Can medical students accurately predict their learning? A study comparing perceived and actual performance in neuroanatomy.

It is important that clinicians are able to adequately assess their level of knowledge and competence in order to be safe practitioners of medicine. The medical literature contains numerous examples of poor self-assessment accuracy amongst medical students over a range of subjects however this ability in neuroanatomy has yet to be observed. Second year medical students attending neuroanatomy revision sessions at the University of Southampton and the competitors of the National Undergraduate Neuroanatomy Competition were asked to rate their level of knowledge in neuroanatomy. The responses from the former group were compared to performance on a ten item multiple choice question examination and the latter group were compared to their performance within the competition. In both cohorts, self-assessments of perceived level of knowledge correlated weakly to their performance in their respective objective knowledge assessments (r = 0.30 and r = 0.44). Within the NUNC, this correlation improved when students were instead asked to rate their performance on a specific examination within the competition (spotter, rS = 0.68; MCQ, rS = 0.58). Despite its inherent difficulty, medical student self-assessment accuracy in neuroanatomy is comparable to other subjects within the medical curriculum. Anat Sci Educ 9: 488-495. © 2016 American Association of Anatomists.

Idiopathic monomorphic ventricular tachycardia originating from the left aortic sinus cusp in children: endocardial mapping and radiofrequency catheter ablation.

BACKGROUND: Idiopathic repetitive monomorphic ventricular tachycardia with an inferior axis and left bundle branch block pattern typically originates from the superior right ventricular outflow tract. When indicated, radiofrequency catheter ablation is usually safe and effective. However, a left ventricular origin has been described recently in adult patients in whom ablation attempts in the right ventricular outflow tract were unsuccessful. Experience in pediatric patients is limited. PATIENTS AND METHODS: Since 1998, 13 young patients suffering from symptomatic ventricular tachycardia episodes with an inferior axis and left bundle branch block pattern underwent an electrophysiological study and radiofrequency catheter ablation. In 2 patients, age 13 and 15 years, no endocardial local electrograms preceding the surface ECG QRS complex could be recorded within the right ventricular outflow tract during ventricular ectopy. Detailed mapping within the left ventricular outflow tract and in the aortic root revealed local electrograms 25 and 53 ms earlier than the QRS complex and a 11/12 and 12/12 lead match during pacing inferior and anterior to the ostium of the left main coronary artery in the left aortic sinus cusp. Earliest activation was recorded 10 and 12 mm away from the coronary artery ostium identified angiographically. In each of the patients, one single radiofrequency current application (60 degrees C, 30 W, duration 30 and 60 s, respectively) resulted in complete cessation of ventricular ectopy. Subsequent selective injection into the left coronary artery did not reveal any abnormalities. During follow-up (2 and 34 months) off any antiarrhythmic drugs, both of the patients are in continuous normal sinus rhythm. CONCLUSION: In young patients with symptomatic idiopathic ventricular tachycardia originating from the left aortic sinus cusp, radiofrequency catheter ablation was safe and effective.

[Cardiac troponin I after heart surgery corrective operation in infancy and childhood]. / Kardiales Troponin I nach kardiochirurgischer Korrekturoperation im Säuglings- und Kindesalter.

BACKGROUND: Perioperative myocardial damage is an important determinant for postoperative cardiac function and recovery. Cardiac troponin I (cTNI) is a specific marker for myocardial damage. The aim of our study was to evaluate pre- and postoperative cTNI levels, the pattern of elevation in the first four postoperative days and the prognostic value after pediatric cardiac operation. METHODS: Cardiac troponin I levels were measured in 115 children mean age 36 +/- 45 months (range 4 days to 189 months) undergoing elective operation of a congenital heart defect. Routine measurements were made preoperatively, immediately after cardiopulmonary bypass and serially 8, 18, 42, 90, 138 hours thereafter. Data from 13 patients undergoing surgery without cardiopulmonary bypass served as controls. Postoperative cTNI levels were correlated with intra- and postoperative parameters (such as duration of aortic crossclamping, cardiopulmonary bypass time and need for postoperative inotropic support). RESULTS: All preoperative cTNI levels were in the normal range. Postoperatively, the highest median cTNI levels were found in patients after repair of tetralogy of Fallot (TOF), atrioventricular septal defect (AVSD) and implantation of a homo- or xenograft. Postoperative cTNI levels correlated significantly with duration of cardiopulmonary bypass and aortic crossclamping, operative approach (ventriculotomy versus atriotomy) and inotropic support (p < 0.0001). Peak cTNI levels were found immediately after surgery in 77.4% of our patients, 8 hours postoperative in 13.9% and at 18 hours after the surgery in 5.2% of the patients. In three children cTNI continued to increase; a secondary increase was found in one patient. Two of these children died, two had a prolonged postoperative recovery. CONCLUSION: The postoperative level of cardiac troponin I could be used as a marker of perioperative myocardial injury caused by ischemia and operative trauma. Peak levels usually could be obtained immediately after surgery, but a further increase of cTNI during the following 18 hours may occur and is not necessarily related to impaired recovery. However still increasing cTNI levels after 18 hours postoperatively and a secondary increase as well may be used as indicators of poor outcome.

Achieving a healthy lifestyle among United States adults: a long way to go.

OBJECTIVE: The United States population has been advised to engage in various healthy lifestyle factors known to be associated with reduced morbidity and mortality from various chronic conditions. These include not smoking, adequate fruit and vegetable intake, adequate physical activity, and normal body weight. Little is known about the prevalence of United States adults who engage in all four of these behaviors, however. DESIGN: Cross-sectional analysis. SETTING: The third National Health and Nutrition Examination Survey (1988-1994). PARTICIPANTS: 16,176 participants aged > or = 21 years. MAIN OUTCOME MEASURES: Percentage of participants engaging in four healthy lifestyle factors. RESULTS: Overall, 6.8% of the US population engaged in all four healthy lifestyle factors. Women were more likely than men (P = .001), and Whites and participants of "other race or ethnicity" were more likely than African Americans and Mexican Americans to engage in all four healthy lifestyle factors. A significant positive educational gradient was also evident (P for linear trend <.001). The highest percentages of participants engaging in all four lifestyle factors occurred among men (15.8%) and women (18.4%) of "other" race who had at least 13 years of education. The lowest percentages were observed for White men (1.1%) and African-American women (0.9%) with little education. CONCLUSIONS: The small proportion of US adults engaging in four healthy lifestyle factors demonstrates the enormity of the task that awaits the public health community in persuading Americans to adopt a multidimensional healthy lifestyle.

Cigarette smoking and diabetes mellitus: evidence of a positive association from a large prospective cohort study.

OBJECTIVE: Only a few prospective studies have examined the relationship between the frequency of cigarette smoking and the incidence of diabetes mellitus. The purpose of this study was to determine whether greater frequency of cigarette smoking accelerated the development of diabetes mellitus, and whether quitting reversed the effect. METHODS: Data were collected in the Cancer Prevention Study I, a prospective cohort study conducted from 1959 through 1972 by the American Cancer Society where volunteers recruited more than one million acquaintances in 25 US states. From these over one million original participants, 275,190 men and 434,637 women aged > or = 30 years were selected for the primary analysis using predetermined criteria. RESULTS: As smoking increased, the rate of diabetes increased for both men and women. Among those who smoked > or = 2 packs per day at baseline, men had a 45% higher diabetes rate than men who had never smoked; the comparable increase for women was 74%. Quitting smoking reduced the rate of diabetes to that of non-smokers after 5 years in women and after 10 years in men. CONCLUSIONS: A dose-response relationship seems likely between smoking and incidence of diabetes. Smokers who quit may derive substantial benefit from doing so. Confirmation of these observations is needed through additional epidemiological and biological research.

C-reactive protein and body mass index in children: findings from the Third National Health and Nutrition Examination Survey, 1988-1994.

OBJECTIVES: To examine the relationship between C-reactive protein (CRP) concentration and body mass index (BMI) in children. STUDY DESIGN: With the use of data from 5305 children aged 6 to 18 years in the Third National Health and Nutrition Examination Survey (1988 to 1994), a cross-sectional health survey, we examined whether CRP concentrations were elevated among overweight children. RESULTS: Among children whose BMI was below the age- and sex-specific 15th percentile, 6.6% of boys and 10.7% of girls had an elevated CRP concentration (>2.1 mg/L) compared with 24.2% of boys and 31.9% of girls whose BMI was > or =95th percentile. After adjustment was done for age, sex, race or ethnicity, poverty income ratio, high-density lipoprotein cholesterol concentration, white blood cell count, and history of chronic bronchitis, the adjusted odds of having an elevated CRP concentration were 2.20 (95% CI 1.30, 3.75) for children with a BMI of 85th to <95th percentile and 4.92 (95% CI 3.39, 7.15) for children with a BMI of > or =95th percentile compared with children who had a BMI of 15th to <85th percentile. The associations did not differ significantly by age, sex, or race or ethnicity. CONCLUSIONS: In a large representative sample of US children, CRP concentration was significantly elevated among children with a BMI > or=85th percentile, thus confirming previous findings of this association in children and extending previous research in adults to children. Excess body weight may be associated with a state of chronic low-grade inflammation in children.

Recording of diabetes on death certificates. Has it improved?

OBJECTIVE: To determine whether the recording of diabetes on death certificates improved from 1986 to 1993. METHOD: Comparison of two National Mortality Follow-back Surveys that selected independent samples of death certificates with the purpose of obtaining information from informants about the decedents. RESULTS: The recording of diabetes on death certificates did not improve from 1986 to 1993. CONCLUSION: Periodic monitoring of the accuracy of death certificates is essential for proper interpretation of mortality statistics which are routinely used to describe the burden of diabetes in our society.

Reducing risk for cardiovascular disease in uninsured women: combined results from two WISEWOMAN projects.

OBJECTIVE: to evaluate the effectiveness of a cardiovascular disease (CVD) risk factor reduction program for financially disadvantaged women. The program included cholesterol and blood pressure assessments and tailored physical activity and nutrition interventions. METHODS: Women who attended selected National Breast and Cervical Cancer Early Detection Program sites in North Carolina and Massachusetts received either enhanced physical activity and nutrition interventions (EI) or minimum interventions (MI). The effectiveness of EI was assessed by pooling data from the North Carolina and Massachusetts projects after 1 year, and a mixed models analysis of covariance was used to compare changes in CVD risk factors across groups. RESULTS: The blood pressure, total cholesterol, and high-density lipoprotein cholesterol profiles of both groups improved, body weight was maintained, and smoking declined. The 10-year estimated coronary heart disease death rate (per 1,000 women) at baseline was 64.8 for the El group and 61.9 for the MI group. The rate declined by 3.5 deaths per 1,000 for the EI and 0.7 per 1,000 for the MI. Although the decline was statistically significant for the EI group, the difference between groups was not significant. CONCLUSION: Further lifestyle intervention research targeting financially disadvantaged women is needed.

Cardiovascular disease risk factor intervention in low-income women: the North Carolina WISEWOMAN project.

OBJECTIVES: The North Carolina WISEWOMAN project was initiated to evaluate the feasibility of expanding an existing cancer screening program to include a cardiovascular disease (CVD) screening and intervention program among low-income women. METHODS: Seventeen North Carolina county health departments were designated as minimum intervention (MI), and 14 as enhanced intervention (EI). The EI included three specially constructed counseling sessions spanning 6 months using a structured assessment and intervention program tailored to lower income women. RESULTS: Of the 2,148 women screened, 40% had elevated total cholesterol (> or = 240 mg/dL), 39% had low high-density lipoprotein cholesterol (HDL-C) levels (< 45 mg/dL), and 63% were hypertensive (systolic blood pressure 140 and/or diastolic blood pressure > or = 90 mm Hg or on hypertensive medication). The majority of women (86%) had at least one of these three risk factors. Seventy-six percent were either overweight or obese. After 6 months of follow-up in the EI health departments, changes in total cholesterol levels, HDL-C levels, diastolic blood pressure, and BMI were observed (-5.8 mg/dL, -0.9 mg/dL, -1.7 mm Hg, and -0.3 kg/m(2), respectively), but were not significantly different from MI health departments. A dietary score that summarized fat and cholesterol intake improved by 2.1 units in the EI group, compared with essentially no change in the MI group. CONCLUSIONS: Expanding existing cancer screening programs to include CVD intervention was feasible and may be an effective means for promoting healthful dietary practices among low-income women.

Iron deficiency anemia: higher prevalence in Mexican American than in non-Hispanic white females in the third National Health and Nutrition Examination Survey, 1988-1994.

BACKGROUND: Mexican American females have a higher prevalence of iron deficiency than do non-Hispanic white females. OBJECTIVE: The objective was to estimate the prevalence of iron deficiency anemia and examine potential reasons for this difference between Mexican American (n = 1194) and non-Hispanic white (n = 1183) females aged 12-39 y. DESIGN: We used data from the third National Health and Nutrition Examination Survey (1988-1994). Iron deficiency anemia was defined as abnormal results from >/=2 of 3 tests (erythrocyte protoporphyrin, transferrin saturation, and serum ferritin) and a low hemoglobin concentration. We used multiple logistic regression to adjust for factors that were more prevalent in Mexican American females and significantly associated with iron deficiency anemia. RESULTS: The prevalence of iron deficiency anemia was 6.2 +/- 0.8% (f1.gif" BORDER="0"> +/- SE) in Mexican American females and 2.3 +/- 0.4% in non-Hispanic white females. Mean dietary iron intake, mean serum vitamin C concentrations, and the proportion of females using oral contraceptives were similar in the 2 groups. Age <20 y and education were not associated with iron deficiency anemia. After adjustment for poverty level, parity, and iron supplement use, the prevalence of iron deficiency anemia was 2.3 times higher in Mexican American than in non-Hispanic white females (95% CI: 1.4, 3.9). In those with a poverty income ratio (based on household income) >3.0, however, the prevalence of iron deficiency anemia was 2.6 +/- 0.9% in Mexican American and 1.9 +/- 0.6% in non-Hispanic white females (NS). CONCLUSION: Although much of the ethnic disparity in iron deficiency anemia remains unexplained, factors associated with household income may be involved.

Are health care professionals advising obese patients to lose weight?

CONTEXT: Implementation of the National Institutes of Health's 1998 guidelines, which recommended that health care professionals advise obese patients to lose weight, required baseline data for evaluation. OBJECTIVES: To describe the proportion and characteristics of obese persons advised to lose weight by their health care professional during the previous 12 months and to determine whether the advice was associated with reported attempts to lose weight. DESIGN: The Behavioral Risk Factor Surveillance System, a random-digit telephone survey conducted in 1996 by state health departments. SETTING: Population-based sample from 50 states and the District of Columbia. PARTICIPANTS: A total of 12835 adults, 18 years and older, classified as obese (body mass index > or =30 kg/m2), who had visited their physician for a routine checkup during the previous 12 months. MAIN OUTCOME MEASURES: Reported advice from a health care professional to lose weight, and reported attempts to lose weight. RESULTS: Forty-two percent of participants reported that their health care professional advised them to lose weight. Using multivariate logistic regression analysis, we found that the persons who were more likely to receive advice were female, middle aged, had higher levels of education, lived in the northeast, reported poorer perceived health, were more obese, and had diabetes mellitus. Persons who reported receiving advice to lose weight were significantly more likely to report trying to lose weight than those who did not (OR, 2.79; 95% CI, 2.53-3.08). CONCLUSIONS: Less than half of obese adults report being advised to lose weight by health care professionals. Barriers to counseling need to be identified and addressed.

Serum vitamin C concentrations and diabetes: findings from the Third National Health and Nutrition Examination Survey, 1988-1994.

BACKGROUND: Previous studies suggested that diabetes mellitus may lower serum vitamin C concentrations, but most of these studies used clinic-based populations with established diabetes of varying duration and did not adjust for important covariates. OBJECTIVE: Using a population-based sample and adjusting for important covariates, we asked whether serum vitamin C concentrations in persons with newly diagnosed diabetes differed from those in persons without diabetes. DESIGN: Data were obtained from the third National Health and Nutrition Examination Survey (1988-1994). Serum vitamin C was assayed by using reversed-phase HPLC with multiwavelength detection. Diabetes status (n = 237 persons with diabetes; n = 1803 persons without diabetes) was determined by oral-glucose-tolerance testing of the sample aged 40-74 y. RESULTS: After adjustment for age and sex, mean serum vitamin C concentrations were significantly lower in persons with newly diagnosed diabetes than in those without diabetes. After adjustment for dietary intake of vitamin C and other important covariates, however, mean concentrations did not differ according to diabetes status. CONCLUSION: When assessing serum vitamin C concentrations by diabetes status in the future, researchers should measure and account for all factors that influence serum vitamin C concentrations.

Is diabetes mellitus associated with prostate cancer incidence and survival?

Results of two recent prospective incidence studies have suggested that certain subgroups of men with diabetes mellitus may be protected from developing prostate cancer. Two earlier studies, however, concluded that diabetes increased the risk of mortality from prostate cancer. With hundreds of thousands of male respondents, the 1959-1972 Cancer Prevention Study provided a unique opportunity to explore whether men with diabetes were more likely to develop prostate cancer during a 13-year follow-up period than were men without diabetes. After adjusting for factors associated with prostate cancer in previous studies, we found little association between diabetes at baseline and prostate cancer incidence [incidence density ratio (IDR) = 1.05; 95% confidence interval (CI) = 0.81-1.36]. Men who had diabetes mellitus for 5 or more years, however, had a higher incidence of prostate cancer than did men without diabetes (IDR = 1.56; 95% CI = 1.02-2.38). Among all study participants who were diagnosed with prostate cancer, men with diabetes were only slightly more likely to die from prostate cancer than were men without diabetes (IDR = 1.11; 95% CI = 0.76-1.62).

Trends in body weight among American Indians: findings from a telephone survey, 1985 through 1996.

OBJECTIVES: This study compared trends in body mass index for American Indian men and women across selected regions of the United States. METHODS: Self-reported data were collected from the Behavioral Risk Factor Surveillance System. RESULTS: Among women in the Dakotas, New Mexico and Arizona, and Washington and Oregon, average adjusted body mass index increased significantly by 0.1 to 0.2 units per year. Among men in Alaska and the Dakotas, average adjusted body mass index also increased significantly by 0.1 to 0.2 units each year. CONCLUSIONS: Because of rapid increases in average body mass index, some American Indian populations could be burdened by an increased incidence of chronic disease.

Diabetes mellitus and serum carotenoids: findings from the Third National Health and Nutrition Examination Survey.

Little is known about carotenoids, a diverse group of plant compounds with antioxidant activity, and their association with diabetes, a condition characterized by oxidative stress. Data from phase I of the Third National Health and Nutrition Examination Survey (1988-1991) were used to examine concentrations of alpha-carotene, beta-carotene, cryptoxanthin, lutein/zeaxanthin, and lycopene in 40- to 74-year-old persons with a normal glucose tolerance (n = 1,010), impaired glucose tolerance (n = 277), newly diagnosed diabetes (n = 148), and previously diagnosed diabetes (n = 230) based on World Health Organization criteria. After adjustment for age, sex, race, education, serum cotinine, serum cholesterol, body mass index, physical activity, alcohol consumption, vitamin use, and carotene and energy intake, geometric means of beta-carotene were 0.363, 0.316, and 0.290 micromol/liter for persons with a normal glucose tolerance, impaired glucose tolerance, and newly diagnosed diabetes, respectively (p = 0.004 for linear trend), and geometric means for serum lycopene were 0.277, 0.259, and 0.231 micromol/liter, respectively (p = 0.044 for linear trend). All serum carotenoids were inversely related to fasting serum insulin after adjustment for confounders (p < 0.05 for each carotenoid). If confirmed, these data suggest new opportunities for research that include exploring a possible role for carotenoids in the pathogenesis of insulin resistance and diabetes.

Health insurance status and cardiovascular disease risk factors among 50-64-year-old U.S. women: findings from the Third National Health and Nutrition Examination Survey.

To examine the cardiovascular disease risk factors profile and use of preventive health services for cardiovascular disease among uninsured women aged 50-64 years, we studied data from the National Health and Nutrition Examination Survey III (NHANES III), conducted from 1988 to 1994. Insured women (n = 1308) and uninsured women (n = 303) had similar levels of blood pressure and lipids, but uninsured women were more likely to be current smokers, sedentary, and overweight and to consume less fiber, vitamin C, folate, calcium, and potassium than insured women. Compared with insured women, uninsured women were less likely to have had their blood pressure checked during the previous 6 months, to have had their cholesterol level checked, and to be aware of hypercholesterolemia. Insured women (24.9%) were three times more likely to use estrogen replacement therapy than uninsured women (7.9%). NHANES III data suggest that women without health insurance have a worse cardiovascular disease risk factor profile and use healthcare services less frequently than women with health insurance.

Colorectal cancer: another complication of diabetes mellitus?

Delayed stool transit and other gastrointestinal abnormalities are commonly observed in persons with diabetes mellitus and are also known to be associated with colorectal cancer. Previous studies of the contribution of diabetes to colorectal cancer incidence and mortality have been limited by small sample sizes and failure to adjust for covariates. With more than 1 million respondents, the 1959-1972 Cancer Prevention Study provided a unique opportunity to explore whether persons with diabetes (n=15,487) were more likely to develop colorectal cancer during a 13-year follow-up period than were persons without diabetes (n=850,946). After adjustment for colorectal cancer risk factors, such as race, educational level, body mass index, smoking, alcohol use, dietary intake, aspirin use, physical activity, and family history of colorectal cancer, the incidence density ratio comparing colorectal cancer in those with diabetes and those without diabetes was 1.30 (95% confidence interval 1.03-1.65) for men and 1.16 (95% confidence interval 0.87-1.53) for women. However, diabetes was not associated with greater case fatality. Future studies should explore the possibility of a cancer-promoting gastrointestinal milieu, including delayed stool transit and elevated fecal bile acid concentrations, associated with hyperglycemia and diabetic neuropathy.

[Heart transplantation in infancy: experiences at the Giessen Pediatric Heart Center]. / Herztransplantation im Säuglingsalter: Erfahrungen am Kinderherzzentrum Giessen.

From June 1988 to December 1996 heart transplantations were performed in 36 newborns and infants below one year of age. Diagnosis were hypoplastic left heart syndrome (n = 26), endocardial fibroelastosis (n = 4), cardiomyopathy (n = 3), and other complex congenital heart defects (n = 3). Mean waiting time for transplantation was 52 days, the mean donor-recipient bodyweight ratio was 1.8. Seven patients (19%) died after transplantation mainly within the first month after transplantation. The cumulative probability of survival is 79% in all patients. The influence of increasing experience is indicated when patients transplanted from 1988-1993 (n = 15) are compared with transplants from 1994-1996 (n = 21). The overall survival in the first group was 50%, whereas patients transplanted from 1994 showed a probability of survival of 92%. The 1-year survival rate in the later group was 100%. In 20 patients a total of 31 rejection episodes were observed. 2 infants died due to rejection. 71% of all rejections occurred during the first month after transplantation. Renal function was slightly impaired one year after transplantation in all patients without tendency for deterioration in the sequel. The somatic development is normal in nearly all infants and the quality of life is excellent. All infants live at home without any restrictions. Two patients, however, suffer from a neurologic deficit. Until now there is no evidence of coronary vascular disease or malignancy. Heart transplantation is in our opinion a reconsiderable alternative in the treatment of complex cardiac disease and cardiomyopathy in infants.

A dilemma within the family: commentary on who should know and who should tell.

Dilemmas for nurses may reflect a conflict between values and the choices a patient and family may make. When the debate involves the young children of a dying family member, who decides what is best for the children and how does the conflict get resolved? Rarely are the solutions simple. Following professional principle is imperative. Respecting the perspective of the dying often requires a set of fine balancing strategies: those of the professional and those of the family.