The impact of deliberate reflection with WISE-MD modules on surgical clerkship students\u27 critical thinking: a prospective, randomized controlled pilot study

Purpose: Critical thinking underlies several Association of American Medical Colleges (AAMC)-defined core entrustable professional activities (EPAs). Critical-thinking ability affects health care quality and safety. Tested tools to teach, assess, improve, and nurture good critical-thinking skills are needed. This prospective randomized controlled pilot study evaluated the addition of deliberate reflection (DR), guidance with Web Initiative in Surgical Education (WISE-MD) modules, to promote surgical clerks\u27 critical-thinking ability. The goal was to promote the application of reflective awareness principles to enhance learning outcomes and critical thinking about the module content. Participants and methods: Surgical clerkship (SC) students were recruited from two different blocks and randomly assigned to a control or intervention group. The intervention group was asked to record responses using a DR guide as they viewed two selected WISE-MD modules while the control group was asked to view two modules recording free thought. We hypothesized that the intervention group would show a significantly greater pre- to postintervention increase in critical-thinking ability than students in the control group. Results: Neither group showed a difference in pre- and posttest free-thought critical-thinking outcomes; however, the intervention group verbalized more thoughtful clinical reasoning during the intervention. Conclusion: Despite an unsupported hypothesis, this study provides a forum for discussion in medical education. It took a sponsored tool in surgical education (WISE-MD) and posed the toughest evaluation criteria of an educational intervention; does it affect the way we think? and not just what we learn, but how we learn it? The answer is significant and will require more resources before we arrive at a definitive answer

The impact of deliberate reflection with WISE-MDTM modules on critical thinking of nurse practitioner students: A prospective, randomized controlled pilot study

Objective: Nurse practitioner (NP) students at our graduate school of nursing use WISE-MDTM simulation modules in the curriculum. This prospective randomized controlled pilot study was undertaken to evaluate critical-thinking outcomes associated with adding metacognitive deliberate-reflection guidance to the learning strategy with WISE-MDTM simulation modules. Methods: Of 33 NP students randomly assigned to intervention and control groups, 16 completed the study. The intervention group received WISE-MDTM learning modules with specific guidance or deliberate reflection. Controls used the modules with instructions for periodic free-thought reflections. Students’ tape-recorded reflections were categorized according to author-developed critical-thinking categories. Data were analyzed using NVIVOTM. Students’ feedback was collected by post-intervention anonymous survey. Results: Critical thinking outcomes (student responses to exercises after free-thinking or deliberate-reflection guidance) did not differ between groups. However, the intervention group demonstrated a higher level of critical thought after deliberate-reflection guidance. Post-intervention quantitative and qualitative feedback from both groups endorsed the value of the WISE-MDTM modules for NP education. Conclusions: Despite no difference in unprompted outcomes between groups, the intervention group often verbalized more thoughtful clinical decision-making. We speculate that the deliberate-reflection guidance intervention utilized with students throughout only two modules was insufficient for them to internalize the critical-thinking process. We propose using free-thought reflections with one or two WISE-MDTM modules to identify struggling students’ clinical decision-making process. These students’ remediation plan could include recording their deliberate-reflection process while viewing WISE-MDTM modules. Students would be guided to verbalize and record their critical-thinking processes for faculty review until students sufficiently integrate the process into their clinical decision-making

wuHMM: a robust algorithm to detect DNA copy number variation using long oligonucleotide microarray data

Copy number variants (CNVs) are currently defined as genomic sequences that are polymorphic in copy number and range in length from 1000 to several million base pairs. Among current array-based CNV detection platforms, long-oligonucleotide arrays promise the highest resolution. However, the performance of currently available analytical tools suffers when applied to these data because of the lower signal:noise ratio inherent in oligonucleotide-based hybridization assays. We have developed wuHMM, an algorithm for mapping CNVs from array comparative genomic hybridization (aCGH) platforms comprised of 385 000 to more than 3 million probes. wuHMM is unique in that it can utilize sequence divergence information to reduce the false positive rate (FPR). We apply wuHMM to 385K-aCGH, 2.1M-aCGH and 3.1M-aCGH experiments comparing the 129X1/SvJ and C57BL/6J inbred mouse genomes. We assess wuHMM's performance on the 385K platform by comparison to the higher resolution platforms and we independently validate 10 CNVs. The method requires no training data and is robust with respect to changes in algorithm parameters. At a FPR of <10%, the algorithm can detect CNVs with five probes on the 385K platform and three on the 2.1M and 3.1M platforms, resulting in effective resolutions of 24 kb, 2–5 kb and 1 kb, respectively

Copy number variant detection in inbred strains from short read sequence data

Summary: We have developed an algorithm to detect copy number variants (CNVs) in homozygous organisms, such as inbred laboratory strains of mice, from short read sequence data. Our novel approach exploits the fact that inbred mice are homozygous at virtually every position in the genome to detect CNVs using a hidden Markov model (HMM). This HMM uses both the density of sequence reads mapped to the genome, and the rate of apparent heterozygous single nucleotide polymorphisms, to determine genomic copy number. We tested our algorithm on short read sequence data generated from re-sequencing chromosome 17 of the mouse strains A/J and CAST/EiJ with the Illumina platform. In total, we identified 118 copy number variants (43 for A/J and 75 for CAST/EiJ). We investigated the performance of our algorithm through comparison to CNVs previously identified by array-comparative genomic hybridization (array CGH). We performed quantitative-PCR validation on a subset of the calls that differed from the array CGH data sets

Heat tolerance predicts the importance of species interaction effects as the climate changes

Few studies have quantified the relative importance of direct effects of climate change on communities versus indirect effects that are mediated thorough species interactions, and the limited evidence is conflicting. Trait-based approaches have been popular in studies of climate change, but can they be used to estimate direct versus indirect effects? At the species level, thermal tolerance is a trait that is often used to predict winners and losers under scenarios of climate change. But thermal tolerance might also inform when species interactions are likely to be important because only subsets of species will be able to exploit the available warmer climatic niche space, and competition may intensify in the remaining, compressed cooler climatic niche space. Here, we explore the relative roles of the direct effects of temperature change and indirect effects of species interactions on forest ant communities that were heated as part of a large-scale climate manipulation at high-A nd low-latitude sites in eastern North America. Overall, we found mixed support for the importance of negative species interactions (competition), but found that the magnitude of these interaction effects was predictable based on the heat tolerance of the focal species. Forager abundance and nest site occupancy of heat-intolerant species were more often influenced by negative interactions with other species than by direct effects of temperature. Our findings suggest that measures of species-specific heat tolerance may roughly predict when species interactions will influence responses to global climate change

Climatic warming destabilizes forest ant communities

How will ecological communities change in response to climate warming? Direct effects of temperature and indirect cascading effects of species interactions are already altering the structure of local communities, but the dynamics of community change are still poorly understood. We explore the cumulative effects of warming on the dynamics and turnover of forest ant communities that were warmed as part of a 5-year climate manipulation experiment at two sites in eastern North America. At the community level, warming consistently increased occupancy of nests and decreased extinction and nest abandonment. This consistency was largely driven by strong responses of a subset of thermophilic species at each site. As colonies of thermophilic species persisted in nests for longer periods of time under warmer temperatures, turnover was diminished, and species interactions were likely altered. We found that dynamical (Lyapunov) community stability decreased with warming both within and between sites. These results refute null expectations of simple temperature-driven increases in the activity and movement of thermophilic ectotherms. The reduction in stability under warming contrasts with the findings of previous studies that suggest resilience of species interactions to experimental and natural warming. In the face of warmer, no-analog climates, communities of the future May become increasingly fragile and unstable

Radio-induced low-grade glioma: report of two cases and review of the literature

With the increasing number of cancer survivors, we can observe a population that will present a higher risk of developing secondary long-term toxicities related to adjuvant chemo and radiotherapy regimens. Among these, children surviving from acute lymphoblastic leukemia (ALL) that were treated with prophylactic cranial irradiation represent a group of patients at a high risk of developing secondary brain tumors. Radiation-induced intracranial tumors have been documented since 1950, and today, more than one-hundred cases have been described. We report our experience with two young patients who were hospitalized for low grade gliomas and had a positive anamnesis for ALL and consequent radiotherapy

Do Relatively More Efficient Firms Demand Additional Audit Effort (Hours)?

We examine whether firms with higher relative efficiency (operational performance) require additional audit effort (hours) to signal audit quality to demonstrate that their financial reporting systems are robust. Therefore, we use a Korean sample of publicly listed firms because of the Korean audit hour policy which mandates that audit hour information be made available for market participants. We find that client firms with higher relative efficiency have higher audit hours, suggesting that management has an incentive to demand additional audit hours for signalling purposes, and that shareholders, amongst other stakeholders, have an incentive to demand external monitoring to reduce potential agency problems. The results show that relative efficiency is a unique measure of firm performance that can provide insights into a client firm's business and audit risk. We also find evidence suggesting that audit firms do not subject clients to a fee (fee per hour) premium based on relative efficiency, supporting our finding that client firms require audit effort for signalling purposes. Thus, our results have important implications for policymakers about audit effort demand

Do Relatively More Efficient Firms Demand Additional Audit Effort (Hours)?

We examine whether firms with higher relative efficiency (operational performance) require additional audit effort (hours) to signal audit quality to demonstrate that their financial reporting systems are robust. Therefore, we use a Korean sample of publicly listed firms because of the Korean audit hour policy which mandates that audit hour information be made available for market participants. We find that client firms with higher relative efficiency have higher audit hours, suggesting that management has an incentive to demand additional audit hours for signalling purposes, and that shareholders, amongst other stakeholders, have an incentive to demand external monitoring to reduce potential agency problems. The results show that relative efficiency is a unique measure of firm performance that can provide insights into a client firm's business and audit risk. We also find evidence suggesting that audit firms do not subject clients to a fee (fee per hour) premium based on relative efficiency, supporting our finding that client firms require audit effort for signalling purposes. Thus, our results have important implications for policymakers about audit effort demand

Study of Intraventricular Cerliponase Alfa for CLN2 Disease

BACKGROUND Recombinant human tripeptidyl peptidase 1 (cerliponase alfa) is an enzyme-replacement therapy that has been developed to treat neuronal ceroid lipofuscinosis type 2 (CLN2) disease, a rare lysosomal disorder that causes progressive dementia in children. METHODS In a multicenter, open-label study, we evaluated the effect of intraventricular infusion of cerliponase alfa every 2 weeks in children with CLN2 disease who were between the ages of 3 and 16 years. Treatment was initiated at a dose of 30 mg, 100 mg, or 300 mg; all the patients then received the 300-mg dose for at least 96 weeks. The primary outcome was the time until a 2-point decline in the score on the motor and language domains of the CLN2 Clinical Rating Scale (which ranges from 0 to 6, with 0 representing no function and 3 representing normal function in each of the two domains), which was compared with the time until a 2-point decline in 42 historical controls. We also compared the rate of decline in the motor–language score between the two groups, using data from baseline to the last assessment with a score of more than 0, divided by the length of follow-up (in units of 48 weeks). RESULTS Twenty-four patients were enrolled, 23 of whom constituted the efficacy population. The median time until a 2-point decline in the motor–language score was not reached for treated patients and was 345 days for historical controls. The mean (±SD) unadjusted rate of decline in the motor–language score per 48-week period was 0.27±0.35 points in treated patients and 2.12±0.98 points in 42 historical controls (mean difference, 1.85; P<0.001). Common adverse events included convulsions, pyrexia, vomiting, hypersensitivity reactions, and failure of the intraventricular device. In 2 patients, infections developed in the intraventricular device that was used to administer the infusion, which required antibiotic treatment and device replacement. CONCLUSIONS Intraventricular infusion of cerliponase alfa in patients with CLN2 disease resulted in less decline in motor and language function than that in historical controls. Serious adverse events included failure of the intraventricular device and device-related infections. (Funded by BioMarin Pharmaceutical and others; CLN2 ClinicalTrials.gov numbers, NCT01907087 and NCT02485899.