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Biomedical subjects

D Danoff

Publications and source records attributed to D Danoff.

At least 19 recordsLinked to original sources
PubMed1999

Teaching professionalism in undergraduate medical education.

CONTEXT: There is a growing consensus among medical educators that to promote the professional development of medical students, schools of medicine should provide explicit learning experiences in professionalism. OBJECTIVE: To determine whether and how schools of medicine were teaching professionalism in the 1998-1999 academic year. DESIGN, SETTING, AND PARTICIPANTS: A 2-stage survey was sent to 125 US medical schools in the fall of 1998. A total of 116 (92.3%) responded to the first stage of the survey. The second survey led to a qualitative analysis of curriculum materials submitted by 41 schools. MAIN OUTCOME MEASURES: Presence or absence of learning experiences (didactic or experiential) in undergraduate medical curriculum explicitly intended to promote professionalism in medical students, with curriculum evaluation based on 4 attributes commonly recognized as essential to professionalism: subordination of one's self-interests, adherence to high ethical and moral standards, response to societal needs, and demonstration of evincible core humanistic values. RESULTS: Of the 116 responding medical schools, 104 (89.7%) reported that they offer some formal instruction related to professionalism. Fewer schools have explicit methods for assessing professional behaviors (n = 64 [55.2%]) or conduct targeted faculty development programs (n = 39 [33.6%]). Schools use diverse strategies to promote professionalism, ranging from an isolated white-coat ceremony or other orientation experience (n = 71 [78.9%]) to an integrated sequence of courses over multiple years of the curriculum (n = 25 [27.8%]). Of the 41 schools that provided curriculum materials, 27 (65.9%) addressed subordinating self-interests; 31 (75.6%), adhering to high ethical and moral standards; 17 (41.5%), responding to societal needs; and 22 (53.7%), evincing core humanistic values. CONCLUSIONS: Our results suggest that the teaching of professionalism in undergraduate medical education varies widely. Although most medical schools in the United States now address this important topic in some manner, the strategies used to teach professionalism may not always be adequate.

Clinical Competence↗
PubMed1999

Recommendations for incorporating palliative care education into the acute care hospital setting.

This article presents recommendations for improving the education of physicians about end-of-life care in the acute care hospital setting. The authors, who have a variety of backgrounds and represent several types of institutions, formulated and reached consensus on these recommendations as members of the Acute Care Hospital Working Group, one of eight working groups convened at the National Consensus Conference on Medical Education for Care Near the End of Life in May 1997. A recently published literature review on the status of palliative care education, a summary of recent research on education about end-of-life care, and expert opinion were helpful in developing the recommendations. The authors emphasize that the acute care setting offers many opportunities for education about care at the end of life. Faculty should support learners' appreciation of the importance of end-of-life care, and convey the meaning and privilege of attending to patients and families at this difficult time. Faculty should teach students and residents to provide care that embodies attention to the control of distressing physical, physiologic, and spiritual symptoms, appropriate awareness of patients' differing cultural backgrounds and their impact upon the experience of dying, excellent communication skills, the application of bioethical principles, timely referral and smooth transition to other care settings that meet patient and family goals, and the role of the interdisciplinary team in meeting the diverse needs of dying patients and their families.

Education, Medical, Continuing↗
PubMed1998

Systemic immune reactions to HMG-CoA reductase inhibitors. Report of 4 cases and review of the literature.

Four patients with systemic autoimmune disorders, 3 of a serious nature, presented to 1 cardiologist over a 20-month span. In 3 of these cases, an HMG-CoA reductase inhibitor was presumably etiologic, while in the fourth case, the HMG-CoA reductase inhibitor might have unmasked the disorder. It would be useful to determine the true frequency of this complication, particularly in older patients not included in most of the statin trials to date. It is well established that autoimmune phenomena and particularly the development of autoantibodies increase with age. The data presented in this report that the group of HMG-CoA reductase inhibitors could be a heretofore poorly recognized etiologic agent. This issue might be addressed by a case-control study looking at the prevalence of statin use in elderly patients with systemic autoimmune disorders and in controls. Until then, the authors advise caution in the use of this class of medications in patient subgroups for whom no clear-cut clinical benefit has yet been proven.

Aged↗
PubMed1998

A long-term study of hydroxychloroquine withdrawal on exacerbations in systemic lupus erythematosus. The Canadian Hydroxychloroquine Study Group.

The ability of antimalarials to moderate severe disease activity in systemic lupus erythematosus (SLE) is plausible but undemonstrated. We evaluated the long-term effectiveness of maintaining treatment with hydroxychloroquine sulphate (HCQ) to prevent major flares in quiescent SLE. Forty-seven patients with quiescent SLE who had been randomized to take HCQ (n = 25) or placebo (n = 22) as part of a 24-week withdrawal trial were evaluated for an additional 3 years. The primary outcome was time to a major flare of SLE which resulted in either the institution of or an increase in the current dosage of prednisone of 10 mg/day or more, or institution of therapy with immunosuppressive agents. Secondary outcomes included the specific subtype of these major flares (glomerulonephritis, vasculitis or other) and hospitalization for an exacerbation of SLE. An intent-to-treat analysis was conducted. Over the 42 months of study, 11 of 22 (50%) patients randomized initially to placebo, and seven of 25 (28%) patients randomized to continue treatment experienced a major flare. The relative risk of major flare for those randomized to continue HCQ compared with controls was 0.43 (95% CI: 0.17, 1.12). The relative risks for subtypes of flares were 0.26 (95% CI: 0.03, 2.54) for nephritis, 0.51 (95% CI: 0.09, 3.08) for vasculitis and 0.65 (95% CI: 0.17, 2.41) for flares characterized by other symptoms. The relative risk of hospitalization for major flare for patients randomized to continue hydroxychloroquine was 0.58 (95% CI: 0.13, 2.60). While the results are not statistically significant, they are compatible with the clinical belief that HCQ has a long-term protective effect against major disease flares in SLE and suggest that on average, HCQ use reduces major flares by 57% (95% CI: 83% reduction to 12% increase).

Adult↗
PubMed1998

Impact of disease activity and cumulative damage on the health of lupus patients.

To test if lupus activity and damage predict physical function and general health in lupus was the objective of this study. Ninety-six patients with lupus were seen at baseline and monthly for 4 months. Sociodemographic characteristics and lupus damage (SLICC/ACR DI), were collected at baseline while lupus activity (SLAM-R, SLEDAI), health status measures (HAQ, SF-36) and immunological tests were collected at each visit. Associations of lupus activity and damage with general health and physical function were evaluated. Baseline health status measures were greatly impaired and comparable to those of severe medical illnesses. In cross-sectional analyses, baseline activity score measured by SLAM-R, but not by SLEDAI, correlated with most subscales of SF-36. Baseline damage score SLICC/ACR DI correlated only with the HAQ and the physical function subscale of SF-36. Differences in both activity measures (SLAM-R and SLEDAI) over time correlated with change in health status measures while baseline cumulative damage (SLICC/ACR DI) correlated with the average level of physical function only. Lupus activity measures, SLAM-R and SLEDAI, although differing cross-sectionally, both reflected patients' health status performance over time and lupus damage measure, SLICC/ACR DI, performed well in assessing physical function. Lupus patients scores for health are poor and comparable to those found in severe medical illnesses.

Activities of Daily Living↗
PubMed1997

Stress and depressed mood in medical students, law students, and graduate students at McGill University.

PURPOSE: To investigate stress in medical students, law students, and graduate students at McGill University using a well-validated measure, the Derogatis Stress Profile (DSP). METHOD: The DSP was administered to the medical students in November and December 1994. For comparison, the DSP was also administered to the undergraduate law students and the graduate students. In November 1995 the DSP was administered to the first- and second-year medical students. Results were analyzed with a number of statistical methods. RESULTS: The response rates for the medical students, the law students, and the graduate students in 1994-95 were 70%, 96%, and 43%, respectively. The response rate for the first- and second-year medical students in 1995-96 was 57%. The medical students had subjective feelings of stress that are marginally above population norms, but their total-stress scores (related to environmental factors, personality mediators, and emotional responses) were below those of the general population, the law students, and the graduate students. Elevated depression scores in a minority of the students did not seem to be related directly to the stresses associated with medical school. The transition from basic science training to clinical training was associated with an increase in stress and depressed mood. CONCLUSION: Medical students are not greatly stressed relative to other groups, hence other explanations must be sought for the elevated levels of depression in some students. One situation in which stress appears to be particularly important is in the transition from basic science training to clinical training. Targeted interventions may be an effective way of dealing with this problem.

Adult↗
PubMed1996

Laboratory tests as predictors of disease exacerbations in systemic lupus erythematosus. Why some tests fail.

OBJECTIVE: To evaluate whether changes in laboratory test values are either simultaneous with or precede disease exacerbations in patients with systemic lupus erythematosus (SLE). METHODS: At 9, 6, and 3 months preceding a flare in disease activity (defined as a rise of > or = 6 points in the modified SLE Disease Activity Index), laboratory tests were performed to measure patients' hematocrit levels, white blood cell, lymphocyte, and platelet counts, erythrocyte sedimentation rate, C1q binding, DNA binding, and levels of C3 and C4. Flares were classified as either present or absent, and were divided into renal, vasculitic, central nervous system, skin, serosal, and musculoskeletal subgroups. The predictive patterns were 1) the simultaneous change in the test value from the mean of 9, 6, and 3 months preceding a flare to the time of the flare; 2) the gradual change, following a linear time trend, in test results for the same time points; and 3) the change from the mean of 9 and 6 months to 3 months preceding a flare, as a measure of predictive ability. These analyses used repeated-measures analysis of variance models. Multiple linear regression was used to study the cross-sectional association of average-over-time differences in test results with patients' flare subgroup. RESULTS: Among 202 patients with SLE (median followup 86.5 months), 83 flares occurred in 53 patients. Of 189 statistical contrasts performed, only 14 were significant (versus 10 expected), and the differences were of minor importance. Nonetheless, evaluation of all test results over each patient's observed disease course revealed significant differences between selected test values in association with specific types of flare. CONCLUSION: Fluctuations in laboratory test values are poor predictors of disease exacerbations in SLE. Cross-sectional evaluation of some test results revealed differences at the time of flare for those patients who were destined to have different types of flares, because these values differed over the entire study period. This pattern explains the frequent cross-sectional association of disease activity with laboratory test results, and the inconsistent association of flares with recent changes in test values.

Adolescent↗
PubMed1996

Rheumatic disease patients, prone to Sjögren's syndrome and/or lymphoma, mount an antibody response to BHRF1, the Epstein-Barr viral homologue of BCL-2.

The IgG response to Epstein-Barr virus (EBV) early antigens [BHRF1 (p 17.1), the viral homologue of bcl-2, and BMRF1 (p50.10), a DNA binding protein] was measured in patients with rheumatic disease to see whether there was any association with lymphoma. Patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Sjögren's syndrome (SS), rheumatic disease patients with lymphoma, patients with lymphoma who did not have a rheumatic disease and normal individuals were tested for the presence of anti-EA peptide antibodies by ELISA. Whereas antibodies to early EBV peptides were detected only in one normal individual, patients with rheumatic diseases, especially those with either SS and/or lymphoma, had a much higher frequency of antibody detection. Antibodies to BMRF1 p50.10 were found in 7-50% of patients, and to BHRF1 p17.1 in 4-27%, depending on the group studied. Patients with lymphoma lacking a rheumatic disease had a 2-fold lower frequency of anti-BHRF1 antibodies, compared to the lymphoma plus rheumatic disease group. The increased immune response to the EBV EA proteins in the rheumatic diseases probably reflects the presence of reactivated virus, and the BHRF1 protein (the viral homologue to bcl-2) could, via inhibiting apoptosis, contribute to the lymphoproliferative nature of these diseases.

Adult↗
PubMed1996

Content specificity and oral certification exams.

This study reports on the generalizability of different skills assessed in the oral certification examinations in Internal Medicine of the Royal College of Physicians and Surgeons of Canada. Assessments from the 1992 examination were examined prospectively to determine (i) inter-rater reliability, (ii) correlation from morning to afternoon sessions, and (iii) overall test reliability. While inter-rater reliability was acceptable and in the range reported from previous studies, the generalizability across sessions was very low, ranging from 0.30 to 0.47, presumably reflecting content specificity. As a consequence, the overall test reliability was low, ranging from 0.57 to 0.69. Collapsing the overall scores into three decision categories (pass, borderline, fail) lowered the test reliability still further. Strategies to resolve this problem are suggested.

Adult↗
PubMed1996

Routine immunologic tests in systemic lupus erythematosus: is there a need for more studies?

OBJECTIVE: To evaluate the sensitivity, specificity, and likelihood ratios of anti-dsDNA, C3, C4, and Clq binding tests for predicting flares in systemic lupus erythematosus (SLE) and to evaluate the conflicting results reported in the recent literature. METHODS: Test results from 9 to 3 months preceding 83 flares among 53 patients from a cohort study of 202 patients with SLE were assessed for their ability to predict renal and nonrenal flares and all flares combined. A flare was defined as a 6 point rise in a modified SLE Disease Activity Index. RESULTS: For all 4 tests, sensitivity approximated 50% and specificity was less than 75%. For anti-dsDNA, Clq binding, and C4, both positive and negative likelihood ratios were close to 1.0, suggesting little clinical value for routine testing. For C3, likelihood ratios for a positive test approximated 2.0, meeting the minimal level for clinical significance. Review of previous studies suggested that sample size, the use of a standardized disease activity measure to define a flare, the severity of the flare, and the study duration could not explain the discrepant results among studies. The 2 studies with testing every 4 to 6 weeks found that a rising anti-dsDNA predicted flares, while those with less frequent testing did not. CONCLUSION: While our study provided no major support for routine testing with anti-dsDNA, C3, C4, or Clq binding, additional longitudinal studies are needed to assess monthly testing of anti-dsDNA as a predictor of flare in SLE.

Adult↗
PubMed1995

Small changes in outpatients lupus activity are better detected by clinical instruments than by laboratory tests.

OBJECTIVE: To evaluate and compare responsiveness of laboratory and clinical measures over 4 months in outpatient systemic lupus erythematosus (SLE). METHODS: We studied 23 patients with SLE at monthly intervals during 4 mo and collected demographic data, prednisone dose, global patient and physician assessment of disease activity on 10 cm visual analog scales (VAS), scores on 3 clinical measures of lupus disease activity [SLE disease activity index (SLEDAI), SLE activity measure (SLAM), lupus activity index (LAI)], and results of 5 routine laboratory tests [erythrocyte sedimentation rate (ESR), anti-dsDNA, C3, C4, circulating immune complexes]. We calculated correlations between a particular measure and our gold standard (physician's VAS) for individual patients and pooled this information using a novel application of the meta-analytic approach. RESULTS: The range of disease activity by patient and physician VAS varied from inactive to moderately active> Change in patient global assessment and all 3 clinical measures showed significant positive correlations with change in physician VAS (p < 0.05). Change in ESR, anti-dsDNA, or level of C3, C4, or circulating immune complexes did not correlate with change in physician VAS. CONCLUSION: Clinical measures of disease activity in SLE are more responsive to small changes than traditional laboratory tests. All 3 clinical measures appeared to perform equally well. At least one SLE disease activity measure should be used in SLE trials. The new analytic method will likely be of value in similar evaluations of responsiveness in other diseases.

Adult↗
PubMed1994

The impact of disease activity, treatment and disease severity on short-term costs of systemic lupus erythematosus.

OBJECTIVE: To assess the impact of disease activity, current treatment, and global disease severity (or damage) on short-term direct and indirect costs of systemic lupus erythematosus (SLE). METHODS: 150 patients were evaluated twice, one year apart. Disease activity was assessed by the SLE disease activity index, and ordinal scales were used to evaluate treatment (prednisone = 0, 1 to 20 mg/day, > 20 mg/day, and use of immunosuppressive agents) and global disease severity [renal severity = 0 to 3, central nervous system (CNS) severity = 0 to 2, hematologic severity = 0 to 1]. Costs were assessed with the economic portion of the Health Assessment Questionnaire adapted for Canada. RESULTS: Global disease severity was significantly correlated with both direct (p = 0.0001) and indirect (p = 0.02) costs, and current treatment with indirect costs (p = 0.002). The renal and CNS subscales of the global severity measure predicted direct costs (p < 0.01) and the CNS subscale predicted indirect costs (p = 0.002). Stepwise multivariable models selected the global severity index (p = 0.004) as a predictor of direct costs, and either the treatment index (p = 0.02) or the global severity index (p = 0.02) as a predictor of indirect costs. CONCLUSION: The global disease severity index, particularly the subscales involving the renal and CNS organ systems, and the treatment index are predictors of the short-term costs of SLE.

Absenteeism↗