Challenges and Opportunities to Enhance the Clinical Reasoning Skills of Medical Students: Lessons Learned from the Advanced Clinical Transactions Pilot Program

Medical school faculty must foster high-quality patient care while simultaneously assessing the clinical skills and reasoning of students in order to promote their independent functioning in the clinical setting. A growing concern noted across medical faculty is that students may complete their undergraduate medical studies without sufficient understanding of how simple clinical tasks are done with real patients. These concerns have been validated by results from numerous studies that have reported many medical students express a lack of confidence and competence to critically evaluate patient needs based on data, a factor that has been linked to problems in performance and patient safety (Radcliffe and Lester 2003; Seabrook 2004; Chumley et al. 2005; Patey et al. 2007)

The Effect of Sand and Dust Storms (SDSs) and Rain on the Performance of Cellular Networks in the Millimeter Wave Band

Future cellular systems are expected to use millimeter-wave (mm-Wave) frequency bands in addition to the existing microwave bands under 6 GHz. Severe weather conditions, including sand and dust storms (SDSs) and heavy rainfalls, challenge reliable communications over wireless links at those higher frequencies. In such conditions, besides frequency-dependent path-loss, radio signals experience additional attenuation. The SDS attenuation is related to visibility, receiver distance to the storm origin point, soil type, frequency, temperature and humidity. On the other hand, the rainfall attenuation is affected by rainfall rate, polarization, carrier frequency, temperature and raindrop size distribution. Leveraging on experimental measurements carried out in previous works, a novel unified mathematical framework is introduced in this paper to include SDS/rainfall-dependent attenuation in the performance evaluation of terrestrial wireless cellular networks in terms of coverage probability, bit error rate (BER) and achievable rate in the mm-Wave band. Extensive numerical results are presented to show the effects of the different SDS/rainfall parameters on performance, showing that the degradation due to SDS is generally higher than that due to rain and may cause a reduction of even six orders of magnitude in the average achievable bit rate when the frequency increases from 28 to 38 GHz

Lower utilization of primary, specialty and preventive care services by individuals residing with persons in poor health.

BACKGROUND: Since household time and financial resources for health care are primarily spent for those household members with the most urgent health needs, individuals residing with persons in poor health may be at risk of underusing health-care services. We examined whether these individuals had a lower use of primary, specialty and preventive care than those who did not reside with persons in poor health. METHODS: Data collected in 2000 from a representative sample of 8,210 French individuals aged 18 years and older from 3,810 households were analysed with logistic regression models adjusted for health, demographic and socioeconomic variables. RESULTS: We found that individuals residing with one other survey respondent had a higher risk of not using primary care, specialty care and preventive care in the 12 months preceding the study when the health status of the other survey respondent was poorer (fair or alternatively poor versus good). Furthermore, individuals residing with two other survey respondents had a higher risk of not using primary care, specialty care and preventive care in the 12 months preceding the study when they resided with a higher number of respondents in fair or poor health (one or alternatively two versus zero). CONCLUSION: The lower use of health services by individuals residing with persons in poor health may signal a need for health practitioners to broaden the scope of care beyond their patients, and for policy makers to consider the long-term impact of this situation on the health-care system

Exacerbations, Health Resource Utilization, and Costs Among Medicare Beneficiaries with Chronic Obstructive Pulmonary Disease Treated with Nebulized Arformoterol Following a Respiratory Event.

BACKGROUND: Long-acting beta2-agonists (LABAs), with or without inhaled corticosteroids (ICSs), delivered by handheld inhalers or nebulizers are recommended as maintenance therapy in chronic obstructive pulmonary disease (COPD). This study evaluated exacerbations, health resource utilization (HRU), and costs among Medicare beneficiaries with COPD on handheld ICS+LABA who switched to nebulized arformoterol (ARF) or continued ICS+LABA following a respiratory event. METHODS: Using Medicare claims, we identified beneficiaries with COPD (international classification of disease, 9th revision, clinical modification [ICD-9-CM] 490-492.xx, 494.xx, 496.xx) between 2010-2014 who had ≥ 1 year of continuous enrollment in Parts A, B, and D; ≥ 2 COPD-related outpatient visits ≥ 30 days apart or ≥ 1 hospitalization(s); ICS+LABA use 90-days before ARF initiation; and a respiratory event (COPD-related hospitalization or emergency department [ED] visit < 30 days before ARF initiation). Using propensity scores, 423 beneficiaries who switched to ARF were matched to 423 beneficiaries who continued on handheld ICS+LABA (controls). Difference-in-difference regression models examined outcomes at 180-days follow-up. RESULTS: Beneficiaries who switched to ARF had 1.5 fewer exacerbations (p=0.015) but no difference in hospitalizations and ED visits compared to controls. Durable medical equipment (DME) costs were higher among ARF users than controls ($1590), yet total health care costs were similar due to cost offsets by ARF in pharmacy (-$794), inpatient (-$524), and outpatient care (-$65). ARF accounted for 55% ($886.63) of DME costs, with the remaining costs attributed to oxygen therapy ($428.10) and nebulized corticosteroids ($590.85). CONCLUSIONS: Switching from handheld ICS+LABA to nebulized ARF resulted in fewer COPD exacerbations among Medicare beneficiaries. Nebulized LABAs may improve outcomes in selected patients with COPD

Impact of an Individualized Physical Activity Intervention on Improving Mental Health Outcomes in Family Caregivers of Persons with Dementia: A Randomized Controlled Trial

Purpose: This study examined secondary benefits of an individualized physical activity intervention on improving dementia family caregivers’ subjective burden, depressive symptoms and positive affect. Design and Methods: A community-based randomized controlled trial (RCT) was implemented with family caregivers of persons with dementia (N = 211) who received the Enhanced Physical Activity Intervention (EPAI: treatment intervention, n = 106) or the Caregiver Skill Building Intervention (CSBI: control intervention, n = 105). Interventions were delivered over 12 months, including a baseline home visit and regularly spaced telephone calls. Data were collected in person at baseline, 6 and 12-months; and telephonically at 3 and 9-months. The EPAI integrated physical activity and caregiving content while the CSBI focused only on caregiving content. Descriptive, bivariate and intention-to-treat analyses using generalized estimating equations (GEE) were performed to examine secondary benefits of the EPAI on family caregiver burden, depressive symptoms and positive affect. Results: Compared to caregivers in the CSBI group, caregivers in the EPAI significantly increased their overall and total moderate physical activity and showed a positive interaction between the intervention and time for positive affect at both six (p = 0.01) and 12-months (p = 0.03). The EPAI was significantly associated with improving burden at 3 months (p = 0.03) but had no significant effect on depressive symptoms. Implications: Caregiver involvement in an individualized physical activity intervention was associated with increased overall and total moderate physical activity and improved positive affect from baseline to 12 months. Improved positive affect may help caregivers to feel better about themselves and their situation, and better enable them to continue providing care for their family member for a longer time at lower risk to their own mental health