Gerald H. Stein

Improved detection of human breast lesions following experimental training

This study was designed to evaluate the effect of breast examination training with silicone models on the detection of lesions in natural breast tissue. Six women with a total of 13 benign breast lumps were examined by 20 trainees before and after a 20–30 minute training session or a period of unrelated activity. Following the training, percentage of correct detections, duration of examination, and reports of false positives increased. Confidence in correct detections and false positives also increased, although confidence in correct detections was greater than confidence in false positives. The results indicate the effectiveness of the training and suggest a need for a more complex model for training discrimination between normal nodularity and breast lesions.

Progress in manual breast examination

Manual breast examination, despite recent advances in mechanical screening devices, remains a primary diagnostic procedure for early detection of breast cancer. The potential effectiveness of breast self—examination for reducing mortality relies on the effectiveness of a technology for training women to detect small tumors through manual palpation. Research indicates that although the regular practice of breast self—examination can lead to the detection of small tumors, current training methods are inadequate to ensure proper performance and maintain regular practice. An alternative interdisciplinary research and training approach, involving medicine, biomaterials engineering, psychophysics, and experimental psychology, is suggested. A dynamic lifelike breast model with variable lumps would provide the basis for generating systematic data regarding the factors affecting detection of small lumps and lead to development and evaluation of efficient and effective methods to teach manual examination. Cancer 40:364–370, 1977.

Lump detection in simulated human breasts

Sixteen observers palpated silicone models of human breasts containing lumps 1.6-12.1 mm in diameter. Detectability depended on the size of the lump, producing a systematic psychometric function. In eight observers who participated in three or more sessions, performance improved with practice, with most improvement occurring within one or two 26-trial sessions. Three-week retention measures disclosed no appreciable decrease in performance, but a significant correlation was found between the number of lumps detected and duration of trial (p < .01). There was no difference in performance between four observers who used their preferred hands and four observers who used their nonpreferred hands. These data establish that examination of breast models for the detection of lumps simulating cancer is a task amenable to experimental analysis.

Toward an Effective Technology of Instruction in Breast Self-examination

aged 40 to 44 and is the leading cause of cancer deaths in women aged 25 to 74. It is estimated that 1 of every 11 American women will develop breast cancer at some time during her life, about 107,000 new cases being diagnosed in 1980 alone [ 1, 2] . In addition to a profound reduction in life expectancy, victims of breast cancer must also face the prospect of expensive, disfiguring, and often partially disabling surgery. The aggregate cost of breast cancer to our society, in terms of both morbidity and mortality, is impossible to estimate; but any significant reduction in its toll with respect to either of these factors would constitute a major contribution to womens health.

Serum lipids as protective factors for subarachnoid hemorrhage

Identification of common serum lipid profiles in patients with subarachnoid hemorrhage (SAH) may allow a better understanding of its pathogenesis. We conducted a hospital-based case-control study in Japan. One hundred and fifty consecutive cases of spontaneous SAH during a 5-year period were examined and their lipid profiles assessed. Age- and gender-matched controls were identified for each case through random hospital sampling. Median serum total cholesterol was 161 mg/dl (range 77-288) in patients with SAH, and 209 mg/dl (134-441) in controls (p < 0.001). Median serum triglycerides were 95 mg/dl (range 28-589) in SAH and 122 mg/dl (31-371) in controls (p < 0.001). A high serum total cholesterol of more than 5.20 mmol/L (200 mg/dl) (odds ratio 0.22 [95% confidence interval 0.12-0.40]) and a high serum triglyceride of more than 1.70 mmol/L (150 mg/dl) (odds ratio 0.29 [95% CI 0.14-0.60]) were independent protective factors for SAH. In conclusion, higher values of both serum cholesterol and triglyceride may be inversely associated with the occurrence of SAH.

Long-term lipid profiles with isradipine and hydrochlorothiazide treatment in elderly hypertensive patients

Lipid profiles were determined in 56 elderly patients with benign essential hypertension during an open-label 1-year study of the safety and efficacy of isradipine, a new calcium antagonist, in controlling blood pressure. Patients with diastolic blood pressures between 96 and 115 mm Hg were titrated with isradipine (mean dose of 11 mg/day) to reduce blood pressure to less than 90 mm Hg. Ten of these patients received concomitant hydrochlorothiazide (HCTZ) 50 mg/day for additional control. Sera were analyzed using standard methods at the end of a 2− to 4-week washout period, and at the end of Months 6 and 12, for total cholesterol (CHOL) and HDL- and LDL-cholesterol. Changes in lipid values (mg/dl) from baseline to 12 months with isradipine alone (n = 38) were as follows: CHOL, −7.5; HDL, +3.9 (p < 0.05); LDL, −6.2; CHOL/HDL, −0.6 (p < 0.05). For patients receiving concomitant HCTZ (n = 9), the changes were as follows: CHOL, −4.9; HDL, +3.4; LDL, −16.8; CHOL/HDL, −0.4. In conclusion, isradipine alone was associated with significant improvements in HDL cholesterol and total CHOL/HDL ratio. Lipid profiles of patients receiving isradipine and HCTZ were minimally affected. Favorable lipid changes with isradipine suggest that it may have advantages in the treatment of hypertensive patients.

Comparison of Enalapril and Thiazide Diuretics in the Elderly Hypertensive Patient

One hundred seventy-four patients, 65 years of age or older, entered a double-blind, seven-center, 16-week, controlled study to compare the effects of enalapril and hydrochlorothiazide (HCTZ) in an elderly hypertensive population. Sixty-eight percent of the patients were men, 32% were women. Thirty-two percent of the patients had isolated systolic hypertension. Approximately 80% of the patients were white. After a 4-week placebo run-in period, patients with sitting diastolic BP (DBP) of 90-120 mm Hg or systolic BP (SBP) greater than or equal to 160 mg Hg and DBP less than 90 mm Hg (isolated systolic hypertension) were randomized to receive 10 mg of enalapril or 12.5 mg of HCTZ once daily. If after 4 weeks their BPs were not controlled (i.e., DBP greater than 85 mm Hg or SBP greater than 140 mm Hg), the dose of the drug was doubled. If after successive 4-week intervals, their BPs were still not controlled, the other drug was added to their regimen and this was then doubled. The initial mean BPs were 167/94 mm Hg in both groups. By the end of the monotherapy phase at 8 weeks, the mean BPs had fallen significantly (p less than or equal to 0.01) to 148/85 mm Hg in both groups. By 16 weeks, the mean BPs had again fallen similarly: in the enalapril group to 144/83 mm Hg, and in the HCTZ group to 145/83 mm Hg. Seventy-nine percent of the enalapril group and 85% of the HCTZ group had controlled BPs at this time (DBP less than or equal to 85 or SBP less than or equal to 140 mm Hg). White and nonwhite patients in both drug groups had similar falls in SBP and DBP both at the end of the monotherapy period and the overall study. The white patients experienced more rapid falls in BP with enalapril, the nonwhite patients with HCTZ. Three serious adverse experiences occurred in the enalapril group, none of which were considered likely to be due to the drug therapy. Overall, 49% of the enalapril group and 61% of the HCTZ group reported an adverse effect during the study (not significant). Laboratory adverse effects occurred 10% more frequently in the HCTZ group: enalapril, 22%; HCTZ, 32% (not significant); none was serious. Both drugs therefore appeared to be equally efficacious antihypertensive agents in these elderly patients.

Plasma Lipid Profiles and Antihypertensive Agents: Effects of Lisinopril, Enalapril, Nitrendipine, Hydralazine, and Hydrochlorothiazide:

Previous studies have documented potentially adverse effects of diuretics and beta-blocking agents on plasma lipid profiles. This study was designed to establish the effects on lipid profiles of the angiotensin-converting enzyme inhibitors lisinopril and enalapril, alone and in combination with hydrochlorothiazide (HCTZ), the calcium-channel blocker nitrendipine, HCTZ, and hydralazine. After a two-week, single-blind, placebo phase, 77 patients with essential hypertension were given active agent as monotherapy in a double-blind fashion for 8–20 weeks. The dose of each agent was titrated to achieve diastolic blood pressure <90 mm Hg. At the end of placebo and treatment phases, plasma was analyzed for triglycerides, total cholesterol, and high- (HDL), and low-density lipoprotein (LDL) cholesterol. Overall, few changes in lipid contents were noted. Total cholesterol decreased during therapy with hydralazine but increased in patients receiving the combination of lisinopril and HCTZ. HDL cholesterol was depressed in those taking HCTZ alone and in combination with lisinopril. LDL cholesterol was lowered during therapy with hydralazine but was otherwise unaffected by all other agents. None of the agents evaluated significantly affected triglyceride concentrations. Thus, monotherapy with lisinopril, enalapril, and nitrendipine do not affect plasma lipid concentrations. Hydralazine lowers total and LDL cholesterol. If these findings are confirmed in trials with larger numbers of patients, these effects on lipid profiles may influence choice of agent in the therapy of essential hypertension.

Preliminary report of a Web-based instrument to assess and teach knowledge and clinical thinking to medical student

Objectives We report the preliminary development of a unique Web-based instrument for assessing and teaching knowledge and developing clinical thinking called the “Sequential Questions and Answers” (SQA) test. Included in this feasibility report are physicians’ answers to the Sequential Questions and Answers pre- and posttests and their brief questionnaire replies. Methods The authors refined the SQA test case scenario for content, ease of modifications of case scenarios, test uploading and answer retrieval. Eleven geographically distant physicians evaluated the SQA test, taking the pretest and posttest within two weeks. These physicians completed a brief questionnaire about the SQA test. Results Eleven physicians completed the SQA pre- and posttest; all answers were downloaded for analysis. They reported the ease of website login and navigating within the test module together with many helpful suggestions. Their average posttest score gain was 53% (p=0.012). Conclusions We report the successful launch of a unique Web-based instrument referred to as the Sequential Questions and Answers test. This distinctive test combines teaching organization of the clinical narrative into an assessment tool that promotes acquiring medical knowledge and clinical thinking. We successfully demonstrated the feasibility of geographically distant physicians to access the SQA instrument. The physicians’ helpful suggestions will be added to future SQA test versions. Medical schools might explore the integration of this multi-language-capable SQA assessment and teaching instrument into their undergraduate medical curriculum.

Content analysis of medical students’ seminars: a unique method of analyzing clinical thinking

BackgroundThe study of communication skills of Asian medical students during structured Problem-based Learning (PBL) seminars represented a unique opportunity to assess their critical thinking development. This study reports the first application of the health education technology, content analysis (CA), to a Japanese web-based seminar (webinar).MethodsThe authors assigned twelve randomly selected medical students from two universities and two clinical instructors to two virtual classrooms for four PBL structured tutoring sessions that were audio-video captured for CA. Both of the instructors were US-trained physicians. This analysis consisted of coding the students’ verbal comments into seven types, ranging from trivial to advanced knowledge integration comments that served as a proxy for clinical thinking.ResultsThe most basic level of verbal simple responses accounted for a majority (85%) of the total students’ verbal comments. Only 15% of the students’ comments represented more advanced types of critical thinking. The male students responded more than the female students; male students attending University 2 responded more than male students from University 1. The total mean students’ verbal response time for the four sessions with the male instructor was 6.9%; total mean students’ verbal response time for the four sessions with the female instructor was 19% (p < 0.05).ConclusionsThis report is the first to describe the application of CA to a multi-university real time audio and video PBL medical student clinical training webinar in two Japanese medical schools. These results are preliminary, mostly limited by a small sample size (n = 12) and limited time frame (four sessions). CA technology has the potential to improve clinical thinking for medical students. This report may stimulate improvements for implementation.