Computer-based summative assessment of clinical reasoning in clerkships: A mixed-method comparison of key feature problems with case-based multiple choice questions

Background: It is yet unclear if there are differences between using electronic key feature problems (KFPs) or electronic case-based multiple choice questions (cbMCQ) for the assessment of clinical decision making. Summary of Work: Fifth year medical students were exposed to clerkships which ended with a summative exam. Assessment of knowledge per exam was done by 6-9 KFPs, 9-20 cbMCQ and 9-28 MC questions. Each KFP consisted of a case vignette and three key features (KF) using “long menu” as question format. We sought students’ perceptions of the KFPs and cbMCQs in focus groups (n of students=39). Furthermore statistical data of 11 exams (n of students=377) concerning the KFPs and (cb)MCQs were compared. Summary of Results: The analysis of the focus groups resulted in four themes reflecting students’ perceptions of KFPs and their comparison with (cb)MCQ: KFPs were perceived as (i) more realistic, (ii) more difficult, (iii) more motivating for the intense study of clinical reasoning than (cb)MCQ and (iv) showed an overall good acceptance when some preconditions are taken into account. The statistical analysis revealed that there was no difference in difficulty; however KFP showed a higher discrimination and reliability (G-coefficient) even when corrected for testing times. Correlation of the different exam parts was intermediate. Conclusions: Students perceived the KFPs as more motivating for the study of clinical reasoning. Statistically KFPs showed a higher discrimination and higher reliability than cbMCQs. Take-home messages: Including KFPs with long menu questions into summative clerkship exams seems to offer positive educational effects.

International variation in GP treatment strategies for subclinical hypothyroidism in older adults: a case-based survey

Background: There is limited evidence about the impact of treatment for subclinical hypothyroidism, especially among older people. Aim: To investigate the variation in GP treatment strategies for older patients with subclinical hypothyroidism depending on country and patient characteristics. Design and setting: Case-based survey of GPs in the Netherlands, Germany, England, Ireland, Switzerland, and New Zealand. Method: The treatment strategy of GPs (treatment yes/no, starting-dose thyroxine) was assessed for eight cases presenting a woman with subclinical hypothyroidism. The cases differed in the patient characteristics of age (70 versus 85 years), vitality status (vital versus vulnerable), and thyroid-stimulating hormone (TSH) concentration (6 versus 15 mU/L). Results: A total of 526 GPs participated (the Netherlands n = 129, Germany n = 61, England n = 22, Ireland n = 21, Switzerland n = 262, New Zealand n = 31; overall response 19%). Across countries, differences in treatment strategy were observed. GPs from the Netherlands (mean treatment percentage 34%), England (40%), and New Zealand (39%) were less inclined to start treatment than GPs in Germany (73%), Ireland (62%), and Switzerland (52%) (P = 0.05). Overall, GPs were less inclined to start treatment in 85-year-old than in 70-year-old females (pooled odds ratio [OR] 0.74 [95% confidence interval [CI] = 0.63 to 0.87]). Females with a TSH of 15 mU/L were more likely to get treated than those with a TSH of 6 mU/L (pooled OR 9.49 [95% CI = 5.81 to 15.5]). Conclusion: GP treatment strategies of older people with subclinical hypothyroidism vary largely by country and patient characteristics. This variation underlines the need for a new generation of international guidelines based on the outcomes of randomised clinical trials set within primary care

Internet-based stress management for women with preterm labour: a case-based experience report

Pregnant women with preterm labour (PTL) in pregnancy often experience increased distress and anxieties regarding both the pregnancy and the child's health. The pathogenesis of PTL is, among other causes, related to the stress-associated activation of the maternal-foetal stress system. In spite of these psychobiological associations, only a few research studies have investigated the potential of psychological stress-reducing interventions. The following paper will present an online anxiety and stress management self-help program for pregnant women with PTL. Structure and content of the program will be illustrated by a case-based experience report. L.B., 32 years (G3, P1), was recruited at gestational week 27 while hospitalized for PTL for 3 weeks. She worked independently through the program for 6 weeks and had regular written contact with a therapist. Processing the program had a positive impact on L.B.'s anxiety and stress levels, as well as on her experienced depressive symptoms and bonding to the foetus. As PTL and the risk of PTB are associated with distress, psychological stress-reducing interventions might be beneficial. This study examines the applicability of an online intervention for pregnant women with PTL. The case report illustrates how adequate low-threshold psychological support could be provided to these women.

Knowledge representation through graphs

Due to the increasing amount of data, knowledge aggregation, representation and reasoning are highly important for companies. In this paper, knowledge aggregation is presented as the first step. In the sequel, successful knowledge representation, for instance through graphs, enables knowledge-based reasoning. There exist various forms of knowledge representation through graphs; some of which allow to handle uncertainty and imprecision by invoking the technology of fuzzy sets. The paper provides an overview of different types of graphs stressing their relationships and their essential features.

New ruralities – old gender dynamics?: A reflection on high-value crop agriculture in the light of the feminisation debates

While a remarkable continuity in smallholder agricultural production has been identified, the shift from subsistence orientation towards more wage dependence appears in a different light when analysed under a gender perspective. "Feminisation" has been a catchphrase to characterise some of these processes; however, the debate has been subject to overgeneralisation, and can only inadequately grasp the gender dynamics in what has been referred to as "new ruralities". Illustrated for high-value crop production as an expression of agricultural transition in the Global South, this contribution offers a critical account of the feminisation thesis. Instead of discarding the notion of feminisation, it advocates a reassessment of its potential as a comprehensive framework against which empirical findings can be reflected. While conventional uses of the feminisation thesis have, in their great majority, come up with the conclusion that for women it can always only get worse, I propose a perspective which reveals gains and risks and how they are shared between men and women as they engage in new agricultural labour markets. This perspective rests on a methodology for case-based, comparative studies developed in this paper as a contribution for assessing the nature of agricultural transition and to investigate the qualitative change associated with new ruralities. A distinctive appreciation of the substance of agricultural change for different members of the rural society – namely men and women, but also different men, and different women – is the premise for overcoming barriers to shared development, and for framing effective governance in the context of global development.

Synchronous and Time-Lagged Effects between Occupational Self-Efficacy and Objective and Subjective Career Success: Findings from a Four-Wave and 9-Year Longitudinal Study

We integrated research on the dimensionality of career success into social-cognitive career theory and explored the positive feedback loop between occupational self-efficacy and objective and subjective career success over time (self-efficacy → objective success → subjective success → self-efficacy). Furthermore, we theoretically accounted for synchronous and time-lagged effects, as well as indirect reciprocity between the variables. We tested the proposed model by means of longitudinal structural equation modeling in a 9-year four-wave panel design, by applying a model comparison approach and indirect effect analyses (N = 608 professionals). The findings supported the proposed positive feedback loop between occupational self-efficacy and career success. Supporting our time-based reasoning, the findings showed that unfolding effects between occupational self-efficacy and objective career success take more time (i.e., time-lagged or over time) than unfolding effects between objective and subjective career success, as well as between subjective career success and occupational self-efficacy (i.e., synchronous or concurrently). Indirect effects of past on future occupational self-efficacy via objective and subjective career success were significant, providing support for an indirect reciprocity model. Results are discussed with respect to extensions of social-cognitive career theory and occupational self-efficacy development over time.

Improvement of the processes around the radiology workplace : avoidance of time delays

Radiologists have been confronted with multiple new challenges in recent years. While there has been a steady increase in the number of radiological examinations and imaging material per examination, examination protocols have become more complex and highly time-consuming whereas case-based remuneration is on the decline. The identification of inefficient components in examination processes and reporting is therefore essential. Where and why do time delays occur? How can they be avoided? The following article provides a brief overview and is designed to stimulate discussion.

Variation in treatment strategies of Swiss general practitioners for subclinical hypothyroidism in older adults.

QUESTIONS UNDER STUDY As the best management of subclinical hypothyroidism is controversial, we aimed to assess variations in treatment strategies depending on different Swiss regions, physician and patient characteristics. METHODS We performed a case-based survey among general practitioners (GPs) in different Swiss regions, which consisted of eight hypothetical cases presenting a female patient with subclinical hypothyroidism and nonspecific complaints differing by age, vitality status and thyroid-stimulating hormone (TSH) concentration. RESULTS A total of 262 GPs participated in the survey. There was considerable variation in the levothyroxine starting dose chosen by GPs, ranging from 25 µg to 100 µg. Across the Swiss regions, GPs in the Bern region were significantly more inclined to treat, with a higher probability of initiating treatment (60%, p = 0.01) and higher mean starting doses (45 µg, p <0.01) compared with the French-speaking region (44%, 36 µg); the Zurich region had intermediate values (52%, 39 µg). We found no association between treatment rate and other physician characteristics. GPs were more reluctant to initiate treatment in 85-year-old than in 70-year-old women (odds ratio [OR] 0.77, 95% confidence interval [CI] 0.63-0.94), and more likely to treat women with a TSH of 15 mU/l than those with a TSH of 6mU/l (OR 8.71, 95% CI 6.21-12.20). CONCLUSIONS There are strong variations in treatment strategies for elderly patients with subclinical hypothyroidism across different Swiss regions, including use of higher starting doses than the recommended 25 µg in the Swiss guidelines, which recommend a starting dose of 25 µg. These variations likely reflect the current uncertainty about the benefits of treatment, which arise from the current lack of evidence from adequately powered clinical trials.

Social Network Analysis and Qualitative Comparative Analysis: Their mutual benefit for the explanation of policy network structures

By switching the level of analysis and aggregating data from the micro-level of individual cases to the macro-level, quantitative data can be analysed within a more case-based approach. This paper presents such an approach in two steps: In a first step, it discusses the combination of Social Network Analysis (SNA) and Qualitative Comparative Analysis (QCA) in a sequential mixed-methods research design. In such a design, quantitative social network data on individual cases and their relations at the micro-level are used to describe the structure of the network that these cases constitute at the macro-level. Different network structures can then be compared by QCA. This strategy allows adding an element of potential causal explanation to SNA, while SNA-indicators allow for a systematic description of the cases to be compared by QCA. Because mixing methods can be a promising, but also a risky endeavour, the methodological part also discusses the possibility that underlying assumptions of both methods could clash. In a second step, the research design presented beforehand is applied to an empirical study of policy network structures in Swiss politics. Through a comparison of 11 policy networks, causal paths that lead to a conflictual or consensual policy network structure are identified and discussed. The analysis reveals that different theoretical factors matter and that multiple conjunctural causation is at work. Based on both the methodological discussion and the empirical application, it appears that a combination of SNA and QCA can represent a helpful methodological design for social science research and a possibility of using quantitative data with a more case-based approach.

Family characteristics as risk factors for childhood acute lymphoblastic leukemia: a population-based case-control study

To date, few risk factors for childhood acute lymphoblastic leukemia (ALL) have been confirmed and the scientific literature is full of controversial "evidence." We examined if family characteristics, particularly maternal and paternal age and number of older siblings, were risk factors for childhood acute lymphoblastic leukemia (ALL).