Assessing performance in final year medical students. Can a postgraduate measure be used in an undergraduate setting?

BACKGROUND: The transition between medical school and graduate performance should be a continuum. This study aimed to evaluate an assessment tool developed for practising doctors when applied to undergraduates. METHODS: A 12-item rating form was developed from that used for practising doctors by the Royal Australasian College of Physicians. Over a 2-year period, senior doctors, junior doctors and nurses completed the rating form on final year medical students. Some students completed self-assessments. We performed factor analysis and correlated scores between raters and attachments. Correlating ratings with concurrent traditional assessment results across the year tested construct validity. RESULTS: Ten forms per student were distributed for all 123 students and 856 were returned (70%). Internal consistency was very high. In all, 71.1% of the variance was accounted for by two factors (clinical skills and humanistic). This factor structure is unchanged when restricted to different raters and is the same as that noted previously when rating practising doctors. There were good correlations between raters (including self) and between attachments. Nurse ratings were reliable but nurses rated students significantly lower on humanistic qualities. Correlations with traditional assessments were high when all traditional assessments were combined. Women scored more favourably than men on humanistic qualities. CONCLUSION: A rating instrument for doctors in practice retains the same factor structure and a high degree of reliability and validity for senior medical students. Reliable ratings by nurses have implications for measures of collegiality and teamwork. We believe the instrument could be a useful outcome measure for medical programmes and employers.     

Comparison of blood pressure measurements on the bare arm, below a rolled-up sleeve, or over a sleeve

BACKGROUND: This study examined the effect of measuring blood pressure below subjects' rolled-up sleeves, over the sleeve, or on the bare arm. This is an important day-to-day issue for the busy GP. METHODS: The sample consisted of 201 subjects in family practice clinics and residents of a senior citizens' home. A digital device was used in all cases. Each participant underwent three blood pressure measurements in each of the following conditions in random order: cuff on bare arm; cuff over the sleeve; and cuff below the rolled-up sleeve. Differences between measurements were plotted against the mean blood pressure. Confounding factors controlled for were age, sex, clothing pressure and skin-fold thickness. RESULTS: Differences in mean blood pressure readings between the clothed and bare arm were 0.5 mmHg (SD 7.5) for systolic pressure and 1 mmHg (SD 5) for diastolic pressure; neither difference was significant. However, in hypertensive subjects (>140 mmHg systolic), although the mean difference remained small (systolic pressure, 2 mmHg, SD 10), the range of difference for individual subjects was -32 mmHg to +22 mmHg. CONCLUSION: The degree of clothing under the sphygmomanometer cuff does not have a clinically important effect on the blood pressure measurement. In patients known or found to be hypertensive, measurement on the bare arm is recommended.     

Post-traumatic stress disorder among family physicians in Bosnia and Herzegovina

BACKGROUND: The traumatic events experienced by thousands of people in Bosnia and Herzegovina during the 1992-1995 conflict may have a lasting effect on the mental health of the country, characterized by high rates of post-traumatic stress disorder (PTSD). A diagnosis of PTSD among family physicians could affect their ability to diagnose and treat patients for depression, anxiety and PTSD. OBJECTIVE: The aim of the present study was to determine the prevalence of PTSD among family medicine physicians in Bosnia and Herzegovina. METHODS: A self-administered questionnaire, including the PTSD Checklist-Civilian Version (PCL-C) which is a validated scale for PTSD screening, was distributed to family medicine residents and specialists in Bosnia and Herzegovina. The prevalence of PTSD was determined, and factors related to PTSD were considered. RESULTS: One hundred and thirty-three (90.5%) of the 147 physicians who were available to be surveyed completed the questionnaire. Of the 88% who had a traumatic experience during the war, 18% met the criteria for PTSD. The likelihood of meeting the criteria for PTSD was not affected by age, sex or whether the physician had worked in a field hospital during the war. However, a positive response to the question "Do you think the traumatic event you experienced during the war still affects you today?" was highly associated with the diagnosis of PTSD (odds ratio 7.26, 95% confidence interval: 1.57-33.60). Also, this question was shown to have a high degree of sensitivity and negative predictive value, and may be of use as a screening tool for ruling out the presence of PTSD after a traumatic war experience.     

Patient and family physician preferences for care and communication in the eventuality of anthrax terrorism

BACKGROUND: The threat of bioterrorism consequent to the September 11, 2001 attack in the USA generated suggestions for improved medical response mainly through hospital preparedness. OBJECTIVES: The aim of the present study was to investigate the impact of this period of tension on patients' first choice for care and for receiving relevant information, and on primary care doctors' feelings of responsibility in the eventuality of an anthrax attack. METHODS: During October 11-31, 2001, 500 patients from 30 clinics throughout Israel were asked to complete a questionnaire on their awareness of the anthrax threat, measures taken to prepare for it, and preferred sources of care and information. Their 30 physicians, and an additional 20, completed a questionnaire on knowledge about anthrax and anthrax-related patient behaviours and clinic visits. RESULTS: The outstanding finding was the low rate (30%) of patients who chose the hospital emergency department as their first choice for care or information if they were worried about an anthrax attack or the media communicated that an attack was in progress. The other two-thirds preferred their family doctor or the health authorities. Most of the physicians (89%) felt it was their responsibility to treat anthrax-infected patients and that they should therefore be supplied with appropriate guidelines. CONCLUSION: This study suggests that in Israel, a country with a high degree of awareness of civil defence aspects, both patients and primary care doctors believe that family physicians should have a major role in the case of bioterrorist attacks. This must be seriously considered during formulation of relevant health services programmes.     

GPs working in solo practice: obstacles and motivations for working in a group? A qualitative study

OBJECTIVE: Our aim was to analyse the obstacles and eventual motivations of solo GPs for working in group practice. METHODS: A qualitative study using 12 focus groups was carried out in primary care in French-speaking Belgium. The subjects comprised four samples of GPs: 20 GP trainers, 18 GP trainees, 25 women GPs and 25 other GPs. The focus groups were taped and transcribed. Two independent researchers carried out the analysis using the QSR NUD.IST software. RESULTS: The participants (88 GPs) did not share a common definition of group practice-in particular multidisciplinary working-the need for a common pool of patients and shared premises. Their main sources of motivation for eventually setting up a group practice were better quality of life, continuity of care and sharing professional knowledge. The main obstacles were a required agreement between colleagues, the loss of a personal patient-GP relationship, budgetary constraints, and divergent views on group practice and GPs' profession (especially true for the association of GPs from different age groups). CONCLUSION: The current study shows that GPs working solo have divergent views of group practice. However, they clearly perceive advantages to this type of association (e.g. better quality of life and continuity of care). This study also confirms the high level of stress and tiredness felt by GPs and especially senior practitioners.     

Genetic association tests for family data with missing parental genotypes: a comparison

We consider three tests for genetic association in data from nuclear families (the Family-Based Association Test (FBAT) test proposed by Rabinowitz and Laird ([2000] Hum. Hered. 50:211-223), a second test proposed by Rabinowitz ([2002] J. Am. Stat. Assoc. 97:742-758), and the Family Genotype Analysis Program (FGAP) nonfounder or partial score test proposed by Clayton ([1999] Am. J. Hum. Genet. 65:1170-1177) and Whittemore and Tu ([2000] Am. J. Hum. Genet. 66:1329-1340)). We show that each test statistic arises from the efficient score of the family data as the solution to a set of constraints on its null expectation. Moreover, the FBAT and Rabinowitz tests (but not the FGAP test) are locally the most powerful among all tests satisfying their constraints. We used simulations to examine how the three tests perform in situations when their assumptions are violated and the number of families is not huge. We found that the FBAT test tended to have less power than the other two tests, particularly when applied to families in whom all offspring were affected. The Rabinowitz and FGAP tests performed similarly, although the latter tended to extract more information from families containing one typed parent. While none of the tests showed good power to detect rare, recessively acting genes, the Rabinowitz test with a sample variance estimate performed particularly poorly in this case. However, the Rabinowitz test with a model-based variance had power comparable to that of the FGAP test, and more accurate type I error rates. We conclude that for the situations we considered, the Rabinowitz test with model-based variance has good power without forfeiting robustness against misspecification of parental genotype probabilities. However, its utility is limited by the lack of a simple algorithm to apply it to families with varying structures and phenotypes.     

Pedigree disequilibrium tests for multilocus haplotypes

Association tests of multilocus haplotypes are of interest both in linkage disequilibrium mapping and in candidate gene studies. For case-parent trios, I discuss the extension of existing multilocus methods to include ambiguous haplotypes in tests of models which distinguish between the cis and trans phase. A likelihood-ratio test is proposed, using the expectation-maximization (E-M) algorithm to account for haplotype ambiguities. Assumptions about the population structure are required, but realistic situations, including population stratification, which violate the assumptions lead to conservative tests. I describe a permutation procedure for the null hypothesis of interest, which controls for violation of the assumptions. For general pedigrees, I describe extensions of the pedigree disequilibrium test to include uncertain haplotypes. The summary statistics are replaced by their expected values over prior distributions of haplotype frequencies. If prior distributions are not available, a valid test is possible by using the E-M algorithm to estimate the null distribution of haplotype frequencies. Similar methods are available for quantitative traits. Exact permutation tests are difficult to construct in small samples, but an approximate procedure is appropriate in large samples, and can be used to account for dependencies between tests of multiple haplotypes and loci.     

Targeted psychosocial interventions for bipolar disorder

Pharmacotherapy is the foundation of treatment for bipolar disorder, but research suggests that adjunctive psychosocial interventions that are manualized, reproducible, time-limited, empirically supported, and strategically target a number of critical domains, can efficiently provide additional benefits. Psychoeducation as an adjunct of pharmacotherapy may be beneficial, but questions remain about the utility of this treatment for patients who are already compliant with medication treatment. Family educational interventions have demonstrated encouraging results in relapse prevention, but follow-up data are limited and application to patients who have limited social networks may be problematic. Reports on interpersonal and social rhythm therapy in patients with bipolar disorder are scarce, and what is available shows no differential effect on time to remission or relapse, but a significant impact on subsyndromal symptoms. Follow-up data suggest that patients receiving cognitive behavior therapy have significantly fewer bipolar episodes, shorter episodes, fewer hospitalizations, and less subsyndromal mood symptoms. It is unclear, however, if cognitive behavior therapy is superior to other active psychosocial treatments and whether its mechanism in patients with bipolar disorder is through changing dysfunctional cognitions or simply enhancing early symptom detection. Psychotherapies should be considered early in the course of illness to improve medication compliance and to help patients identify prodromes of relapse in order to take steps for prevention. In addition, some strategies may have a beneficial effect on residual symptoms, particularly symptoms of depression, and thus help move patients toward a more comprehensive functional recovery.     

Characterization of the human Ly-6 antigens,the newly annotated member Ly-6K included,as molecular markers for head-and-neck squamous cell carcinoma

The E48 antigen is a successfully explored molecular marker for the diagnosis and therapy of HNSCC. The applicability of E48 as an HNSCC-associated antigen, however, is restricted due to its heterogeneous expression in 30% of tumors; and identification of additional target antigens is therefore desired. E48 belongs to the Ly-6 antigen family, comprising a group of highly homologous, low m.w., GPI-anchored surface proteins, of which some show tissue-restricted expression patterns. To identify novel human HNSCC-associated Ly-6 members with squamous cell-associated expression patterns, we performed comprehensive gene-screening consisting of BLAST searches within GenBank databases, followed by expression analysis. Using this approach, the Ly-6K gene could be annotated as a novel member of the human Ly-6 family. Expression of the human Ly-6 genes E48, Ly-6K, PSCA, GML, RIG-E, G6C and Ly-6H was prescreened by qualitative RT-PCR and subsequently analyzed by quantitative RT-PCR in normal keratinocytes, HNSCC cell lines, normal mucosa, HNSCC tumors as well as normal peripheral blood and bone marrow cells. PSCA was highly expressed in normal mucosa, but 100-fold decreased expression was seen in HNSCC. For Ly-6H, GML and G6C, no or very low expression was observed in keratinocytes and HNSCC. Expression of RIG-E was high in normal and malignant squamous cells and in peripheral blood and bone marrow cells, thus limiting its applicability as an HNSCC-associated marker. In contrast, besides the E48 gene, the Ly-6K gene also appeared to be selectively expressed in HNSCC and normal squamous cells. Moreover, expression of Ly-6K was shown in HNSCC cell lines, in which no E48 expression could be detected. These data justify further evaluation of Ly-6K as potential target antigen for the diagnosis and therapy of HNSCC.