Virtual patient design : exploring what works and why : a grounded theory study

Objectives: Virtual patients (VPs) are online representations of clinical cases used in medical education. Widely adopted, they are well placed to teach clinical reasoning skills. International technology standards mean VPs can be created, shared and repurposed between institutions. A systematic review has highlighted the lack of evidence to support which of the numerous VP designs may be effective, and why. We set out to research the influence of VP design on medical undergraduates. Methods: This is a grounded theory study into the influence of VP design on undergraduate medical students. Following a review of the literature and publicly available VP cases, we identified important design properties. We integrated them into two substantial VPs produced for this research. Using purposeful iterative sampling, 46 medical undergraduates were recruited to participate in six focus groups. Participants completed both VPs, an evaluation and a 1-hour focus group discussion. These were digitally recorded, transcribed and analysed using grounded theory, supported by computer-assisted analysis. Following open, axial and selective coding, we produced a theoretical model describing how students learn from VPs. Results: We identified a central core phenomenon designated ‘learning from the VP’. This had four categories: VP Construction; External Preconditions; Student–VP Interaction, and Consequences. From these, we constructed a three-layer model describing the interactions of students with VPs. The inner layer consists of the student's cognitive and behavioural preconditions prior to sitting a case. The middle layer considers the VP as an ‘encoded object’, an e-learning artefact and as a ‘constructed activity’, with associated pedagogic and organisational elements. The outer layer describes cognitive and behavioural change. Conclusions: This is the first grounded theory study to explore VP design. This original research has produced a model which enhances understanding of how and why the delivery and design of VPs influence learning. The model may be of practical use to authors, institutions and researchers

Scalable Spatial Super-Resolution using Entangled Photons

N00N states -- maximally path-entangled states of N photons -- exhibit spatial interference patterns sharper than any classical interference pattern. This is known as super-resolution. However, even with perfectly efficient number-resolving detectors, the detection efficiency of all previously demonstrated methods to measure such interference decreases exponentially with the number of photons in the N00N state, often leading to the conclusion that N00N states are unsuitable for spatial measurements. Here, we create spatial super-resolution fringes with two-, three-, and four-photon N00N states, and demonstrate a scalable implementation of the so-called ``optical centroid measurement'' which provides an in-principle perfect detection efficiency. Moreover, we compare the N00N-state interference to the corresponding classical super-resolution interference. Although both provide the same increase in spatial frequency, the visibility of the classical fringes decreases exponentially with the number of detected photons, while the visibility of our experimentally measured N00N-state super-resolution fringes remains approximately constant with N. Our implementation of the optical centroid measurement is a scalable method to measure high photon-number quantum interference, an essential step forward for quantum-enhanced measurements, overcoming what was believed to be a fundamental challenge to quantum metrology

Hot isostatic pressing of ceramic waste from spent nuclear fuel.

Argonne National Laboratory has developed a process to immobilize waste salt containing fission products, uranium, and transuranic elements as chlorides in a glass-bonded ceramic waste form. This salt was generated in the electrorefining operation used in electrometallurgical treatment of spent Experimental Breeder Reactor-II fuel. The ceramic waste process culminated with a hot isostatic pressing operation. This paper reviews the installation and operation of a hot isostatic press in a radioactive environment. Processing conditions for the hot isostatic press are presented for non-irradiated material and irradiated material. Sufficient testing was performed to demonstrate that a hot isostatic press could be used as the final step of the processing of ceramic waste for the electrometallurgical spent fuel treatment process

Principal forms X^2 + nY^2 representing many integers

In 1966, Shanks and Schmid investigated the asymptotic behavior of the number of positive integers less than or equal to x which are represented by the quadratic form X^2+nY^2. Based on some numerical computations, they observed that the constant occurring in the main term appears to be the largest for n=2. In this paper, we prove that in fact this constant is unbounded as n runs through positive integers with a fixed number of prime divisors.Comment: 10 pages, title has been changed, Sections 2 and 3 are new, to appear in Abh. Math. Sem. Univ. Hambur

Ineffectiveness of colchicine for the prevention of restenosis after coronary angioplasty

AbstractColchicine, an antimitogenic agent, has shown promise in preventing restenosis after coronary angioplasty in experimental animal models. A prospective trial was conducted involving 197 patients randomized in a 2:1 fashion to treatment with oral colchicine, 0.6 mg twice daily (130 patients), or placebo (67 patients) for 6 months after elective coronary angioplasty. Treatment in all patients began between 12 h before angioplasty and 24 h after angioplasty. Compliance monitoring revealed that 96% of all prescribed pills were ingested. Demographic characteristics were similar in colchicine- and placebo-treated groups. A mean of 2.7 lesions/patient were dilated. Side effects resulted in a 6.9% dropout rate in the colchicine-treated patients.Complete quantitative angiographic follow-up was obtained in 145 patients (74%) with 393 dilated lesions. Quantitative angiographic measurements were obtained in two orthogonal views at baseline before angioplasty and immediately and at 6 months after angioplasty. The quantitative mean lumen diameter stenosis before angioplasty was 67% both in the 152 lesions in the placebo-treated group and in the 241 lesions in the colchkine-treated group; this value was reduced to 24% immediately after angio-plasty in the lesions in both treatment groups.At the 6-month angiogram, lesions had restenosed to 47% lumen diameter narrowing in the placebo-treated group compared with 46% in the colchicine-treated group (p = NS). Forty-one percent of colchicine-treated patients developed restenosis in at least one lesion compared with 45% of the placebo-treated group (p = NS). In conclusion, colchicine was ineffective for preventing restenosis after coronary angioplasty

Virtual patients design and its effect on clinical reasoning and student experience : a protocol for a randomised factorial multi-centre study

Background Virtual Patients (VPs) are web-based representations of realistic clinical cases. They are proposed as being an optimal method for teaching clinical reasoning skills. International standards exist which define precisely what constitutes a VP. There are multiple design possibilities for VPs, however there is little formal evidence to support individual design features. The purpose of this trial is to explore the effect of two different potentially important design features on clinical reasoning skills and the student experience. These are the branching case pathways (present or absent) and structured clinical reasoning feedback (present or absent). Methods/Design This is a multi-centre randomised 2x2 factorial design study evaluating two independent variables of VP design, branching (present or absent), and structured clinical reasoning feedback (present or absent).The study will be carried out in medical student volunteers in one year group from three university medical schools in the United Kingdom, Warwick, Keele and Birmingham. There are four core musculoskeletal topics. Each case can be designed in four different ways, equating to 16 VPs required for the research. Students will be randomised to four groups, completing the four VP topics in the same order, but with each group exposed to a different VP design sequentially. All students will be exposed to the four designs. Primary outcomes are performance for each case design in a standardized fifteen item clinical reasoning assessment, integrated into each VP, which is identical for each topic. Additionally a 15-item self-reported evaluation is completed for each VP, based on a widely used EViP tool. Student patterns of use of the VPs will be recorded. In one centre, formative clinical and examination performance will be recorded, along with a self reported pre and post-intervention reasoning score, the DTI. Our power calculations indicate a sample size of 112 is required for both primary outcomes