Developing a viva exam to assess clinical reasoning in pre-registration osteopathy students

Background: Clinical reasoning (CR) is a core capability for health practitioners. Assessing CR requires a suite of tools to encompass a wide scope of contexts and cognitive abilities. The aim of this project was to develop an oral examination and grading rubric for the assessment of CR in osteopathy, trial it with senior students in three accredited university programs in Australia and New Zealand, and to evaluate its content and face validity. Methods: Experienced osteopathic academics developed 20 cases and a grading rubric. Thirty senior students were recruited, 10 from each university. Twelve fourth year and 18 fifth year students participated. Three members of the research team were trained and examined students at an institution different from their own. Two cases were presented to each student participant in a series of vignettes. The rubric was constructed to follow a set of examiner questions that related to each attribute of CR. Data were analysed to explore differences in examiner marking, as well as relationships between cases, institutions, and different year levels. A non-examining member of the research team acted as an observer at each location. Results: No statistical difference was found between the total and single question scores, nor for the total scores between examiners. Significant differences were found between 4th and 5th students on total score and a number of single questions. The rubric was found to be internally consistent. Conclusions: A viva examination of clinical reasoning, trialled with senior osteopathy students, showed face and content validity. Results suggested that the viva exam may also differentiate between 4th and 5th year students’ capabilities in CR. Further work is required to establish the reliability of assessment, to further refine the rubric, and to train examiners before it is implemented as a high-stakes assessment in accredited osteopathy programs

Understanding clinical reasoning in osteopathy: a qualitative research approach.

Background Clinical reasoning has been described as a process that draws heavily on the knowledge, skills and attributes that are particular to each health profession. However, the clinical reasoning processes of practitioners of different disciplines demonstrate many similarities, including hypothesis generation and reflective practice. The aim of this study was to understand clinical reasoning in osteopathy from the perspective of osteopathic clinical educators and the extent to which it was similar or different from clinical reasoning in other health professions. Methods This study was informed by constructivist grounded theory. Participants were clinical educators in osteopathic teaching institutions in Australia, New Zealand and the UK. Focus groups and written critical reflections provided a rich data set. Data were analysed using constant comparison to develop inductive categories. Results According to participants, clinical reasoning in osteopathy is different from clinical reasoning in other health professions. Osteopaths use a two-phase approach: an initial biomedical screen for serious pathology, followed by use of osteopathic reasoning models that are based on the relationship between structure and function in the human body. Clinical reasoning in osteopathy was also described as occurring in a number of contexts (e.g. patient, practitioner and community) and drawing on a range of metaskills (e.g. hypothesis generation and reflexivity) that have been described in other health professions. Conclusions The use of diagnostic reasoning models that are based on the relationship between structure and function in the human body differentiated clinical reasoning in osteopathy. These models were not used to name a medical condition but rather to guide the selection of treatment approaches. If confirmed by further research that clinical reasoning in osteopathy is distinct from clinical reasoning in other health professions, then osteopaths may have a unique perspective to bring to multidisciplinary decision-making and potentially enhance the quality of patient care. Where commonalities exist in the clinical reasoning processes of osteopathy and other health professions, shared learning opportunities may be available, including the exchange of scaffolded clinical reasoning exercises and assessment practices among health disciplines

Understanding clinical reasoning in osteopathy: a qualitative research approach.

BACKGROUND: Clinical reasoning has been described as a process that draws heavily on the knowledge, skills and attributes that are particular to each health profession. However, the clinical reasoning processes of practitioners of different disciplines demonstrate many similarities, including hypothesis generation and reflective practice. The aim of this study was to understand clinical reasoning in osteopathy from the perspective of osteopathic clinical educators and the extent to which it was similar or different from clinical reasoning in other health professions. METHODS: This study was informed by constructivist grounded theory. Participants were clinical educators in osteopathic teaching institutions in Australia, New Zealand and the UK. Focus groups and written critical reflections provided a rich data set. Data were analysed using constant comparison to develop inductive categories. RESULTS: According to participants, clinical reasoning in osteopathy is different from clinical reasoning in other health professions. Osteopaths use a two-phase approach: an initial biomedical screen for serious pathology, followed by use of osteopathic reasoning models that are based on the relationship between structure and function in the human body. Clinical reasoning in osteopathy was also described as occurring in a number of contexts (e.g. patient, practitioner and community) and drawing on a range of metaskills (e.g. hypothesis generation and reflexivity) that have been described in other health professions. CONCLUSIONS: The use of diagnostic reasoning models that are based on the relationship between structure and function in the human body differentiated clinical reasoning in osteopathy. These models were not used to name a medical condition but rather to guide the selection of treatment approaches. If confirmed by further research that clinical reasoning in osteopathy is distinct from clinical reasoning in other health professions, then osteopaths may have a unique perspective to bring to multidisciplinary decision-making and potentially enhance the quality of patient care. Where commonalities exist in the clinical reasoning processes of osteopathy and other health professions, shared learning opportunities may be available, including the exchange of scaffolded clinical reasoning exercises and assessment practices among health disciplines

Weak lensing surveys and the intrinsic correlation of galaxy ellipticities

We explore the possibility that an intrinsic correlation between galaxy ellipticities arising during the galaxy formation process may account for part of the shear signal recently reported by several groups engaged in weak lensing surveys. Using high resolution N-body simulations we measure the projected ellipticities of dark matter halos and their correlations as a function of pair separation. With this simplifying, but not necessarily realistic assumption (halo shapes as a proxy for galaxy shapes), we find a positive detection of correlations up to scales of at least 20 h^-1mpc (limited by the box size). The signal is not strongly affected by variations in the halo finding technique, or by the resolution of the simulations. We translate our 3d results into angular measurements of ellipticity correlation functions and shear variance which can be directly compared to observations. We also measure similar results from simulated angular surveys made by projecting our simulation boxes onto the plane of the sky and applying a radial selection function. Interestingly, the shear variance we measure is a small, but not entirely negligible fraction (from ~10-20 %) of that seen by the observational groups, and the ellipticity correlation functions approximately mimic the functional form expected to be caused by weak lensing. The amplitude depends on the width in redshift of the galaxy distribution. If photometric redshifts are used to pick out a screen of background galaxies with a small width, then the intrinsic correlation may become comparable to the weak lensing signal. Although we are dealing with simulated dark matter halos, whether there is a signal from real galaxies could be checked with a nearby sample with known redshifts.Comment: 12 pages, 11 ps figures, emulateapj.sty, submitted to Ap

In utero exposure to cigarette smoke dysregulates human fetal ovarian developmental signalling

STUDY QUESTION How does maternal cigarette smoking disturb development of the human fetal ovary?<p></p> SUMMARY ANSWER Maternal smoking increases fetal estrogen titres and dysregulates several developmental processes in the fetal ovary.<p></p> WHAT IS KNOWN ALREADY Exposure to maternal cigarette smoking during gestation reduces human fetal ovarian cell numbers, germ cell proliferation and subsequent adult fecundity.<p></p> STUDY DESIGN, SIZE, DURATION The effects of maternal cigarette smoking on the second trimester human fetal ovary, fetal endocrine signalling and fetal chemical burden were studied. A total of 105 fetuses were studied, 56 from mothers who smoked during pregnancy and 49 from those who did not.<p></p> PARTICIPANTS/MATERIALS, SETTING METHODS Ovary, liver and plasma samples were collected from electively terminated, normally progressing, second trimester human fetuses. Circulating fetal hormones, levels of 73 fetal ovarian transcripts, protein localization, density of oocytes/primordial follicles and levels of 16 polycyclic aromatic hydrocarbons (PAHs) in the fetal liver were determined.<p></p> MAIN RESULTS AND THE ROLE OF CHANCE Circulating fetal estrogen levels were very high and were increased by maternal smoking (ANOVA, P = 0.055–0.004 versus control). Smoke exposure also dysregulated (two-way ANOVA, smoking versus gestation weeks interaction, P = 0.046–0.023) four fetal ovarian genes (cytochrome P450 scc [CYP11A1], NOBOX oogenesis homeobox [NOBOX], activator of apoptosis harakiri [HRK], nuclear receptor subfamily 2, group E, member 1 [NR2E1]), shifted the ovarian Inhibin βA/inhibin α ratio (NHBA/INHA) transcript ratio in favour of activin (ANOVA, P = 0.049 versus control) and reduced the proportion of dominant-negative estrogen receptor 2 (ERβ: ESR2) isoforms in half the exposed fetuses. PAHs, ligands for the aryl hydrocarbon receptor (AHR), were increased nearly 6-fold by maternal smoking (ANOVA, P = 0.011 versus control). A fifth transcript, COUP transcription factor 1 (nuclear receptor subfamily 2, group F, member 1: NR2F1, which contains multiple AHR-binding sites), was both significantly increased (ANOVA, P = 0.026 versus control) and dysregulated by (two-way ANOVA, smoking versus gestation weeks interaction, P = 0.021) maternal smoking. NR2F1 is associated with repression of FSHR expression and smoke-exposed ovaries failed to show the normal increase in FSHR expression during the second trimester. There was a significantly higher number of DEAD (Asp-Glu-Ala-Asp) box polypeptide 4 (DDX4) VASA-positive (ANOVA, P = 0.016 versus control), but not POU domain, class 1, transcription factor 1 (POU5F1) OCT3/4-positive, oocytes in smoke-exposed fetuses and this matched with a significantly higher number of primordial follicles (ANOVA, P = 0.024 versus control).<p></p> LIMITATIONS, REASONS FOR CAUTION The effects of maternal smoking on establishment of the maximum fetal primordial follicle pool cannot be reliably studied in our population since the process is not completed until 28 weeks of gestation and normal fetuses older than 21 weeks of gestation are not available for study. Our data suggest that some fetal ovaries are affected by smoke exposure while others are not, indicating that additional studies, with larger numbers, may show more significant effects.<p></p> WIDER IMPLICATIONS OF THE FINDINGS Fetal exposure to chemicals in cigarette smoke is known to lead to reduced fecundity in women. Our study suggests, for the first time, that this occurs via mechanisms involving activation of AHR, disruption of inhibin/activin and estrogen signalling, increased exposure to estrogen and dysregulation of multiple molecular pathways in the exposed human fetal ovary. Our data also suggest that alterations in the ESR2 positive and dominant negative isoforms may be associated with reduced sensitivity of some fetuses to increased estrogens and maternal smoking

The FARMSCAPE approach to farming systems research

Abstract From six years of participatory action research has emerged Farmers', Advisers' and Researchers' Monitoring, Simulation. Communication And Performance Evaluation (FARMSCAPE) as an approach for supporting farmers' management of dryland crop production. In contrast to the strategy of producing decision support software for farmers, FARMSCAPE features simulation-aided discussions about management among farmers, advisers, and (sometimes) researchers. The key is a capability to flexibly simulate the consequences of a wide range of crop and cropland management alternatives in a variable climate at a paddock scale using local soil and weather data. The high level of interest among farmers has led to a current focus on transfer of the technology to agricultural service providers. Keywords: Farming systems, on-farm, simulation, soil monitoring, action research The term "farming systems research" is most commonly used in Australia to mean "research on bio-physical sub-systems aimed at improving systems of farming". Research methodology tends to be a flexible and pragmatic use of formal experimental design and statistical analysis. Experiments are designed to represent aspects of farming sufficiently realistically for results to be meaningful to farmers and advisers but without unnecessarily or overly straining professional standards for methodology concerning making valid comparisons with adequate confidence. In the interest of the former, experiments are often located on commercial farms, and, increasingly, with farmers. A second established way of interpreting the term "farming systems research" is "systems research which is about farming". Here the emphasis is the application to farming of systems concepts and methodologies that have evolved over the past 50 years, mainly outside agriculture. This paradigm has been termed "systems agriculture" (1). Emphasis here is on approaches to learning/ research/ intervention when the system under study does not lend itself readily to scientific experimentation. Feasibility of the latter declines with increases in scale and/or, complexity and temporal variability. Two pools of methodological resources for addressing such systems are available—often termed "hard" and "soft" approaches. "Hard" systems approaches have, at their core, mathematical models of the systems of interest designed to represent the essential aspects of function in relation to environment. But the hard lesson in the main stream of the hard systems movement has been that the approach turns out to be appropriate only to those aspects of systems that are not complicated by people with purposes and freedom of choice (3). The fact that the specific nature of a farm system substantially reflects the design and management efforts of a farmer means that a "soft" systems approach, eg participative action research, should enhance the usefulness and impact of the research on real farming. McCown, RL; Carberry, PS; Foale, MA; Hochman, Z; Coutts, JA; Dalgliesh, NP (1998) The FARMSCAPE approach to farming systems research Proc. 9th Aust. Agron. Conf., Wagga Wagga (1998) 633-636

Longitudinal brain atrophy rates in transient ischemic attack and minor ischemic stroke patients and cognitive profiles

Introduction: Patients with transient ischemic attack (TIA) and minor stroke demonstrate cognitive impairment, and a four-fold risk of late-life dementia. Aim: To study the extent to which the rates of brain volume loss in TIA patients differ from healthy controls and how they are correlated with cognitive impairment. Methods: TIA or minor stroke patients were tested with a neuropsychological battery and underwent T1 weighted volumetric magnetic resonance imaging scans at fixed intervals over a 3 years period. Linear mixed effects regression models were used to compare brain atrophy rates between groups, and to determine the relationship between atrophy rates and cognitive function in TIA and minor stroke patients. Results: Whole brain atrophy rates were calculated for the TIA and minor stroke patients; n = 38 between 24 h and 18 months, and n = 68 participants between 18 and 36 months, and were compared to healthy controls. TIA and minor stroke patients demonstrated a significantly higher whole brain atrophy rate than healthy controls over a 3 years interval (p = 0.043). Diabetes (p = 0.012) independently predicted higher atrophy rate across groups. There was a relationship between higher rates of brain atrophy and processing speed (composite P = 0.047 and digit symbol coding P = 0.02), but there was no relationship with brain atrophy rates and memory or executive composite scores or individual cognitive tests for language (Boston naming, memory recall, verbal fluency or Trails A or B score). Conclusion: TIA and minor stroke patients experience a significantly higher rate of whole brain atrophy. In this cohort of TIA and minor stroke patients changes in brain volume over time precede cognitive decline

Functional near infrared spectroscopy (fNIRS) to assess cognitive function in infants in rural Africa

Cortical mapping of cognitive function during infancy is poorly understood in low-income countries due to the lack of transportable neuroimaging methods. We have successfully piloted functional near infrared spectroscopy (fNIRS) as a neuroimaging tool in rural Gambia. Four-to-eight month old infants watched videos of Gambian adults perform social movements, while haemodynamic responses were recorded using fNIRS. We found distinct regions of the posterior superior temporal and inferior frontal cortex that evidenced either visual-social activation or vocally selective activation (vocal > non-vocal). The patterns of selective cortical activation in Gambian infants replicated those observed within similar aged infants in the UK. These are the first reported data on the measurement of localized functional brain activity in young infants in Africa and demonstrate the potential that fNIRS offers for field-based neuroimaging research of cognitive function in resource-poor rural communities

Functional near infrared spectroscopy (fNIRS) to assess cognitive function in infants in rural Africa

Cortical mapping of cognitive function during infancy is poorly understood in low-income countries due to the lack of transportable neuroimaging methods. We have successfully piloted functional near infrared spectroscopy (fNIRS) as a neuroimaging tool in rural Gambia. Four-to-eight month old infants watched videos of Gambian adults perform social movements, while haemodynamic responses were recorded using fNIRS. We found distinct regions of the posterior superior temporal and inferior frontal cortex that evidenced either visual-social activation or vocally selective activation (vocal > non-vocal). The patterns of selective cortical activation in Gambian infants replicated those observed within similar aged infants in the UK. These are the first reported data on the measurement of localized functional brain activity in young infants in Africa and demonstrate the potential that fNIRS offers for field-based neuroimaging research of cognitive function in resource-poor rural communities