Randall S. Robbs

Problem-based learning outcomes: the glass half-full.

Purpose To compare the characteristics and outcome data of students from a single institution with a two-track, problem-based learning (PBL) and standard (STND) curriculum. Method PBL and STND students from nine graduating classes at Southern Illinois University School of Medicine were compared using common medical school performance outcomes (USMLE Step 1, USMLE Step 2, clerkship mean ratings, number of clerkship honors and remediation designations, and the senior clinical competency exam), as well as common admission and demographic variables. Results PBL students were older, and the cohort had a higher proportion of women. The two tracks had similar USMLE Step 1 and 2 mean scores and pass rates. Performance differences were significant for PBL students in two clerkships as well as in the clerkship subcategories of clinical performance, knowledge and clinical reasoning, and noncognitive behaviors. In addition, the proportion of PBL students earning honors was greater. Conclusions The traditional undergraduate educational outcomes for the PBL and STND students are very positive. In several of the clerkship performance measures, the PBL students performed significantly better, and in no circumstance did they perform worse than the STND students.

Alzheimer disease assessment scale: useful for both early detection and staging of dementia of the Alzheimer type.

The Alzheimer Disease Assessment Scale (ADAS) was administered to 61 patients with dementia of the Alzheimer type (DAT) and 52 elderly controls. The DAT group was subdivided into different severity levels of dementia based on scores from the Mini-Mental State Exam: very mild (≥24), mild (20 to 23), moderate (10 to 19), and severe (0 to 9). The mean scores on the ADAS Cognitive subscale for the four levels of dementia (very mild = 23.1 ± 7.7, mild = 22.9 ± 8.9, moderate = 38.6 ± 9.8, severe = 54.8 ± 7.6) were statistically different from one another (p < 0.0001, except very mild vs. mild) and were significantly worse than the scores of the elderly control group (5.5 ± 2.7, p < 0.0001, ANOVA). Furthermore, the ADAS Cognitive subscale was highly effective in discriminating individual Alzheimer patients from elderly controls. The ADAS Cognitive score correctly classified 100% of the very mild group, 91% of the entire mild group, and 100% of the moderate and severe groups when a cutoff score of 2 SDs above the control group mean was used. Age and education had only minimal effects on the ADAS Cognitive score. The ADAS is a valuable screening test that only takes 30 min to administer and has utility in both early detection and staging of DAT.

A Comparison of Phonemic, Semantic, and Alternating Word Fluency in Parkinson's Disease

Abstract Word fluency in 45 medicated non-demented Parkinson’s disease (PD) patients and 45 normal control subjects was studied with a Phonemic Word Fluency (PWF) task using the letters F, A, and S, a Semantic Word Fluency (SWF) task using the categories animals, boys’ names, and states, and an Alternating Word Fluency (AWF) task requiring the person to alternate between colors and occupations, animals and states, and words beginning with C and P. The number of words generated did not differ for trials with F, A, S, or states, but PD patients generated significantly fewer animal names and boys’ names. PD patients also generated significantly fewer words on each of the three AWF trials. The PD patients scored 21% lower than the normal control group on the total AWF score, but only 10% lower for the PWF and SWF scores. The greater impairment on the AWF task which requires the use of internal attentional control to rapidly shift mental set can be considered a type of executive functioning deficit. This is consistent with the growing literature suggesting frontal systems dysfunction in PD and with the view that dopaminergic treatment only incompletely restores functioning in the frontostriatal system.

Alzheimer disease assessment scale : a subtest analysis

SummaryThe Alzheimer Disease Assessment Scale (ADAS) was administered to 61 Alzheimer patients, 52 elderly controls, and 80 controls between age 7 and 54 years. The Alzheimer group was categorized into different severity levels of dementia based on MMSE scores: very mild (≥ 24), mild (≥20), moderate (10–19), and severe (0–9). All 11 ADAS Cognitive subtest scores for the mild, moderate, and severe dementia groups were statistically worse than the elderly control group. This was also the case for the very mild group, except for Naming, Commands, Constructional Praxis, and Ideational Praxis. In terms of magnitude of effect, memory and spontaneous language items were the earliest indicators on the ADAS, while praxis, commands, and naming items were only sensitive later in the course of the disorder. The best single indicators of progression throughout the severity continuum of dementia (i.e., from normal to severe) were the Orientation subtest, the ADAS Cognitive score, and the ADAS Total score. The ADAS Noncognitive subtests generally did not show the progression with increasing dementia that was evident on the ADAS Cognitive subtests. Differences in educational level had no statistically significant effects on any of the ADAS subtest scores, and age differences were few and small in magnitude. The differential rate of decline of the various ADAS subtests appears to reflect both the changing pattern of cognitive impairments as a function of severity of DAT and also to some extent the psychometric limitations of some of the subtests.

Long-Term Consequences of Severe Closed Head Injury on Episodic Memory

This is the first systematic investigation of the very long-term effects of severe closed head injury (CHI) on objective measures of memory, and the first to employ both a normal control group and an other injury control group consisting of spinal cord injury (SCI) patients. The CHI group displayed significantly poorer performance on every memory measure, and the effect sizes were large. This impairment in episodic memory is neither due to pre-injury nor post-injury differences between CHI and normal control subjects because the same differences were found when the CHI group was compared to a group of SCI patients. The findings demonstrate severe impairment in learning and retention many years after sustaining a severe CHI, which is likely in part due to the bilateral hippocampal damage shown in neuropathological studies. This life-long memory impairment needs to be addressed by community service programs.

Renal effects of contrast media in diabetic patients undergoing diagnostic or interventional coronary angiography

BACKGROUND The use of safe iodinated contrast media (CM) to prevent contrast-induced nephropathy (CIN) is an important consideration among renally impaired diabetic patients during coronary angiography. HYPOTHESIS Diabetic patients with normal or mild renal dysfunction are less likely to receive renal protective measures during angiography, yet they may also be at risk for CIN. We compared the renal effects of iopamidol and iodixanol in diabetic patients who were referred for angiography. METHODS Diabetic patients (N=122) with a serum creatinine (SCr) level of < or = 2 mg/dl were double-blind randomized to receive nonionic CM: iopamidol-370 (low osmolar, monomeric) or iodixanol-320 (iso-osmolar, dimeric). Renal stability was evaluated at baseline and at Days 1, 3, and 7 post-angiography. The primary endpoint was a > or = 25% increase in SCr. RESULTS Seventeen (10 iopamidol, 7 iodixanol; P=NS) patients had an increase in SCr > or = 25% over baseline. Over all days, analysis revealed nonsignificant differences in the incidence of CIN between the two study groups regardless of how CIN was defined. CONCLUSIONS Diabetic patients with normal or mild renal dysfunction are at risk for CIN. No significant difference in renal response was observed for these CM in this at-risk population.

A large-scale study of the reliabilities of checklist scores and ratings of interpersonal and communication skills evaluated on a standardized-patient examination

AbstractChecklists and rating scales are both used for assessing examinees in standardized-patient (SP) examinations. A common presumption, is that checklists are more objective than and hence superior to rating scales with respect to psychometric properties such as reliability. Recently, this presumption has been questioned and studies have been cited which support the clain that “objectified methods do not inherently provide more reliable scores.” The purpose of this study was to further explore this issue, using a specially designed checklist/rating scale form for assessing interpersonal and communication skills. Methods. A 26-item checklist/rating scale form was developed, which consisted of five sections of 3 to 7 checklist items each, with a space provided at the end of each section for the SP to make a single global rating of the items in that section. Analyses were performed on data for 1,048 fourth-year medical students in the eight schools in the New York City Consortium, tested on the 7-case SP examination administered at The Morchand Center of Mount Sinai School of Medicine. Results/Conclusion. The intercase reliabilities for the checklist scores and ratings, respectively, were: 0.33 and 0.39 for eliciting information, 0.33 and 0.39 for non-verbal behavior, 0.55 and 0.52 for patient education, 0.48 and 0.45 for professional manner, and 0.49 and 0.52 for patient satisfaction. The correlations between the checklist scores and ratings for the five sections were 0.66, 0.60, 0.80, 0.69, and 0.75, respectively. The pattern of these results provides further support for the claim that “objectified” measures, like checklists, “do not inherently provide more reliable scores.”

Biobehavioral Factors Mediate Exercise Effects on Fatigue in Breast Cancer Survivors

PURPOSE This study aimed to examine mediators of fatigue response to an exercise intervention for breast cancer survivors in a pilot randomized controlled trial. METHODS Postmenopausal breast cancer survivors (n = 46; ≤stage 2), off primary treatment, and reporting fatigue and/or sleep dysfunction were randomized to a 3-month exercise intervention (160 min·wk of moderate-intensity aerobic walking, twice weekly resistance training with resistance bands) or control group. Six discussion group sessions provided behavioral support to improve adherence. Fatigue, serum cytokines, accelerometer physical activity, cardiorespiratory fitness, sleep dysfunction, and psychosocial factors were assessed at baseline and 3 months. RESULTS The exercise intervention effect sizes for fatigue were as follows: fatigue intensity d = 0.30 (P = 0.34), interference d = -0.38 (P = 0.22), and general fatigue d = -0.49 (P = 0.13). Using the Freedman-Schatzkin difference-in-coefficients tests, increase in fatigue intensity was significantly mediated by interleukin 6 (IL-6) (82%), IL-10 (94%), IL-6/IL-10 (49%), and tumor necrosis factor-α (TNF-α):IL-10 (78%) with reduced sleep dysfunction increasing the relationship between intervention and fatigue intensity rather than mediating intervention effects (-88%). Decrease in fatigue interference was mediated by sleep dysfunction (35%), whereas IL-10 and pro-anti-inflammatory cytokine ratios increased the relationship between intervention and interference (-25% to -40%). The reduction in general fatigue was significantly mediated by minutes of physical activity (76%), sleep dysfunction (45%), and physical activity enjoyment (40%), with IL-10 (-40%) and IL-6/IL-10 (-11%) increasing the intervention-fatigue relationship. In the intervention group, higher baseline fatigue, anxiety, depression, and perceived exercise barrier interference predicted a greater decline in fatigue interference and/or general fatigue during the intervention. CONCLUSIONS Biobehavioral factors mediated and enhanced intervention effects on fatigue, whereas psychosocial factors predicted fatigue response. Further study is warranted to confirm our results and to improve understanding of relationships that mediate and strengthen the intervention-fatigue association.

The Effect of Examinee and Patient Ethnicity in Clinical-Skills Assessment with Standardized Patients

AbstractContext: Ethnicity has been a continuing concern for the valid assessment of clinical performance with standardized patients (SPs). The concern is that examinee ethnicity and SP ethnicity might interact, such that examinees might score higher in encounters with SPs of the same ethnicity. Objective: To test for an interaction of examinee ethnicity and SP ethnicity on clinical performance in an SP examination. Main Outcome Measures: History-taking andphysical-examination scores and interpersonal-and communication-skills scores, both based on checklists completed by SPs. Poststation scores for answers to case-related questions concerning pathophysiology, diagnosis, test selection, and test interpretation. Setting And Participants: Two graduating classes of over 1,000 fourth-year medical students each in the New York City Consortium were tested on the SP assessment administered at The Morchand Centerof Mount Sinai School of Medicine. Design And Analysis: The primary analyses were two-way (2 × 2) analyses, to test the main and interaction effects of examinee ethnicity and SP ethnicity. Effect-size measures (standardized mean differences, d) were computed to provide a sharper picture of the effects. Results: Of the 24 interaction analyses, only three were statistically significant (notsignificantly more than expected by chance) and the results were mixed: one analysis showed better examinee performance in encounters with SPs of thesame ethnic background and the other two showed the opposite. For all 24 interactions, significant or not, the results showed weak effects and no consistent pattern. White examinees scored on average 0.12 standard deviations above black examinees in encounters with white SPs, and 0.11 standard deviations higher in encounters with black SPs. Conclusions: These initial results are encouraging and should dispel some of the concern about ethnicity in SP assessment, at least about the operation of an examinee-by-SP-ethnicity interaction that would pose a serious threat to the validity of the examination scores.

Inflammation and psychosocial factors mediate exercise effects on sleep quality in breast cancer survivors: Pilot randomized controlled trial

To improve mechanistic understanding, this pilot randomized controlled trial examined mediators of an exercise intervention effects on sleep in breast cancer survivors (BCS).