Doctors' clinical decision making: using theory to develop an educational intervention

Medical education aims to train students to become safe and effective clinical practitioners. This includes the ability to make safe and effective clinical judgements and decisions (GMC 2009). It is assumed that trainee doctors acquire these skills through the hidden curriculum. This is not necessarily the case. There is reason to believe that medical education should include some explicit training for doctors to improve their clinical judgements and decisions. This is known as training in clinical reasoning. This thesis explored how to enhance doctors' clinical reasoning through effective training. The aims were to develop and evaluate an intervention informed by decision theory to Improve doctors' reasoning about clinical judgements and decisions. A series of empirical studies were conducted to achieve these aims. A systematic review and questionnaire study were conducted to evaluate existing interventions that aimed to enhance doctors' clinical reasoning skills. There was little agreement between medical educators on how to effectively enhance doctors' clinical reasoning through training. However, the minority of interventions that aimed to improve doctors' awareness about their own reasoning processes were effective. Little is known about how to improve the processes doctors use to make clinical judgements and decisions in practice. A qualitative interview study was conducted to explore doctors' views and experiences of how to make effective clinical judgements and decisions. Doctors had limited explicit insight into their own reasoning processes, such as the methods that lead to good decisions and factors that bias their reasoning. A quasi-experimental. study was developed to evaluate the feasibility of an intervention to enhance doctors' understanding about their own reasoning processes. A brief tutorial was shown that explained the basic science underpinning human judgement and decision making. Doctors were receptive to learning about this information. They found it relevant to their clinical practice and gained knowledge about decision sciences concepts. Findings from this thesis suggest that, potentially, doctors can improve their clinical judgements and decisions through training to understand how they think about clinical problems

An Explicit Positivity Preserving Scheme: Application to Biological Model

This paper deals with the construction of nonstandard finite difference method (NFSD) for nonlinear initial value problems modeled by a system of nonlinear ordinary differential equations. The proposed scheme preserves the positivity property as well as the requirement of conservation law and boundedness. In order to illustrate the accuracy of the new scheme, the numerical results compared with the standard ones. Keywords: Positivity, Boundedness, Nonstandard finite difference

The Efficacy of FlexMaster’s IntroFile, PreRaCe and Gates Glidden Drills in Straight-Line Access: A CBCT Assessment

Introduction: An overlooked but important part of successful root canal treatment is a straight-line access (SLA). The purpose of this in vitro study was to compare the efficacy of IntroFile and PreRaCe rotary instruments with Gates Glidden (GG) drills in gaining SLA by cone-beam computed tomography (CBCT). Methods and Materials: A total of forty five extracted mandibular first molars were selected and mounted in dental like arches. Subsequently, they were randomly classified into three groups (n=15). After preparation of a standard access cavity, orifices of the mesiobuccal canal was reached and a #10 file was inserted to explore the canals until the file tip was visible at the apex. Then, preoperative CBCT images were taken. SLA was gained in three groups; group 1, FlexMaster’s IntroFile (FM); group 2, PreRaCe (RC) and group 3, GG. Again, the first binding file at the working length (WL) was placed in the canal and postoperative CBCT images in similar positions were taken. The pre/post operative morphology of the canal was evaluated for changes. Data was analyzed using the one-way ANOVA and post-hoc Bonferroni analysis. Results: The average amount of reduction in coronal canal curvature in FM, RC and GG groups was 2.43±1.79, 3.17±2.05 and 8.7±3.45, respectively. This descending trend was statistically significant. The difference between pre/post SLA changes in FM and RC groups was significant compared to GG group, while there were no significant differences between RC and FM. Conclusion: GG drills produced extraordinary results in reducing coronal curvature of the canal and achieving SLA. They are also more effective than nickel-titanium (NiTi) rotary instruments in canals with coronal curvature

Realist evaluation of UK medical education quality assurance

OBJECTIVES: The aim of the study was to explore what components of the General Medical Council's (GMC) Quality Assurance Framework work, for whom, in what circumstances and how? SETTING: UK undergraduate and postgraduate medical education and training. PARTICIPANTS: We conducted interviews with a stratified sample of 36 individuals. This included those who had direct experiences, as well as those with external insights, representing local, national and international organisations within and outside medicine. INTERVENTION: The GMC quality assure education to protect patient and public safety utilising complex intervention components including meeting standards, institutional visits and monitoring performance. However, the context in which these are implemented matters. We undertook an innovative realist evaluation to test an initial programme theory. Data were analysed using framework analysis. RESULTS: Across components of the intervention, we identified key mechanisms, including transparent reporting to promote quality improvement; dialogical feedback; partnership working facilitating interactions between regulators and providers, and role clarity in conducting proportionate interventions appropriate to risk. The GMC's framework was commended for being comprehensive and enabling a broad understanding of an organisation's performance. Unintended consequences included confusion over roles and boundaries in different contexts which often undermined effectiveness. CONCLUSIONS: This realist evaluation substantiates the literature and reveals deeper understandings about quality assuring medical education. While standardised approaches are implemented, interventions need to be contextually proportionate. Routine communication is beneficial to verify data, share concerns and check risk; however, ongoing partnership working can foster assurance. The study provides a modified programme theory to explicate how education providers and regulators can work more effectively together to uphold education quality, and ultimately protect public safety. The findings have influenced the GMC's approach to quality assurance which impacts on all medical students and doctors in training

Effects of low level laser therapy on mucositis in patients under chemotherapy and bone marrow transplantation

Background: Oral mucositis is among the most important adverse effects of chemotherapy and bone marrow transplantation and prevention from this side effect is important to improve the situations in patients. Hence, in this study the main aim was to determine the effects of low-level laser therapy on mucositis in patients under chemotherapy and bone marrow transplantation. Materials and Methods: In this randomized controlled clinical trial, 60 consecutive patients under chemotherapy and bone marrow transplantation in a training hospital in 2018 were enrolled and randomly assigned to receive either low-level laser therapy (630 and 780 nm) or off-laser. Finally, the frequency rate and severity of mucositis (grades 0 to 4 according to WHO severity index) were determined and compared across the groups. Results: Mucositis was present in 30% and 56.7% in laser and control groups, respectively with statistically significant difference (p=0.037). The severity of mucositis was same across the laser and control groups (p=0.785). Conclusion: Low-level laser therapy is an effective modality for preventing from mucositis in patients treated by chemotherapy and bone marrow transplantation. Accordingly, utilization of this safe and effective therapeutic method is recommended

Evaluating Sleep Disorders amongst Children with Attention Deficit/ Hyperactivity Disorder (ADHD)

Background: The attention deficit/ hyperactivity disorder (ADHD) is one of the most compromising mental disorders of childhood and adolescence. Subsequently, different studies in recent years were conducted on the relationship between sleep disturbances and ADHD in children. About 30% of children and 60% to 80% of adults with ADHD develop sleep disorders, which may result in cognitive and behavioral changes in the patients. The current study aimed at comparing sleep disorders in children with ADHD and their normal peers in Tabriz, Iran. Materials and Methods: The current case-control study was conducted on the target population of children within the age range of 6 to 12 years, which included 50 children with ADHD receiving medication, 55 children with ADHD symptoms without receiving any medication, and 71 normal children, all of which screened from the school students of Tabriz using the child symptom inventory-4 (CSI-4) and selected by the multi-stage cluster sampling method. The children's sleep habits questionnaire (CSHQ) was completed by their mothers and data were analyzed using the multivariate analysis of variance (MANOVA). Results: According to the results of the current study, a significant number of children with ADHD showed sleep disorder that can accounts for some degree of their behavioral dysregulation. There was a significant difference among the study groups regarding the subscales of sleep resistance and sleep duration, daytime sleep, parasomnia,  and sleep apnea (p 0.05). Conclusion: Since children with ADHD usually have more sleep problems, considering the sleep quality in such children is of great importance; in the treatment of such children their sleep problems should be considered particularly

Molecular evaluation of Ex3 VNTR polymorphism of the DRD4 gene in patients with autism spectrum disorder

Abstract Objective Autism Spectrum Disorders (ASDs) are a group of neurodevelopmental disorders that affect social and communication skills. They are characterized by severe communication and social skills disabilities and limited and repetitive activities and their prevalence appear to be steadily increasing. Genes involved in the dopamine pathway may play an important role in the development of autism and this study we evaluated the possible association between Ex3 VNTR polymorphism of the DRD4 gene and autism spectrum disorder in the Iranian population. Materials & Methods In this case-control study,97 children with autism and 103 healthy individuals were selected from the northwestern area of Iran as the case group and the control group, respectively. After genomic extraction from peripheral blood samples by the proteinase K method, the polymerase chain reaction (PCR) technique was used to determine the genotypes of polymorphism. The data then were coded and analyzed using SPSS22 software. Result The results of the study showed that the allele frequencies were different in the two groups and some of these differences were statistically significant. The most common allele in both the ASD and the control group was the 700 bp allele and its frequency was significantly different in the two groups, being more common in the ASD group. (p-value=0.0018). The other allele with a statistically different frequency was the 800 bp allele which was less frequent in the ASD group (p-value=0.0017). Conclusion These results suggest a potential association between Ex3 VNTR polymorphism of the DRD4 gene and autism spectrum disorder in the Iranian population and necessitate further studies evaluating the DRD4 gene

The rs6323 and uVNTR Polymorphisms in the MAOA Gene are Associated with Attention Deficit Hyperactivity Disorder in Iranian Azeri Children

Background: ADHD is the most prevalent psychiatric health issue in youth, which may also affect adults. Environmental and genetic factors both contribute significantly to the development and progression of this condition. Monoamine oxidases, which catalyze the metabolism of dopaminergic neurotransmitters, are involved in the pathogenesis of ADHD. The purpose of this study was to determine the connection between polymorphic variations rs6323 and uVNTR in the (Un translate variable nucleotide tandem repeat) MAO-A gene and the risk for ADHD in Iranian-Azeri children.Methods: Clinical evaluation was used to recruit 137 ADHD patients (female 22, male 115) and 100 controls (female 48, male 52) from the East Azerbaijan region in northern Iran. Genomic DNA was taken from their peripheral blood samples and genotyping was performed using PCR-based amplification of target sites. SPSS (Version 16) and the javastat online statistics program (http://statpages.org/ctab2x2.html) were used for statistical analysis.Results: The rs6323TT genotype was shown to be a significant risk factor for ADHD (OR 3.619, 95 percent CI 0.878-17.213, p = 0.044). In comparison, no significant differences in allele frequencies were observed between ADHD patients and the control group (p > 0.05). The 5R allele of uVNTR was shown to have a substantial protective impact against the development of ADHD (OR0.349, 95 percent confidence interval 0.151-0.797, p = 0.006).Conclusion: Our findings indicate that MAOA gene polymorphisms may play a role in the start and development of ADHD in Iranian-Azeri youngsters. However, more research with larger sample sizes is necessary to corroborate these results

Effectiveness of Brainwave Entrainment in Alpha Band on Working Memory, Anti-Saccade and Anxiety Level of Anxious Participants

The aim of this study was to determine the effect of Brainwave Entrainment in alpha band on working memory, anti-saccade and anxiety level of anxious participants. The present study is a quasi-experimental project of pre-test-post-test with control group. In this regard, after screening 250 university students, 30 anxious participants were selected by Beck anxiety inventory and randomly divided into one experimental group and one control group (15 groups each). All participants were assessed in the pre-test and post-test stages by the Corsi Blocks Tapping test, Antisaccade Task and Beck Anxiety inventory. Participants in the experimental groups received 10 Hz binaural beats for 30 minutes for 5 days a week in a period of one month. Data were analyzed using multivariate analysis of covariance. The findings showed that 10 Hz binaural beats (alpha bands) significantly improved pasticipant's working memory, increased antisaccade and decreased anxiety level. Therefore, brainwave entrainment in the alpha band is recommended as a non-invasive intervention method to reduce the level of anxiety and improve cognitive functions

Developing a Clinical Decision Support System for Prediction Postoperative Coronary Artery Bypass Grafting Infection in Diabetic Patients

Background: Postoperative infection in Coronary Artery Bypass Graft (CABG) is one of the most common complications for diabetic patients, due to an increase in the hospitalization and cost. To address these issues, it is necessary to apply some solutions. Objective: The study aimed to the development of a Clinical Decision Support System (CDSS) for predicting the CABG postoperative infection in diabetic patients.Material and Methods: This developmental study is conducted on a private hospital in Tehran in 2016. From 1061 CABG surgery medical records, we selected 210 cases randomly. After data gathering, we used statistical tests for selecting related features. Then an Artificial Neural Network (ANN), which was a one-layer perceptron network model and a supervised training algorithm with gradient descent, was constructed using MATLAB software. The software was then developed and tested using the receiver operating characteristic (ROC) diagram and the confusion matrix. Results: Based on the correlation analysis, from 28 variables in the data, 20 variables had a significant relationship with infection after CABG (P<0.05). The results of the confusion matrix showed that the sensitivity of the system was 69%, and the specificity and the accuracy were 97% and 84%, respectively. The Receiver Operating Characteristic (ROC) diagram shows the appropriate performance of the CDSS.  Conclusion: The use of CDSS can play an important role in predicting infection after CABG in patients with diabetes. The designed software can be used as a supporting tool for physicians to predict infections caused by CABG in diabetic patients as a susceptible group. However, other factors affecting infection must also be considered for accurate prediction