Background Acquisition of procedures is an important element in health professions education. Traditionally procedures are taught using a "see one - do one" approach. That is a teacher demonstrates and describes a procedure and afterwards the students practice the procedure. A more recent teaching approach for the acquisition of procedural skills was presented by Walker and Peyton. Peyton's teaching approach is a stepwise teaching approach and consists of the following four steps: demonstration, deconstruction, comprehension and performance. The aims of this study were (i) to systematically evaluate the effectiveness of Peyton's 4-step teaching approach on the acquisition of procedural skills in health professions education and (ii) to evaluate whether studies with fewer students per teacher showed a larger between group difference than studies with more students per teacher. Methods We searched in Medline, PsycInfo, Embase and ERIC for eligible studies. Records were screened by two independent reviewers. A random effects meta-analysis was performed to evaluate skill acquisition and time needed to perform the procedures at post-acquisition and retention tests. A meta-regression was used to explore the effect of the number of students per teacher on the estimated effect of the educational interventions. Results An effect size of 0.45 SMD (95% CI [0.15; 0.75]) at post-acquisition and 0.7 SMD (95% CI [-0.09; 1.49]) at retention testing were in favour of Peyton's teaching approach for skill acquisition. The groups using Peyton's teaching approach needed considerably less time to perform the procedure at post-acquisition (SMD: -0.8; 95% [CI -2.13 to 1.62]) and retention (SMD: -2.65; 95% CI [-7.77 to 2.47]) testing. The effectiveness of Peyton's teaching approach was less clear in subgroup analyses using peer teachers. Meta-regression showed that the number of students per teacher was an important moderator variable. Conclusion Peyton's teaching approach is an effective teaching approach for skill acquisition of procedural skills in health professions education. When peer students or student tutors are used as teachers the effectiveness of Peyton's teaching approach is less clear. Peyton's teaching approach is more effective when small groups with few students per teacher are used.

The effectiveness of the Peyton's 4-step teaching approach on skill acquisition of procedures in health professions education: A systematic review and meta-analysis with integrated meta-regression.

Breast cancer is the most common cancer diagnosed among women worldwide and more than half are diagnosed above the age of 60 years. Life expectancy is increasing and the number of breast cancer cases diagnosed among older women are expected to increase. Undertreatment, mostly due to unjustifiable fears of advanced-age and associated comorbidities, is commonly practiced in this group of patients who are under-represented in clinical trials and their management is not properly addressed in clinical practice guidelines. With modern surgery and anesthesia, breast surgeries are considered safe and is usually associated with very low complication rates, regardless of extent of surgery. However, oncoplastic surgery and management of the axilla can be tailored based on patients'- and disease-related factors. Most of chemotherapeutic agents, along with targeted therapy and anti-Human epidermal growth factor receptor-2 (HER2) drugs can be safely given for older patients, however, dose adjustment and close monitoring of potential adverse events might be needed. The recently introduced cyclin-D kinase (CDK) 4/6-inhibitors in combination with aromatase inhibitors (AI) or fulvestrant, which changed the landscape of breast cancer therapy, are both safe and effective in older patients and had substituted more aggressive and potentially toxic interventions. Despite its proven efficacy, adjusting or even omitting adjuvant radiation therapy, at least in low-risk older patients, is safe and frequently practiced. In this paper, we review existing data related to breast cancer management among older patients across the continuum; from resection of the primary tumor through adjuvant chemotherapy, radiation and endocrine therapy up to the management of recurrent and advanced-stage disease. 

Breast Cancer in Geriatric Patients: Current Landscape and Future Prospects

In developing countries, breast cancer is diagnosed at a much younger age. In this study we investigate the dichotomies between older and young breast cancer patients in our region. The study involved two cohorts; older patients (≥ 65 years, n = 553) and younger ones (≤ 40 years, n = 417). Statistical models were used to investigate the associations between age groups, clinical characteristics and treatment outcomes. Compared to younger patients, older patients were more likely to present with advanced-stage disease (20.6% vs. 15.1%, p = .028). However, among those with non-metastatic disease, younger patients tended to have more aggressive pathological features, including positive axillary lymph nodes (73.2% vs. 55.6%, p < .001), T-3/4 (28.2% vs. 13.8%, p < .001) and HER2-positive disease (29.3% vs. 16.3%, p < .001). The 5-year overall survival (OS) rate was significantly better for the younger (72.1%) compared to the older (67.6%), p = .035. However, no significant difference was observed in disease-free survival (DFS) between the two groups.In conclusion, younger patients with breast cancer present with worse clinical and pathological features, albeit a better OS rate. The difference in DFS between the two groups was not insignificant, suggesting that older women were more likely to die from non-cancer related causes.

/pdf/differences-in-clinicopathological-characteristics-treatment-3l852s2400.pdf

Differences in clinicopathological characteristics, treatment, and survival outcomes between older and younger breast cancer patients.

/pdf/the-association-between-guideline-adherence-age-and-overall-le8zsehf.pdf

The association between guideline adherence, age and overall survival among women with non-metastatic breast cancer: A systematic review.

Medical institutions worldwide faced an unprecedented situation during COVID-19 of identifying alternative strategies to sustain the continuum of learning process. This led to several innovations in the traditional medical curriculum. This study explored the effectiveness and feasibility of using the Peyton's framework modified for a virtual platform (Microsoft Teams) for teaching clinical skills to first and second-year medical students at The Aga Khan University, Karachi, Pakistan.In 2020-2021, the modified Peyton's framework was integrated in the clinical skills (CS) curriculum for all first- and second-year students (N=200). For evaluation, a mixed-method design was used, with pre-and post-session questionnaires. Students' satisfaction was obtained through the standard session evaluation tool of the university. For the qualitative arm, to explore the instructors' experiences, purposive sampling was used (n=8) and a focused group discussion (FGD) was conducted. Finally, performance of the students at the end of year summative Objective Structured Clinical Examination (OSCE) was compared with the students of previous year. Quantitative data were analysed using STATA® version 15.1, using paired t-test to compare the differences in OSCE scores in selected CS stations. A p-value of <0.05 was considered significant for all tests. The FGD was transcribed and analysed through manual content analysis.Nine clinical skills (that included history and examination skills) were taught using the virtual platform. There was a significant improvement in post-session questionnaires in seven of these skills (p value <0.01). Session evaluations showed that most students were satisfied with the learning experience. The instructors showed that the online teaching offered a promising platform for teaching history taking skills. The OSCE scores showed mixed results, with significant improvement in two out of four repeated stations by using paired t-test [abdominal exam (87.33 ± 8.99, <0.001); and precordial examination (88.45 ± 8.36, 0.001)].Modifying Peyton's framework to a virtual platform allowed us to sustain the continuum of clinical education during the COVID-19 pandemic. The results support the use of a blended learning environment for teaching clinical skills. 

Teaching Clinical Skills Using Online Modality through Modified Peyton's Framework: An Experience from a Medical University in Pakistan.

Background Radiotherapy (RT) is of critical importance in the locoregional management of early breast cancer. Although RT is routinely used following breast conserving surgery (BCS), patients may occasionally be effectively treated with BCS alone. Currently, the selection of patients undergoing BCS who do not need breast irradiation is under investigation. With the advancement of personalized medicine, there is an increasing interest in reduction of aggressive treatments especially in older women. The primary objective of this study was to identify elderly patients who may forego breast irradiation after BCS without measurable consequences on local tumor growth and survival. Methods We analyzed 2384 early breast cancer patients aged 70 and older who were treated in 17 German certified breast cancer centers between 2001 and 2009. We compared RT versus no RT after guideline adherent (GA) BCS. The outcomes studied were breast cancer recurrence (RFS) and breast cancer-specific survival (BCSS). Low-risk patients were defined by luminal A, tumor size T1 or T2 and node-negative whereas higher-risk patients were defined by patients with G3 or T3/T4 or node-positive or other than Luminal A tumors. To test if there is a difference between two or more survival curves, we used the Gp family of tests of Harrington and Fleming. Results The median age was 77 yrs (mean 77.6±5.6 y) and the median observation time 46 mths (mean 48.9±24.8 mths). 950 (39.8%) patients were low-risk and 1434 (60.2%) were higher-risk. 1298 (54.4%) patients received GA BCS of which 85.0% (1103) received GA-RT and only 15% (195) did not. For low-risk patients with GA-BCS there were no significant differences in RFS (log rank p = 0.651) and in BCSS (p = 0.573) stratified by GA-RT. 5 years RFS in both groups were > 97%. For higher-risk patients with GA-BCS we found a significant difference (p<0.001) in RFS and tumor-associated OS stratified by GA-RT. The results remain the same after adjusting by adjuvant systemic treatment (AST) and comorbidity (ASA and NYHA). Conclusions Patients aged 70 years and older suffering from low-risk early breast cancer with GA-BCS can avoid breast irradiation with <3% chance of relapse. In the case of higher-risk, breast irradiation should be used routinely following GA-BCS. As a side effect of these results, removing the entire breast of elderly low risk patients to spare them from breast irradiation seems to be not necessary.

Effect of adjuvant radiotherapy in elderly patients with breast cancer.

Background and objectives Skills-lab training is crucial for the development of advanced laparoscopic skills. In this study, we examined whether a systematic deconstructive and comprehensive tutoring approach improves training results in laparoscopic suturing and intracorporeal knot tying. Methods Sixteen residents in obstetrics and gynecology participating in structured skills-lab laparoscopy training were randomized in 2 equal-sized groups receiving 1-on-1 tutoring either in the traditional method or according to the Peyton's 4-step approach, involving an additional training step, with the trainees instructing the tutor to perform the exercises. A validated assessment tool (revised Objective Structured Assessment of Technical Skills) and the number of completed square knots per training session and the mean time per knot were used to assess the efficacy of training in both groups. Results Trainees in Peyton's group achieved significantly higher revised Objective Structured Assessment of Technical Skills scores (28.6 vs 23.9 points; P = .05) and were able to improve their scores during autonomous training repetitions, in contrast to the trainees not in Peyton's group (difference +4.75 vs -4.29 points, P = .02). Additionally, they seemed to be able to perform a greater number of successful knots during the exercise and to complete each knot quicker with the later observations failing to reach the threshold of statistical significance. Conclusion Peyton's 4-step approach seemed to be superior for teaching laparoscopic skills to obstetrics and gynecology residents in the skills-lab setting and can be therefore proposed for training curricula.

The Role of Deconstructive Teaching in the Training of Laparoscopy.

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Effect of adjuvant radiotherapy in elderly patients with breast cancer.

The Role of Deconstructive Teaching in the Training of Laparoscopy.