Order effects in standardized patient examinations.
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Anxiety↗
Biomedical subjects
R G Williams
Publications and source records attributed to R G Williams.
Oral contraceptive therapy and the surgical management of ENT patients: a review of current clinical practice.
The current policy of British Otolaryngologists with regard to the preoperative cessation of the oral contraceptive pill is reported. This is based on a confidential questionnaire sent to all members of the British Association of Otolaryngologists. The overall response rate was 66%, 91% of which were from practising otolaryngologists and forms the basis of this report, the remaining 9% being from respondents not engaged in active surgery. Although there is evidence to show an increased risk of developing thromboembolic complications after major abdominal, gynaecological and hip surgery in those patients taking the oestrogen-containing contraceptive pill, the risk following minor and intermediate surgery (which forms the bulk of the otolaryngologist's workload) is not known. Not surprisingly therefore the results of the survey show a varied policy across the country with 36.5% of respondents choosing to continue the pill and 25% always stopping the pill preoperatively. The remainder elect to stop the pill only in certain circumstances.
Contraceptives, Oral↗
Pulmonary arteries: MR imaging in patients with congenital obstruction of the right ventricular outflow tract.
Thirty-five patients with congenital obstruction of the right ventricular outflow tract underwent magnetic resonance (MR) imaging for evaluation of the pulmonary arteries. All patients underwent cardiac catheterization, and 33 underwent two-dimensional Doppler echocardiography. Results of the three imaging studies were compared. With regard to the presence of a pulmonary confluence, results of MR imaging and angiography were in agreement in 31 of the 35 patients (89%), results of echocardiography and MR imaging were in agreement in 27 of 33 patients (82%), and results of echocardiography and angiography were in agreement in 27 of 33 patients (82%). There was good correlation of measurements of main pulmonary artery size among all three methods and of right and left pulmonary artery size obtained at MR imaging and angiography. Echocardiographic measurements of right and left pulmonary artery size correlated poorly with those obtained at MR imaging and angiography. Results indicated that MR imaging is useful in evaluating the pulmonary arteries in patients with congenital heart disease.
Angiography↗
Isolated noncompaction of left ventricular myocardium. A study of eight cases.
Isolated noncompaction of left ventricular myocardium is a rare disorder of endomyocardial morphogenesis characterized by numerous, excessively prominent ventricular trabeculations and deep intertrabecular recesses. This study comprised eight cases, including three at necropsy. Ages ranged from 11 months to 22.5 years, with follow-up as long as 5 years. Gross morphological severity ranged from moderately abnormal ventricular trabeculations to profoundly abnormal, loosely compacted trabeculations. Echocardiographic images were diagnostic and corresponded to the morphological appearances at necropsy. The depths of the intertrabecular recesses were assessed by a quantitative echocardiographic X-to-Y ratio and were significantly greater than in normal control subjects (p less than 0.001). Clinical manifestations of the disorder included depressed left ventricular systolic function in five patients, ventricular arrhythmias in five, systemic embolization in three, distinctive facial dysmorphism in three, and familial recurrence in four patients. We conclude that isolated noncompaction of left ventricular myocardium is a rare if not unique disorder with characteristic morphological features that can be identified by two-dimensional echocardiography. The incidence of cardiovascular complications is high. The disorder may be associated with facial dysmorphism and familial recurrence.
Abnormalities, Multiple↗
Standardized patients for the assessment of dental students' clinical skills.
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Clinical Competence↗
Perioperative echocardiographic evaluation.
The integration of pre-, intra- and postoperative echo-cardiography has advanced the health of patients with congenital heart disease by providing an accurate initial evaluation, improving the timing and choice of intervention and detecting residual abnormalities in a timely fashion.
Child↗
Reliability of different grading systems used in evaluating surgical students.
Inter-rater agreement in assigning grades using five different grading systems was determined. The performance of 16 students in a surgery clerkship was rated by 21 faculty raters using a pass-fail grading system, a pass-fail-honors system, a letter grade system, a number grade scale from 1 to 10, and a number grade scale from 1 to 100. Inter-rater agreement coefficients were used to assess relative and absolute reliabilities, respectively. Both the letter grade and 1 to 10 number grade systems provided good discrimination, had high to moderate reliability, and required only five raters to achieve a mean rating with the commonly recommended reliability of 0.80. Using the letter grade system, however, a majority of raters agreed on a specific grade assignment for 14 of 16 students, in contrast to the 1 to 10 scale, for which this was true for only 4 of 16 students. The results of this reliability study favor the use of a letter grading system.
Clinical Clerkship↗
Doppler color flow mapping and prediction of ventricular septal defect outcome.
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Echocardiography, Doppler↗
Using a standardized-patient examination to establish the predictive validity of the MCAT and undergraduate GPA as admissions criteria.
Performance of senior medical students on an objectively scored examination of clinical competence based on standardized-patient cases was used to assess the predictive validity of the two most commonly used admission measures, the Medical College Admissions Test and the undergraduate grade point average. The students were in the classes of 1986 and 1987 at Southern Illinois University School of Medicine. The correlations of the admissions measures with clinical performances were quite weak, and none of the admissions measures consistently showed a clear advantage as a predictor of clinical performance. Correlations of the admissions measures with scores on National Board of Medical Examiners (NBME) Part I and Part II examinations were small to moderate, although somewhat larger than the correlations with clinical performances. Correlations were corrected for attenuation due to differential unreliabilities of the clinical examination results and the scores on NBME examinations, and for restriction of range due to the stringent medical school selection process. Corrected correlations were small to moderate and showed the same pattern as the uncorrected ones. The study documents that traditional admissions measures are useful for selecting students who will perform effectively in clinical as well as basic science settings.
Clinical Competence↗
Altered laryngeal function following thyroidectomy.
The laryngograph was used to record and compare the voice changes in 11 thyroidectomy patients and 14 controls. The frequency histogram was studied and the change in its spread following surgery used to identify abnormal vocal fold movements due to recurrent laryngeal nerve damage. It also demonstrated changes which occur in thyroidectomy patients and not in patients having other operations. The possible causes include external laryngeal nerve damage.
Adult↗
Definitive repair in patients with pulmonary atresia and intact ventricular septum.
Between 1977 and 1988, 22 patients underwent definitive repair for pulmonary atresia with intact ventricular septum. Fifteen underwent biventricular repair (mean age 24 months). All had mild to moderate right ventricular hypoplasia at the time of definitive repair. Repair consisted of closure of the atrial septal defect with enlargement of the right ventricular cavity and outflow tract with a patch in eight, insertion of a valved homograft in three, and superior vena cava-pulmonary artery connection in four. There was one operative death (7%). Seven patients had severe right ventricular hypoplasia at the time of definitive repair and underwent a Fontan procedure (mean age 46 months). In two a valved connection was made to the right ventricle and in five a right atrial-pulmonary artery nonvalved connection. There were two operative deaths (29%). Three patients had right ventricular-coronary sinusoids: Two of them underwent a Fontan procedure and one a biventricular repair. We conclude that with adequate early palliation a biventricular repair may be successfully performed for patients with mild or moderate right ventricular hypoplasia, and the Fontan procedure may be used for those with severe right ventricular hypoplasia.
Child↗
Catecholaminergic parasympathetic efferents within the dorsal motor nucleus of the vagus in the rat: a quantitative analysis.
Catecholaminergic vagal motor neurones were identified within the dorsal motor nucleus of the vagus, by retrograde tracing of True blue from the stomach followed by immunocytochemistry using antibodies directed against tyrosine hydroxylase. Presumed dopaminergic efferents were largely confined to caudal regions, where they averaged as much as 30% of the labelled efferents. Most but not all of these were also identified on the basis of acetylcholinesterase histochemistry.
Acetylcholinesterase↗
Hemodynamic responses to isolated increments in heart rate by atrial pacing after a Fontan procedure.
The physiologic role of the right ventricle has long been a subject of interest to physiologists. The Fontan operation provides a human model for studying the circulation in series devoid of a subpulmonic right ventricle. The hemodynamic response to isotonic exercise in this setting has been established, and differs appreciably from normal. However, the physiologic response to an increase in heart rate (atrial pacing) as an isolated variable has not been examined and compared to atrial pacing in hearts with two concordant subarterial ventricles. Accordingly, we compared the supine bicycle exercise response to rate-equivalent right atrial pacing in nine patients after atriopulmonary anastomoses (the Fontan operation) for single ventricle or tricuspid atresia. Cardiac index increased 77% with exercise (rest 2.6 L/min/m2; exercise 4.6 L/min/m2) but decreased 12% with atrial pacing (rest 2.5 L/min/m2; pacing 2.2 L/min/m2). Pulmonary arterial oxygen saturation declined significantly during exercise (rest 68%; exercise 31%) and during atrial pacing (control 72%; pacing 64%). The mean increment in pulmonary arterial pressure was 1.3 times greater with exercise (rest 14 mm Hg; exercise 20 mm Hg) than with pacing (control 12 mm Hg; pacing 16 mm Hg). Peak systemic arterial systolic pressure increased 14% with exercise but was unchanged by pacing. Systemic and pulmonary vascular resistances fell with exercise but changed insignificantly during atrial pacing. Stroke volume rose slightly with exercise but fell significantly with pacing.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Enterobius vermicularis infection in a children's ward.
Following the discovery that two patients on a children's orthopaedic ward were excreting Enterobius, all patients and staff on the ward were screened for the presence of pinworms. None of the staff was infected but 11 (55%) of 20 patients either had Enterobius ova on the anal margin or excreted worms following piperazine treatment. Epidemiological investigations indicated that this was unlikely to be a ward outbreak because four of the infected children had been on the ward for under 3 days, i.e., less than the prepatent period for Enterobius. Although none of the children was symptomatic, all children and staff on the ward were treated with piperazine. Faecal samples were collected from nine children and the majority of their worm load was shed within 32 h of starting therapy. Microscopic examination of the adult male worms showed that each patient was excreting both Enterobius vermicularis and E. gregorii.
Animals↗
Rapid identification of bacterial antigen in blood cultures and cerebrospinal fluid.
The ability of antibody coated latex particle suspensions to aid the diagnosis of septicaemia and meningitis in children was assessed in 272 blood culture sets and 85 cerebrospinal fluid specimens. This was also assessed in cases caused by Neisseria meningitidis group B infection. The method was 100% sensitive and 99% specific, with good predictive values (range 63% to 100%) and provided valuable support to the routine bacteriological examination of blood culture and cerebrospinal fluid.
Antigens, Bacterial↗
Results of the Senning procedure in infants with simple and complex transposition of the great arteries.
Because of interest in the arterial switch operation, recent experience with the Senning operation in patients with simple and complex transposition of the great arteries (TGA) was examined. Between 1982 and 1985, 35 patients with simple TGA (group I) and 10 patients with complex TGA (group II) underwent a Senning operation. Mean duration of follow-up was 14 months for group I and 24 months for group II. In group I, 1 patient died early and no patient died late; infrequently, right ventricular dysfunction, tricuspid regurgitation, baffle obstruction or arrhythmias occurred. In group II, no patient died early and 3 died late. In addition, many patients required prolonged digoxin therapy. Because the arterial switch operation has a high early mortality risk and an undetermined long-term morbidity and mortality risk, the Senning operation (or other venous switch operations) is considered the preferred surgical approach for simple TGA. In contrast, an arterial switch operation is performed in patients with complex TGA (without subpulmonic obstruction). Comparison of the early and late morbidity and mortality of the arterial vs the venous switch operation may be helpful in selecting the appropriate surgical approach to complex TGA.
Female↗
Use of in situ pericardium for surgical relief of pulmonary venous obstruction following Mustard's operation.
A technique is described for relief of pulmonary venous obstruction following the Mustard procedure. The functional left atrium is enlarged by using the pericardium in situ. This is expected to allow for growth of the pericardial patch and to avoid recurrent obstructions. This technique has also been used in reoperations for systemic venous obstruction after enlargement of the systemic baffle with a patch.
Heart Atria↗
A comprehensive performance-based assessment of fourth-year students' clinical skills.
Written examinations are widely used for assessment in clinical clerkships and for licensure and specialty board certification, as opposed to assessment based on actual performance with patients. This reliance on written examinations is due to their ease of use and perceived objectivity and occurs despite the fact that the examinations assess few components of clinical competence. Simulated patients can standardize the presentation of a patient problem; and, if the patients are employed in an assessment in a manner parallel to the design of written test items, the assessment can have an objectivity similar to that enjoyed by written tests. Such an assessment allows the major components of clinical competence to be tested. The results and feasibility of using simulated patients in a multiple-station assessment of an entire senior class in January 1986 are described. A second assessment was administered to a different senior class in December 1986. This latter assessment was designed in collaboration with another medical school that administered the same assessment to its senior students in March 1987.
Clinical Clerkship↗