The Importance of Measuring Competency-Based Outcomes: Standard Evaluation Measures Are Not Surrogates for Clinical Performance of Internal Medicine Residents

Background: Despite recent emphasis on educational outcomes, program directors still rely on standard evaluation techniques such as tests of knowledge and subjective ratings. Purposes: To assess the correlation of standard internal medicine (IM) residency evaluation scores (attending global evaluations, In-Training examination, and Mini-Clinical Examination Exercise) with documented performance of preventive measures for continuity clinic patients. Methods: Cross-sectional study of 132 IM residents attending an IM teaching clinic, July 2000 to June 2003, comparing standard evaluations with chart audit. Results: Mean resident performance ranged from 53% (SD = 24) through 89% (SD = 20) across the 6 preventive measures abstracted from 1,102 patient charts. We found weak and mostly not significant correlations between standard measures and performance of preventive services. Conclusions: Standard measures are not adequate surrogates for measuring clinical outcomes. This supports the Accreditation Council for Graduate Medical Education's recommendations to incorporate novel Toolbox measures, like chart audit, into residency evaluations.     

Large-scale evaluation of genetic variants in candidate genes for colorectal cancer risk in the Nurses' Health Study and the Health Professionals' Follow-up Study

Advances in genomics offer new strategies for assessing the association of common genetic variations at multiple loci and risk of many diseases, including colorectal cancer. Low-penetrance alleles of genes in many biological pathways, such as DNA repair, metabolism, inflammation, cell cycle, apoptosis, and Wnt signaling, may influence the risk of nonfamilial colorectal cancer. To identify susceptibility genes for colorectal cancer, we designed a large-scale case-control association study nested within the Nurses' Health Study (190 cases and 190 controls) and the Health Professionals' Follow-up Study (168 cases and 168 controls). We used a custom GoldenGate (Illumina) oligonucleotide pool assay including 1,536 single nucleotide polymorphisms (SNP) selected in candidate genes from cancer-related pathways, which have been sequenced and genotyped in the SNP500Cancer project; 1,412 of the 1,536 (92%) of the SNPs were genotyped successfully within 388 genes. SNPs in high linkage disequilibrium (r(2) >/= 0.90) with another assayed SNP were excluded from further analyses. As expected by chance (and not significant compared with a corrected Bonferroni P = 0.00004), in the additive model, 11 of 1,253 (0.9%) SNPs had a P(trend) < 0.01 and 38 of 1,253 (3.0%) SNPs had a P(trend) >/= 0.01 and P(trend) < 0.05. Of note, the MGMT Lys(178)Arg (rs2308237) SNP, in linkage disequilibrium with the previously reported MGMT Ile(143)Val SNP, had an inverse association with colorectal cancer risk (MGMT Lys(178)Arg: odds ratio, 0.52; 95% confidence interval, 0.35-0.78; unadjusted P(trend) = 0.0003 for the additive model; gene-based test global P = 0.00003). The SNP500Cancer database and the Illumina GoldenGate Assay allowed us to test a larger number of SNPs than previously possible. We identified several SNPs worthy of investigation in larger studies.     

Ventilatory changes in convalescent infants positioned in car seats

Because premature infants have been shown to be at risk for hypoxia and bradycardia when positioned in standard car seats, this study was done to confirm this finding in a larger sample, to investigate convalescent term infants in the neonatal intensive care unit for respiratory compromise in car seats, and to determine the physiologic mechanism or mechanisms responsible. Extensive multichannel polygraph recordings were obtained and pulmonary function tests were performed on 50 convalescent infants from the neonatal intensive care unit before, during, and after placement in a Cosco-Peterson First Ride car seat. Mean total dynamic compliance, total pulmonary resistance, and work of breathing improved in the car seat. Thirty percent of premature infants experienced hypoxia, bradycardia, or both in a car seat; in this group, tidal volume was lower (p = 0.02). In 11 of 16 infants with abnormal findings, oxygen desaturation was temporally related to episodes of short and mixed apnea. No term convalescent infant experienced respiratory difficulty in a car seat regardless of primary diagnosis. We conclude that premature infants may have respiratory compromise of a multifactorial nature when in car seats. Further development of car seats is necessary if such respiratory problems are to be avoided.     

Correlation of the histologic appearance of intraepithelial neoplasia of the cervix with human papillomavirus types. Emphasis on low grade lesions including so-called flat condyloma

Cervical condylomas and intraepithelial neoplasia (CIN) were correlated with human papillomavirus (HPV) types and analyzed for the presence of abnormal mitotic figures. Colposcopically directed cervical biopsies were divided in half and processed for routine microscopy and Southern blot hybridization. Of 83 specimens from 71 patients, 70 (84%) contained HPV-DNA sequences. The HPV distribution was as follows: HPV 16 in 6/25 flat condylomas (FC), 2/8 CIN I, 8/18 CIN II, 12/14 CIN III; HPV 18 in 1/25 FC; HPV 31 in 3/25 FC, 3/18 CIN II, and 1/14 CIN III; HPV 6/11 in 12/18 exophytic condylomas (EC), 5/25 FC, 2/8 CIN I, and 3/18 CIN II. Uncharacterized HPVs were identified in 4/18 EC, 5/25 FC, 2/8 CIN I, and 1/18 CIN II. A similar heterogeneous distribution of HPV types was found in flat condylomas and CIN I. A more homogeneous distribution was noted in the exophytic condylomas and high grade CIN lesions, with HPV 6/11 found in the former and predominantly HPV 16 in the latter. Abnormal mitotic figures were predominantly seen in the high grade CIN lesions. Based on our findings, we would recommend that the term flat condyloma be abandoned and that low grade flat lesions of the cervix be graded according to CIN criteria.     

Left-handedness in relation to breast cancer risk in postmenopausal women

Breast cancer risk may be influenced by intrauterine exposure to steroid hormones. We evaluated left-handedness, a marker of intrauterine hormone exposure, in relation to breast cancer risk in our population-based, case-control study. Case women 50-79 years of age with a first diagnosis of invasive breast cancer were ascertained through statewide cancer registries in Wisconsin, Massachusetts, and New Hampshire. Control women were identified in each state through lists of licensed drivers (for ages 50-64) and Medicare beneficiaries (for ages 65-79), and selected at random to correspond with the age distribution of case women. Exposure information, including handedness, was obtained through a telephone interview. Our results indicated a modest association between left-handedness and breast cancer risk (OR = 1.42; 95% CI = 1.10-1.83). The effect of left-handedness was modified by age; we observed the greatest risk ratio in the oldest age group. Left-handedness was not associated with breast tumor laterality. Our results are consistent with the hypothesis that intrauterine hormone exposures play a role in the development of breast cancer.     

Active and passive smoking in breast cancer: prospective results from the Nurses' Health Study

BACKGROUND: The role of active and passive smoking in breast cancer remains controversial. METHODS: Using data collected in the prospective Nurses' Health Study, we examined the influence of active and passive smoking on the incidence of invasive breast cancer. The analysis was based on women responding to the 1982 questionnaire, which included questions on passive smoking exposure. Information on active smoking was collected in biennial questionnaires. A total of 78,206 women were followed prospectively from 1982 until June 1996. RESULTS: Of these women, 3,140 reported a diagnosis of invasive breast cancer during follow-up. Compared with never active smoking, relative risks (RR) of breast cancer were 1.04 (95% CI = 0.94-1.15) for current active smoking and 1.09 (95% CI = 1.00-1.18) for past active smoking. The RR for regular passive exposure at work and at home was 0.90 (95% CI = 0.67-1.22). For active smoking, a modest increase in risk was confined to women who began smoking before the age of 17 (RR = 1.19; 95% CI = 1.03-1.37). CONCLUSION: Results suggest that passive smoking is unrelated to breast cancer. However, results for active smoking are compatible with a small increase in risk when smoking is initiated at young ages.     

Physical activity, body mass index, and ovulatory disorder infertility

Few studies have examined whether activity and adiposity levels typical of American women affect their risk of ovulatory disorder infertility, and none has examined moderate and vigorous intensity exercise separately. We investigated these associations in the Nurses' Health Study II, comparing prospectively collected data on adiposity and activity for 830 cases of incident ovulatory infertility and 26,125 pregnancies. We observed a U-shaped association between body mass index (BMI) and relative risk of ovulatory infertility, with increased risk for BMI below 20.0 or above 24.0 kg/m2. On the basis of the BMI distribution of U.S. women, these findings suggest that 12% (95% confidence interval = 7-20%) of ovulatory infertility in the U.S. may be attributable to underweight (BMI <20.0) and 25% (95% CI = 20-31%) to overweight (BMI > or = 25.0). An increase in vigorous activity (but not moderate activity) was associated with reduced relative risk of ovulatory infertility. Each hour per week of vigorous activity was associated with a 7% (95% CI = 4-10%) lower relative risk of ovulatory infertility. After adjustment for BMI, a 5% (95% CI = 2-8%) reduction in relative risk per hour of weekly activity remained. These data suggest that, among American women, more ovulatory infertility is attributable to overweight and a sedentary lifestyle than to underweight and overexertion.