Administration of open-ended test questions by computer in a clerkship final examination.

PURPOSE: To evaluate the reliability, efficiency, and cost of administering open-ended test questions by computer. METHODS: A total of 1,194 students in groups of approximately 30 were tested at the end of a required surgical clerkship from 1993 through 1998. For the academic years 1993--94 and 1994--95, the administration of open-ended test questions by computer was compared experimentally with administration by paper-and-pencil for two years. The paper-and-pencil mode of the test was discontinued in 1995, and the administration of the test by computer was evaluated for all students through 1998. Computerized item analysis of responses was added to the students' post-examination review session in 1996. RESULTS: There was no significant difference in the performances of 440 students (1993--94 and 1994--95) on the different modes of test administration. Alpha reliability estimates were comparable. Most students preferred the computer administration, which the faculty judged to be efficient and cost-effective. The immediate availability of item-analysis data strengthened the post-examination review sessions. CONCLUSION: Routine administration of open-ended test questions by computer is practical, and it enables faculty to provide feedback to students immediately after the examination.

Management of labyrinthine fistulae secondary to cholesteatoma.

Improvements in diagnosis and management of chronic ear disease in general and cholesteatoma in particular have led to a decreased incidence of serious labyrinthine complications. Unfortunately, significant disease still does occur and, if unrecognized, may result in significant morbidity. Labyrinthine fistulae secondary to cholesteatoma cause potentially irreversible symptoms such as hearing loss and vertigo. This study reviews 17 patients who developed labyrinthine fistula secondary to cholesteatoma. Sixteen involved the horizontal semicircular canal and one involved the oval window. The cholesteatoma matrix was removed in all cases and the underlying fistula repaired primarily. Cochlear function was preserved in all patients. Sixteen of 17 patients have had no further difficulty with vertigo beyond the immediate postoperative period. The evaluation and contemporary management of this difficult problem are discussed.

Interleukin-8 expression in otitis media.

Based on recent studies in the authors' laboratory on the correlation of cytokines and inflammation in otitis media (OM), the authors hypothesized that in chronic otitis media with effusion (COME) interleukin-8 (IL-8) is responsible for 1. the accumulation of leukocytes in the middle ear cleft and 2. in situ leukocyte activation with subsequent tissue damage. Additionally, the authors hypothesized that IL-8 expression is at least in part under the control of interleukin-1 (IL-1) and tumor necrosis factor (TNF). To begin to test this hypothesis, middle ear effusions (MEE) obtained from children ages 2 to 90 months (mean age, 29 months) undergoing tympanostomy tube placement for the presence of these inflammatory cytokines were analyzed. For these studies, IL-8, interleukin-1 beta (IL-1 beta), tumor necrosis factor-alpha (TNF-alpha), and tumor necrosis factor-beta (TNF-beta) were measured in MEE by radioimmunoassay (RIA) or enzyme-linked immunoassay (ELISA). IL-8, IL-1 beta, TNF-alpha, and TNF-beta were present in 92%, 67%, 77%, and 0% of effusions, respectively. The mean (+/- SEM) values for IL-8, IL-1 beta, and TNF-alpha were 4805 (+/- 913) pg/mg, 4076 (+/- 1510) pg/mg, and 163 (+/- 90) pg/mg. Further analysis indicated that levels of IL-8 correlated with IL-1 beta (R2 = .500, P = .000) and TNF-alpha (R2 = .387, P = .023). Thus the authors' studies clearly demonstrate that IL-8 is consistently present in the MEE of children with COME and is strongly correlated with levels of IL-1 beta and TNF-alpha, both known inducers of IL-8 production. These results support the authors' hypothesis that IL-1 beta, TNF-alpha, and IL-8 are intimately involved in the inflammatory cascade in the middle ear and suggest regulation of these cytokines as possible sites of future therapeutic intervention in otitis media with effusion (OME).

Efficacy of ambulatory systemic vasodilator therapy with oral prazosin in chronic refractory heart failure. Concomitant relief of pulmonary congestion and elevation of pump output demonstrated by improvements in symptomatology, exercise tolerance, hemodynamics and echocardiography.

The long-term efficacy of the new oral vasodilator, prazosin (PZ), was evaluated in nine patients with refractory heart failure due to chronic coronary heart disease. Ventricular function was assessed by cardiac catheterization, echocardiography, and treadmill testing; symptomatic evaluation was carried out for two to four months. One hour following 2-7 mg PZ, control left ventricular filling pressure was reduced (32 to 18 mm Hg, P less than 0.001) and cardiac index was elevated (1.95 to 2.89 L/min/m2, P less than 0.001) for a 6-hour period. After two weeks of PZ 2 to 7 mg four times daily, echographic end-diastolic dimension fell (5.7 to 5.4 cm, P less than 0.001) while shortening fraction increased (27.6 to 30.2%, P less than 0.005). Treadmill exercise duration increased from 209 to 317 seconds (P less than 0.001). Symptoms diminished throughout the duration of follow-up (mean 94 days) with improvement in NYHA functional class (3.7 to 2.2, P less than 0.001). Thus, prazosin possesses sustained nitroprusside-like balanced dilator actions on the systemic arterial and venous systems and is effective in the ambulatory management of chronic severe heart failure.

Hemodynamic assessment of the glutaraldehyde-preserved porcine heterograft in the aortic and mitral positions.

Although glutaraldehyde-preserved porcine heterograft (PH) valves may have a lowered incidence of thromboembolism compared to mechanical valves, data concerning postoperative function in PH valves are incomplete. Accordingly, 26 patients receiving PH in the aortic (AO) or mitral position (MIT) were studied at cardiac postoperative catheterization (mean 19 weeks). The 12 AO patients had an average peak systolic gradient of 19 mm Hg (range 3-52 mm Hg); mean valve area (VA) 1.33 cm2 (0.75-2.5; two patients had postoperative aortic insufficiency. The 14 MIT patients had a mean gradient of 7.9 mm Hg (0-13.1); VA 1.84 cm2 (0.70-3.2; postoperative mitral regurgitation occurred in two patients. AO stent diameter (SD) related to VA, r = 0.85; and peak gradient, r = -0.75. However, MIT SD did not relate to VA or peak gradient. At the 14-month follow-up examination 9 of 11 AO and 7 of 11 MIT patients improved by at least one functional class. Thus, with the advantage of reduced thromboembolism and generally satisfactory valve hemodynamics, further clinical trial of glutaraldehyde-preserved porcine heterografts is justified.

Sustained reduction of cardiac impedance and preload in congestive heart failure with the antihypertensive vasodilator prazosin.

To elucidate the hemodynamic effects of prazosin, an antihypertensive agent, in congestive heart failure, we studied 10 patients with ischemic cardiomyopathy and severe ventricular dysfunction. After an oral dose of 2 to 7 mg, heart rate was unchanged (P greater than 0.05). One hour after prazosin administration, mean arterial pressure declined from 95 to 78 mm Hg (P less than 0.001); left ventricular filling pressure declined from 30 to 18 mm Hg (P less than 0.001), cardiac index increased from 2.1 to 2.9 liters per minutes per square meter (P less than 0.001), and systemic vascular resistance fell from 2074 to 1156 dynes sec cm-5 (P less than 0.001). In both forearms vascular resistance and venous tone were reduced (86 to 48 mm Hg per ml per 100 g per minute, and 59 to 18 mm Hg per ml, respectively [P less than 0.001]). All responses persisted for a least six hours (P less than 0.01). Prazosin benefits severe congestive heart failure by inducing a sustained fall of both cardiac preload and impedance.

Combined dopamine and nitroprusside therapy in congestive heart failure. Greater augmentation of cardiac performance by addition of inotropic stimulation to afterload reduction.

The hemodynamic benefits of combining administration of dopamine with nitroprusside (NP) were evaluated in nine patients with chronic congestive heart failure due to ischemic, idiopathic myocardial or valvular cardiac disease. NP alone (68 microng/min) produced decline in left ventricular end-diastolic pressure (LVEDP) from 25.4 to 14.1 mm Hg (p less than 0.01) but modest increase in cardiac index (CI) from 2.41 to 3.02 L/min/m2 (P less than 0.05). Dopamine alone (6 microng/kg/min) caused an elevation of CI to 3.36 (P less than 0.01) but without decrease of LVEDP. Simultaneous infusion of the two agents resulted in favorable alterations in both hemodynamic variables: LVEDP decreased to 15.7 (P less than 0.01) and CI increased to 3.52 (P less than 0.01). It is concluded that dopamine substantially enhances the effectiveness of nitroprusside therapy in congestive heart failure by providing concomitantly the principal beneficial actions of the vasodilator and dopamine used separately. Thus combined dopamine with NP treatment considerably raises low CI while markedly reducing elevated LVEDP and provides a potentially efficacious pharmacologic modality for the treatment of severe congestive heart failure due to left ventricular dysfunction.