Mary Noel

Treatment of glioma patients with ketogenic diets: report of two cases treated with an IRB-approved energy-restricted ketogenic diet protocol and review of the literature.

BackgroundBased on the hypothesis that cancer cells may not be able to metabolize ketones as efficiently as normal brain cells, the ketogenic diet (KD) has been proposed as a complementary or alternative therapy for treatment of malignant gliomas.Case presentationWe report here our experience in treating two glioma patients with an IRB-approved energy-restricted ketogenic diet (ERKD) protocol as monotherapy and review the literature on KD therapy for human glioma patients. An ERKD protocol was used in this pilot clinical study. In addition to the two patients who enrolled in this study, we also reviewed findings from 30 other patients, including 5 patients from case reports, 19 patients from a clinical trial reported by Rieger and 6 patients described by Champ. A total of 32 glioma patients have been treated using several different KD protocols as adjunctive/complementary therapy. The two patients who enrolled in our ERKD pilot study were monitored with twice daily measurements of blood glucose and ketones and daily weights. However, both patients showed tumor progression while on the ERKD therapy. Immunohistochemistry reactions showed that their tumors had tissue expression of at least one of the two critical mitochondrial ketolytic enzymes (succinyl CoA: 3-oxoacid CoA transferase, beta-3-hydroxybutyrate dehydrogenase 1). The other 30 glioma patients in the literature were treated with several different KD protocols with varying responses. Prolonged remissions ranging from more than 5 years to 4 months were reported in the case reports. Only one of these patients was treated using KD as monotherapy. The best responses reported in the more recent patient series were stable disease for approximately 6 weeks. No major side effects due to KD have been reported in any of these patients.ConclusionsWe conclude that 1. KD is safe and without major side effects; 2. ketosis can be induced using customary foods; 3. treatment with KD may be effective in controlling the progression of some gliomas; and 4. further studies are needed to determine factors that influence the effectiveness of KD, whether as a monotherapy, or as adjunctive or supplemental therapy in treating glioma patients.Trial registrationClinicalTrials.gov# NCT01535911

Medical students, clinical preventive services, and shared decision-making.

OBJECTIVE Improving access to preventive care requires addressing patient, provider, and systems barriers. Patients often lack knowledge or are skeptical about the importance of prevention. Physicians feel that they have too little time, are not trained to deliver preventive services, and are concerned about the effectiveness of prevention. We have implemented an educational module in the required family practice clerkship (1) to enhance medical student learning about common clinical preventive services and (2) to teach students how to inform and involve patients in shared decision making about those services. DESCRIPTION Students are asked to examine available evidence-based information for preventive screening services. They are encouraged to look at the recommendations of various organizations and use such resources as reports from the U.S. Preventive Services Task Force to determine recommendations they want to be knowledgeable about in talking with their patients. For learning shared decision making, students are trained to use a model adapted from Braddock and colleagues(1) to discuss specific screening services and to engage patients in the process of making informed decisions about what is best for their own health. The shared decision making is presented and modeled by faculty, discussed in small groups, and students practice using Web-based cases and simulations. The students are evaluated using formative and summative performance-based assessments as they interact with simulated patients about (1) screening for high blood cholesterol and other lipid abnormalities, (2) screening for colorectal cancer, (3) screening for prostate cancer, and (4) screening for breast cancer. The final student evaluation is a ten-minute, videotaped discussion with a simulated patient about screening for colorectal cancer that is graded against a checklist that focuses primarily on the elements of shared decision making. DISCUSSION Our medical students appear quite willing to accept shared decision making as a skill that they should have in working with patients, and this was the primary focus of the newly implemented module. However, we have learned that students need to deepen their understanding of screening services in order to help patients understand the associated benefits and risks. The final videotaped interaction with a simulated patient about colorectal cancer screening has been very helpful in making it more obvious to faculty what students believe and know about screening for colorectal cancer. As the students are asked to discuss clinical issues with patients and discuss the pros and cons of screening tests as part of the shared decision-making process, their thinking becomes transparent and it is evident where curricular changes and enhancements are required. We have found that an explicit model that allows students to demonstrate a process for shared decision making is a good introductory tool. We think it would be helpful to provide students with more formative feedback. We would like to develop faculty development programs around shared decision making so that more of our clinical faculty would model such a process with patients. Performance-based assessments are resource-intensive, but they appear to be worth the added effort in terms of enhanced skills development and a more comprehensive appraisal of student learning.

A repurposed tool: the Programme Evaluation SOAP Note

Medical Education 2010: 44 : 298–305

Using a formative simulated patient exercise for curriculum evaluation

BackgroundIt is not clear that teaching specific history taking, physical examination and patient teaching techniques to medical students results in durable behavioural changes. We used a quasi-experimental design that approximated a randomized double blinded trial to examine whether a Participatory Decision-Making (PDM) educational module taught in a clerkship improves performance on a Simulated Patient Exercise (SPE) in another clerkship, and how this is influenced by the time between training and assessment.MethodsThird year medical students in an internal medicine clerkship were assessed on their use of PDM skills in an SPE conducted in the second week of the clerkship. The rotational structure of the third year clerkships formed a pseudo-randomized design where students had 1) completed the family practice clerkship containing a training module on PDM skills approximately four weeks prior to the SPE, 2) completed the family medicine clerkship and the training module approximately 12 weeks prior to the SPE or 3) had not completed the family medicine clerkship and the PDM training module at the time they were assessed via the SPE.ResultsBased on limited pilot data there were statistically significant differences between students who received PDM training approximately four weeks prior to the SPE and students who received training approximately 12 weeks prior to the SPE. Students who received training 12 weeks prior to the SPE performed better than those who received training four weeks prior to the SPE. In a second comparison students who received training four weeks prior to the SPE performed better than those who did not receive training but the differences narrowly missed statistical significance (P < 0.05).ConclusionThis pilot study demonstrated the feasibility of a methodology for conducting rigorous curricular evaluations using natural experiments based on the structure of clinical rotations. In addition, it provided preliminary data suggesting targeted educational interventions can result in marked improvements in the clinical skills spontaneously exhibited by physician trainees in a setting different from which the skills were taught.

Investigating the Ketogenic Diet As Treatment for Primary Aggressive Brain Cancer: Challenges and Lessons Learned

Survival of glioblastoma multiforme (GBM) with the current recommended treatment is poor. Reported median survivals are approximately 8–15 months. Based on recent publications from animal models, combining cancer drugs, radiation, and diet-metabolic treatments may be a new route to better survivals. To investigate this possibility, we have begun a clinical trial that has enrolled 15 subjects using a ketogenic diet (KD) as an addition to current standard treatments that include surgery, radiation therapy, and chemotherapy. Of the 15 enrolled, 10 completed the protocol. This perspective describes the challenges and lessons learned during this clinical trial and discusses the critical elements that are essential for investigating treatment with a KD. We also reviewed and compared various types of KDs. We believe that the diet selected should be standardized within individual clinical trials, and more importantly, the patients’ blood should be monitored for glucose and ketones twice daily so that the supervising dietitian can work with the patient and their caregivers to make appropriate changes in the diet. Compliance with the diet is best in highly motivated patients who have excellent home support from a family member or a friend who can help to overcome administrative, physical, and cognition deficiencies associated with the disease. Treatment of GBM using a KD represents a reasonable investigative approach. This perspective summarizes the challenges and lessons learned implementing and continuing KD therapy while the patients are concurrently being treated with radiation and chemotherapy.

The Web-Based Worksheet: An Opportunity for Prompt, Consistent, and Expert Feedback in a Community-Based Hospice Experience

We faced a challenge in providing a consistent high-quality learning experience in hospice care, especially because our community-based medical school has students rotating in hospices in six separated communities and the number of faculty with expertise in palliative care is limited. To address these concerns, a Web-based worksheet with interaction with a central campus faculty member was designed for use in a hospice module in a family practice clerkship.

Gateway assessments of medical students for programme development.

computeror manikin-based simulation. A key limitation of this technique is that the presence of a simulator cues the learner to anticipate an abnormality. Why the idea was necessary We were interested in determining whether students would correctly identify actual abnormal findings during an SP encounter. We therefore developed cases specifically for SPs with known physical abnormalities for our senior medical student clinical skills examination. What was done Cases were developed for 2 experienced SPs with stable cardiovascular abnormalities. The presenting problem for each case was neurological, but the case history was constructed to ensure that a cardiovascular examination would be warranted as part of the focused physical examination. Case 1 was portrayed by an SP with a mechanical aortic valve. Physical findings included a loud metallic valvular click and a grade II)III ⁄ VI systolic murmur. Case 2 was portrayed by an SP with chronic renal failure. His physical findings included a grade II)III ⁄ VI systolic murmur. Students were allowed 15 minutes with the patient, followed by 10 minutes to document pertinent interview and physical examination findings. All student)SP encounters were videotaped. Evaluation of results and impact A total of 53 students encountered these cases. Notes were reviewed for written documentation of the abnormal cardiac findings. Correct documentation for each SP were: case 1 (n 1⁄4 27) valvular click 6 (22%), murmur 6 (22%); case 2 (n 1⁄4 26) murmur 10 (38%). None of the students who described the click in case 1 also correctly described the murmur. Across both cases, 5 additional students documented the presence of a murmur, but described it incorrectly. A total of 23 students (43%) specifically wrote no murmur, rub or gallop for cardiac auscultation. Video review showed that all 23 of these students performed a technically sufficient examination to detect the murmur. Documentation of any cardiovascular examination was missing from 9 notes. The limited correct documentation of the abnormal cardiac findings we observed is quite concerning. We initially thought that students might have missed the abnormalities due to inadequate examinations; however, videotape review suggested otherwise. Deliberate disregard of findings in the SP is a possible explanation, although students are instructed to accept all information obtained from SPs. Careless documentation may explain the lack of inclusion of findings, but the specific recording of no murmur, rub or gallop in a substantial percentage of notes suggests that the students simply did not identify the auscultatory abnormalities. Students must both master the technical skills of the physical examination and learn to differentiate between normal and abnormal findings. Assessments using SPs are typically used to observe how well students select and perform specific, focused examinations. By using SPs with stable physical findings, student skill in detecting abnormalities can also be determined. We are continuing to develop cases for SPs with actual physical findings to enrich the assessment of our students.

Expanding the objective structured clinical examination (OSCE) to teach documentation, coding and billing.

13 Research is an important part of clinicians’ work. However, I have gained the impression that successful researchers are sometimes valued over enthusiastic clinical teachers. Research success is easy to quantify whereas teaching quality may be not, particularly not objectively (Katarey 2012). This per se holds true, but that is where students again come into play. Courses are evaluated regularly, and who is better to judge a teacher’s performance than participating students? I, therefore, propose that universities should systematically identify qualified educators – based in part on student evaluations – and support this important clinical sub-population with the same resources as research staff. And, what enables clinical teachers to be good at their craft? In this student’s opinion, it is as Steve Jobs once put it, ‘‘The only way to do great work is to love what you do’’ (Stanford News Service 2005).

Weight loss: An important but often overlooked clue for the diagnosis of cancer.

e19661 Background: One of the primary goals of care for cancer patients is to detect growth and or recurrence as early as possible. We retrospectively evaluated a weight change of 5% or more as an ...