Search PubMed⌕ Search

Biomedical subjects

R W Schwartz

Publications and source records attributed to R W Schwartz.

At least 19 recordsLinked to original sources
PubMed1992

Problem-based learning: an effective educational method for a surgery clerkship.

Problem-based learning (PBL) has been implemented during the clinical years in a few medical schools. The purpose of this study is to determine whether PBL provides a better education than traditional methods. Students in the first and third rotations (n = 42) went through the traditional clerkship, which utilized Socratic teaching (SI), while students in the second and fourth rotations (n = 36) were taught by the PBL method. Two performance measures were used to assess clerkship effectiveness. One was a modified essay examination (MEE) administered as part of the departmental evaluation. The other was the NBME-II exam and its surgery subsection NBME-II-S. The MEE was designed to measure six dimensions of the problem-solving process. The NBME-II was utilized to measure knowledge. Unpaired t tests were used to identify statistically significant group differences. The PBL group performed significantly better on two MEE dimensions: (1) differential diagnosis formation (PBL, 92.5 +/- 0.8; SI, 89.1 +/- 0.5; P < 0.01) and (2) interpretation of clinical data (PBL, 93.3 +/- 0.6; SI, 91.6 +/- 0.4; P < 0.03). A third dimension, ordering appropriate lab and diagnostic studies, approached significance (P = 0.057), and the PBL group performed better. On the NBME-II there was not a significant difference between the two groups. However, the trend (P = 0.059) was for the PBL group to score higher on the NBME-II-S (PBL mean: 502 +/- 15; SI mean: 468 +/- 12). When overall achievement was controlled for, the PBL group performed significantly better than the SI group (P = 0.046) on the NBME-II-S.(ABSTRACT TRUNCATED AT 250 WORDS)

Education, Medical↗
PubMed1992

Management of local recurrence in well-differentiated thyroid carcinoma.

Local recurrence of well-differentiated thyroid carcinoma has a reported mortality approaching 50%. The University of Kentucky experience was reviewed to determine whether aggressive surveillance and treatment with reoperation and/or I-131 ablation increased survival following recurrence. Records of 66 consecutive patients with well-differentiated thyroid carcinoma treated at the University of Kentucky Medical Center (1980-1989) were reviewed. Forty-nine cases of papillary carcinoma and 17 cases of follicular carcinoma were studied; median follow-up was 68 months. At presentation, patients with follicular carcinoma were older (48 versus 35 years; P less than 0.05) and more frequently had metastatic disease (17% versus 2%, P less than 0.05). Fifty-eight (88%) patients were alive and disease-free at last follow-up. Fifteen patients (24%) had developed recurrent disease; median time to recurrence was 24 months. Multivariate regression examined the variables of age, sex, histology, tumor size, cervical adenopathy, capsular and vascular invasion, multicentricity, and surgical procedure. While distant metastases affected actuarial survival, no factor independently predicted local recurrence. In six patients with local recurrence, nonpalpable disease was detected by I-131 scan. All were treated with ablation and remain disease-free (mean follow-up 42 months). Eight patients with local recurrence presented with palpable lesions; seven underwent surgery. While two patients developed repeated local recurrences, the other five remain disease-free (mean follow-up 52 months). Early detection and aggressive treatment of local recurrence improve survival in patients with well-differentiated thyroid carcinoma. To facilitate use of I-131, we advise total thyroidectomy for patients with well-differentiated thyroid carcinoma.

Adenocarcinoma↗
PubMed1992

Undergraduate surgical education for the twenty-first century.

This article addresses the problems associated with current undergraduate surgical education and discusses the requirements necessary for its improvement during the third and fourth years of medical school. It asserts that, coincident with the emphasis on faculty research and publication and expanded resident patient care duties, teaching, particularly medical student teaching, has assumed a very low priority. Third-year medical students are attached to surgical teams, where their education is haphazard and disorganized. Furthermore, because any teaching that occurs is teacher oriented rather than student centered, knowledge is accumulated passively and is not well retained. Traditional evaluation using shelf multiple choice examinations and ward ratings by residents and faculty may provide inaccurate assessments of the students' performance. The undergraduate surgical education program should be directed by a faculty member who has been grounded in educational techniques and research and supported by a department chairman committed to bettering the program. In the clerkship, medical students should be assigned to faculty rather than to services and should be presented problems that require solution. Students also should be provided with the resources to solve the problems and should be given sufficient time to solve them. Some operating room experience and bedside teaching should occur during the clerkship. A variety of evaluation and testing methods based on the learning objectives of the clerkship should be used. Third-year students should not be promoted until they have demonstrated their acquisition of appropriate knowledge and skills.(ABSTRACT TRUNCATED AT 250 WORDS)

Education, Medical, Undergraduate↗
PubMed1992

Diagnosis and treatment of thyroid, adrenal, and thymic tumors.

The authors review 41 recent articles concerning the diagnosis and treatment of thyroid, adrenal, and thymic tumors. Diagnostic and evaluative techniques for thyroid nodules are inexact; fine-needle aspiration cytology offers the best results. Most authors favor total thyroidectomy and postoperative 131I ablation. The issue of elective versus therapeutic cervical lymphoidectomy remains controversial. Chemotherapy is of very little use in treating differentiated thyroid carcinoma. The most useful follow-up technique is whole-body scanning in conjunction with thyroglobulin determination. Persistent hypercalcitoninemia after surgery for medullary thyroid carcinoma is not uncommon and does not necessarily indicate demonstrably recurrent disease. In imaging adrenal tumors, magnetic resonance imaging appears to have some advantages over computed tomography. Pheochromocytomas may not always present classically; a clear understanding of the biochemical diagnosis is essential. Patients with thymomas have a good prognosis. Surgical treatment of encapsulated thymomas is appropriate, although more extensive thymomas are best treated multimodally.

Adrenal Gland Neoplasms↗
PubMed1992

Developing students' cognitive skills in a problem-based surgery clerkship.

In 1989-90, 57 students in a new program for the third-year surgery clerkship at the University of Kentucky College of Medicine participated either in a control group (22 students) receiving a traditional method of instruction (Socratic instruction, SI) or in an experimental group (35 students) taking part in problem-based learning (PBL) sessions. The two groups' performances on six evaluative instruments designed to test either their factual knowledge or their knowledge application (i.e., clinical problem-solving skills) were compared. The measures of factual knowledge were associated with higher scores for the SI group on two quizzes; scores were not significantly different on another quiz and on a cumulative final examination. The measures of knowledge application (administered at the end of the clerkship) were associated with higher scores for the PBL group: scores were significantly higher on a modified essay examination and approached significance on a standardized-patient examination. The authors conclude that their results (1) have important similarities to those of previous research suggesting that a PBL format is essentially equivalent to a traditional curricular format in improving students' factual knowledge and (2) support the hypothesis that PBL is superior in improving clinical problem-solving skills.

Clinical Clerkship↗
PubMed1992

A randomized comparison of patient-controlled versus standard analgesic requirements in patients undergoing cholecystectomy.

In the current study, 55 patients undergoing elective cholecystectomy were randomly allocated to receive postoperative analgesia (morphine sulfate) administered through either patient-controlled intravenous (PCA) or standard intramuscular (IM) routes. There were no significant differences in length of hospitalization or required dose of morphine sulfate. Patients randomized to PCA reported significantly improved subjective relief from pain and a smaller percentage of time in pain during each of the first two postoperative days. In addition, they reported less sedation and less interference with both postoperative breathing and pulmonary recovery than patients who received IM morphine. Theoretically, PCA regimens can deliver narcotic analgesia at a higher and more varied rate (with fewer side effects) compared with standard IM narcotic delivery, which is more limited by considerations of clinical doses. In PCA dosing, patients should experience less time in pain and sedation. The results of the current study support this premise.

Adult↗
PubMed1991

Gastric carcinoma metastatic to the breast.

A patient with signet ring adenocarcinoma of the stomach with metastatic disease to the breast treated at our institution is presented and added to the 14 cases reported in the literature. A review of the common clinical features and possible mechanisms of metastases is given. While the majority of patients present with symptoms referable to their gastric malignancy, the patient in this case initially sought treatment because of her breast mass. Metastatic deposits within the breast may be difficult to distinguish from primary breast carcinoma. For this reason, immunohistochemistry utilizing carcinoembryonic antigen (CEA), C-ERB B-2, and gross cystic protein were used in this case to confirm an extramammary source. In order to prevent unnecessary breast surgery and provide proper treatment of the gastric primary, the patient's complete clinical presentation must be used to guide diagnostic evaluation.

Adenocarcinoma, Mucinous↗
PubMed1991

Diagnosis and treatment of primary adrenal tumors.

The authors review 21 articles concerning primary adrenal tumors published in 1989. Specifically, the articles deal with the radiologic evaluation of the adrenal mass, functional evaluation of adrenal tumors, technical and perioperative considerations of adrenalectomy, and adrenocortical carcinoma. Several conclusions can be drawn from these recent articles. First, diagnostic accuracy should improve with advances in magnetic resonance imaging and improvements in fine needle aspiration technology. Second, the size of an asymptomatic nonfunctional adrenal mass requiring removal still remains to be definitively determined. Third, adrenocortical carcinomas are generally curable only if small and localized. Finally, adjuvant treatment regimens for more advanced adrenocortical carcinomas using mitotane, suramin, and conventional multiagent chemotherapy need to be evaluated in randomized trials.

Adenoma↗
PubMed1991

Treatment of thyroid malignancies.

Clinically significant thyroid malignancies are relatively uncommon, although their prevalence in autopsy series ranges up to 11%. New data confirm an increased incidence of carcinoma in solitary thyroid nodules in younger patients and a greater likelihood for younger patients to present with metastatic disease. Treatment of differentiated thyroid carcinoma is controversial, although many series indicate excellent results with total thyroidectomy. Although iodine-131 ablation has been standard in most centers after total thyroidectomy when residual thyroid tissues are present, new data indicate that selective use of this therapy may be appropriate. Prophylactic neck dissection does not improve survival or lessen recurrence in differentiated thyroid cancers and may increase morbidity. It should, therefore, be reserved for the patient with clinically enlarged cervical nodes.

Adenocarcinoma↗
PubMed1991

A student-centered, problem-based surgery clerkship.

In the academic year 1989-90, the department of surgery at one college of medicine revised its third-year clerkship to focus on students' learning decision-making skills and critical thinking (cognitive skills) and acquiring knowledge about surgery. Learning to perform procedures and tasks (psychomotor skills) would be accomplished in the required fourth-year acting internships. Problem-based learning (PBL) was chosen as the clerkship's primary instructional method. Comprehensive student and program evaluation systems were established. The response by faculty and students has been very positive. Students believe that the new clerkship has helped them increase their abilities in resource use, time management, and retention of knowledge. Faculty have noted students' increased eagerness and enthusiasm for learning.

Clinical Clerkship↗
PubMed1991

Stability of medical specialty selection at the University of Kentucky.

In the fall of 1989, all graduates of a 30-year-old medical college were surveyed by questionnaire concerning their motivations for their original selections of specialties, motivations for changing their specialties when such changes had occurred, and factors involved in their current choices of specialties. The 723 respondents were grouped by specialty response into one of three groups (primary care plus medicine and pediatrics subspecialties; surgery; or controllable lifestyle), and responses were statistically analyzed. The most important factors influencing initial specialty selection were perceived match of personality and specialty; technology and methodology characteristic of the specialty; and time for family activities, in that order. The ratings of the 175 respondents who stated that they had changed specialties indicated that time for avocational pursuits and time for family activities were the most important reasons for change. The reasons for selecting a different specialty varied. This study's findings suggest that a student's likelihood of making an inappropriate specialty choice may be reduced by a broad undergraduate medical education with realistic experiences in clinical activity. Students' lack of awareness of the lifestyle of a particular specialty may be a significant factor in the flow of physicians from noncontrollable lifestyle specialty areas. Those who counsel medical students need to be aware of the increasing importance of controllable lifestyle features, changing attitudes, faculty role-modeling, and mentors as strong influences on students' choices of specialties.

Career Choice↗
PubMed1991

Primary solid neoplasms of the greater omentum.

Primary solid tumors of the greater omentum are rare, with only 42 reported cases. Malignant hemangiopericytomas constitute only three of these cases. The 40-year-old patient described in this report had abdominal pain, a palpable abdominal mass, early satiety, and weight loss. At laparotomy a large omental hemangiopericytoma was excised, and no other evidence of disease was grossly evident. Eighteen months after initial laparotomy, the patient had widespread progression of the tumor and, despite chemotherapy, died 2 months later. A review of reported cases shows that abdominal discomfort (56%) and mass (35%) are the most common clinical characteristics of a primary omental tumor. Weight loss, ascites, and peritoneal implants usually indicate malignancy. Rare long-term follow-up prevents definitive conclusions regarding therapy and prognosis. At present, surgical excision alone appears to be the treatment of choice, with no demonstrable benefit from either chemotherapy or radiation.

Adult↗
PubMed1990

Effects of atherosclerosis on the cutaneous regional and microcirculatory response to ischemia.

The cutaneous vascular response to gravity load is abnormal in atherosclerosis. In this study we compared the macrocirculatory and microcirculatory response to ischemia in atherosclerotic smokers, nonatherosclerotic smokers, and healthy nonsmokers. Using videodensitometry, the capillary blood velocity of hallux nail fold capillaries was measured at rest and following 1 minute of ankle cuff occlusion. Blood-flow velocity of the dorsal metatarsal artery was measured by ultrasound Doppler. Resting dorsal metatarsal artery velocity and capillary blood velocity of atherosclerotic subjects were lower than those of nonatherosclerotic smokers and nonsmokers. The dorsal metatarsal artery velocity and capillary blood velocity increased in each group following occlusion. Peak postocclusion dorsal metatarsal artery velocity was lower in the atherosclerotic subjects, but peak capillary blood velocity was not significantly different among groups. Atherosclerosis does not alter the mechanisms of reactive hyperemia in either the macrocirculation or the microcirculation. The magnitude of hyperemia is diminished at the macrocirculatory level.

Arteriosclerosis↗
PubMed1990

The controllable lifestyle factor and students' attitudes about specialty selection.

Questionnaires were distributed to 346 fourth-year students in nine medical schools. The students were asked to state their selected specialty and to rank the importance that each of 25 influences, listed as questionnaire items, had had in making their choice of specialty. Factor analysis showed that particular items were significantly associated with particular factors. The first factor emphasized perceived lifestyle (items in this category gave importance to remuneration, personal time, and prestige); the second factor emphasized cerebral activities and a practice orientation; and the third factor stressed altruistic values and attitudes. The authors classified the selected specialties into three groups: those characterized as having a non-controllable lifestyle (NCL), those with a controllable lifestyle (CL), and surgery. (CL specialties were defined as those that allow the physician to control the number of hours devoted to practicing the specialty.) Data were analyzed using factor analysis, and analysis of variance, and the Scheffé method. Analysis indicated that the perceived lifestyle factor was most closely associated with the responses of those students choosing CL specialties. Furthermore, this factor received the highest total loading of the three factors from all the students, thus indicating the level of interest in lifestyle factors. Responses to items that defined the cerebral and practice factor were highest from the group of students choosing CL specialties and lowest from the group choosing NCL specialties. The NCL students scored highest in the altruism factor and the CL students scored the lowest. The surgery and NCL groups were similar in attitude patterns, and both were substantially different in attitude patterns from those of the CL groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Altruism↗
PubMed1990

Splenic vein thrombosis.

A retrospective review of all admissions to the University of Kentucky Medical Center from 1977 to 1987 revealed six persons in whom splenic vein thrombosis could be documented. The patients had either upper gastrointestinal bleeding from gastroesophageal varices or abdominal pain. Pancreatic disease was present in five patients (83%), three (50%) had splenic enlargement, and five (83%) had normal results of liver function tests. Angiography showed an occluded splenic vein with collateral flow and a patent portal vein in each of the four patients studied. All patients had splenectomy, with or without additional procedures. After a mean follow-up period of 9 1/2 months, five patients (83%) were alive, and none has had further gastrointestinal bleeding. One patient had died of recurrent pancreatic carcinoma at nine months. Our data suggest that localized portal hypertension induced by splenic vein thrombosis is appropriately treated by splenectomy.

Acute Disease↗