Breast disease and undergraduate medical education: a randomized trial to assess the effect of a home study module on medical student performance.

BACKGROUND: This study sought to demonstrate the effectiveness of a home study module (HSM) on student performance at a large urban medical school. METHOD: Second-year students were randomized to receive: 1) a HSM in addition to regular teaching of clinical breast examination or, 2) the regular teaching alone. The HSM included adult learning principles, problem-based learning, and practice guidelines. Students completed a pretest, a post-test, and course evaluation. The pre- and post-tests examined students' knowledge and comfort levels. RESULTS: Of 176 students, 136 agreed to participate and 127 completed both pre- and post-tests. Baseline pretest indicated no significant difference between the intervention and control groups. Post-test showed that students receiving the HSM gained significantly more knowledge than had the control group, and their comfort levels shifted nonsignificantly more. Student evaluations indicated perceived value of the HSM. INTERPRETATION: Student performance can be enhanced and comfort levels increased by providing a critical core of knowledge in the form of a HSM. This approach may be applicable to other important subjects.

Risk-adapted therapy for clinical stage I-II Hodgkin's disease: 7-years results of radiotherapy alone for low-risk disease, and ABVD and radiotherapy for high-risk disease.

Treatment outcomes were documented for 204 adult patients with clinical Stage I-II Hodgkin's disease who were treated with risk-adapted ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) and radiotherapy (RT) at the Toronto-Sunnybrook Regional Cancer Centre between 1984 and 1994. Forty-nine patients with clinical Stage I disease (excluding bulky mediastinal presentations) and 50 patients with a combination of clinical Stage IIA disease, age 50 years or less, and favourable pathology (lymphocyte predominant or nodular sclerosing histology) were identified as low risk and treated with RT alone to 35 Gy. One hundred and five high-risk patients were treated with chemotherapy (86 with ABVD) followed by RT to 25 Gy. The 7-year cause-specific, overall and disease-free survivals were 95%, 90% and 75% respectively for the low-risk cohort, and 91%, 90% and 88% respectively for the high-risk cohort. In-field relapses accounted for 50% of the failures in both groups. Sixteen of 24 (67%) patients with RT failure and 6/14 (43%) with combined modality therapy (CMT) failure were salvaged. Twenty-eight per cent of the patients treated with RT and 21% of those treated with CMT developed hypothyroidism by 7 years. Fatal complications were recorded in 6% of the low-risk patients managed with RT and 8% of high-risk patients managed with CMT. Septic death and second malignancy accounted for the majority of treatment-related fatalities. Risk-adapted therapy emphasizing RT alone for selected patients with favourable prognostic factors and CMT based on ABVD provides excellent long-term disease control. Further treatment refinements, including the wider application of CMT with lower doses of chemotherapy and RT, will be required to reduce the rate of fatal complications to more acceptable levels.

Commitment of a cancer organization to a program for training in communication skills.

An Ontario cancer agency started an initiative to improve and promote effective communications between health care providers and their patients, using a 4.5-hour workshop developed by the Bayer Institute for Health Care Communications. Each of the eight regional cancer centers in Ontario sent two people, one physician and one other health care professional, for training in delivery of the workshop. Subsequently, each center provided workshops for physicians, nurses, pharmacists, physicists, social workers, psychologists, radiotherapists, and secretarial staff. The ongoing workshops are multiprofessional in composition and interactive and participatory in design. Between September 1996 and September 1997, the workshops involved over 400 cancer care professionals. Their success has been attributed to the knowledge, skills, and enthusiasm of the trained pair of facilitators; the interactive and participatory nature of the workshop design; the multiprofessional participation; and the support of the board of directors and senior management and the administration of each cancer center.

Dapsone in prevention of recurrent neutrophilic eccrine hidradenitis.

Neutrophilic eccrine hidradenitis has been described in patients with acute myelogenous leukemia and other malignant diseases, usually during chemotherapy. We describe a 46-year-old man with Hodgkin's disease in whom neutrophilic eccrine hidradenitis developed after each of the first two treatments with lomustine. Dapsone, 100 mg daily, was initiated 48 hours before the patient's third treatment with lomustine and was continued for 14 days. This regimen was successful in suppressing the reaction during the first course and three subsequent courses of lomustine.

Isolated chloroma: the effect of early antileukemic therapy.

OBJECTIVE: To evaluate the effect of antileukemic chemotherapy administered at diagnosis on the survival of patients with isolated chloroma. DESIGN: Retrospective review of locally identified patients and analysis of cases from the medical literature. PATIENTS: The records of all patients with isolated chloroma identified at three teaching hospitals in Toronto between 1980 and 1994 were reviewed. A MEDLINE search was done to identify all cases of isolated chloroma reported in the English-language medical literature. Patients with a previous known hematologic disorder were excluded. MEASUREMENTS: The effect of therapy on 1) the interval between diagnosis of chloroma and diagnosis of acute myeloid leukemia and 2) survival was determined. RESULTS: 7 local patients and 83 published cases were identified, for a total of 90 evaluable patients. For the entire group, the median time to the diagnosis of acute myeloid leukemia was 9 months, and median survival was 22 months. Chemotherapy was administered to 49 patients (54%) at diagnosis of chloroma. Significantly fewer patients treated with chemotherapy subsequently developed acute myeloid leukemia (41% compared with 71%; P = 0.001). Survival was longer in patients treated with chemotherapy (> 50% alive with a median follow-up of 25 months compared with a median survival of 13 months for those initially untreated; P = 0.001). Multivariate analysis showed that neither local radiotherapy nor surgery had an effect on survival. CONCLUSIONS: Administration of antileukemic chemotherapy at diagnosis of chloroma is associated with a significantly lower probability of developing acute myeloid leukemia and with longer survival.

A phase II trial of prednisone, oral etoposide, and novantrone (PEN) as initial treatment of non-Hodgkin's lymphoma in elderly patients.

This phase II study was designed to improve the outcome of elderly patients with advanced aggressive non-Hodgkin's lymphomas (NHL's) by employing a novel chemotherapy regimen PEN (prednisone, oral etoposide and mitoxantrone), as initial treatment. Between July 1991 and September 1993, 43 patients (14 male, 29 female) aged 66-82 years (median 74) received 1-8 (median 4) courses of PEN (total 192) q28 days (prednisone 50 mg od x 14 days, oral etoposide 50 mg od x 14 days and mitoxantrone 8 mg/m2 i.v. day 1) in the ambulatory setting. Pathologies of patients' tumors classified by the Working Formulation (WF) included C = 4, D = 2, E = 1, F = 7, G = 25, H = 4. Eighteen patients (42%) had stage IV, 15 (35%) stage III, 9 (21%) stage II and 1 (2%) stage I disease. Nineteen patients (44%) had B symptoms, 7 (16%) primarily extranodal disease and 15 (35%) bone marrow involvement. Patients with congestive heart failure, current anti-failure medication or pretreatment Muga left ventricular ejection fraction (LVEF) of < 45% (median pretreatment 60%) were excluded from PEN. After a median follow-up of 8.5 months (range 1-30), 14 of 33 evaluable patients (42%) have achieved CR of their disease for 8+ months (range 4-19) and 6 (18%) PR for 6+ months (range 5-10), giving an overall response rate of 61%. Ten (30%) patients did not respond to PEN and 10 were not evaluable for response. Response to PEN was not predicted by any pretreatment characteristic.(ABSTRACT TRUNCATED AT 250 WORDS)

Station gender bias in a multiple-station test of clinical skills.

PURPOSE: To apply differential item functioning (DIF) procedures to investigate station gender bias in multiple-station tests of clinical skills, and to compare these results with those obtained by comparing the station-score distributions of men and women examinees. METHOD: The data were from 23 stations used in the selection of seven successive cohorts (1987-1993) of candidates to the Ontario Pre-Internship Program for graduates of foreign medical schools. The stations had been used on at least three occasions, with a minimum sample of about 210 candidates per station. Each station's score was expressed as both a binary score and a continuous score, and DIF was assessed using the Mantel-Haenszel procedure with the binary scores and analysis of covariance with the continuous scores. For each station, DIF effect sizes were calculated and compared with the gender-group mean differences. RESULTS: Using the binary scores, significant DIF was observed for three stations; using the continuous scores, significant DIF was observed for five stations. Significant gender differences were observed in the scores of nine stations. In eight, these differences favored women. Overall, in more stations the direction of DIF favored the men, while the women demonstrated higher levels of ability. CONCLUSION: The results suggest the importance of using a DIF approach for controlling the "ability factor" in studies of this kind: although significant gender differences were observed in the continuous score distributions of nine stations, generally these differences were not indicative of station gender bias.

An objective structured clinical examination for the licentiate: report of the pilot project of the Medical Council of Canada.

The Medical Council of Canada (MCC) administers a qualifying examination for the issuance of a license to practice medicine. To date, this examination does not test the clinical skills of history taking, physical examination, and communication. The MCC is implementing an objective structured clinical examination (OSCE) to test these skills in October 1992. A pilot examination was developed to test the feasibility, reliability, and validity of running a multisite, two-form, four-hour, 20-station OSCE for national licensure. In February 1991, 240 volunteer first- and second-year residents were tested at four sites. The candidates were randomly assigned to one of two forms of the test and one of two sites for two of the four sites. Generalizability analysis revealed that the variance due to form was 0.0 and that due to site was .16 compared with a total variance of 280.86. The reliabilities (inter-station) were .56 and .60 for the two forms. Station total-test score correlations, used to measure station validity, were significant for 38 of the 40 stations used (range .14-.60). The results of the OSCE correlated moderately with the MCC qualifying examination; these correlations were .32 and .35 for the two test forms. Content validity was assessed by postexamination questionnaires given to the physician examiners using a scale of 0 (low) to 10 (high). The physicians' mean ratings were: importance of the stations, 8.1 (SD, 1.8); success of the examination in testing core skills, 8.1 (SD, 1.6); and degree of challenge, 7.8 (SD, 2.1). The results indicate that a full-scale national administration of an OSCE for licensure is feasible using the model developed. Aspects of validity have been established and strategies to augment reliability have been developed.

Validity and generalizability of global ratings in an objective structured clinical examination.

The performance of foreign medical graduates on multistation standardized patient-based tests and used to determine the validity and generalizability of global ratings of their clinical competence made by expert examiners. Data were derived from the entrance examinations of the 1989 and 1990 applicants to the Ontario Pre-Internship Program and the exit examination of 24 participants from the 1989 cohort. For each candidate, the examiners completed a detailed checklist and two five-point global ratings dealing with the candidate's approach to the patients' problem and attitude toward the patient. Generalizability coefficients for both ratings were satisfactory and stable across cohorts. Construct validity of the global ratings was demonstrated by comparing entry and exit ratings and by evidence of significant and positive correlations between the global ratings and total test scores. Tentative evidence of criterion validity of the global ratings was demonstrated. These findings suggest that global ratings by expert examiners can be used as an effective form of assessment in multistation standardized patient examinations.

Validity and reliability of a domain-referenced test of clinical competence for foreign medical graduates.

The authors determined the reliability and validity of domain-referenced scores obtained from a multiple-station clinical skills examination administered at the University of Toronto to a group of foreign medical graduates in early 1990. Issues associated with the identification of essential checklist items and the setting of minimum passing scores (cutting scores) for each station and for the total test were addressed. In addition, they examined the consistency of classification of candidates and the perceived appropriateness of the number of candidates classified "competent." The findings provide evidence of the validity of standard-setting procedures based on both the performance of criterion groups and the judgment of "experts."

Essential thrombocythemia with the Philadelphia chromosome and BCR-ABL gene rearrangement. An entity distinct from chronic myeloid leukemia and Philadelphia chromosome-negative essential thrombocythemia.

A 64-year-old woman presented with a platelet count of 3,225 x 10(9)/L. Bone marrow morphology showed massive megakaryocytic hyperplasia; cytogenetic studies showed the presence of the Philadelphia chromosome (Ph). The presence of a rearrangement involving the major breakpoint cluster region (mbcr) on chromosome 22 was confirmed by Southern blotting techniques. A diagnosis of Ph positive essential thrombocythemia (ET) was made. Such cases constitute less than 5% of patients with ET and it has been proposed that they be considered examples of chronic myelogenous leukemia (CML) because of a shared propensity to progress to blast crisis. An argument is presented for retaining Ph positive ET as an entity separate from Ph negative ET and Ph positive CML.

Splenic hypofunction in systemic lupus erythematosus: response to pneumococcal vaccine.

A woman who presented with splenic hypofunction as a complication of systemic lupus erythematosus is described. Pneumococcal vaccine was given. Her antibody response was measured and the responses of other cases are discussed.