Writing multiple-choice test items that promote and measure critical thinking.

Faculties are concerned about measurement of critical thinking especially since the National League for Nursing Accrediting Commission cited such measurement as a requirement for accreditation (NLNAC, 1997). Some writers and researchers (Alfaro-LeFevre, 1995; Blat, 1989; McPeck, 1981, 1990) describe the need to measure critical thinking within the context of a specific discipline. Based on McPeck's position that critical thinking is discipline-specific, guidelines for developing multiple-choice test items as a means of measuring critical thinking within the discipline of nursing are discussed. Specifically, criteria described by Morrison, Smith, and Britt (1996) for writing critical-thinking multiple-choice test items are reviewed and explained for promoting and measuring critical thinking.

Suicidal ideation and attempts: a longitudinal investigation of children of depressed and well mothers.

OBJECTIVE: This study uses a prospective longitudinal design to examine suicidality (ideation, plans, attempts, and completions) in children and adolescents, to compare suicidality in the offspring of depressed and well mothers, and to identify correlates and predictors of suicidality. METHOD: Two children (n = 192) from each of the families in an ongoing longitudinal study of the offspring of mothers with major depressive disorder (n = 42), with bipolar disorder (n = 26), or without past or current psychiatric diagnosis (n = 30) were studied. Assessment of suicidality, based on diagnostic interviews, was made when the younger of the sibling pairs were approximately 6, 9, and 14 years of age and older siblings were approximately 6, 9, 13, and 18 years of age. RESULTS: Children of depressed mothers were more likely to report suicidal thoughts or behaviors than were children of well mothers (particularly the older sibling cohort). Developmental trajectories of suicidality differed for offspring of mothers with major depressive disorder and bipolar disorder. Links were found between lifetime reports of suicidality and the adolescent's mood problems (e.g., hypomanic behavior), coping strategies, and parental rejection. Also, child's and mother's suicidality were related. CONCLUSIONS: These findings have implications for planning interventions targeted at preventing suicide in youth.

Affective language between depressed mothers and their children: the potential impact of psychotherapy.

OBJECTIVE: To determine whether depressed mothers who had had psychotherapy were more able to communicate accurately about emotions than depressed mothers who had not had treatment. METHOD: Three groups of mother-child pairs were studied: mothers without psychiatric diagnosis or treatment (n = 31), depressed mothers without treatment (n = 10), and depressed mothers with psychotherapy (n = 43). Photographs of infants expressing emotions were viewed and discussed by the mother-child pair and were rated independently. RESULTS: A comparison by analysis of variance and Duncan procedures revealed significant differences between groups in both mothers' and children's accuracy scores. Mothers who had had psychotherapy were more able to interpret emotional expression with accuracy (p < .05), particularly about negative emotions such as anger and sadness (p < .01), than were the mothers of the depressed no treatment group. Depressed mothers without treatment were more inaccurate (for example, sadness interpreted as anger). CONCLUSIONS: Psychotherapy may contribute to the depressed mother's achievement of accuracy in speaking with her child about emotions. The depressed mother whose depressive illness goes untreated is more inclined to be inaccurate and may pass these inclinations on to her child. The generality of the psychotherapy variable makes these findings preliminary.

Structure-activity relationships for the formation of secondary radicals and inhibition of keratinocyte proliferation by 9-anthrones.

The biological properties of tumor-promoting and antipsoriatic 9-anthrones have been hypothesized to be mediated by free radical products such as the corresponding 9-anthron-10-yl radicals or by O2-, OH, and other persistent secondary radicals that are formed in the skin after topical treatment with 9-anthrones. To gain additional insights into the possible role of reactive oxygen or secondary radicals in mediating the biological effects of 9-anthrones, we have used EPR spectroscopy to investigate the formation of these species by a series of 9-anthrones or 9-anthrone dimers with known tumor-promoting and antipsoriatic activities. The effect of the 9-anthrones on keratinocyte proliferation in vitro was also investigated. 5,5-Dimethyl-1-pyrroline N-oxide was used as a spin trap to detect reactive oxygen-centered radicals in aqueous buffer/dimethylsulfoxide solutions. Super-radicals in aqueous buffer/dimethylsulfoxide solutions. Superoxide was trapped during the autoxidation of most of the 9-anthrones. For 9-anthrones that generated no detectable superoxide, evidence of anthronyl-peroxyl radical formation was found instead. In the presence of Fe3+ complexed to EDTA, but not diethylenetriaminepentaacetic acid, the hydroxyl radical was produced by all of the 9-anthrones. 9-Anthrone dimers produced oxygen-centered radicals only weakly or not at all. Direct EPR was used to detect 9-anthrone-derived secondary radicals in keratinocyte suspensions or in dimethysulfoxide solutions. These radicals were similar to those previously reported to occur in skin after topical treatment with the antipsoriatic drug anthralin (1,8-dihydroxy-9-anthrone). In contrast to the ubiquitous ability of the 9-anthrones to generate reactive oxygen radicals, only the hydroxy-substituted 9-anthrones or their dimers possessed significant secondary radical-forming ability. The ability of the 9-anthrones or dimers to form secondary radicals in keratinocytes was found to correlate with their in vitro inhibition of keratinocyte proliferation. The data suggest the possible importance of reactive dimeric intermediates in mediating the biological effects of the 9-anthrones.

Cisplatin-based chemotherapy for ovarian germ cell malignancies: the Australian experience.

PURPOSE: This study was performed to evaluate the Australian experience with cisplatin-based treatment of ovarian germ cell tumors (OGCT) with respect to survival and toxicity of treatment. PATIENTS AND METHODS: A retrospective review was undertaken based on a standardized questionnaire, which was sent to all major gynecologic oncology centers in Australia. RESULTS: Data on 58 patients were obtained. Overall survival at 5 years for all patients was 87%. There was one death from disease among 14 patients with dysgerminoma, and four deaths from disease among 44 patients with nondysgerminomas. Cisplatin-based chemotherapy was associated with a low incidence of serious complications, with only one treatment-related death (from bleomycin-induced respiratory failure). CONCLUSION: Our large series demonstrates that cisplatin-based chemotherapy is highly effective for patients with OGCT. Although direct comparisons cannot be made, the survival of our patients with advanced tumors was comparable to that seen in male germ cell tumors, rather than inferior as is commonly believed. Future studies should aim to refine treatment to minimize toxicity, while further increasing curability.

Making the system work. Training pediatric oncology patients to cope and their parents to coach them during BMA/LP procedures.

Three 4- to 7-year-old pediatric oncology patients were taught to engage in distraction prior to painful bone marrow aspirations and lumbar puncture procedures and to use party blowers as a breathing technique during the painful procedures. Parents were taught to coach their children to use these coping behaviors. Using a multiple baseline across subjects design, results indicated that all of the parents increased their rate of coaching. Each child responded with increased coping and decreased observable distress after the first treatment session. One child returned to baseline levels of coping and distress on the next two sessions. The other two children maintained their high rates of coping and low rates of observable distress during the remaining treatment and during the maintenance sessions. Parents' coaching of their children to use coping behaviors also remained high during maintenance sessions.

The prognostic value of clinical, pathologic, and biologic parameters in ovarian cancer.

BACKGROUND: The prognosis in ovarian cancer remains poor, and there is a need to identify patients who are less likely to respond to treatment. METHODS: In a study of 133 unselected patients with ovarian adenocarcinoma treated by a standard protocol, variables such as age, tumor type, International Federation of Gynecology and Obstetrics stage, cellular differentiation, amount of residual disease after surgery, and results from flow cytometry were correlated with survival and relapse at 24 months. RESULTS: Although stage and cellular differentiation were found to be significant associations with survival and relapse, multivariate analyses identified only residual disease and ploidy status (and the related DNA index and percentage of aneuploid cells) as independent prognostic variables. The magnitude of the effect of ploidy depended on the amount of residual disease; among patients with less disease (< 2 cm), the mortality rate was nearly fourfold higher for those with aneuploid tumors than for those with diploid tumors. CONCLUSIONS: Routine use of ploidy determination in ovarian cancer is an important prognostic indicator, especially for a subgroup of patients with minimal residual disease.

The management of ovarian carcinoma is improved by the use of cancer-associated serum antigen and CA 125 assays.

BACKGROUND: The new tumor-associated mucin assay, cancer-associated serum antigen (CASA), was assessed with the CA 125 assay for use in the management of patients with epithelial ovarian cancer. METHODS: CASA and CA 125 were assessed retrospectively for use in (1) monitoring 28 patients with Stage 3 or 4 ovarian carcinoma during therapy, (2) predicting the outcome of 41 second-look laparotomies (SLL), and (3) predicting the survival outcome by measuring these levels after surgery but before chemotherapy in 65 patients with Stage 3 disease. RESULTS: Of 20 patients with recurrence after an initial response, the presence of CASA levels detected recurrence in 65% before clinical detection; CA 125, 50%; and the combination of CASA and CA 125, 80%. Six patients whose disease was in long-term remission did not have elevations of either marker. When used to predict the results of SLL, the positive predictive values of CASA and CA 125 were 77% and 100%, respectively. The negative predictive values for CASA and CA 125 were 71% and 66%, respectively. CASA detected 50% of positive SLL where microscopic disease only was found; the CA 125 test did not. Multivariate analysis of survival rates using levels of CASA and CA 125, age, residual disease, tumor type and grade, or the presence or absence of cisplatin in the chemotherapeutic regimen found that postoperative CASA levels ranked above all prognostic factors except age. CASA levels may be more accurate than surgical reporting of residual disease or they may define a subset of patients with biologically more aggressive ovarian carcinoma. CONCLUSIONS: The CASA test is sensitive to ovarian carcinoma, and both CASA and CA 125 are more useful when used in conjunction.

Carcinoma of the cervix-recurrences in Queensland 1982-1986.

A retrospective study of recurrent cancer of the cervix was carried out on patients who attended the Gynaecologic Oncology Unit, Royal Brisbane Hospital, between the years 1982 and 1986. Ninety-four recurrences were assessed out of 526 patients (17.7%). The likely recurrence was related to stage. Sixty-seven percent had pelvic recurrences with 33% recurring in extrapelvic sites alone. The most common site of tumor recurrence was central pelvis (47%). Histopathology recurrences were analyzed and recurrence was found to be more common with the rare tumor types. Mortality of recurrent carcinoma of the cervix is high. Multivariate analysis shows lymph node metastases and histologic status of resection margins to be independent variables predictive of recurrence. Lymphvascular space involvement has not been an independent variable after adjusting for nodes and margins. Cytology of vaginal vault or residual cervix smear shows that 58% of patients with central recurrence had an abnormal smear. The relative literature was discussed in relation to the findings of our unit.

Invasive squamous cell carcinoma of the vulva: behaviour and results in the light of changing management regimens. A review of clinicohistological features predictive of regional lymph node involvement and local recurrence.

Ninety-nine patients with carcinoma of the vulva were referred to the Gynaecologic Oncology Unit, Royal Brisbane Hospital, over 10 years. Ninety of these patients had a squamous cell carcinoma (SCC). They were assessed by the 1969 FIGO clinical staging. Each stage was related to nodal involvement, size, depth, histological grade, lymphvascular space involvement, perineural permeation and multifocal disease site. The operability rate was 85%. Treatment was individualized in line with recent philosophies for more conservative surgery where appropriate. Mortality was 2.6%. Five-year survival of surgically treated patients was 60.3%; node negative patients 100%, and node positive patients 25.2%. After adjustment for stage and size, the only other independent statistically significant feature was perineural penetration. Local recurrence was more likely with increased stage and size, unclear margins and multifocal involvement. It is important to note that medically unfit patients who had vulvectomy alone and who later developed positive nodes had 100% mortality. This group of patients significantly decreases survival rates, confirming the importance of carrying out inguinofemoral lymphadenectomy at the time of initial surgery. Morbidity was decreased by conservative surgery. Lymphoedema remains the most common chronic complication. No significant difference was shown in local recurrence between different types of surgery, wide excision, hemivulvectomy, simple vulvectomy or radical vulvectomy (22%), confirming the safety of the more conservative approach of recent years.

Preoperative discrimination between ovarian carcinoma, non-ovarian gynecological malignancy and benign adnexal masses using serum levels of CA125 and the polymorphic epithelial mucin antigens CASA, OSA and MSA.

Serum levels of the tumor associated antigens CA125, CASA, OSA and MSA were determined preoperatively in a non-consecutive series of patients with: invasive epithelial ovarian cancer (OC, n = 87), ovarian tumors of low malignant potential (LMP, n = 9), benign adnexal masses (BAM, n = 48) and other peritoneal and pelvic malignancies (n = 48). In addition, serum levels of CASA, OSA, and MSA were determined in 3477 asymptomatic well women. Ninety-eight percent of the asymptomatic women had CASA levels < 6.0 U ml-1, OSA levels < 5.5 U ml-1 and MSA levels < 80.0 U ml-1. Serum CA125 levels were> 35 U ml-1 in 89% of OC, in 44% of LMP, and in 23% of BAM. Serum CASA levels were> 6.0 U ml-1 in 58% of OC, in 0% of LMP, and in 0% of BAM. Serum OSA levels were> 5.5 U ml-1 in 61% of OC in 0% of LMP and in 4% of BAM. Serum MSA levels were> 80.0 U ml-1 in 56% of OC, in 11% of LMP, and in 10% of BAM. When cut-off levels were set to exclude all patients with BAM, the best discrimination from OC using a single assay was achieved using CASA (58%). However, a combination of CASA and CA125 gave positive levels in 69% of OC at levels which precluded BAM. All markers were also elevated in some colon cancers, cervical cancers, uterine cancers and other peritoneal malignancies. A combination of CA125 and CASA levels, obtained preoperatively may assist the general gynecologist in avoiding potentially difficult oncologic surgery.

Cancer of the cervix--old and young, now and then.

A study of two 5-year periods, 1960-1964 and 1982-1986, in Queensland is made. Changing patterns of preinvasive and invasive cervical carcinoma in the world literature are discussed. The age of presentation, stage, histology, and results in Queensland for cervical carcinoma are analyzed. There are over 500 patients in each quinquennium. While the total female population has increased 86%, the maximum increase is in patients under 35 years and over 65. There has been a 50% decrease in the incidence of cervical carcinoma, but a doubling under the age of 30. The stage at diagnosis has markedly improved with 88% stage Ib in the young as opposed to 50% formerly. Late-stage disease remains a problem of the aged. The mortality in both time spans increases with age. Histologic patterns show an increase in nonsquamous patterns and increased mortality in the rare patterns. We have no evidence of the emergence of a rapidly progressive carcinoma in the young. Papanicolaou smear and education programs appear to be preventing cervical carcinoma and allowing diagnosis of the disease at an earlier stage and age. This is reflected in a decrease in mortality from 9.6 per 100,000 (1960-1964) to 4 per 100,000 (1982-1986).

The accuracy of cervicovaginal cytology in the detection of recurrent cervical carcinoma following radiotherapy.

The accuracy of cervicovaginal cytology testing in the detection of recurrent cervical carcinoma was investigated by correlating clinical and histology records with cytology smear results for two groups of patients. All patients had been treated with radiotherapy, with or without pelvic surgery, for carcinoma of the uterine cervix. Abnormal cervicovaginal smear results were present for 45.7% (32/70) of patients with histologically diagnosed recurrent cervical carcinoma including a correct prediction of recurrent cervical carcinoma in 32.8% (23/70) of cases. A cytologic diagnosis of recurrent carcinoma was present for 48.9% (23/47) of cases with local recurrence. The positive predictive value for a histologic diagnosis of recurrent cervical carcinoma after a positive cytology report for a group of 61 patients was estimated to be 98.4%. A cytologic diagnosis of locally recurrent cervical carcinoma preceded clinical signs in 15/61 (24.6%) of cases. These results indicate that although cervicovaginal cytology after radiotherapy for cervical cancer does not have high sensitivity it is a reliable test for the diagnosis of local recurrence. Cytologic examination of the vaginal vault or cervix after treatment may thus provide an early diagnosis of tumor recurrence or persistence, in some cases prior to the onset of clinical signs.

Prognostic significance of tumor ploidy in patients with advanced ovarian carcinoma.

Fresh tumor specimens obtained from 53 consecutive patients with FIGO Stage III ovarian carcinoma were analyzed by flow cytometry. All patients were treated by a standard protocol: maximal tumor excision and cisplatin/cyclophosphamide/adriamycin chemotherapy, and followed-up for at least 24 months. Thirty-two percent of tumors were diploid (DNA index = 1.00) and 68% aneuploid (DNA index greater than 1.00), with more aneuploid tumors being associated with larger residual tumor and poor cellular differentiation. Patients with diploid tumors were found to survive significantly better than those with aneuploid tumors, in terms of survival rate (65% versus 31%), median survival time (33 months versus 13 months), and mean disease-free interval (17.8 months versus 8.2 months). The influence of the amount of residual tumor after primary surgery on survival was only significant in patients with diploid tumors. Our results support previous findings that tumor ploidy is an important prognostic indicator in ovarian cancer. We found aneuploidy to be associated with a poorer clinical outcome in Stage III disease, regardless of the amount of residual tumor after primary surgery and the degree of cellular differentiation.

Papillary carcinomas of the endometrium.

A retrospective study of patients with papillary endometrial carcinomas was performed. Of 761 patients with endometrial carcinomas treated at the Royal Brisbane Hospital between 1982 and 1989, 19 (2.4%) had papillary endometrial carcinoma (PEC) and 21 (2.8%) had papillary serous endometrial carcinoma (SPEC). Patients were similar in age and parity but survival was significantly poorer in cases of SPEC than PEC. Patients with SPEC had a 47% 3-year survival with surgically documented localized disease. Recurrences were mainly outside the field of adjuvant radiotherapy. It thus appears that local treatment is not sufficient and some form of systemic treatment is required.

Lectin receptors of amyloid in corneas with lattice dystrophy.

We analyzed lectin binding patterns of amyloid glycoconjugates in patients with lattice dystrophy of the cornea. Results of paraffin and frozen sections differed in some instances. With paraffin sections, three lectins--wheat germ agglutinin (WGA), Ricinus communis agglutinin I (RCA-I), and concanavalin A (Con A)--stained the abnormal deposits. In frozen sections, the abnormal deposits were stained by five lectins--WGA, RCA-I, Con A, peanut agglutinin (PNA), and soybean agglutinin (SBA). In paraffin sections, PNA and SBA did not stain amyloid deposits. In both paraffin and frozen sections, some lectin-positive deposits corresponded to the Congo red-positive material, whereas others were present surrounding and encroaching on the Congo red-reactive material. This study demonstrates that WGA-, RCA-I-, Con A-, PNA-, and SBA-positive abnormal deposits are present in corneas with lattice dystrophy. Since lectins bind to specific sugar residues, we conclude that the abnormal deposits consist, at least in part, of glycoconjugates and that these glycoconjugates contain oligosaccharides with N-acetylglucosamine/sialic acid, mannose/glucose and terminal beta-galactose residues and chains with terminal beta-galactose-N-acetylgalactosamine disaccharides.