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PubMed2002

Learning the relationship between smoking, drinking alcohol and the risk of esophageal cancer.

This study examined the effect of outcome feedback on learning the multiplicative relationship between daily intakes of tobacco and alcohol, and the risk of esophageal cancer. In the first of two experiments, 65 French adults judged the risk of esophageal cancer associated with combinations of five levels of intake of tobacco and five of wine. They made these judgments both before and after learning sessions in which they were shown the actual risk for each vignette. In the second experiment, 35 French adults underwent the same testing and learning, and were re-tested twice 1 month later. The study hypotheses were supported. First, prior to the learning sessions, the participants used a subadditive rule to combine the perceived risk of esophageal cancer from smoking and drinking. Second, they learned after only one training session to change to the multiplicative rule that is consistent with epidemiological data. Third, this learning persisted for 1 month. This methodology may prove useful in correcting people's underestimation of their health risks.

Adult↗

PubMed2004

Impact of fellowship training on the learning curve for laparoscopic gastric bypass.

BACKGROUND: We have previously shown that the learning curve for laparoscopic Roux-en-Y gastric bypass (LRYGBP) is approximately 75 cases. Patients have worse outcomes during the learning curve. Our aim was to evaluate the impact of fellowship training on outcomes during a surgeon's early experience with LRYGBP. METHODS: The study population consisted of the first 75 consecutive LRYGBP operations attempted by two laparoscopic surgeons, one with laparoscopic gastric bypass fellowship training (Group A) and one without laparoscopic bypass fellowship training (Group B). OUtcome parameters included mortality, major perioperative complications, operative time, and conversion to an open operation. RESULTS: Age, BMI, and gender distribution were similar in both groups. Operative time was significantly longer in Group B (189 min. vs 122 min., P<0.05). Conversion to an open procedure occurred uncommonly in both groups (3%). Major complications occurred more frequently in Group B (13% vs 8%, P=NS). In addition, the complications in Group B were more severe, resulting in 2 deaths. No deaths occurred in Group A. CONCLUSION: Laparoscopic bypass fellowship training improves perioperative outcomes during a surgeon's early experience with LRYGBP.

Adolescent↗

PubMedDate not supplied

Implementing problem-based learning in a family medicine clerkship.

BACKGROUND AND OBJECTIVES: Problem-based learning (PBL) has been implemented in the curriculum of many medical schools, but limited information is available about the outcome of this learning technique. The educational intervention presented in this paper implemented a PBL learning component in our third-year family medicine clerkship and measured the outcomes of this curricular change. METHODS: One third of the curricular time devoted to didactic teaching in our family medicine clerkship was replaced with PBL activities. Simulated cases were developed and presented to students who, with the aid of faculty facilitators, studied the cases, gathered information about the cases, and developed diagnostic and management plans for the cases. The outcome of the intervention was measured by a) comparing students' scores on the National Board of Medical Examiners (NBME) family medicine clerkship examination to scores achieved by students in the year before PBL was introduced and b) students' evaluations of the relevance and success of PBL in the clerkship curriculum. RESULTS: Students' NBME clerkship examination scores increased from a mean of 66 the year before PBL began to 73 after PBL was implemented. More than 80% of students reported that PBL was a good way to learn family medicine, and 85% reported that the PBL technique provided sufficient information to formulate learning issues. CONCLUSIONS: PBL can be introduced into a third-year family medicine clerkship curriculum with general acceptance by students. Students rated the technique highly, and their examination scores improved.

Clinical Clerkship↗

PubMed2006

Determining treatment outcome in early intervention programs for autism spectrum disorders: a critical analysis of measurement issues in learning based interventions.

One of the areas receiving the greatest attention from researchers studying autism spectrum disorders in recent years involves psychologically based early intervention programs. Various claims of cure, marked improvement in social and communication skills, and improved I.Q. are among the conclusions that have been drawn by various researchers. However, little has been done to analyze the dependent variables used in these studies and their impact on the conclusions reached regarding treatment effectiveness. Obviously, this set of measures is crucial since these methods define which behaviors "improved" and to what extent. The present review analyzes the current status, strengths, and weaknesses of these measurements.

Autistic Disorder↗

PubMed1992

Effects of ischemia duration on neurological outcome, CA1 histopathology, and nonmatching to sample learning in monkeys.

BACKGROUND AND PURPOSE: Male cynomolgus monkeys (n = 10) were subjected to varying durations of global cerebral ischemia to determine the relation between dose (ischemic duration) and response (outcome). METHODS: Each monkey was anesthetized with halothane, and global cerebral ischemia was produced by a neck tourniquet and trimethaphan-induced hypotension. The animal was subjected to 3 (n = 3), 9 (n = 3), or 12 (n = 4) minutes of ischemia. Neurological examinations were performed daily for 30 days or until the monkey was neurologically normal. Approximately 1 month after ischemia, the animal was evaluated for evidence of neurobehavioral abnormalities with the nonmatching to sample test. When testing was complete, the monkey was killed with an overdose of pentobarbital and the brain perfused with formalin and removed for histopathologic analysis, with particular attention devoted to the hippocampal CA1 region. RESULTS: Monkeys subjected to 3 or 9 minutes of ischemia were neurologically normal (except for a very mild injury in one 9-minute animal) immediately after ischemia and had normal CA1 histology. Monkeys subjected to 12 minutes of ischemia were grossly abnormal neurologically after ischemia, but two of the four animals made a complete recovery (neurological deficit score of 0) by 30 days. Monkeys subjected to 12 minutes of ischemia had mild damage in the CA1 region, with all other brain regions appearing normal. None of the animals had demonstrable decrements in neurobehavioral function as measured by the nonmatching to sample test. CONCLUSIONS: We conclude that neurobehavioral testing after global cerebral ischemia in primates is feasible, but the ischemic time necessary to produce CA1 damage that could potentially be quantified antemortem with the nonmatching to sample test is greater than 12 minutes in cynomolgus monkeys and may produce temporary severe gross neurological abnormalities as well.

Animals↗

PubMed2001

Barriers and gateways: a study of nursing students' utilisation of learning support resources.

Many first year nursing students require additional academic support from both their lecturers and learning resources. Anecdotal evidence at an Australian university suggested that 'at risk' students did not follow up lecturer referral. This study identified what learning resources were accessed and what factors influenced students' decisions to follow up or not to follow up lecturer referral. First-year nursing students (n =150) were surveyed towards the end of their second semester regarding their use of learning support services. Twelve students were randomly selected and interviewed regarding their use of learning support and their first year learning experience. Demographic data were analyzed using descriptive statistics. Qualitative data were subjected to content analysis. Results revealed learning support utilisation was related to age and publicity but unrelated to gender or culture. Older students entering through non-traditional entry modes displayed a tendency to self refer to learning support. Younger students (<25 years) often lacked effective learning strategies and were reluctant to access on-campus learning support. For all students positive on and off campus support led to positive outcomes. Faculty and learning support lecturers need to foster integration of learning support for all students and encourage peer-learning partnerships within the foundation subjects.

Adult↗

PubMed2001

Student placements--is there evidence supporting team skill development in clinical practice settings?

This paper proposes the clinical setting as an ideal learning environment for the development of skills conductive to collaborative practice. The argument is supported by findings from a small evaluation study. One cohort of physiotherapy students (n = 43) were surveyed immediately prior to their graduation in 1997, regarding their experience of the availability and quality of interprofessional learning opportunities in the various clinical placement areas, that comprised the final and intensive component of their clinical education programme. Their perception of interprofessional learning processes and outcomes was explored and their views as to factors that facilitated or inhibited their learning elicited. Interprofessional learning opportunities were available across the practice spectrum with a slightly more positive 'snapshot' of collaborative practice in the acute sector depicted. Case conferences, team meetings, ward rounds and discharge planning were confirmed as important interprofessional learning activities. Innovative methods of promoting collaborative practice and prerequisite skills, used currently by therapists, acting as clinical educators, emerged as potential strategies for interprofessional clinical education. The importance of the educational skill and orientation of the clinical educator in nurturing team skills development in students was highlighted.

Clinical Clerkship↗

PubMed1996

The operative learning curve and its effect on facial nerve outcome in vestibular schwannoma surgery.

The successful removal of vestibular schwannomas requires a team approach by skillful and appropriately trained surgeons. It is generally perceived that the results of surgery, especially facial nerve outcome, will improve as the surgical team acquires more experience. This study of 300 patients undergoing surgical removal of vestibular schwannomas confirms that there was a significant learning curve for facial nerve outcome. In the first 50 cases, 52% had satisfactory outcomes (House grades I-III), whereas in the last 50 cases 92% had satisfactory outcomes. The major improvement came between the first 50 cases and the second 50 cases (House grades I-III results at 12 months improved from 52% to 78%). After the second 50 patients there was a gradual, but continued improvement, which is also attributable to increased surgical experience. Most of this learning curve was related to the translabyrinthine approach. House grades I-III results were attained for 45% of the first 40 and 70% of the second 40 translabyrinthine tumor removals.

Ear Neoplasms↗

PubMed2005

Human neural learning depends on reward prediction errors in the blocking paradigm.

Learning occurs when an outcome deviates from expectation (prediction error). According to formal learning theory, the defining paradigm demonstrating the role of prediction errors in learning is the blocking test. Here, a novel stimulus is blocked from learning when it is associated with a fully predicted outcome, presumably because the occurrence of the outcome fails to produce a prediction error. We investigated the role of prediction errors in human reward-directed learning using a blocking paradigm and measured brain activation with functional magnetic resonance imaging. Participants showed blocking of behavioral learning with juice rewards as predicted by learning theory. The medial orbitofrontal cortex and the ventral putamen showed significantly lower responses to blocked, compared with nonblocked, reward-predicting stimuli. In reward-predicting control situations, deactivation in orbitofrontal cortex and ventral putamen occurred at the time of unpredicted reward omissions. Responses in discrete parts of orbitofrontal cortex correlated with the degree of behavioral learning during, and after, the learning phase. These data suggest that learning in primary reward structures in the human brain correlates with prediction errors in a manner that complies with principles of formal learning theory.

Adult↗

PubMed2025

Privacy-Enhancing Sequential Learning under Heterogeneous Selection Bias in Multi-Site EHR Data.

OBJECTIVE: To develop privacy-enhancing statistical methods for estimation of binary disease risk model association parameters across multiple electronic health record (EHR) sites with heterogeneous selection mechanisms, without sharing raw individual-level data. We illustrate their utility through a cross-biobank analysis of smoking and 97 cancer subtypes using data from the NIH All of Us (AOU) and the Michigan Genomics Initiative (MGI). MATERIALS AND METHODS: Large-scale biobanks often follow heterogeneous recruitment strategies and store data in separate cloud-based platforms, making centralized algorithms infeasible. To address this, we propose two decentralized sequential estimators namely, Sequential Pseudo-likelihood (SPL) and Sequential Augmented Inverse Probability Weighting (SAIPW) that leverage external population-level information to adjust for selection bias, with valid variance estimation. SAIPW additionally protects against misspecification of the selection model using flexible machine learning based auxiliary outcome models. We compare SPL and SAIPW with the existing Sequential Unweighted (SUW) estimator and with centralized and meta learning extensions of IPW and AIPW in simulations under both correctly specified and misspecified selection mechanisms. We apply the methods to harmonized data from MGI ( n = 50,935) and AOU ( n = 241,563) to estimate smoking-cancer associations. RESULTS: In simulations, SUW exhibited substantial bias and poor coverage. SPL and SAIPW yielded unbiased estimates with valid coverage probabilities under correct model specification, with SAIPW remaining robust under selection model misspecification. Both approaches showed no notable efficiency loss relative to centralized methods. Meta-learning methods were efficient for large sites but failed in settings with small cohort sizes and rare outcome prevalence. In real-data analysis, strong associations were consistently identified between smoking and cancers of the lung, bladder, and larynx, aligning with established epidemiological evidence. CONCLUSION: Our framework enables valid, privacy-enhancing inference across EHR cohorts with heterogeneous selection, supporting scalable, decentralized research using real-world data.

Journal Article↗

PubMed1991

Neurobehavioral sequelae of fetal cocaine exposure.

The number of infants born to cocaine-using mothers has continued to rise during the past 5 years. Maternal cocaine use during pregnancy is associated with medical and life-style characteristics detrimental to fetal and infant development. Cocaine exposure has been independently linked to growth retardation and impaired fetal oxygenation even when polydrug use and other confounding factors are considered. Neurologic and neurobehavioral abnormalities noted in the immediate neonatal period have also been associated with fetal cocaine exposure. The direct and indirect toxic effects of cocaine, per se, have not yet been independently linked to specific behavioral outcomes because of small sample sizes, confounding factors, and lack of long-term follow-up. The impoverished environments and increased risk for out-of-family placement of cocaine-exposed infants are known independent correlates of negative developmental outcomes. Poor maternal nutrition, lack of prenatal care, and other health and life-style factors related to maternal cocaine use during pregnancy also appear to be factors mediating the developmental problems of cocaine-exposed infants. The cocaine-using mother often uses other drugs, particularly alcohol, independently known to be linked to growth and behavioral impairments similar to those proposed for cocaine-exposed infants. Accounting for these multiple confounding variables in studies of the specific effects of cocaine on neurobehavioral outcome may be scientifically appropriate, but in clinical practice these factors cannot be "isolated," and their statistical consideration in studies does not diminish clinical risk. Finally, currently available studies of behavioral outcome have restricted their samples to term infants. It is possible that preterm infants may be less affected by prenatal cocaine exposure because of decreased exposure. However, because epidemiologic studies suggest that prematurity is a sequelae of maternal cocaine use, restriction of samples to term or appropriately sized infants may underestimate the spectrum of morbidity associated with cocaine exposure. We believe that maternal cocaine use during pregnancy is a "marker" variable for early impairments in infant growth and behavioral functioning that have long-term implications for later developmental outcome, especially for learning disabilities and behavioral disorders. Critically assessing the independent contribution of cocaine to negative developmental outcome and determining whether early neonatal abnormalities are permanent or modifiable may allow clinical intervention and improved social policy. Assessing the independent effects of cocaine on child developmental outcome will require carefully designed, long-term, longitudinal, population-based studies with samples large enough to allow multivariate data analyses and statistical control of confounding medical and social variables.

Behavior↗

PubMed2005

Automatically identifying health outcome information in MEDLINE records.

OBJECTIVE: Understanding the effect of a given intervention on the patient's health outcome is one of the key elements in providing optimal patient care. This study presents a methodology for automatic identification of outcomes-related information in medical text and evaluates its potential in satisfying clinical information needs related to health care outcomes. DESIGN: An annotation scheme based on an evidence-based medicine model for critical appraisal of evidence was developed and used to annotate 633 MEDLINE citations. Textual, structural, and meta-information features essential to outcome identification were learned from the created collection and used to develop an automatic system. Accuracy of automatic outcome identification was assessed in an intrinsic evaluation and in an extrinsic evaluation, in which ranking of MEDLINE search results obtained using PubMed Clinical Queries relied on identified outcome statements. MEASUREMENTS: The accuracy and positive predictive value of outcome identification were calculated. Effectiveness of the outcome-based ranking was measured using mean average precision and precision at rank 10. RESULTS: Automatic outcome identification achieved 88% to 93% accuracy. The positive predictive value of individual sentences identified as outcomes ranged from 30% to 37%. Outcome-based ranking improved retrieval accuracy, tripling mean average precision and achieving 389% improvement in precision at rank 10. CONCLUSION: Preliminary results in outcome-based document ranking show potential validity of the evidence-based medicine-model approach in timely delivery of information critical to clinical decision support at the point of service.

Artificial Intelligence↗

PubMed2005

An examination of the structure and nomological network of trainee reactions: a closer look at "smile sheets".

Although D. L. Kirkpatrick (1959, 1996) popularized the concept of trainee reactions over 40 years ago, few studies have critically examined trainees' reactions to learning events. In this article, research on mood and emotion is used to develop a theoretical framework for research on trainee reactions. Two studies examine the factor structure of reactions and their nomological network. In Study 1, 178 undergraduate and 101 graduate students listened to a computer-delivered multimedia lecture. Results suggest that (a) reactions can be conceptualized as hierarchical, with overall satisfaction explaining associations among distinct reaction facets (enjoyment, relevance, and technology satisfaction), and (b) reactions are predicted by trainee characteristics. In Study 2, 97 undergraduates experienced the same lecture in 1 of 3 randomly assigned delivery technologies. Reactions were influenced by technology and were related to learning process (engagement) and outcomes (intentions regarding delivery technology, content, and learning). Both studies support the theoretical framework proposed.

Adult↗

PubMed2006

Using an outcomes-logic-model approach to evaluate a faculty development program for medical educators.

PURPOSE: This study used an outcomes-logic-model approach to examine the impact of participating in a nontraditional professional development program. Building and using a logic model provides a structure for the program to examine the degree that the desired learner outcomes, the program delivery methods, and the measurement approaches are aligned. METHOD: Structured telephone interviews were conducted in 2001 with 16 Harvard Medical School (HMS) participants in the Harvard Macy Program for Physician Educators (HM-PE): five who completed the program in 1998, five in 1999, and six in 2000. Interviews were also conducted with four Faculty Scholars, alumni of the HM-PE program who taught in subsequent programs. In 2004, online questionnaires were sent to the 16 participants and four Faculty Scholars. Immediate outcomes, such as greater use of active learning principles, and intermediate outcomes, such as commitment to medical education, were examined. RESULTS: Of those interviewed in 2001, 80% responded to the 2004 online questionnaire. Thirteen of 16 (81%) HMS respondents reported increased knowledge about and confidence using learner-center teaching methods; 10 of 16 (63%) said they gave fewer lectures and added alternative educational methods. Thirteen of 16 (81%) reported a stronger commitment to the field of medical education: almost one third felt the HM-PE program was a turning point in their careers. CONCLUSIONS: The outcomes logic model provided data to judge how well the program mission and plan were implemented, and whether outcomes had been attained.

Boston↗

PubMed2004

Assessing outcomes of cancer care: lessons to be learned from a retrospective review of the management of small cell lung cancer at the Cancer Therapy Centre, Liverpool Hospital, January 1996-July 2000.

The purpose of the present paper was to review the outcomes of care of small cell lung cancer (SCLC) at one Sydney teaching hospital. A retrospective cohort study was carried out of patients with SCLC seen between January 1996 and July 2000. The main outcomes were relapse-free and overall survival. Secondary outcomes of interest were the uniformity of staging investigations, initial treatment, use of prophylactic cranial irradiation (PCI), patterns of relapse and treatment received following relapse. One hundred and three patients with SCLC were treated at the Liverpool Hospital Cancer Therapy Centre during this period. There were 58 men (56%) and 45 women (44%). Forty-two patients (41%) had limited stage disease (LD) and 61 (59%) had extensive stage disease (ED). There was considerable variation in staging investigations. There was little variation in systemic treatment of SCLC. Only 32 of 42 patients with limited stage SCLC were candidates for thoracic radiotherapy and only seven patients received PCI. Median relapse-free survival was 11.2 months (95% confidence interval (CI): 7.7-14.8) for patients with LD and 6 months (95%CI: 4.4-7.5) for ED. Median overall survival was 15.1 months (95%CI: 11-19.1) for patients with LD and 8.9 months (95%CI: 7.5-10.2) for ED. Some health outcomes similar to that reported in clinical trials can be achieved in clinical practice. Measuring health outcomes is an important process of maintaining quality of care.

Aged↗

PubMed1991

Caring for depression in America: lessons learned from early findings of the medical outcomes study.

Research has documented that depressive disorders are a highly prevalent condition among adults in general population and patient samples and that these disorders are strongly associated with functional limitations. But data have not been available to compare the societal importance of depression to other major health conditions. In addition, although about one-half of persons with psychiatric disorders are believed to have their only contact with health care providers in the primary care sector, research findings suggest that depression often remains undetected and untreated in this secto; and there have been few data on how appropriateness of care for depression differs for patients in different health care delivery systems, or whose care is financed by prepayment or fee-for-service arrangements. As a result, it is not clear which health care systems should be promoted as providing appropriate care for this important psychiatric disorder. Data from the Medical Outcomes Study corroborate and strengthen the conclusion that depression is of considerable clinical and social importance in both outpatient medical and mental health specialty care sectors. Specifically, we have learned that depression is associated with as much limitation in multiple aspects of daily functioning and well-being as are most common chronic medical conditions. In addition, we have found that rates of detection of depressive disorder in the primary care sector are low and influenced by nonclinical factors such as type of payment for services. These findings increase the urgency of improving care for depression in the primary care sector, and of carefully evaluating how changes in the financing and organization of health care delivery systems affect the clinical care of psychiatric disorders.

Adult↗

PubMed2004

Demonstration of the effectiveness and acceptability of self-study module use in residency education.

Educators face increasing challenges to promote lifelong learning skills, to include new content areas in an already full curriculum and to maximize limited resources for curriculum implementation. Self-study modules (hereafter modules) offer potential solutions. Three modules on preventive medicine topics were evaluated in Family Medicine residencies. A retrospective pre-/post-test of a resident's ability to meet the module's objectives was used for evaluation. Additionally, residents rated the appropriateness and acceptability of the modules, their preference for 13 methods of learning, and completed a multiple-choice knowledge test. This study demonstrates the effectiveness of modules at multiple levels of evaluation in accordance with a modified version of Kirkpatrick's hierarchy of levels of evaluation. Residents found the modules to be acceptable and useful. Significant gains were seen in residents' abilities to meet objectives. The multiple-choice knowledge test was used to demonstrate mastery of the module materials at an appropriate performance level for future practitioners. Module use was in the top five choices of preferred learning methods. No correlation was seen between residents' preference for learning using modules and educational outcomes. Modules are an effective and acceptable learning method for residents. Even those who prefer other learning methods show improved educational outcomes.

Humans↗

PubMed2000

The transformative process of residency education.

The author explores a model for transformative learning proposed by the education scholar Victoria Marsick. He begins by outlining Marsick's eight principles (or outcomes) of transformative learning: increased autonomy; increased independence; the ability to separate one's feelings and opinions from those of others; the ability to critically and respectfully examine the views of others; the ability to set personal and professional goals; the ability to see how one's actions affect the system in which one works; the ability to balance and choose among conflicting priorities and at some point transcend self-interest; and the ability to acknowledge one's role in constructing one's reality. Using illustrative examples from his experiences as a resident and a teacher of residents, the author describes each principle of the transformative model. He then suggests how educators can use these principles to ensure a transformative residency experience by which novice professionals become reflective and confident practitioners.

Clinical Competence↗