Utilisation, Reliability and Validity of Clinical Evaluation Exercise in Otolaryngology Training

OBJECTIVES

To investigate the utilisation, reliability and validity of clinical evaluation exercise (CEX) in otolaryngology training.

DESIGN

Retrospective database analysis.

SETTING

Online assessment database.

PARTICIPANTS

We analysed all CEXs submitted by north London core (CT) and speciality trainees (ST) in otolaryngology from 2010 to 2013.

MAIN OUTCOME MEASURES

Internal consistency of the 7 CEX items rated as either O: outstanding, S: satisfactory or D: development required. Overall performance rating (pS) of 1-4 assessed against completion of training level. Receiver operating characteristic was used to describe CEX sensitivity and specificity. Overall score (cS), pS and the number of 'D'-rated items were used to investigate construct validity.

RESULTS

One thousand one hundred and sixty CEXs from 45 trainees were included. CEX showed good internal consistency (Cronbach's alpha= 0.85). CEX was highly sensitive (99%), yet not specific (6%). cS and pS for ST was higher than CT (99.1% ± 0.4 versus 96.6% ± 0.8 and 3.06 ± 0.05 versus 1.92 ± 0.04, respectively P < 0.001). pS showed a significant stepwise increase from CT1 to ST6 (P < 0.001). In contrast, cS only showed improvement up to ST4 (P = 0.025). The most frequently utilised item 'management and follow-up planning' was found to be the best predictor of cS and pS (rs  = +0.69 and +0.21, respectively).

CONCLUSION

CEX is reliable in assessing early years otolaryngology trainees in clinical examination, but not at higher level. It has the potential to be used in a summative capacity in selecting trainees for ST positions. This would also encourage trainees to master all domains of otolaryngology clinical examination by end of CT.

Utilisation and outcomes of case-based discussion in otolaryngology training

OBJECTIVES

To assess the reliability, validity and outcomes of Case-based Discussion (CBD) in otolaryngology training.

DESIGN

Retrospective database analysis.

SETTING

National electronic database.

PARTICIPANTS

North London otolaryngology trainees.

MAIN OUTCOME MEASURES

We tested the tool's reliability along with its capacity to denote trainee progress. A score was calculated (cS) and compared across core (CT) and specialty trainees (ST) at all levels. The number of items rated as "development required" (D) was also examined.

RESULTS

One thousand four hundred and fifty-six CBDs were submitted by 46 trainees from 2007 to 2013, averaging 13.6 per trainee per year. Items relating to knowledge, management and judgement were more popular (98% usage), and better predictors of cS compared to other parameters (rs: +0.74, +0.70 and +0.72, respectively). CBD was found to be reliable (Cronbach's α = 0.848) and highly sensitive (99%), yet not specific. cS was significantly higher in ST than CT (95.3% ± 0.6 versus 88.7% ± 1.3). pS showed a similar pattern (3.15 ± 0.4 versus 2.0 ± 0.05) (P < 0.001). cS and pS increased from CT1 to ST8 (rs: +0.60 and +0.34, respectively). The number of D-rated items decreased with increasing year of training.

CONCLUSION

Case-based discussion is a reliable and valid tool in otolaryngology training. It is highly sensitive but not specific. Trainees should be encouraged to use it at all levels.

Adverse effects to quality of life arising from treatment can recover with intermittent androgen suppression in men with prostate cancer

Health-related quality of life (HQOL) research is a means of broadening the assessment of treatment effects. This longitudinal study investigated the dynamic change to quality of life (QOL) and testosterone dependant physiology in men commencing an intermittent maximal androgen blockade program (IMAB). Two hundred and fifty men were accrued to the multi-centre study of IMAB (Flutamide 250 mg TDS, Leuprolide 22.5 mg depot) ceasing treatment after 9 months if PSA <4 ng/ml, and restarting when PSA >20 ng/ml. QOL was assessed every 3 months for 30 months using the EORTC QLQ-C30 and EORTC QLQ-PR25 module. Data completion for the whole study was 90%. At baseline, our cohort was less symptomatic and had better function than the EORTC reference cohort, which may be related to a shift in clinical practice with time. Testosterone suppression (AS) lead to a significant reduction in global HQOL and deterioration in most function and symptom scales. During the off period, there was a trend of progressive improvement in HQOL that paralleled testosterone recovery but was slower than the rate of deterioration during the treatment phase. Maximum recovery of HQOL occurred most frequently by months 9-12. Testosterone recovery was slower and less complete in older men, and lead to concomitant poorer HOQL recovery. Whilst the magnitude of mean change to scale scores was small, there was a consistent and simultaneous deterioration during maximal androgen blockade (MAB) and improvement during androgen recovery. Older men are more likely to show an impaired testosterone recovery, and this was paralleled by a slower HQOL recovery. Newer methods of analysis to describe results in a way that has meaning to the individual patient are warranted.

Characterization of a novel airway epithelial cell-specific short chain alcohol dehydrogenase/reductase gene whose expression is up-regulated by retinoids and is involved in the metabolism of retinol

Multiple retinoic acid responsive cDNAs were isolated from a high density cDNA microarray membrane, which was developed from a cDNA library of human tracheobronchial epithelial cells. Five selected cDNA clones encoded the sequence of the same novel gene. The predicted open reading frame of the novel gene encoded a protein of 319 amino acids. The deduced amino acid sequence contains four motifs that are conserved in the short-chain alcohol dehydrogenase/reductase (SDR) family of proteins. The novel gene shows the greatest homology to a group of dehydrogenases that can oxidize retinol (retinol dehydrogenases). The mRNA of the novel gene was found in trachea, colon, tongue, and esophagus. In situ hybridization of airway tissue sections demonstrated epithelial cell-specific gene expression, especially in the ciliated cell type. Both all-trans-retinoic acid and 9-cis-retinoic acid were able to elevate the expression of the novel gene in primary human tracheobronchial epithelial cells in vitro. This elevation coincided with an enhanced retinol metabolism in these cultures. COS cells transfected with an expression construct of the novel gene were also elevated in the metabolism of retinol. The results suggested that the novel gene represents a new member of the SDR family that may play a critical role in retinol metabolism in airway epithelia as well as in other epithelia of colon, tongue, and esophagus.

Laparascopic excision of pelvic kidney with single vaginal ectopic ureter

An ectopic vaginal ureter is an uncommon cause of urinary incontinence. Most cases are associated with a duplex kidney where the orthotopic lower moiety ureter enters the bladder. The authors present a case of chronic, continuous low-grade urinary incontinence caused by the rare combination of a pelvic kidney and a single ectopic ureter draining into the vagina. This ectopic kidney was successfully removed laparoscopically. A review of the English-language literature showed this to be only the second reported case treated by laparoscopic nephrectomy.

Transthoracic right atrial cannulation for total parenteral nutrition- case report

A man with severe peripheral vascular disease and requiring total parenteral nutrition because of short bowel syndrome was referred because a central venous catheter could not be inserted by conventional techniques. A right thoracotomy was performed and a Hickman catheter inserted via the right atrial appendage into the right atrium. This catheter was used for a total of seven months for total parenteral nutrition. For the last two months of this time, the patient was maintained at home on a Home Parenteral Nutrition Programme. After four months of total parenteral nutrition the patient developed recurrent fevers and the catheter was found to have migrated from the right atrium into the pulmonary artery. The catheter was resited under X-ray control and used for a further three months until the recurrence of fever and dyspnoea heralded the onset of septic pulmonary emboli resulting in his death.