EBRT. Of all patients, 34.4% required further EBRT, most commonly due to close margins.

Feasibility of Prospectively Comparing Opioid Analgesia With Opioid-Free Analgesia After Outpatient General Surgery: A Pilot Randomized Clinical Trial.

Importance: The overprescription of opioids to surgical patients is recognized as an important factor contributing to the opioid crisis. However, the value of prescribing opioid analgesia (OA) vs opioid-free analgesia (OFA) after postoperative discharge remains uncertain. Objective: To investigate the feasibility of conducting a full-scale randomized clinical trial (RCT) to assess the comparative effectiveness of OA vs OFA after outpatient general surgery. Design, Setting, and Participants: This parallel, 2-group, assessor-blind, pragmatic pilot RCT was conducted from January 29 to September 3, 2020 (last follow-up on October 2, 2020). at 2 university-affiliated hospitals in Montreal, Quebec, Canada. Participants were adult patients (aged ≥18 years) undergoing outpatient abdominal (ie, cholecystectomy, appendectomy, or hernia repair) or breast (ie, partial or total mastectomy) general surgical procedures. Exclusion criteria were contraindications to drugs used in the trial, preoperative opioid use, conditions that could affect assessment of outcomes, and intraoperative or early complications requiring hospitalization. Interventions: Patients were randomized 1:1 to receive OA (around-the-clock nonopioids and opioids for breakthrough pain) or OFA (around-the-clock nonopioids with increasing doses and/or addition of nonopioid medications for breakthrough pain) after postoperative discharge. Main Outcomes and Measures: Main outcomes were a priori RCT feasibility criteria (ie, rates of surgeon agreement, patient eligibility, patient consent, treatment adherence, loss to follow-up, and missing follow-up data). Secondary outcomes included pain intensity and interference, analgesic intake, 30-day unplanned health care use, and adverse events. Between-group comparison of outcomes followed the intention-to-treat principle. Results: A total of 15 surgeons were approached; all (100%; 95% CI, 78%-100%) agreed to have patients recruited and adhered to the study procedures. Rates of patient eligibility and consent were 73% (95% CI, 66%-78%) and 57% (95% CI, 49%-65%), respectively. Seventy-six patients were randomized (39 [51%] to OA and 37 [49%] to OFA) and included in the intention-to-treat analysis (mean [SD] age, 55.5 [14.5] years; 50 [66%] female); 40 (53%) underwent abdominal surgery, and 36 (47%) underwent breast surgery. Seventy-five patients (99%; 95% CI, 93%-100%) adhered to the allocated treatment; 1 patient randomly assigned to OFA received an opioid prescription. Seventeen patients (44%) randomly assigned to OA consumed opioids after discharge. Seventy-three patients (96%; 95% CI, 89%-99%) completed the 30-day follow-up. The rate of missing questionnaires was 37 of 3724 (1%; 95% CI, 0.7%-1.4%). All the a priori RCT feasibility criteria were fulfilled. Conclusions and Relevance: The findings of this pilot RCT support the feasibility of conducting a robust, full-scale RCT to inform evidence-based prescribing of analgesia after outpatient general surgery. Trial Registration: ClinicalTrials.gov Identifier: NCT04254679.

Learning and caring in communities of practice: using relationships and collective learning to improve primary care for patients with multimorbidity.

We introduce a primary care practice model for caring for patients with multimorbidity. Primary care for these patients requires flexibility and ongoing coordination, and it often must be tailored to individual circumstances. Such complex and flexible care could be accomplished within communities of practice, whose participants are willing to learn from their shared practice, further each other's goals, share their stories of success and failure, and promote the continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use an iterative approach to care improvement that integrates what they learn and do collectively over time. Clinicians in these communities would define common goals, cocreate care plans, and engage in reflective case-based learning. As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding these conditions, we can foster the development of collective learning and improve primary care for these patients.

Breast tumor resembling the tall cell variant of papillary thyroid carcinoma.

We describe the case of a 66-year-old woman with a palpable mass in her left breast. Although the diagnosis on core biopsy was an intraductal papilloma, the surgically excised lesion showed it to be an infiltrating carcinoma which appeared to arise in a complex sclerosing lesion and is similar to the recently described breast tumor resembling the tall cell variant of papillary thyroid carcinoma.

12 Tips: Guidelines for authoring virtual patient cases.

BACKGROUND: Virtual patient cases are an increasingly utilized and compelling pedagogical strategy for medical education informatics. They provide educators with the opportunity to develop richly layered, multidimensional teaching situations for their learners. However, 'virtual patients are notoriously difficult to author, adapt and exchange' (MedBiquitous Virtual Patient Specification, Virtual Patient Working Group 2007), and case creation can be daunting. Authors may be uncertain about the process of virtual patient case development and this can translate into ambiguity and hesitation. AIMS: This installment of the '12 tips' presents specific guidelines that are intended to provide medical educators with guidelines to facilitate the development of virtual patient cases. METHODS: These 12 tips are based upon comprehensive, research-based, theory-grounded and criterion-referenced guidelines and founded in pedagogical principles, theories of cognition, and recognition of current technology and availability of authoring applications. RESULTS: It is anticipated that the 12 tips will provide medical educators interested in authoring virtual patient cases one set of useful guidelines to facilitate the process. CONCLUSIONS: Virtual patient cases provide medical educators with an innovative tool for medical education. These guidelines will assist authors in case development.

Objective Assessment of the Entrustable Professional Activity Handover in Undergraduate and Postgraduate Surgical Learners.

OBJECTIVE: This study used a virtual patient simulation (VPS) to quantifiably and objectively assess undergraduate (UG) to postgraduate (PG) medical learners' acquisition of the entrustable professional activity (EPA) "handover," focusing particularly on the transition to residency. This EPA is critical because it is part of a core competency for UG and PG training in both the United States and Canada, and is essential for patient safety and comprehensive professional communication. DESIGN: Data were collected from 3 separate groups of participants: 2 UG cohorts from an earlier study, as well as a PG cohort at the beginning of residency. All participants completed the same trauma VPS, which required a free text summary statement that was used as a surrogate for an oral handover. These were collected and scored independently, using previously developed validated rubrics, one procedural and the second semantic. SETTING: All study participants were from one site. The VPS case was completed online. PARTICIPANTS: Two different UG groups, one designated junior (N = 52), was studied at the beginning of their clerkship year, a second group, designated senior (N = 30), was studied at the end of their clerkship year. These groups were compared to a third group of PG learners (N = 31) during the initial 2 weeks of their residency. Informed consent was obtained from all participants. RESULTS: A procedural rubric assessed learners' cognitive knowledge of trauma care-management. A semantic rubric assessed their use of the professional language necessary for a safe and succinct clinical handover communication. An Analysis of Variance comparing scores on the procedural rubric was highly significant with Tukey LSD tests indicating that all 3 groups were significantly different. Students increased their scores on the procedural rubric at each stage of their training. A parallel Analysis of Variance comparing students' scores on the semantic rubric revealed no significant increase in scores, indicating that students did not improve in their capacity to communicate professionally as they progressed through their training. CONCLUSIONS: Taken together, these results demonstrate that training was successful in teaching cognitive-based procedures, but not effective in teaching professional communication, which is critical to the EPA handover. Greater emphasis needs to be placed on ensuring the acquisition of professional communication skills throughout the continuum of UG and PG clinical activities. Faculty development should serve as a support to assist medical educators to address this requirement. These results also demonstrate that VPS with associated objective and validated rubrics can be used as an assessment methodology to quantifiably measure learner performance with respect to the EPA handover. A similar strategy should be considered across the UG and PG continuum for other EPAs and could form the nexus for further research.

Development and Validation of a Tool to Evaluate the Evolution of Clinical Reasoning in Trauma Using Virtual Patients.

CONTEXT: Undergraduate medical students at a large academic trauma center are required to manage a series of online virtual trauma patients as a mandatory exercise during their surgical rotation. PURPOSE: Clinical reasoning during undergraduate medical education can be difficult to assess. The purpose of the study was to determine whether we could use components of the students' virtual patient management to measure changes in their clinical reasoning over the course of the clerkship year. In order to accomplish this, we decided to determine if the use of scoring rubrics could change the traditional subjective assessment to a more objective evaluation. BASIC PROCEDURES: Two groups of students, one at the beginning of clerkship (Juniors) and one at the end of clerkship (Seniors), were chosen. Each group was given the same virtual patient case, a clinical scenario based on the Advanced Trauma Life Support (ATLS) Primary Trauma Survey, which had to be completed during their trauma rotation. The learner was required to make several key patient management choices based on their clinical reasoning, which would take them along different routes through the case. At the end of the case they had to create a summary report akin to sign-off. These summaries were graded independently by two domain "Experts" using a traditional subjective surgical approach to assessment and by two "Non-Experts" using two internally validated scoring rubrics. One rubric assessed procedural or domain knowledge (Procedural Rubric), while the other rubric highlighted semantic qualifiers (Semantic Rubric). Each of the rubrics was designed to reflect established components of clinical reasoning. Student's t-tests were used to compare the rubric scores for the two groups and Cohen's d was used to determine effect size. Kendall's τ was used to compare the difference between the two groups based on the "Expert's" subjective assessment. Inter-rater reliability (IRR) was determined using Cronbach's alpha. MAIN FINDINGS: The Seniors did better than the Juniors with respect to "Procedural" issues but not for "Semantic" issues using the rubrics as assessed by the "Non-Experts". The average Procedural rubric score for the Senior group was 59% ± 13% while for the junior group, it was 51% ± 12% (t(80)= 2.715; p = 0.008; Cohen's d = 1.53). The average Semantic rubric score for the Senior group was 31% ± 15% while for the Junior group, it was 28% ± 14% (t(80) = 1.010; p = .316, ns). There was no statistical difference in the marks given to the Senior versus Junior groups by the "Experts" (Kendall's τ = 0.182, p = 0.07). The IRR between the "Non-Experts" using the rubrics was higher than the IRR of the "Experts" using the traditional surgical approach to assessment. The Cronbach's alpha for the Procedural and Semantic rubrics was 0.94 and 0.97, respectively, indicating very high IRR. The correlation between the Procedural rubric scores and "Experts" assessment was approximately r = 0.78, and that between the Semantic rubric and the "Experts" assessment was roughly r = 0.66, indicating high concurrent validity for the Procedural rubric and moderately high validity for the Semantic rubric. PRINCIPLE CONCLUSION: Clinical reasoning, as measured by some of its "procedural" features, improves over the course of the clerkship year. Rubrics can be created to objectively assess the summary statement of an online interactive trauma VP for "procedural" issues but not for "semantic" issues. Using IRR as a measure, the quality of assessment is improved using the rubrics. The "Procedural" rubric appears to measure changes in clinical reasoning over the course of 3rd-year undergraduate clinical studies.

From the facts to the screen: a blended model of teaching basic hospital skills to 2nd year medical students.

We report an interactive course design which simulated the clinical setting for practicing basic hospital skills. The two-part course included (1) instructor-led, Flash-based interactive lectures; and (2) web-based case using interactive hospital forms. Our program evaluation showed that integrated sessions complemented with web-based interactive cases and hospital forms offered a better student preparation for the Geriatric Medicine clerkship and improved tutor perceptions of student performance during early rotations in the academic year.

A Learner-Created Virtual Patient Curriculum for Surgical Residents: Successes and Failures.

OBJECTIVE: To determine the feasibility and effectiveness of a learner-created virtual patient (VP) curriculum for postgraduate year 2 surgical residents. DESIGN: Using a social-constructivist model of learning, we designed a learner-created VP curriculum to help postgraduate year 2 residents prepare for their in-training surgical examination. Each resident was assigned to create a VP curriculum based on the learning objectives for this examination, and VP cases were then disseminated to all residents for completion. To measure the learning effects of the curriculum, participants completed 2 simulated in-training examinations, both at the beginning and at the end of the intervention. Study participants also participated in a focus group and completed an online questionnaire about the perceived learning value of the curriculum. SETTING: The study was conducted at the McGill University Health Centre, a tertiary care hospital in Montreal, Canada. PARTICIPANTS: In total, 24 residents from 7 surgical specialties completed both the pretest and posttest, as well as took part in the creation of a VP curriculum. Of those 24 residents, only 19 residents completed the cases created by their peers, with 7 completing greater than 50% of the cases and 12 completing less than 50%. In all 17 residents responded to the online questionnaire and 11 residents participated in the focus group. RESULTS: The VP curriculum failed to improve scores from pretest (59.6%, standard deviation = 8.1) to posttest (55.4%, standard deviation = 6.6; p = 0.01) on the simulated in-training examination. Nonetheless, survey results demonstrated that most residents felt that creating a VP case (89%) and completing cases created by their peers (71%) had educational value. Overall, 71% preferred active participation in a curriculum to traditional didactic teaching. The focus group identified time-related constraints, concern about the quality of the peer-created cases, and questioning of the relationship between the curriculum and the Surgical Foundations examination as barriers to the success of the curriculum. CONCLUSIONS: Despite the fact that a learner-created VP curriculum did not improve scores on a mock in training examination, residents viewed this intervention as a valuable educational experience. Although there were barriers to the implementation of a learner-created curriculum, it is nonetheless important to try and integrate pedagogical concepts into the instructional design of curricula for surgical residents.

Development of an undergraduate medical curriculum: the McGill experience.

In 1997 the Faculty of Medicine at McGill University received a grant from the Molson Foundation. The primary project deliverable, which the authors describe, was an online, multimedia-enhanced, undergraduate medical curriculum. The decision to develop an electronic curriculum was predicated on the belief that the integration of educational technology within mainstream material delivered a "value added" component to both students and faculty, which would, in turn, facilitate teaching and learning. Pedagogical values were deemed to include: (1) the ability to use the media to implement adult learning principles such as learner-centered, self-directed and guided learning, (2) the inherent interactivity of the technology, (3) the potential of the technology to provide a powerful means for fostering forms of "termless" learning that students will need to practice medicine, (4) recognition that use of multimedia can address, in part, the variety of learning styles evidenced by students in the lecture hall and classroom, and (5) the provision of opportunities for horizontal and vertical curricular integration. In addition, it was anticipated that an electronic curriculum would permit: (1) easy incorporation of informatics within mainstream curricula, (2) centralization and standardization of curricular material, (3) editorial functionality for revisions and updates, (4) wide accessibility of material irrespective of venue, (5) search functionality for faculty and students, (6) the ability to perform curriculum inventory, and (7) the potential for use to compensate for decreased faculty time. The ongoing experience at McGill has shown that the merging of technology and pedagogy requires a substantial commitment of resources and recognition of faculty time and change-management issues.

New directions in medical e-curricula and the use of digital repositories.

Medical educators involved in the growth of multimedia-enhanced e-curricula are increasingly aware of the need for digital repositories to catalogue, store and ensure access to learning objects that are integrated within their online material. The experience at the Faculty of Medicine at McGill University during initial development of a mainstream electronic curriculum reflects this growing recognition that repositories can facilitate the development of a more comprehensive as well as effective electronic curricula. Also, digital repositories can help to ensure efficient utilization of resources through the use, re-use, and reprocessing of multimedia learning, addressing the potential for collaboration among repositories and increasing available material exponentially. The authors review different approaches to the development of a digital repository application, as well as global and specific issues that should be examined in the initial requirements definition and development phase, to ensure current initiatives meet long-term requirements. Often, decisions regarding creation of e-curricula and associated digital repositories are left to interested faculty and their individual development teams. However, the development of an e-curricula and digital repository is not predominantly a technical exercise, but rather one that affects global pedagogical strategies and curricular content and involves a commitment of large-scale resources. Outcomes of these decisions can have long-term consequences and as such, should involve faculty at the highest levels including the dean.

International prospective evaluation of scintimammography with (99m)technetium sestamibi.

BACKGROUND: The purpose of this study is to evaluate the efficacy of scintimammography with (99m)Technetium-Sestamibi for the diagnosis of breast cancer. METHODS: This was a multicenter prospective cohort clinical trial. A total of 1,734 women were enrolled of whom 1,243 had complete data upon study completion. RESULTS: The mean +/- standard error age of the patients is 56 +/-12 years (with a range of 19 to 94). Mammographic results were classified by the Breast Imaging Reporting and Data System (BIRADS) as 199 (16%) BIRADS 5, 149 (12%) BIRADS 4, 199 (16%) BIRADS 3, and 696 (56%) BIRADS 2 or 1. Scintimammography was positive for 322 (26%) of the patients and negative for 921 (76%). Histopathology showed malignancy for 201 (16%) of the patients. Sensitivity and specificity of scintimammography was estimated 93% and 87% respectively. A positive predictive value (PPV) of 58% with a negative predictive value of 98% were calculated. CONCLUSIONS: The present study suggests that scintimammography with (99m)Technetium-Sestamibi is highly accurate for the detection of breast cancer.

[Marital communication and depressive symptoms in couples in which the woman has cancer of the breast]. / Communication conjugale et symptômes dépressifs dans des couples dont la femme est atteinte de cancer du sein.

If doctor-patient communication is a frequent subject of research, couples communication where one partner has cancer is quite recent. Some studies deal with couples communication, but from an anecdotic perspective, without any operational measure. The aim of this paper is to study couples' communication frequency and link it to depressive symptomatology. Marital communication was assessed with three scales: frequency of general communication, frequency of communication about cancer and satisfaction with communication. About one month following surgery, 120 breast cancer patients were interviewed; only 11 partners (9%) refused to be interviewed. Results show less communication is associated with higher depressive level. Patients and partners with a passable level of communication, particularly about cancer, are clinically at risk for depression. Communicating frequently about cancer in the couple seems thus associated with a positive effect, i.e. a depressive level found in the general population. Direction of causality between frequency of marital communication and depressive symptomatology cannot be established from this study.