A randomized trial of teaching clinical skills using virtual and live standardized patients.

BACKGROUND: We developed computer-based virtual patient (VP) cases to complement an interactive continuing medical education (CME) course that emphasizes skills practice using standardized patients (SP). Virtual patient simulations have the significant advantages of requiring fewer personnel and resources, being accessible at any time, and being highly standardized. Little is known about the educational effectiveness of these new resources. We conducted a randomized trial to assess the educational effectiveness of VPs and SPs in teaching clinical skills. OBJECTIVE: To determine the effectiveness of VP cases when compared with live SP cases in improving clinical skills and knowledge. DESIGN: Randomized trial. PARTICIPANTS: Fifty-five health care providers (registered nurses 45%, physicians 15%, other provider types 40%) who attended a CME program. INTERVENTIONS: Participants were randomized to receive either 4 live cases (n=32) or 2 live and 2 virtual cases (n=23). Other aspects of the course were identical for both groups. RESULTS: Participants in both groups were equivalent with respect to pre-post workshop improvement in comfort level (P=.66) and preparedness to respond (P=.61), to screen (P=.79), and to care (P=.055) for patients using the skills taught. There was no difference in subjective ratings of effectiveness of the VPs and SPs by participants who experienced both (P=.79). Improvement in diagnostic abilities were equivalent in groups who experienced cases either live or virtually. CONCLUSIONS: Improvements in performance and diagnostic ability were equivalent between the groups and participants rated VP and SP cases equally. Including well-designed VPs has a potentially powerful and efficient place in clinical skills training for practicing health care workers.

Risk of melanoma in medium-sized congenital melanocytic nevi: a follow-up study.

BACKGROUND: The risk of the occurrence of malignant melanoma (MM) in medium-sized (1.5 to 19.9 cm in diameter) congenital melanocytic nevi (CMN) is the subject of controversy. Universally accepted recommendations regarding the management of such lesions have not been made. OBJECTIVE: Our purpose was to assess the risk of MM arising in medium-sized CMN. METHODS: The study included 230 medium-sized CMN in 227 patients, first seen in a private dermatology practice from 1955 to 1996, who were followed up for MM arising within their CMNs. Criteria for entry into the study included (1) a clinically diagnosed medium-sized CMN, (2) minimum follow-up period of 1 year, and (3) a photograph of the lesion in the patient's medical record. RESULTS: No MM occurred in a medium-sized CMN during an average follow-up of 6.7 years (median, 5.8 years) to an average age of 25.5 years (median, 19.1 years). CONCLUSION: The results of this short-term follow-up study do not support the view that there is a clinically significantly increased risk for MM arising in banal-appearing medium-sized CMN or that prophylactic excision of all such lesions is mandatory. Lifelong medical observation seems a reasonable alternative for many medium-sized CMN.

[Angiocardiographic and clinical development of Carpentier's mitral rings]. / Evolucion clínica y angiocardiográfica de los anillos mitrales de Carpentier

Carpentier's ring was inserted in the mitral annulus of 79 patients suffering from mitral valve disease. 49 other patients also underwent surgery on other cardiac valves and are not considered in the present study. The mean follow up time was 19.5 months. The total hospital and late mortality in the isolated ring series was 3.8%. Clinical and hemodynamic improvement was evident postoperatively. The preoperative functional class (NYHA) of the patients was: I, 11.39%; II, 45.5%; III, 34.1%; IV, 8.86% respectively. The postoperative class was: I, 86.8%; II, 7.9%; III, 3.9%; and IV, 1.3% respectively. Postoperative hemodynamic and angiocardiographic evaluation was done in 27 patients. Mean pulmonary artery pressure fell from 49.8 +/- 2.4 mm. Hg to 38 +/- 2 mm. Hg. Mitral regurgitation present preoperatively in 66.6% of cases was present in residual form in only 18.5%. Atrial enlargement was moderate in 42.1% and severe in 57.9% before operation, and 80.3 moderate and 19.7 severe after operation. Tromboembolic accidents occurred in 2 patients (2.2%) both with severe atrial enlargement and atrial fibrillation pre and postoperatively. We conclude that Carpentier's ring is a valid alternative in the surgery of mitral valve disease.

[Determination of serum digoxin concentrations using radioimmunoassay. Evaluation and application of the analytical method]. / Determinación de las concentraciones séricas de digoxina por radioinmunoensayo. Valoración y aplicaciones del método analítico

The different laboratory technich for the determination of digoxin serum concentrations are analysed. Special emphasis is placed on the radioimmunoassay technic. The advantages and disadvantages of this technic are studied and the standard curves obtained in our determinations (n=39) are analysed. It can be seen that they can be reproduced in all cases with a high degree of similarity. The possible causes of error in this microtechnic are also analysed and a modification in the decanting fase, with which the number of repetitions in our laboratory has decreased, is suggested. Finally the criteria for the actual evaluation of the seric digoxin levels used in our laboratory are described and new possibilities in pharmacological investigation by this technic are mentioned.

[Postoperative evaluation of Carpentier's mitral rings]. / Valoración postoperatoria de los anillos mitrales de Carpentier

38 patients with Carpentier's ring inserted in the mitral position at surgery, are studied. The grade of the pre and postoperatory mitral murmur is correlated and compared with the radiographic size of the heart and left auricle as well as the pre and postoperatory angiocardiographic study. Only 3 (7'8%) of the 38 patients presented significant elevation of the pulmonary artery sistolic pressure together with important angiographic regurgitation. These three patients had to be operated on again, 60'52% did not present murmurs on these were grade I murmurs, while 76'32% did not present mitral reguritation. Only 8 of 14 patients with grade II sistole murmur in the postoperative period had grade II regurgitation. This no correlation was observed between the intensity of the murmur and the grade of angiocardiographic mitral regurgitation. We conclude that Carpentier's ring restores the mitral valve function to normal in the majority of cases and the angiocardiographic results are favorable.

[Clinical evaluation of amiodarone hydrochloride as an anti-arrhythmia agent]. / Valoración clínica del clorhidrato de amiodarona como antiarrítmico

15 patients with ventricular and supraventricular arrhythmias treated with Amiodarone hydrochloride via oral were studied. The results obtained show that in 86'6% of the cases the arrhythmia disappeared immediately, in 6'6% the arrhythmia disappeared late and in only one case the arrhythmia persisted. Statistical significance was found in the reduction of cardiac frequency as well as in the corrected QT interval for the frequency. The latter is an indirect consequence of the mode of action of the drug. The only side effect observed was the appearance of corneal opacification. It was demonstrated that this side effect is negligible when low doses which are equally effective are administered. The conclusion that Amiodarone is an excellent oral antiarrhythmic drug is reached. A daily dose of 400 mg during the first 20 days of each month with a rest of 10 days is recommended. In this way, the corneal opacification is minimal or nil. The possibility that the association of the drug with Quinidine could be effective in maintaining sinus rhythm post D.C. is suggested.