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Purpose: To compare learning strategies used in Problem based learning (PBL) and lectures, and the relations between learning strategies and learning outcomes to determine how different learning strategies associated with PBL and lectures contribute to aspects of clinical competence. Design: The 52-item learning strategies questionnaire was given to preclinical medical students during lecture and PBL sessions in first and third year from 1994 to 1998. Response patterns were compared across the two contexts and factor structures investigated. Regression analyses examined relations between learning strategies and outcomes. Main Outcome Measures/Results: Comparison of responses on the 326 complete pairs of lecture and PBL questionnaires indicated differences at the 0.05 level on 44 of the 52 items. The mean differences were greater than 0.5 (on a 5 point scale) at the 0.001 level for 20 items. Of these, five strategies were used more often in PBL and 15 in lectures. Comparisons of learning strategy use across years showed significant changes with time in both instructional contexts. Principal component analysis revealed a stable factor structure with 4 factors distinctly associated with PBL and 4 factors with the lecture learning context. The remaining 6 factors were mixed and independent of context. Exploratory regression analysis revealed that learning outcomes in examinations were influenced by learning strategies. Multiple choice performance was positively predicted by learning associated with lecture class notes and negatively by group work, whereas the OSCE (objective structured clinical exam) performance was positively predicted by class participation in PBL, self-directed note making and lecture class notes. Conclusion: We have developed a learning strategies questionnaire that shows that students' learning strategies are influenced by instructional context, and patterns of learning strategy use change over time. There is tentative evidence that the students' learning strategies influence learning outcomes.

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OBJECTIVE: To review the evidence for an expanded approach to identifying and treating patients with cobalamin deficiency. Controversy surrounds this issue. Some authors claim that seven times more patients are treated than have true deficiency. New diagnostic tests and identification of patients who have neurologic consequences without hematologic abnormalities suggest that some of these patients have a vitamin B12 tissue deficiency. QUALITY OF EVIDENCE: A MEDLINE search of English-language literature from 1990 to 1995 revealed retrospective and prospective studies of diagnostic tests; prospective surveys; a cohort study; and retrospective and prospective case series, some with control groups. No double-blind controlled trials of treatment were found. MAIN FINDINGS: Some patients with neuropsychiatric abnormalities develop a cobalamin tissue deficiency that can be detected by elevated serum homocysteine and methylmalonic acid levels despite normal serum vitamin B12 levels without macrocytic anemia. Serum cobalamin testing is neither sensitive nor specific in the low normal range for cobalamin deficiency. Treatment recommendations vary because no controlled trials support any recommendations. Oral cobalamin is an underused alternative to parenteral treatment. CONCLUSION: Until the newer diagnostic tests become widely available, family physicians must continue to take a traditional approach to diagnosing vitamin B12 deficiency. There is, however, support for a clinical trial of treatment in patients with neuropsychiatric symptoms.

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Vocational training for general practice in Great Britain developed in local medical communities, often separate from undergraduate teaching associated with universities. Courses for skill development in teaching, support in the form of local trainers' groups, and peer assessment through practice assessment visits have contributed to the success of this model. The experience in the Oxford region can contribute to successful development of community teaching in Canada.

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Epidemiologic evidence on the risks and benefits of hormone replacement therapy (HRT) for postmenopausal women is accumulating. The apparent 50% reduction in risk of cardiovascular mortality could lead to universal HRT. Until a prospective, controlled trial is concluded, women must consider all the consequences of HRT. For the undecided, who would take HRT only to prevent osteoporosis, bone mass estimates might be warranted.

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A retrospective chart audit was undertaken to determine the clinical reasons for vitamin B(12) therapy in family practice. Abnormal laboratory tests and symptoms were the most common reasons for initiating therapy. The high proportion of cases with little supporting evidence of B(12) deficiency suggests that other factors influence treatment decisions.

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Increased reporting of genital herpes has led to claims in the lay press of an epidemic of herpes genitalis. In a study at Queen's University Student Health Service during a nine-month period, a first diagnosis of genital herpes was made in 5.9/1,000 students attending the clinic. Excluding those patients with recurrent illness by history, the incidence of genital herpes was 4.5/1,000. Recovery of the virus was successful in 91 percent of attempted cultures. Complications were low. Genital herpes is an important sexually transmitted disease in the student population, but claims of an epidemic are exaggerated.

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