Narrative descriptions should replace grades and numerical ratings for clinical performance in medical education in the United States

Background: In medical education, evaluation of clinical performance is based almost universally on rating scales for defined aspects of performance and scores on examinations and checklists. Unfortunately, scores and grades do not capture progress and competence among learners in the complex tasks and roles required to practice medicine. While the literature suggests serious problems with the validity and reliability of ratings of clinical performance based on numerical scores, the critical issue is not that judgments about what is observed vary from rater to rater but that these judgments are lost when translated into numbers on a scale. As the Next Accreditation System of the Accreditation Council on Graduate Medical Education (ACGME) takes effect, medical educators have an opportunity to create new processes of evaluation to document and facilitate progress of medical learners in the required areas of competence. Proposal and initial experience: Narrative descriptions of learner performance in the clinical environment, gathered using a framework for observation that builds a shared understanding of competence among the faculty, promise to provide meaningful qualitative data closely linked to the work of physicians. With descriptions grouped in categories and matched to milestones, core faculty can place each learner along the milestones' continua of progress. This provides the foundation for meaningful feedback to facilitate the progress of each learner as well as documentation of progress toward competence. Implications: This narrative evaluation system addresses educational needs as well as the goals of the Next Accreditation System for explicitly documented progress. Educators at other levels of education and in other professions experience similar needs for authentic assessment and, with meaningful frameworks that describe roles and tasks, may also find useful a system built on descriptions of learner performance in actual work settings. Conclusions: We must place medical learning and assessment in the contexts and domains in which learners do clinical work. The approach proposed here for gathering qualitative performance data in different contexts and domains is one step along the road to moving learners toward competence and mastery

Learning on line using WIKI technology: A pilot study in a pediatric clerkship

Methods Students on the Pediatric Clerkship at Jefferson Medical College research case-vignettes in 20 topic areas and discuss their answers in small group with a faculty facilitator to achieve the learning objectives. Using the Blackboard course management system and Learning Objects TeamsLx software one topic area, with 10 case vignettes, was transferred to on line learning and piloted by 14 students divided into 5 groups. Instructions for use of the WIKI communication forum were provided on-line. Each group was assigned 2 case-vignettes. Outcomes data was obtained from questionnaires and student interviews. Results: No student had prior experience with online learning. Although students reported the WIKI as ‘easy to use’ none used it for sharing and collaboration; they used email, phone or in person communication instead. Positives of the WIKI compared to small group format were: high quality, in depth answers; excellent learning from reading the answers; ability to work anytime, anywhere. Negatives were: time – students estimated they spent 5 times as long researching and writing their answers; clinical thinking was not learned as well; social interaction was missing; answers were too detailed and took a long time to read. Students indicated they would like to have online activities such as this as part of their clerkship. Conclusions: On-line instruction on how to use a WIKI was insufficient for this group of students. Further research needs to be done on depth versus breadth of learning, time on task, clinical thinking, social interaction and collaboration using WIKI on line learning

Development and evaluation of an interactive multimedia clinical skills teaching program designed for the pediatric clerkship.

Background and Purpose: The physical examination section of a multimedia program developed to teach infant history and physical examination skills was evaluated. Methods: 71 students participated: one group viewed only the physical examination section (PX), one the history section (HX), one none of the program (CX). Physical examination skills were assessed by direct observation of medical students performing an abdominal exam and scored using a checklist at baseline, immediately after intervention and at the end of the pediatric clerkship. Results were analyzed using ANOVA with repeated measures. Results: Baseline scores were: PX 2.5; HX 2.8. The PX group scored significantly higher immediately post intervention at 6.8 compared to the HX group 3.1. At the end of the clerkship significant differences between the groups remained. Final group mean scores were: PX 5.5, HX 4.4 and CX 2.7. Conclusion: The program improved examination skills with attenuation over 6 weeks

The SABRE project and the SABRE Proof-of-Principle

SABRE aims to directly measure the annual modulation of the dark matter interaction rate with NaI(Tl) crystals. A modulation compatible with the standard hypothesis, in which our Galaxy is immersed in a dark matter halo, has been measured by the DAMA experiment in the same target material. Other direct detection experiments, using different target materials, seem to exclude the interpretation of such modulation in the simplest scenario of WIMP-nucleon elastic scattering. The SABRE experiment aims to carry out an independent search with sufficient sensitivity to confirm or refute the DAMA claim. The goal of the SABRE experiment is to achieve the lowest background rate for a NaI(Tl) experiment (order of 0.1 cpd/kg/keV(ee) in the energy region of interest for dark matter). This challenging goal could be achievable by operating high-purity crystals inside a liquid scintillator veto for active background rejection. In addition, twin detectors will be located in the northern and southern hemispheres to identify possible contributions to the modulation from seasonal or site-related effects. The SABRE project includes an initial Proof-of-Principle phase at LNGS (Italy), to assess the radio-purity of the crystals and the efficiency of the liquid scintillator veto. This paper describes the general concept of SABRE and the expected sensitivity to WIMP annual modulation.The SABRE program is supported by funding from INFN (Italy), NSF (USA), and ARC (Australia Grants: LE170100162, LE16010080, DP170101675, LP150100075). F. Froborg has received funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Sklodowska-Curie grant agreement No 703650. We acknowledge the generous hospitality and constant support of the Laboratori Nazionali del Gran Sasso (Italy)

Why do women invest in pre-pregnancy health and care? A qualitative investigation with women attending maternity services

Background Despite the importance attributed to good pre-pregnancy care and its potential to improve pregnancy and child health outcomes, relatively little is known about why women invest in pre-pregnancy health and care. We sought to gain insight into why women invested in pre-pregnancy health and care. Methods We carried out 20 qualitative in-depth interviews with pregnant or recently pregnant women who were drawn from a survey of antenatal clinic attendees in London, UK. Interviewees were purposively sampled to include high and low investors in pre-pregnancy health and care, with variation in age, partnership status, ethnicity and pre-existing medical conditions. Data analysis was conducted using the Framework method. Results We identified three groups in relation to pre-pregnancy health and care: 1) The “prepared” group, who had high levels of pregnancy planning and mostly positive attitudes to micronutrient supplementation outside of pregnancy, carried out pre-pregnancy activities such as taking folic acid and making changes to diet and lifestyle. 2) The “poor knowledge” group, who also had high levels of pregnancy planning, did not carry out pre-pregnancy activities and described themselves as having poor knowledge. Elsewhere in their interviews they expressed a strong dislike of micronutrient supplementation. 3) The “absent pre-pregnancy period” group, had the lowest levels of pregnancy planning and also expressed anti-supplement views. Even discussing the pre-pregnancy period with this group was difficult as responses to questions quickly shifted to focus on pregnancy itself. Knowledge of folic acid was poor in all groups. Conclusion Different pre-pregnancy care approaches are likely to be needed for each of the groups. Among the “prepared” group, who were proactive and receptive to health messages, greater availability of information and better response from health professionals could improve the range of pre-pregnancy activities carried out. Among the “poor knowledge” group, better response from health professionals might yield greater uptake of pre-pregnancy information. A different, general health strategy might be more appropriate for the “absent pre-pregnancy period” group. The fact that general attitudes to micronutrient supplementation were closely related to whether or not women invested in pre-pregnancy health and care was an unanticipated finding and warrants further investigation.This report is independent research commissioned and funded by the Department of Health Policy Research Programme Pre-Pregnancy Health and Care in England: Exploring Implementation and Public Health Impact, 006/0068

Characterization of SABRE crystal NaI-33 with direct underground counting

Ultra-pure NaI(Tl) crystals are the key element for a model-independent verification of the long standing DAMA result and a powerful means to search for the annual modulation signature of dark matter interactions. The SABRE collaboration has been developing cutting-edge techniques for the reduction of intrinsic backgrounds over several years. In this paper we report the first characterization of a 3.4 kg crystal, named NaI-33, performed in an underground passive shielding setup at LNGS. NaI-33 has a record low K contamination of 4.3 ± 0.2 ppb as determined by mass spectrometry. We measured a light yield of 11.1 ± 0.2 photoelectrons/keV and an energy resolution of 13.2% (FWHM/E) at 59.5 keV. We evaluated the activities of Ra and Th inside the crystal to be 5.9±0.6μBq/kg and 1.6±0.3μBq/kg, respectively, which would indicate a contamination from U and Th at part-per-trillion level. We measured an activity of 0.51 ± 0.02 mBq/kg due to Pb out of equilibrium and a α quenching factor of 0.63 ± 0.01 at 5304 keV. We illustrate the analyses techniques developed to reject electronic noise in the lower part of the energy spectrum. A cut-based strategy and a multivariate approach indicated a rate, attributed to the intrinsic radioactivity of the crystal, of ∼ 1 count/day/kg/keV in the [5–20] keV region.The SABRE program is supported by funding from INFN (Italy), NSF (US

Clinical, radiologic, pathologic, and molecular characteristics of long-term survivors of diffuse intrinsic pontine glioma (DIPG): a collaborative report from the International and European Society for Pediatric Oncology DIPG registries

Purpose Diffuse intrinsic pontine glioma (DIPG) is a brainstem malignancy with a median survival of < 1 year. The International and European Society for Pediatric Oncology DIPG Registries collaborated to compare clinical, radiologic, and histomolecular characteristics between short-term survivors (STSs) and long-term survivors (LTSs). Materials and Methods Data abstracted from registry databases included patients from North America, Australia, Germany, Austria, Switzerland, the Netherlands, Italy, France, the United Kingdom, and Croatia. Results Among 1,130 pediatric and young adults with radiographically confirmed DIPG, 122 (11%) were excluded. Of the 1,008 remaining patients, 101 (10%) were LTSs (survival ≥ 2 years). Median survival time was 11 months (interquartile range, 7.5 to 16 months), and 1-, 2-, 3-, 4-, and 5-year survival rates were 42.3% (95% CI, 38.1% to 44.1%), 9.6% (95% CI, 7.8% to 11.3%), 4.3% (95% CI, 3.2% to 5.8%), 3.2% (95% CI, 2.4% to 4.6%), and 2.2% (95% CI, 1.4% to 3.4%), respectively. LTSs, compared with STSs, more commonly presented at age < 3 or > 10 years (11% v 3% and 33% v 23%, respectively; P < .001) and with longer symptom duration ( P < .001). STSs, compared with LTSs, more commonly presented with cranial nerve palsy (83% v 73%, respectively; P = .008), ring enhancement (38% v 23%, respectively; P = .007), necrosis (42% v 26%, respectively; P = .009), and extrapontine extension (92% v 86%, respectively; P = .04). LTSs more commonly received systemic therapy at diagnosis (88% v 75% for STSs; P = .005). Biopsies and autopsies were performed in 299 patients (30%) and 77 patients (10%), respectively; 181 tumors (48%) were molecularly characterized. LTSs were more likely to harbor a HIST1H3B mutation (odds ratio, 1.28; 95% CI, 1.1 to 1.5; P = .002). Conclusion We report clinical, radiologic, and molecular factors that correlate with survival in children and young adults with DIPG, which are important for risk stratification in future clinical trials

The SABRE Proof of Principle

SABRE is a dark matter direct detection experiment based on NaI(Tl) scintillating crystals. The primary goal of the experiment is to test the dark matter interpretation of the DAMA/LIBRA annual modulation signal. To reach its purpose, SABRE will operate an array of ultra-low background NaI(Tl) crystals within an active veto, based on liquid scintillator. Finally two twin detectors will be used, one in the northern hemisphere at Laboratori Nazionali del Gran Sasso, Italy (LNGS) and the other, first of its kind, in the southern hemisphere, in the Stawell Underground Physic Laboratory (SUPL). The collaboration has successfully developed a NaI(Tl) crystal with the impressive potassium content of about 4 ppb, according to the mass spectroscopy measurements. A value that, if confirmed, would be about 3 times lower than the DAMA/LIBRA crystals one. The first phase of the SABRE experiment, called SABRE Proof of Principle (PoP), aims to prove the achieved radiopurity by direct measurement of crystals at LNGS. This work reports the status of the PoP setup and the recent progresses on the development of low radioactivity NaI(Tl) crystals

Estimating adjusted prevalence ratio in clustered cross-sectional epidemiological data

BACKGROUND: Many epidemiologic studies report the odds ratio as a measure of association for cross-sectional studies with common outcomes. In such cases, the prevalence ratios may not be inferred from the estimated odds ratios. This paper overviews the most commonly used procedures to obtain adjusted prevalence ratios and extends the discussion to the analysis of clustered cross-sectional studies. METHODS: Prevalence ratios(PR) were estimated using logistic models with random effects. Their 95% confidence intervals were obtained using delta method and clustered bootstrap. The performance of these approaches was evaluated through simulation studies. Using data from two studies with health-related outcomes in children, we discuss the interpretation of the measures of association and their implications. RESULTS: The results from data analysis highlighted major differences between estimated OR and PR. Results from simulation studies indicate an improved performance of delta method compared to bootstrap when there are small number of clusters. CONCLUSION: We recommend the use of logistic model with random effects for analysis of clustered data. The choice of method to estimate confidence intervals for PR (delta or bootstrap method) should be based on study design