A case-specific method of evaluating clinical skills is presented. The instrument is described together with its evaluation based on results from ninety-two medical students. The method involves direct observation, by pairs of teachers, of student encounters with simulated patients. The purpose of this paper is to explore the methodology of assessing clinical competence. Three aspects of this are addressed: reliability between teachers acting as observers, and the relationship of both observations of process measures and self-assessments with the students' understanding of the patient. Three aspects of clinical skills were evaluated; interviewing, problem orientation and physical examination. The results showed the observers to be highly reliable in observing physical examination but to have a wide range of reliability across cases in their observations of the other aspects of clinical skill. There was no correlation between both teachers' observations and the students' self-assessments with the students' understanding of the patient. This is a worrying finding. The implications of this study are that evaluation of the process of clinical skills is difficult methodologically and, added to which, it is not clear what relevance these observations have to clinical competence. Rather than effort being devoted to refining instruments to measure the process of clinical skills it would seem preferable to devote energy to assessing students' abilities in diagnosis and management, at least until we understand what observations of clinical skills are measuring.
We prospectively measured levels of factors XI and XII in parallel with other coagulation factors in 39 unselected patients with liver disease and in 20 control subjects. Mean levels of factors XI and XII in subjects with liver disease were significantly reduced, being 58% and 61%, respectively, compared with 100% and 94% in controls. Reductions in levels of factors XI and XII were most pronounced in those subjects with low serum albumin. The partial thromboplastin time (APTT) reflected low levels of either factor XI or XII and was most prolonged when both were low, but cause and effect was not demonstrated. Low levels of these factors may explain previous reports of poor response of APTT to infusions of prothrombin complex concentrates. Finally, these low levels strongly suggest that factors XI and XII are produced in the liver.
In a randomized trial to determine whether oral vitamin E reduced stages III and IV bronchopulmonary dysplasia (BPD) by 50%, 268 infants were randomly allocated, after stratification by birth weight and severity of disease, to receive vitamin E 25 units or an indistinguishable placebo. The experimental (E) group and the control (C) group were similar in weight, gestational ages, Apgar scores, severity of illness, and initial oxygen and ventilator exposure. Serum vitamin E levels were significantly different within 48 h of administration and remained well above normal adult levels from the first week of life in the experimental group. There was no difference in the rates of early death, BPD at 28 days, or mortality from BPD. Severity was similar and no difference was seen in the incidence of necrotizing enterocolitis or sepsis. There was no evidence that vitamin E supplementation offered protection against chronic lung disease in infants less than 1,500 g birth weight.
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