Faculty Entrustment of Students in the Core Clerkships: A Comparison between the Longitudinal Integrated Clerkship and the Block Clerkship

INTRODUCTION: Entrustable Professional Activities (EPAs) have been proposed for use in undergraduate medical education. The ability of faculty to entrust students with EPAs may differ between Longitudinal Integrated Clerkships (LICs) and traditional block clerkships. METHODS: Participants were core clerkship faculty, 64 in a LIC and 31 in a sequential block clerkship. We administered a web-based survey at the end of the core clerkship year to measure preceptors’ typical entrustment (on a scale of 0–10) in students for the 13 American Association of Medical Colleges Core EPAs. We compared entrustment between LIC and block faculty using a Mann-Whitney test. RESULTS:LIC faculty were more entrusting of students than block faculty in 12 out of 13 Core EPAs (p DISCUSSION: LIC faculty were more likely than block clerkship faculty to entrust core clerkship students with performance of most EPAs. This finding is likely the result of LIC faculty having increased familiarity with student abilities because of the continuity of supervision and education inherent to LIC. More research is needed to ascertain the specific features of longitudinal clerkships that increase faculty entrustment of students. CONCLUSIONS: Longitudinal educational experiences may facilitate the assessment of medical students with EPAs

Fractional flow reserve versus angiography in guiding management to optimize outcomes in non–ST-elevation myocardial infarction (FAMOUS-NSTEMI): rationale and design of a randomized controlled clinical trial

<p>Background: In patients with acute non–ST-elevation myocardial infarction (NSTEMI), coronary arteriography is usually recommended; but visual interpretation of the angiogram is subjective. We hypothesized that functional assessment of coronary stenosis severity with a pressure-sensitive guide wire (fractional flow reserve [FFR]) would have additive diagnostic, clinical, and health economic utility as compared with angiography-guided standard care.</p> <p>Methods and design: A prospective multicenter parallel-group 1:1 randomized controlled superiority trial in 350 NSTEMI patients with ≥1 coronary stenosis ≥30% severity (threshold for FFR measurement) will be conducted. Patients will be randomized immediately after coronary angiography to the FFR-guided group or angiography-guided group. All patients will then undergo FFR measurement in all vessels with a coronary stenosis ≥30% severity including culprit and nonculprit lesions. Fractional flow reserve will be disclosed to guide treatment in the FFR-guided group but not disclosed in the “angiography-guided” group. In the FFR-guided group, an FFR ≤0.80 will be an indication for revascularization by percutaneous coronary intervention or coronary artery bypass surgery, as appropriate. The primary outcome is the between-group difference in the proportion of patients allocated to medical management only compared with revascularization. Secondary outcomes include the occurrence of cardiac death or hospitalization for myocardial infarction or heart failure, quality of life, and health care costs. The minimum and average follow-up periods for the primary analysis are 6 and 18 months, respectively.</p> <p>Conclusions: Our developmental clinical trial will address the feasibility of FFR measurement in NSTEMI and the influence of FFR disclosure on treatment decisions and health and economic outcomes.</p&gt

U.S. Drinking Water Challenges in the Twenty-First Century

The access of almost all 270 million U.S. residents to reliable, safe drinking water distinguishes the United States in the twentieth century from that of the nineteenth century. The United States is a relatively water-abundant country with moderate population growth; nonetheless, current trends are sufficient to strain water resources over time, especially on a regional basis. We have examined the areas of public water infrastructure, global climate effects, waterborne disease (including emerging and resurging pathogens), land use, groundwater, surface water, and the U.S. regulatory history and its horizon. These issues are integrally interrelated and cross all levels of public and private jurisdictions. We conclude that U.S. public drinking water supplies will face challenges in these areas in the next century and that solutions to at least some of them will require institutional changes

Polarized Narrow-Line Emission from the Nucleus of NGC 4258

The detection of polarized continuum and line emission from the nucleus of NGC 4258 by Wilkes et al. (1995) provides an intriguing application of the unified model of Seyfert nuclei to a galaxy in which there is known to be an edge-on, rotating disk of molecular gas surrounding the nucleus. Unlike most Seyfert nuclei, however, NGC 4258 has strongly polarized narrow emission lines. To further investigate the origin of the polarized emission, we have obtained spectropolarimetric observations of the NGC 4258 nucleus at the Keck-II telescope. The narrow-line polarizations range from 1.0% for [S II] 6716 to 13.9% for the [O II] 7319,7331 blend, and the position angle of polarization is oriented nearly parallel to the projected plane of the masing disk. A correlation between critical density and degree of polarization is detected for the forbidden lines, indicating that the polarized emission arises from relatively dense (n_e > 10^4 cm^-3) gas. An archival Hubble Space Telescope narrow-band [O III] image shows that the narrow-line region has a compact, nearly unresolved core, implying a FWHM size of <2.5 pc. We discuss the possibility that the polarized emission might arise from the accretion disk itself and become polarized by scattering within the disk atmosphere. A more likely scenario is an obscuring torus or strongly warped disk surrounding the inner portion of a narrow-line region which is strongly stratified in density. The compact size of the narrow-line region implies that the obscuring structure must be smaller than ~2.5 pc in diameter.Comment: To appear in the Astronomical Journal. 13 pages, including 1 table and 4 figures. Uses emulateapj.st

Does backreaction enforce the averaged null energy condition in semiclassical gravity?

The expected stress-energy tensor of quantum fields generically violates the local positive energy conditions of general relativity. However, may satisfy some nonlocal conditions such as the averaged null energy condition (ANEC), which would rule out traversable wormholes. Although ANEC holds in Minkowski spacetime, it can be violated in curved spacetimes if one is allowed to choose the spacetime and quantum state arbitrarily, without imposition of the semiclassical Einstein equation G_{ab} = 8 \pi . In this paper we investigate whether ANEC holds for solutions to this equation, by studying a free, massless scalar field with arbitrary curvature coupling in perturbation theory to second order about the flat spacetime/vacuum solution. We "reduce the order" of the perturbation equations to eliminate spurious solutions, and consider the limit in which the lengthscales determined by the incoming state are much larger than the Planck length. We also need to assume that incoming classical gravitational radiation does not dominate the first order metric perturbation. We find that although the ANEC integral can be negative, if we average the ANEC integral transverse to the geodesic with a suitable Planck scale smearing function, then a strictly positive result is obtained in all cases except for the flat spacetime/vacuum solution. This result suggests --- in agreement with conclusions drawn by Ford and Roman from entirely independent arguments --- that if traversable wormholes do exist as solutions to the semiclassical equations, they cannot be macroscopic but must be ``Planck scale''. A large portion of our paper is devoted to the analysis of general issues concerning the nature of the semiclassical Einstein equation and of prescriptions for extracting physically relevant solutions.Comment: 54 pages, 3 figures, uses revtex macros and epsf.tex, to appear in Phys Rev D. A new appendix has been added showing consistency of our results with recent results of Visser [gr-qc/9604008]. Some corrections were made to Appendix A, and several other minor changes to the body of the paper also were mad

The Discovery of a Second Field Methane Brown Dwarf from Sloan Digital Sky Survey Commissioning Data

We report the discovery of a second field methane brown dwarf from the commissioning data of the Sloan Digital Sky Survey (SDSS). The object, SDSS J134646.45-003150.4 (SDSS 1346-00), was selected because of its very red color and stellar appearance. Its spectrum between 0.8-2.5 mic is dominated by strong absorption bands of H_2O and CH_4 and closely mimics those of Gliese 229B and SDSS 162414.37+002915.6 (SDSS 1624+00), two other known methane brown dwarfs. SDSS 1346-00 is approximately 1.5 mag fainter than Gliese 229B, suggesting that it lies about 11 pc from the sun. The ratio of flux at 2.1 mic to that at 1.27 mic is larger for SDSS 1346-00 than for Gliese 229B and SDSS 1624+00, which suggests that SDSS 1346-00 has a slightly higher effective temperature than the others. Based on a search area of 130 sq. deg. and a detection limit of z* = 19.8, we estimate a space density of 0.05 pc^-3 for methane brown dwarfs with T_eff ~ 1000 K in the 40 pc^3 volume of our search. This estimate is based on small-sample statistics and should be treated with appropriate caution.Comment: 9 pages, 3 figures, AASTeX, to appear in ApJ Letters, authors list update

Emission Line Galaxies in the STIS Parallel Survey I: Observations and Data Analysis

In the first three years of operation STIS obtained slitless spectra of approximately 2500 fields in parallel to prime HST observations as part of the STIS Parallel Survey (SPS). The archive contains almost 300 fields at high galactic latitude (|b|>30) with spectroscopic exposure times greater than 3000 seconds. This sample contains 220 fields (excluding special regions and requiring a consistent grating angle) observed between 6 June 1997 and 21 September 2000, with a total survey area of about 160 square arcminutes. At this depth, the SPS detects an average of one emission line galaxy per three fields. We present the analysis of these data, and the identification of 131 low to intermediate redshift galaxies detected by optical emission lines. The sample contains 78 objects with emission lines that we infer to be redshifted [OII]3727 emission at 0.43<z<1.7. The comoving number density of these objects is comparable to that of H-alpha emitting galaxies in the NICMOS parallel observations. One quasar and three probable Seyfert galaxies are detected. Many of the emission-line objects show morphologies suggestive of mergers or interactions. The reduced data are available upon request from the authors.Comment: 58 preprint pages, including 26 figures; accepted for publication in ApJ

Blood pressure variability and cardiovascular risk in the PROspective study of pravastatin in the elderly at risk (PROSPER)

Variability in blood pressure predicts cardiovascular disease in young- and middle-aged subjects, but relevant data for older individuals are sparse. We analysed data from the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) study of 5804 participants aged 70–82 years with a history of, or risk factors for cardiovascular disease. Visit-to-visit variability in blood pressure (standard deviation) was determined using a minimum of five measurements over 1 year; an inception cohort of 4819 subjects had subsequent in-trial 3 years follow-up; longer-term follow-up (mean 7.1 years) was available for 1808 subjects. Higher systolic blood pressure variability independently predicted long-term follow-up vascular and total mortality (hazard ratio per 5 mmHg increase in standard deviation of systolic blood pressure = 1.2, 95% confidence interval 1.1–1.4; hazard ratio 1.1, 95% confidence interval 1.1–1.2, respectively). Variability in diastolic blood pressure associated with increased risk for coronary events (hazard ratio 1.5, 95% confidence interval 1.2–1.8 for each 5 mmHg increase), heart failure hospitalisation (hazard ratio 1.4, 95% confidence interval 1.1–1.8) and vascular (hazard ratio 1.4, 95% confidence interval 1.1–1.7) and total mortality (hazard ratio 1.3, 95% confidence interval 1.1–1.5), all in long-term follow-up. Pulse pressure variability was associated with increased stroke risk (hazard ratio 1.2, 95% confidence interval 1.0–1.4 for each 5 mmHg increase), vascular mortality (hazard ratio 1.2, 95% confidence interval 1.0–1.3) and total mortality (hazard ratio 1.1, 95% confidence interval 1.0–1.2), all in long-term follow-up. All associations were independent of respective mean blood pressure levels, age, gender, in-trial treatment group (pravastatin or placebo) and prior vascular disease and cardiovascular disease risk factors. Our observations suggest variability in diastolic blood pressure is more strongly associated with vascular or total mortality than is systolic pressure variability in older high-risk subjects

Isolation of an Asymmetric RNA Uncoating Intermediate for a Single-Stranded RNA Plant Virus

AbstractWe have determined the three-dimensional structures of both native and expanded forms of turnip crinkle virus (TCV), using cryo-electron microscopy, which allows direct visualization of the encapsidated single-stranded RNA and coat protein (CP) N-terminal regions not seen in the high-resolution X-ray structure of the virion. The expanded form, which is a putative disassembly intermediate during infection, arises from a separation of the capsid-forming domains of the CP subunits. Capsid expansion leads to the formation of pores that could allow exit of the viral RNA. A subset of the CP N-terminal regions becomes proteolytically accessible in the expanded form, although the RNA remains inaccessible to nuclease. Sedimentation velocity assays suggest that the expanded state is metastable and that expansion is not fully reversible. Proteolytically cleaved CP subunits dissociate from the capsid, presumably leading to increased electrostatic repulsion within the viral RNA. Consistent with this idea, electron microscopy images show that proteolysis introduces asymmetry into the TCV capsid and allows initial extrusion of the genome from a defined site. The apparent formation of polysomes in wheat germ extracts suggests that subsequent uncoating is linked to translation. The implication is that the viral RNA and its capsid play multiple roles during primary infections, consistent with ribosome-mediated genome uncoating to avoid host antiviral activity