IntroductionFor assessment to fill an educational role, students must see the results generated by assessment as valuable, and actively engage with this feedback in order to support learning. Few studies include examinees as stakeholders in validation beyond general notions of acceptability. Here, we explore students as stakeholders in the validation of a newly implemented assessment.MethodsA student-relevant validity framework based on the unified theory of validity was created and adapted to a survey format. Likert-style items were used to examine first- and second-year medical students’ perceptions of a new cumulative assessment, with several open-ended items. Analysis included: mean ratings per subscale of validity evidence, thematic analysis of comments, and a correlation between questionnaire subscores and exam performance.ResultsSeventy-seven students participated (20.5%). Student perceptions of the assessment were favourable, with significantly different ratings across validity evidence (Response Process (4.8 (SD = 0.7); scored/6), Content (4.6(0.9)), Consequential (4.4(0.8)), Internal Structure (4.2(0.9)), and Relationship to Other Variables (4.0(1.0))). Exam performance correlated with subscores for Relationship to Other Variables (r = 0.34, p < 0.005) and Response Process (r = 0.24, p < 0.05).DiscussionStudents perceived the assessment as facilitating learning, providing ‘checkpoints’, and were disappointed when it did not meet their expectations regarding the purpose of assessment. If students perceive that results do not reflect their future performance in clinical environments, or do not align with their perceived purpose of assessment, the educational value of assessment may be limited. It is critical to understand when, and how students engage in interpreting and integrating assessment-generated feedback to ensure that assessment contributes positively to learning.
INTRODUCTION: Mesalamine, a 5-ASA agent, is used as first line treatment in mild to moderate IBD. Adverse reactions include GI symptoms and often do not require discontinuation of therapy. Inflammation of the myocardium (myocarditis) is a rare but potentially lethal complication of mesalamine treatment. Early recognition and intervention is vital to prevent progression of inflammation and adverse patient outcomes. CASE DESCRIPTION/METHODS: A 62-year-old woman presented with an 8 month history of GI symptoms. Colonoscopy demonstrated patchy colonic inflammation which was biopsy confirmed. She was treated with mesalamine 500 mg PO OD. At a 6-week follow up visit, she had mild dyspnea and chest discomfort, but a direct causal relationship with mesalamine was not delineated. Due to persistent GI symptoms, her mesalamine dose was increased to 2 g PO BID. After 9 days her cardiorespiratory symptoms worsened. She was advised to discontinue mesalamine and seek emergency care. She was admitted to the CCU where an echocardiogram demonstrated an EF of 15%. Ischemic heart disease was ruled out with cardiac catheterization. Cardiac MRI was consistent with myocarditis. She was started on prednisone 20 mg OD. Following discontinuation of mesalamine with prednisone treatment, her cardiorespiratory symptoms improved. Follow-up echocardiogram showed minimal improvement (EF 20%). DISCUSSION: Mesalamine associated myocarditis is a rare phenomenon that presents 2-4 weeks after initiation of therapy. It is associated with severe clinical sequelae including myocardial dysfunction and death. Early case reports suspected the cause was the sulfapyridine group of sulfasalazine. There have been subsequent case reports of myocarditis from 5-ASA alone. The mechanism is believed to be a hypersensitivity reaction rather than direct cardiotoxicity. Supporting this theory are reports of return of symptoms when a 5-ASA agent is reintroduced. Clinical presentation is variable, and patients may present with normal laboratory and imaging studies. Myocarditis can rarely represent an extra intestinal manifestation of IBD. The improvement of this patient’s symptoms with discontinuation of mesalamine, and the temporal relationship between symptom onset and initiation of mesalamine favors mesalamine induced myocarditis. Given the significant consequences of this rare adverse reaction, dyspnea and chest discomfort in a patient on mesalamine should evoke prompt and permanent discontinuation of the drug. Delayed recognition can lead to patient morbidity.
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