Too Smart to Fail: Guide for the Struggling Medical Student

Medicine is a vocation of perpetual independent learning; long-term success is critically dependent on finding the right resources and establishing effective study methods and test-taking strategies. Students who struggle with the academic transition in medical school have common risk factors and characteristics. We highlight key resources that are available for struggling medical students with an emphasis on West Virginia\u27s HELP, ASPIRE, and STAT programs

Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR): study protocol for a phase II randomised feasibility study of a multidisciplinary rehabilitation package following hip fracture

Objective: To conduct a rigorous feasibility study for a future definitive parallel-group randomised controlled trial (RCT) and economic evaluation of an enhanced rehabilitation package for hip fracture.Setting: Recruitment from 3 acute hospitals in North Wales. Intervention delivery in the community.Participants: Older adults (aged ≥65) who received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by clinical team) and received rehabilitation in the North Wales area.Intervention: Remote randomisation to usual care (control) or usual care+enhanced rehabilitation package (intervention), including six additional home-based physiotherapy sessions delivered by a physiotherapist or technical instructor, novel information workbook and goal-setting diary.Primary and secondary outcome measures: Primary: Barthel Activities of Daily Living (BADL). Secondary measures included Nottingham Extended Activities of Daily Living scale (NEADL), EQ-5D, ICECAP capability, a suite of self-efficacy, psychosocial and service-use measures and costs. Outcome measures were assessed at baseline and 3-month follow-up by blinded researchers.Results: 62 participants were recruited, 61 randomised (control 32; intervention 29) and 49 (79%) completed 3-month follow-up. Minimal differences occurred between the 2 groups for most outcomes, including BADL (adjusted mean difference 0.5). The intervention group showed a medium-sized improvement in the NEADL relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen's d 0.63), and a trend for greater improvement in self-efficacy and mental health, but with small effect sizes. The mean cost of delivering the intervention was £231 per patient. There was a small relative improvement in quality-adjusted life year in the intervention group. No serious adverse events relating to the intervention were reported.Conclusions: The trial methods were feasible in terms of eligibility, recruitment and retention. The effectiveness and cost-effectiveness of the rehabilitation package should be tested in a phase III RCT

Broadleaf Forest Raw Recruitment Data

In humid, broadleaf-dominated forests where gap dynamics and partial canopy mortality appears to dominate the disturbance regime at local scales, paleoecological evidence shows alteration at regional-scales associated with climatic change. Yet, little evidence of these broad-scale events exists in extant forests. To evaluate the potential for the occurrence of large-scale disturbance, we used 76 tree-ring collections spanning ∼840 000 km2 and 5327 tree recruitment dates spanning ∼1.4 million km2 across the humid eastern United States. Rotated principal component analysis indicated a common growth pattern of a simultaneous reduction in competition in 22 populations across 61 000 km2. Growth-release analysis of these populations reveals an intense and coherent canopy disturbance from 1775 to 1780, peaking in 1776. The resulting time series of canopy disturbance is so poorly described by a Gaussian distribution that it can be described as “heavy tailed,” with most of the years from 1775 to 1780 comprising the heavy-tail portion of the distribution. Historical documents provide no evidence that hurricanes or ice storms triggered the 1775–1780 event. Instead, we identify a significant relationship between prior drought and years with elevated rates of disturbance with an intense drought occurring from 1772 to 1775. We further find that years with high rates of canopy disturbance have a propensity to create larger canopy gaps indicating repeated opportunities for rapid change in species composition beyond the landscape scale. Evidence of elevated, regional-scale disturbance reveals how rare events can potentially alter system trajectory: a substantial portion of old-growth forests examined here originated or were substantially altered more than two centuries ago following events lasting just a few years. Our recruitment data, comprised of at least 21 species and several shade-intolerant species, document a pulse of tree recruitment at the subcontinental scale during the late-1600s suggesting that this event was severe enough to open large canopy gaps. These disturbances and their climatic drivers support the hypothesis that punctuated, episodic, climatic events impart a legacy in broadleaf-dominated forests centuries after their occurrence. Given projections of future drought, these results also reveal the potential for abrupt, meso- to large-scale forest change in broadleaf-dominated forests over future decades

The Legacy of Episodic Climatic Events in Shaping Temperate, Broadleaf Forests

In humid, broadleaf-dominated forests where gap dynamics and partial canopy mortality appears to dominate the disturbance regime at local scales, paleoecological evidence shows alteration at regional-scales associated with climatic change. Yet, little evidence of these broad-scale events exists in extant forests. To evaluate the potential for the occurrence of large-scale disturbance, we used 76 tree-ring collections spanning approx. 840 000 sq km and 5327 tree recruitment dates spanning approx. 1.4 million sq km across the humid eastern United States. Rotated principal component analysis indicated a common growth pattern of a simultaneous reduction in competition in 22 populations across 61 000 km2. Growth-release analysis of these populations reveals an intense and coherent canopy disturbance from 1775 to 1780, peaking in 1776. The resulting time series of canopy disturbance is so poorly described by a Gaussian distribution that it can be described as ''heavy tailed,'' with most of the years from 1775 to 1780 comprising the heavy-tail portion of the distribution. Historical documents provide no evidence that hurricanes or ice storms triggered the 1775-1780 event. Instead, we identify a significant relationship between prior drought and years with elevated rates of disturbance with an intense drought occurring from 1772 to 1775. We further find that years with high rates of canopy disturbance have a propensity to create larger canopy gaps indicating repeated opportunities for rapid change in species composition beyond the landscape scale. Evidence of elevated, regional-scale disturbance reveals how rare events can potentially alter system trajectory: a substantial portion of old-growth forests examined here originated or were substantially altered more than two centuries ago following events lasting just a few years. Our recruitment data, comprised of at least 21 species and several shade-intolerant species, document a pulse of tree recruitment at the subcontinental scale during the late-1600s suggesting that this event was severe enough to open large canopy gaps. These disturbances and their climatic drivers support the hypothesis that punctuated, episodic, climatic events impart a legacy in broadleaf-dominated forests centuries after their occurrence. Given projections of future drought, these results also reveal the potential for abrupt, meso- to large-scale forest change in broadleaf-dominated forests over future decades

Supplement 1. Spreadsheet with raw recruitment data in different bins, references from which these data are drawn, and reasons for rejecting potential data from additional references.

<h2>File List</h2><div> <p>File with all studies with potential tree recruitment data - <a href="BroadleafForestRawRecruitmentDataAllRecruitRefs.csv">BroadleafForestRawRecruitmentDataAllRecruitRefs.csv</a> (MD5: 54f0fd574b2b01af437054628333eb59)</p> <p>Rejected studies with potential tree recruitment data with rejection justification - <a href="BroadleafForestRawRecruitmentDataRejectedRecruitRefs.pdf">BroadleafForestRawRecruitmentDataRejectedRecruitRefs.pdf</a> (MD5: de048df6fda4f9d5f8df66736b649fef)</p> <p>Raw tree recruitment data from sources in 10 yr bins - <a href="BroadleafForestRawRecruitmentDataRecruitment10yrBins.csv">BroadleafForestRawRecruitmentDataRecruitment10yrBins.csv</a> (MD5: 160c1bd36ee13b2a59638b57f5be83d3)</p> <p>Raw tree recruitment data from sources in 20 yr bins – <a href="BroadleafForestRawRecruitmentDataRecruitment20yrBins.csv">BroadleafForestRawRecruitmentDataRecruitment20yrBins.csv</a> (MD5: 47b08d2030c8429ed8af9268fc03fa4f)</p> <p>Raw tree recruitment data from sources in 25 yr bins – <a href="BroadleafForestRawRecruitmentDataRecruitment25yrBins.csv">BroadleafForestRawRecruitmentDataRecruitment25yrBins.csv</a> (MD5: 8370085c0949841b03a312875be9fd30)</p> <p>Raw tree recruitment data from sources in 50 yr bins – <a href="BroadleafForestRawRecruitmentDataRecruitment50yrBins.csv">BroadleafForestRawRecruitmentDataRecruitment50yrBins.csv</a> (MD5: 640c87488a975d3ebf285bec2f6db1c7)</p> </div><h2>Description</h2><div> <p>The *.csv spreadsheets includes the raw data of tree recruitment drawn from previously-published studies or recruitment dates from unpublished studies and data sets across the eastern United States. Forest types that would not expected to have episodic recruitment, i.e., broadleaf-dominated forests, were the focus of this collection of recruitment dates. The data does include recruitment dates from conifers because they were present in mixed forests. As stated in the paper, "<i>We examined a larger area than that of the 76 chronologies for disturbance detection because a review of independent and geographically-dispersed studies explicitly discussed a recruitment event, broad compositional change, or stand initiation dates in the late-1600s </i>(Huntington 1914, Haasis 1923, Hough and Forbes 1943, Henry and Swan 1974, Grimm 1983, Guyette et al. 1994, Rentch 2003). Also, we only focused on the period prior to 1850 because of the lareg-scale impacts on forests that occurred after that time.</p> <p>We first sought out potential papers with trees recruitment data from broadleaf-dominated old-growth forests. We then determined which ones had usable data, which ones were duplicates, and so on (please see the supplemnentary material for more detail). The first *.csv file, BroadleafForestRawRecruitmentDataAllRecruitRefs.csv, includes all potential papers we thought might have usable data. We then further examined these for usable data. Rejected papers for our analysls are found in Word file 'BroadleafForestRawRecruitmentDataRejectedRecruitRefs.doc'. Also provided in this file is our justification for rejection of these papers. </p> <p>Raw recruitment dates in the remaining files are grouped according to the bins used in the original studies, <10 yr for the 10 yr binned data and then 20 yr, 25 yr, and 50 yr bins for the remaining data files. The various categories within each bin are related to assessments of uncertainties of each collection. Please see the original manuscript and supplementary material for more detail.</p> </div

Appendix A. Additional information, figures, images, analysis, and discussion material.

Additional information, figures, images, analysis, and discussion material