Understanding the minimum clinically important difference: a review of concepts and methods.

BACKGROUND CONTEXT: The effectiveness of spinal surgery as a treatment option is currently evaluated through the assessment of patient-reported outcomes (PROs). The minimum clinically important difference (MCID) represents the smallest improvement considered worthwhile by a patient. The concept of an MCID is offered as the new standard for determining effectiveness of a given treatment and describing patient satisfaction in reference to that treatment. PURPOSE: Our goal is to review the various definitions of MCID and the methods available to determine MCID. STUDY DESIGN: The primary means of determining the MCID for a specific treatment are divided into anchor-based and distribution-based methods. Each method is further subdivided and examined in detail. METHODS: The overall limitations of the MCID concept are first identified. The basic assumptions, statistical biases, and shortcomings of each method are examined in detail. RESULTS: Each method of determining the MCID has specific shortcomings. Three general limitations in the accurate determination of an MCID have been identified: the multiplicity of MCID determinations, the loss of the patient's perspective, and the relationship between pretreatment baseline and posttreatment change scores. CONCLUSIONS: An ideal means of determining the MCID for a given intervention is yet to be determined. It is possible to develop a useful method provided that the assumptions and methodology are initially declared. Our efforts toward the establishment of a MCID will rely on the establishment of specific external criteria based on the symptoms of the patient and treatment intervention being evaluated.     

Writing and marking examinations for paediatrics

Examinations are an essential element of medical education, which generates vehement debate but unfortunately a relative lack of rigorous critical analysis. There appears to be a background anxiety that research findings that might suggest an examination has been less than fair will lead to endless arguments with candidates who have failed that examination. It is a major responsibility of all those involved in examining to seek evidence of the fairness, reliability, and validity of the methods and the organisation of the tests. Computers have made analysis of results much easier. Access to shared banks of all types of questions and answer sheets should allow examiners to select the subject first and the assessment tool second but from a range of tested and continually modified questions which allow comparison of candidates' performance both in time and between institutions. The creation of examination materials and their evaluation must be considered as valuable an activity as research in academic life. There is little point in child health research if the advances in knowledge and skills that this generates cannot be shown to have been acquired eventually by present and future paediatricians.     

Presentation of hepatitis B virus preS2 epitope on bluetongue virus core-like particles

A chimeric protein containing most of the hepatitis B virus preS₂ region (amino acid residues 1–48) upstream to, and colinear with the amino-terminus of bluetongue virus VP7 protein (preS₂VP7) was expressed by a recombinant Autographa californica nuclear polyhedrosis virus (AcNPV). The chimeric protein formed BTV core-like particles (CLPs) in Spodoptera frugiperda cells only when the cells were coinfected with this recombinant virus and a recombinant baculovirus that expresses unmodified VP7 and VP3 of BTV. The ratio of preS₂VP7 incorporated into CLPs was influenced by the relative multiplicities of infection of the two viruses. Immunoelectron microscopy of the chimeric particles indicated that the preS₂ epitope was exposed on the surface of the CLPs. When insect cells were coinfected with the preS₂ VP7 recombinant virus and a baculovirus vector that synthesized only the VP3 protein, no CLPs were identified.     

No evidence of an association of JC virus and colon neoplasia.

JC virus (JCV) is an ubiquitous human polyomavirus that frequently resides in the kidneys of healthy individuals and is excreted in the urine of a large proportion of the adult population. Polyomaviruses are associated with disease largely in immunocompromised individuals (progressive multifocal leukoencephalopathy). Colorectal cancers can show chromosome instability and it was hypothesized that JCV may account for some of this instability. We screened urine from 45 healthy donors and 233 colorectal cancer/normal tissue pairs for the presence of JCV sequences using a Taqman assay. This assay could detect 1 virus genome in 10 human genomes. In the urine samples, we found an infection rate of approximately 70%. The JCV isolates in these samples could be categorized into four JCV types (2B, 4, 7, and 8), none of which had a rearranged regulatory region. Among the colon tissues, one normal tissue (<0.5%) and none of the matched tumors tested positive for JCV. There is no evidence in these data to indicate that JCV is the cause of genetic instability in colorectal cancer.     

Alcohol exposure and breast cancer: results of the women's contraceptive and reproductive experiences study.

OBJECTIVES: To explore associated biological outcomes and clarify the role of timing of exposure in the alcohol-breast cancer relationship.METHODS: In a population-based study of 4,575 women ages 35 to 64 years diagnosed with invasive breast cancer between 1994 and 1998 and 4,682 controls, we collected details of lifetime alcohol use and factors that could confound or modify the alcohol-breast cancer relationship. We used conditional logistic regression to compute the odds of breast cancer among drinkers relative to nondrinkers at all ages and at ages 35 to 49 and 50 to 64 years separately.RESULTS: Recent consumption (at reference age minus two) of >/=7 drinks per week was associated with increased risk [odds ratio (OR), 1.2; 95% CI, 1.01-1.3] and evidence of dose response was observed. Most of the excess was observed among women ages 50-64 years (OR 1.3; 95% CI, 1.1-1.6), although the test for age interaction was not statistically significant. Exposure later in life seemed more important than early exposure. Excess breast cancer associated with recent consumption was restricted to localized disease. When outcome was examined according to tumor hormone receptor status, highest risks were observed for estrogen receptor-positive/progesterone receptor-negative tumors (OR 1.6; 95% CI, 1.2-2.3).CONCLUSIONS: The effect of timing of alcohol exposure on breast cancer risk is complicated and will require additional study focused on this one issue. Further work is needed to explain how alcohol exposure, sex hormones, and tumor receptor status interact.     

Environmental risk factors and colorectal neoplasia: Recent developments

The vast majority of new cases of colorectal cancer, the second most common cause of death in men and women in the United States, are attributable to environmental rather than genetic causes. Recent research has clarified inconsistencies in the literature and has explored new pathways through which risk factors may act. This review discusses newly published, selected interesting and important findings in colorectal cancer etiology; these include postmenopausal hormone use, nonsteroidal anti-inflammatory drug use, obesity, physical activity, diet, and other confirmed epidemiologic associations. This research provides insight into mechanisms and offers opportunities for prevention.