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A nurse practitioner educator and a physician educator, experts in teaching clinical breast examination techniques, review the essential steps of the procedure and emphasize breast cancer detection. Photographs show each step of the procedure.

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BACKGROUND: The 1995-1998 Delta Project was designed to increase breast cancer screening among disadvantaged African American women with limited literacy skills by educating their health care professionals about breast health. The research team intended to provide onsite training and appropriate educational materials; however, they found no suitable materials. This article presents the results of an assessment of available materials and defines the need for suitable materials. METHODS: Nineteen organizations that develop cancer-related publications submitted materials intended for African American audiences. Sixty-one documents were examined for readability and cultural sensitivity. The Flesch Reading Ease (FRE), Flesch-Kincaid (F-K), and Cultural Sensitivity Assessment Tools (CSAT) were used in testing. RESULTS: The mean FRE score of 65 yielded a F-K mean grade level of 7.5 (desired level: 3.5). Using CSAT, 16 documents (26%) were eliminated because they had no visuals. Twenty-two publications (37%) were culturally sensitive for all audiences and 19 (31%) were for white audiences. Four (6%) pieces specifically addressed African American women. CONCLUSIONS: Printed educational materials on breast cancer do not adequately provide information to undereducated, economically disadvantaged African American women.

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The clinical skills of sophomore medical students at the University of Arkansas are being assessed through the use of the Objective Structured Clinical Examination (OSCE). This exam was developed in order to better standardize the evaluation of practical clinical skills. The exam uses standardized patients, who are lay people trained to accurately and consistently portray a patient encounter. Faculty members at UAMS authored clinical cases for 20 patient encounters that test history taking, physical examination and communication skills. Each student interacts with the patient while being assessed in a standardized way, and then is given educational feedback by a faculty member. Students who do not pass the exam, undergo a remediation program prior to entering the junior year.

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In response to the current emphasis on health maintenance and disease prevention, the authors developed a comprehensive education program in which sophomore medical students interview a standardized patient about breast problems and risk factors, receive one-on-one instruction from the standardized patient during the clinical breast examination, and practice recommendations for screening and instruction in breast self-examination. In this pilot study sophomore students who underwent the comprehensive education program were compared with students who received the traditional, didactic instruction and practiced on plastic breast models. The students who received the didactic instruction had mean scores on a multiple-choice knowledge-base pretest and posttest of 54.6% and 76.8%, respectively. The students who participated in the comprehensive education program had mean pretest and posttest scores of 51.2% and 78.5%, respectively. All students participated in a practical test of the clinical breast examination during an objective structured clinical examination. The students who had received the didactic instruction scored 69.9% (mean), compared with 84.1% for the students who had had the comprehensive education program. The comprehensive breast education program teaches medical students about risk factors, screening recommendations, and clinical breast examination more effectively than do traditional didactic methods.

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OBJECTIVE: To evaluate the frequency of association of angiotensin-converting enzyme (ACE) inhibitor therapy with angioneurotic edema and the frequency of correct diagnosis by treating physicians. DESIGN: Retrospective population-based chart review. SETTING: Medicare patients identified with 1991 and 1992 MEDPRO data set. RESULTS: 51 patients were identified from the MEDPRO data sets. Twenty-four patients (47%) had ACE inhibitor-associated angioneurotic edema of whom 17 (71% of the subgroup) had the medication stopped. Twenty-nine percent of the affected patients were discharged still taking an ACE inhibitor. Twenty-six patients (51% of the total population) had non-ACE inhibitor-associated angioneurotic edema and one patient had an uncertain history. CONCLUSION: ACE inhibitor therapy is the number one cause of angioneurotic edema in our hospitalized patient population. Recognition of the association of this drug with the condition was not recognized in 29% of cases and the offending agent was continued upon discharge from the hospital.

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Common variable hypogammaglobulinemia (immunodeficiency), a disorder characterized by late-onset immunoglobulin deficiency and lack of humoral immunity, has a variable association with bronchiectasis, cholelithiasis, nodular lymphoid hyperplasia, gastrointestinal neoplasia, megaloblastic anemia, and malabsorption. The patient described in this report had all of the above except neoplasia. In addition, he had calcium oxalate renal stones probably secondary to his malabsorption. The first case demonstrating the beneficial effect of home hyperalimentation in patients with severe malabsorption refractory to other treatments is described. Home hyperalimentation overnight allows the patient freedom for daily activities while also being more cost-effective than in-hospital parenteral nutrition.

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Light microscopic changes were studied in the dorsal funiculi of spinal cords from rats irradiated (4000 R) at 3 days of age and killed from 9-60 days postirradiation (P-I). The irradiated site was limited to a 5-mm length of mid-thoracic spinal cord (T only) in one group of rats, to a 5-mm length of lumbosacral spinal cord (L only) in a second group, and to 5-mm lengths of both mid-thoracic and lumbosacral spinal cord (T/L) in the third group. Changes in the lumbosacral regions were essentially the same in both L only and T/L irradiated groups. These changes included a decreased neuroglial population and a concurrent state of hypomyelination from 9-30 days P-I. In contrast, in the mid-thoracic regions of T only and T/L irradiated groups the decrease in the neuroglial population was obvious only through 13 days P-I, and by 30 days this population resembled that of the controls. The irradiated mid-thoracic areas were hypomyelinated, with the fasciculus gracilis showing a greater degree of hypomyelination than the fasciculus cuneatus. By 25 days P-I, myelination appeared to be normal in these areas. Scattered hemorrhages were noted in both lumbosacral and mid-thoracic regions, but necrotic areas occurred only at the lumbosacral level. In general, the mid-thoracic area appeared to be less sensitive to x-radiation at 3 days of age than the lumbosacral area. These data suggest that there may be marked differences in the developmental states of cells at these two levels at 3 days of age.

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Schwann cells, Schwann cell myelin, and connective tissue components develop in the spinal cord of the immature rat following exposure to x-rays. For the purposes of this paper, these intraspinal peripheral nervous tissue constituents are referred to as IPNT. A series of investigations are in progress to elucidate factors related to the development of IPNT, and the present study is a light microscopic evaluation of the relationship between the amount of radiation administered (1,000-3,000R) to the lumbosacral spinal cord in 3-day-old rats and the incidence and distribution of IPNT at intervals up to 60 days postirradiation (P-I). The results showed that IPNT was present in only 33% of the rats exposed to 1,000R, whereas its presence was observed in 86% or more of those in the 2,000-, 2,500-, and 3,000R groups. The distribution of IPNT was quite limited in the 1,000R group, where it was restricted to the spinal cord-dorsal root junction and was found in only a few sections within the irradiated area. The distribution was more widespread with increasing amounts of radiation, and IPNT occupied substantial portions of the dorsal funiculi and extended into the dorsal gray matter in the 3,000R group. In all aR mals developing IPNT in the groups receiving 2,000R or more, the IPNT was present in essentially all sections from the irradiated area. Further studies will compare in detail spinal cords exposed to 1,000R in which IPNT is an infrequent, limited occurrence with those exposed to higher doses where IPNT occurs in a more widespread fashion in essentially all animals.

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Schwann cells, peripheral-type myelin and connective tissue elements develop within the dorsal portion of the X-irradiated spinal cord in immature rats. Factors controlling the distribution of these elements within the irradiated site are not fully understood. In the present study [3H]thymidine autoradiography was used to examine proliferative activities of cells in these areas occupied by peripheral nervous system components, and correlative ultrastructural evaluations were made. At 15 and 20 days post-irradiation (P-I), the Schwann cells occupied the dorsolateral portions of the dorsal funiculi, and heavily labeled cells occurred throughout these areas. By 25 days P-I the Schwann cells extended ventrally into the depths of the dorsal funiculi and into the dorsal gray matter, and labeled cells were concentrated in the deeper portions of these areas. Ultrastructurally, the Schwann cells and peripheral-type myelin were more mature in the superficial portions where proliferative activity was diminished. In contrast, much less mature, peripheral-type myelin occurred in the depths where the labeled cells were concentrated. At 30 and 45 days P-I, labeled cells were much less frequent but usually occurred in the depths when observed. Similarly, a dorsal-ventral gradient in maturity of peripheral-type myelin was evident ultrastructurally. By 60 and 90 days P-I, labeling was rare, and mature Schwann cell myelin was present throughout the areas. Astrocytes and their processes were less numerous in regions invaded by Schwann cells, as compared to controls, and studies are in progress to evaluate the relationships between these glial elements and intraspinal peripheral nervous system components.

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