Computer-Assisted Instruction Improves Clinical Reasoning Skills of Dietetics Students

Objective The effects of a computer-assisted instruction (CAI) tutorial program on learning clinical reasoning skills were compared in undergraduate dietetics students.Design A drill-and-practice program to control for time on task, a tutorial program, and a simulation program, as the test vehicle, were developed. The tutorial and simulation programs presented data on a patient with cardiovascular disease.Setting Subjects were tested in 30 undergraduate dietetics programs.Subjects Participants were 413 undergraduate diet therapy students enrolled in a coordinated program in dietetics (CPD) or a didactic program in dietetics (DPD).Intervention After completion of lectures on cardiovascular disease, subjects were given the drill-and-practice program plus a simulation test (group 1), the tutorial plus a simulation test (group 2), or the simulation test only (group 3).Main outcome measures Scores on the simulation test were compared. Variables included type of CAI, dietetics program, year in school, computer experience, and experience using a medical chart. Mastery of objectives related to lower- and higher-level clinical reasoning skills introduced in the tutorial program was compared.Statistical analysis One-way analysis of variance and Student-Newman Keuls tests were conducted to determine any differences among the three groups. Reliability was determined using the Kuder-Richardson Formula 20.Results The reliability coefficient of the simulation test was 0.93. Group 2 scored higher on the simulation test than group 1 or group 3. As a group, the CPD students scored higher than the DPD students. When CPD and DPD students were divided into the three experimental groups, there was no significant difference between the CPD and DPD student simulation scores. Group 2 mastered all objectives for lower-level reasoning skills and the higher-level decision-making objective better than groups 1 and 3.Applications/conclusions A computer tutorial program enhanced clinical reasoning skills in undergraduate dietetics students. This type of program could be used to supplement many topics taught in diet therapy and provide DPD students with experiential learning before their clinical intern practicums. J Am Diet Assoc. 1995; 95:868–873.     

Neurocognitive consequences of a paediatric brain tumour and its treatment: a meta‐analysis

Aim This meta‐analysis provides a systematic review of studies into intellectual and attentional functioning of paediatric brain tumour survivors (PBTS) as assessed by two widely used measures: the Wechsler Intelligence Scale for Children (3rd edition; WISC‐III) and the Conners’ Continuous Performance Test (CPT). Method Studies were located that reported on performance of PBTS (age range 6–16y). Meta‐analytic effect sizes were calculated for Full‐scale IQ, Performance IQ, and Verbal IQ as measured by the WISC‐III, and mean hit reaction time, errors of omission, and errors of commission as measured by the CPT. Exploratory analyses investigated the possible impacts of treatment mode, tumour location, age at diagnosis, and time since diagnosis on intelligence. Results Twenty‐nine studies were included: 22 reported on the WISC‐III in 710 PBTS and seven on CPT results in 372 PBTS. PBTS performed below average (p_s<0.001) on Full‐scale IQ (Cohen’s d=?0.79), Performance IQ (d=?0.90), and Verbal IQ (d=?0.54). PBTS committed more errors of omission than the norm (d=0.82, p<0.001); no differences were found for mean hit reaction time and errors of commission. Cranial radiotherapy, chemotherapy, and longer time since diagnosis were associated with lower WISC‐III scores (p_s<0.05). Interpretation PBTS have seriously impaired intellectual functioning and attentiveness. Being treated with cranial radiotherapy and/or chemotherapy as well as longer time since diagnosis leads to worse intellectual functioning.     

Free testosterone levels in umbilical‐cord blood predict infant head circumference in females

Aim Fetal androgens influence fetal growth as well as postnatal neurocognitive ability. However, to our knowledge, no published study has prospectively examined the impact of early‐life androgens on infant brain growth. We report the association between circulating fetal androgen levels, measured from umbilical‐cord blood at birth, and a proxy measure of brain growth: head circumference. Method Participants were 82 unselected female infants from a large representative birth cohort (mean gestational age 39.4wks, SD 1.7). Umbilical‐cord blood was obtained at birth and analysed for androgen concentrations (total testosterone, androstenedione, dehyrdroepiandrosterone, and its sulphated metabolite). Head circumference and two other measures of growth – weight (mean 3311.4g, SD 461.3) and length – were measured within 3 days of birth and again at approximately 1 year of age (mean age 13.1mo, SD 1.1). Results Multivariate linear regressions found an inverse association between levels of free testosterone and growth in head circumference (correlation=?.24), even when adjusting for sociodemographic/obstetric covariates and head size at birth. Growth in weight and length could not be predicted by free testosterone concentration. Interpretation This is the first report of an association between prenatal androgen levels and postnatal growth in head circumference. These findings suggest that early‐life androgens may impact brain development during infancy.     

Factor structure of paediatric timed motor examination and its relationship with IQ

Aim Brain systems supporting higher cognitive and motor control develop in a parallel manner, dependent on functional integrity and maturation of related regions, suggesting neighbouring neural circuitry. Concurrent examination of motor and cognitive control can provide a window into neurological development. However, identification of performance‐based measures that do not correlate with IQ has been a challenge. Method Timed motor performance from the Physical and Neurological Examination of Subtle Signs and IQ were analysed in 136 children aged 6 to 16 (mean age 10y 2.6mo, SD 2y 6.4mo; 98 female, 38 male) attending an outpatient neuropsychology clinic and 136 right‐handed comparison individuals aged 6 to 16 (mean age 10y 3.1mo, SD 2y 6.1mo; 98 female, 38 male). Timed activities – three repetitive movements (toe tapping, hand patting, finger tapping) and three sequenced movements (heel–toe tap, hand pronate/supinate, finger sequencing) each performed on the right and left – were included in exploratory factor analyses. Results Among comparison individuals, factor analysis yielded two factors – repetitive and sequenced movements – with the sequenced factor significantly predictive of Verbal IQ (VIQ) (ΔR²=0.018, p=0.019), but not the repetitive factor (ΔR²=0.004, p=0.39). Factor analysis within the clinical group yielded two similar factors (repetitive and sequenced), both significantly predictive of VIQ, (ΔR²=0.028, p=0.015; ΔR²=0.046, p=0.002 respectively). Interpretation Among typical children, repetitive timed tasks may be independent of IQ; however, sequenced tasks share more variance, implying shared neural substrates. Among neurologically vulnerable populations, however, both sequenced and repetitive movements covary with IQ, suggesting that repetitive speed is more indicative of underlying neurological integrity.     

EFFECT OF CORTISOL TREATMENT ON HORMONAL RELATIONSHIPS IN CONGENITAL ADRENAL HYPERPLASIA

The temporal relationship between administration of cortisol and serum 17α-hydroxyprogesterone was investigated in five patients aged 9-19 years with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. There was marked variability in the 17α-hydroxyprogesterone response (determined hourly for 24 h) of individual patients to administration of cortisol. Mean concentration was less than 0.030 μmol/l in one patient but 0.519μ mol/l in another. Levels were higher in all patients while off treatment, and were greatest in those with salt-losing adrenal hyperplasia. Growth hormone secretion was not suppressed by treatment with cortisol. Withdrawal of cortisol for 3 days resulted in a significant decrease in the mean serum FSH/LH ratio and a rise in serum testosterone in all subjects. Episodic release of gonadotrophins persisted in the adolescent patients.     

Impact of gestational age on preterm motor development at 4 months chronological and adjusted ages

A cohort of 62 low-risk preterm infants was identified and followed prospectively through the first 4 months of life to assess whether motor development is determined by biological maturity or the duration of the extrauterine experience. After identification, the cohort was subdivided into two groups according to gestational age at birth: less than 32 weeks gestation (n = 23) and greater than or equal to 32 weeks gestation (n = 39). Neuromotor assessments were performed on every infant at both 4 months chronological and 4 months adjusted ages. Analyses revealed that (1) the two groups of infants differed significantly at 4 months chronological age in terms of tone, primitive reflexes and volitional movement, but not in automatic reactions, and (2) the two groups of infants differed significantly at 4 months adjusted age in terms of primitive reflexes, but not in tone, automatic reactions or volitional movement. These findings suggest that the development of volitional movement and tone appear to evolve according to biological maturity alone. In contrast, primitive reflexes and automatic reactions in the preterm infant may be influenced by both biological maturation and environmental experience.