Development and evaluation of an e-learning package for teaching skin examination. Action research.

BACKGROUND: Dermatology is one of many specialities competing for space in the undergraduate curriculum, and recent review reveals that in some medical schools only a minority of students receives direct teaching from dermatologists. Enlargement of medical schools and dispersion of students over multiple sites further increase the strain on teaching resources. OBJECTIVES: To develop and obtain 'proof of concept' for a technology to teach skin examination, using an approach grounded in modern theories of learning. METHODS: The requirements for an e-learning technology were identified through literature review and qualitative analysis of stakeholders' requirements with respondent and expert validation. A method of teaching skin examination was developed by applying Anderson's theory of skills acquisition. It was prototyped first on paper, then electronically, and its usability as an instructional tool was evaluated. RESULTS: The project delivered, firstly, a specification for skin examination derived from published evidence, textbook content, and staff and student consensus; and secondly, a very useable technology to help students learn skin examination (http://www.skillsbase.man.ac.uk). A validation task was completed in 20 min without significant usability problems, and evaluators found it simple, intuitive, interactive and enjoyable to use. Students saw it as an adjunct that would help them build confidence and revise for examinations. Nonstakeholder teachers expressed concern about the apparent simplicity of its contents and felt that it should only be used in association with traditional teaching methods. CONCLUSIONS: Students, educationalists and teachers were able to codesign a useable skin examination package, which merits evaluation of efficacy. In view of the logistic difficulties of teaching dermatology to the growing student population, the technology may be a useful adjunct to traditional teaching methods. Our approach may inform further developments in educational technology in dermatology.

Measuring clinical performance and outcomes from diabetes information systems: an observational study.

AIMS/HYPOTHESIS: To examine changes in diabetes care provision after the introduction of a district diabetes information system. METHODS: All patients with diabetes registered on the system between 1993 and 1998 (n = 6544) were included in the analysis. Drop-out cohort analysis was used to handle population changes, logistic regression models with general estimating equations were used to examine changes in clinical performance over time. RESULTS: After the introduction of the system, care processes improved appreciably, in both primary and secondary care. The proportion of patients receiving a preventative care review within the calendar year rose from 56% in 1993 to 67% in 1998. The proportion of these in whom each process was completed improved in all categories from 1993 to 1998: blood pressure 96% to 98%; glycaemic check 67% to 93%; lipid check 31% to 68%; renal check 46% to 87%; fundoscopy 79% to 92%; foot screen 87% to 87%. Similarly there was an increase in the proportion of patients achieving intermediate outcome treatment targets (HbA1c < or = 9.0% from 29% to 43%; cholesterol < or = 5.5 mmol/1 5% to 19%; blood pressure < or = 160/90 37% to 46%). CONCLUSION/INTERPRETATION: Our results suggest appreciable improvements in diabetes care between 1993 and 1998. These changes apply to an entire population of patients across primary and shared care. We believe that these improvements could, in part, be attributable to the way in which the district diabetes information system has facilitated the structured cascade of diabetes care.

Consultation skills of medical students before and after changes in curriculum.

The University of Manchester Medical School has adopted problem-based learning as its main educational method, with a change of emphasis from a biomedical to a biopsychosocial approach. The training of junior medical students in clinical interviewing is intended to reinforce and develop their interpersonal skills. We measured the impact of this new curriculum by assessing two intakes of students covering the period before and after its introduction; a third intake was later added to examine the effect of further curriculum adjustments. 86 students, randomly selected, were videorecorded conducting diagnostic interviews with standardized patients 10 weeks after they had started to learn clinical interviewing. Two instruments were developed--a 23-item communication skills scale and a 13-item information-gathering scale and both showed acceptable inter-rater and test-retest reliability. Communication skills did not differ between years. The total score for information-gathering fell by 13% (95% confidence interval -20 to -6%, P < 0.001) in the first year after introduction of the new educational approach but returned to baseline the following year after further modification of the course. Although the new approach yielded no measurable improvement in the process of communication, assessment 10 weeks after the start of interview training may be too early to permit definitive conclusions. We conclude that it is possible to change to a more patient-centred emphasis in teaching medical interviewing. Some initial loss of information content was rectified by adjustment of the course. Our unfavourable early experience highlights the need to evaluate educational change.

Evaluation of an electrochemical sensor for measuring blood ketones.

OBJECTIVE: To evaluate the performance of a hand-held ketone sensor that is able to measure blood beta-hydroxybutyrate (beta-HBA) concentrations within 30 s in patients with diabetic ketoacidosis (DKA) and patients who attend a weight management clinic. RESEARCH DESIGN AND METHODS: Two groups of patients were studied: 19 patients admitted with DKA and 156 patients attending a weight management clinic. Paired capillary and venous whole blood samples were measured using the ketone sensor and also using an enzymatic laboratory reference method. RESULTS: The ketone sensor accurately measured beta-HBA concentrations in patients with DKA (limits of agreement -0.9 to + 1.0 mmol/l) or starvation-induced ketonemia (limits of agreement -0.5 to +0.5 mmol/l). CONCLUSIONS: This ketone sensor accurately measures whole blood beta-HBA concentrations within 30 s.

Three cases of macroprolactinaemia.

A woman with hirsutism but otherwise symptom-free was found to have a raised serum prolactin and a pituitary microadenoma. The hyperprolactinaemia persisted despite bromocriptine therapy and subsequent pituitary surgery, which yielded a non-functioning adenoma. After a further 15 years with persistent hyperprolactinaemia but no symptoms, macroprolactinaemia was diagnosed. Such cases might account for part of the failure rate of pituitary microsurgery for prolactinoma. Testing for macroprolactinaemia is advisable in a woman with hyperprolactinaemia, especially if her ovulatory cycle is normal. Two other cases are reported in which macroprolactinaemia was associated with menstrual disturbances and other hormonal effects: in these, treatment with dopamine agonists suppressed the hyperprolactinaemia and restored normal menstrual cycles.

Pathology and the OSCE: insights from pilot study.

Undergraduate medical education in Manchester in undergoing wholesale revision, with the introduction of problem-based learning (PBL) in each successive year of the curriculum, as the cohort of students who joined the faculty in 1994 advances through the course. This cohort has now entered year 3, which primarily hospital-based. In preparation for this, we have explored the development of an OSCE, not only to assess core interpersonal skills such as history taking, clinical examination, and the ability to explain things to patients, but also to integrate the examination of important skills relating to investigational sciences. These include the correct choice of laboratory tests, accurate interpretation of data, and appropriate selection of clinical responses to test results.

Impaired processing of proopiomelanocortin in corticotroph macroadenomas.

The regulation and secretion of the ACTH precursors POMC and pro-ACTH were assessed directly using a 2-site immunoradiometric assay in six patients with pituitary macroadenomas (> or = 1.2 cm in diameter) and 27 patients with Cushing's disease due to a microadenoma. ACTH precursor levels were elevated in patients with macroadenomas (150-3690 pmol/L; normal range, < 5-40 pmol/L) and significantly higher than those in microadenoma patients (median, 29 pmol/L; range, 9-104 pmol/L; P < 0.001). Patients with macroadenomas also had increased ACTH precursor/ACTH ratios (15-181:1) compared with microadenoma patients (median, 5:1, range, 0.7-18.5:1; P < 0.001). ACTH precursors were unresponsive to high dose dexamethasone in patients with macroadenomas, whereas ACTH and cortisol responses varied. After CRH administration, ACTH precursors were unchanged, whereas cortisol increased significantly, suggesting the release of biologically active ACTH. This study clearly demonstrates reduced processing of POMC to ACTH in large pituitary tumors, a characteristic usually associated with tumors causing the ectopic ACTH syndrome, and provides evidence for differential regulation of ACTH precursors and ACTH by glucocorticoid and CRH. Variation in the clinical symptoms of patients with corticotroph macroadenomas may be attributable to differences in biological potency between the ACTH precursors and ACTH.

A survey of drug treatment and outcomes in diabetic patients with acute myocardial infarcts.

Sixty-four diabetic patients suffering an acute myocardial infarct were retrospectively matched, by age, gender and smoking habit, to non-diabetic controls. The two groups were compared for cardiovascular risk factors, pre-admission and discharge drug treatment, in-hospital drug treatment, and complication and mortality rates. Hypertension was more prevalent in the diabetic (63%) than in the control (42%) group. When comparing drugs on admission to those at discharge, there was a significant increase in antiplatelet and nitrate usage in both groups (P < 0.001), in beta-blocker usage in the control group (P < 0.001) and in loop diuretic usage in the diabetic group (P < 0.001). The usage of angiotensin converting enzyme inhibitors was low: 16% of diabetic patients and 5% of controls at discharge. Thrombolytic therapy was used in 29 diabetics and 37 controls. There was a significantly higher complication rate in the diabetic group than in the control group (P < 0.006), the most common being congestive cardiac failure (59% vs 30%, P < 0.001). Four controls and 13 diabetic patients died; three of the latter had their diabetes diagnosed during the admission. This study did not clearly demonstrate any underlying risk factors or treatment variables to account for the increased morbidity or mortality in diabetic patients with acute myocardial infarct, when compared to a matched non-diabetic population. However, modest associations not detected by this relatively small study are still possible.

Evaluation of a second-generation electrochemical blood glucose monitoring system.

One hundred and ninety-five diabetic patients attending hospital clinics gave blood samples to test the accuracy and precision of a second generation glucose sensor (satellite G, MediSense Inc., Abingdon, UK) with particular emphasis on its performance with venous blood. Sensor results correlated closely with a standard laboratory method; analysis of residuals showed no deviation from zero slope. Mean percentage difference was low (< +/- 6.0%) and the 95% limits of agreement were < +/- 30% with both capillary and venous blood. Error Grid Analysis showed that none of the measurements would have led to serious management errors. Precision of the system was good with coefficients of variation (CV) between 2.8% and 7.1% for glucose concentrations ranging from 3.0 to 24.0 mmol l-1. The mean CV for duplicate measurements was 5.4% with capillary and 4.4% with venous blood. We conclude that the electrochemical glucose method gives accurate and precise measurements of venous and capillary blood glucose.

'Hospital hyperglycaemia'; perception or reality?

Patients' perceptions that clinic fasting blood glucose measurements in Type 2 diabetes are artefactually high were investigated. Eighteen men and 14 women in the Salford cohort of the United Kingdom Prospective Diabetes Study (UKPDS) with a median age of 51 (range 37-69) years measured their fasting blood glucose concentration at home with visually read sticks or meters; they then collected capillary blood into fluoride tubes both at home and in clinic after a median lapse of 77 (range 25-173) min. The clinic samples were measured immediately and after a time lapse equivalent to the time taken to reach clinic to control for continued glycolysis in the home sample. Mean fasting blood glucose was 5.9 +/- 1.9 mmol 1(-1) by the patients' own measurement and 6.0 +/- 1.8 mmol 1(-1) on the home collected sample compared with 6.2 +/- 2.0 mmol 1(-1) and 6.1 +/- 2.0 mmol 1(-1) on the hospital immediate and time-lapsed measurements, respectively (p > 0.05 for all comparisons between home and hospital measurements); although there were no systematic differences, occasional measurements differed more than 2 mmol 1(-1). These data support the use of the fasting blood glucose level as a stable, patient-independent measure of glycaemic control in Type 2 diabetes.