The Effect of Proximity, Explicitness, and Representation of Basic Science Information on Student Clinical Problem-Solving

Problem: Medical and veterinary students memorize facts but then have difficulty applying those facts in clinical problem solving. Cognitive engineering research suggests that the inability of medical and veterinary students to infer concepts from facts may be due in part to specific features of how information is represented and organized in educational materials. First, physical separation of pieces of information may increase the cognitive load on the student. Second, information that is necessary but not explicitly stated may also contribute to the student’s cognitive load. Finally, the types of representations – textual or graphical – may also support or hinder the student’s learning process. This may explain why students have difficulty applying biomedical facts in clinical problem solving. Purpose: To test the hypothesis that three specific aspects of expository text – the patial distance between the facts needed to infer a rule, the explicitness of information, and the format of representation – affected the ability of students to solve clinical problems. Setting: The study was conducted in the parasitology laboratory of a college of veterinary medicine in Texas. Sample: The study subjects were a convenience sample consisting of 132 second-year veterinary students who matriculated in 2007. The age of this class upon admission ranged from 20-52, and the gender makeup of this class consisted of approximately 75% females and 25% males. Results: No statistically significant difference in student ability to solve clinical problems was found when relevant facts were placed in proximity, nor when an explicit rule was stated. Further, no statistically significant difference in student ability to solve clinical problems was found when students were given different representations of material, including tables and concept maps. Findings: The findings from this study indicate that the three properties investigated – proximity, explicitness, and representation – had no statistically significant effect on student learning as it relates to clinical problem-solving ability. However, ad hoc observations as well as findings from other researchers suggest that the subjects were probably using rote learning techniques such as memorization, and therefore were not attempting to infer relationships from the factual material in the interventions, unless they were specifically prompted to look for patterns. A serendipitous finding unrelated to the study hypothesis was that those subjects who correctly answered questions regarding functional (non-morphologic) properties, such as mode of transmission and intermediate host, at the family taxonomic level were significantly more likely to correctly answer clinical case scenarios than were subjects who did not correctly answer questions regarding functional properties. These findings suggest a strong relationship (p < .001) between well-organized knowledge of taxonomic functional properties and clinical problem solving ability. Recommendations: Further study should be undertaken investigating the relationship between knowledge of functional taxonomic properties and clinical problem solving ability. In addition, the effect of prompting students to look for patterns in instructional material, followed by the effect of factors that affect cognitive load such as proximity, explicitness, and representation, should be explored.

AROUSAL, FATIGUE AND MENTAL PERFORMANCE: THE EFFECTS OF FASTING ON COGNITION

This study examined the effects of skipping breakfast on selected aspects of children's cognition, specifically their memory (both immediate and one week following presentation of stimuli), mental tempo, and problem solving accuracy. Test instruments used included the Hagen Central/Incidental Recall Test, Matching Familiar Figures Test, McCarthy Digit Span and Tapping Tests. The study population consisted of 39 nine-to eleven year old healthy children who were admitted for overnight stays at a clinical research setting for two nights approximately one week apart. The study was designed to be able to adequately monitor and control subjects' food consumption. The design chosen was the cross-over design where randomly on either the first or second visit, the child skipped breakfast. In this way, subjects acted as their own controls. Subjects were tested at noon of both visits, this representing an 18-hour fast.^ Analysis focused on whether or not fasting for this period of time affected an individual's performance. Results indicated that for most of the tests, subjects were not significantly affected by skipping breakfast for one morning. However, on tests of short-term central and incidental recall, subjects who had skipped breakfast recalled significantly more of the incidental cues although they did so at no apparent expense to their storing of central information. In the area of problem-solving accuracy, subjects skipping breakfast at time two made significantly more errors on hard sections of the MFF Test. It should be noted that although a large number of tests were conducted, these two tests showed the only significant differences.^ These significant results in the areas of short-term incidental memory and in problem solving accuracy were interpreted as being an effect of subject fatigue. That is, when subjects missed breakfast, they were more likely to become fatigued and in the novel environment presented in the study setting, it is probable that these subjects responded by entering Class II fatigue which is characterized by behavioral excitability, diffused attention and altered performance patterns. ^

Using 'Generic Abilities' to Foster Professionalism in a Post-Professional Program

Introduction To be successful in a profession, persons must have mastery of professional affective behaviors in addition to that profession’s core knowledge base. Health care delivery is more than just developing a good plan of care. The effective health care provider also will have good interpersonal and communication skills, have a commitment to learning, act professionally and responsibly, and have abilities in problem solving and critical thinking. But, these behaviors and characteristics are not taught directly in a professional program. This presentation will demonstrate how these ‘generic abilities’ have been incorporated in a post-professional program and how they can be used in other professional health care, professional development, and leadership programs. [See PDF for complete abstract]

Postoperative renal function preservation with nonischemic femoral arterial cannulation for thoracoabdominal aortic repair.

BACKGROUND: Renal failure after thoracoabdominal aortic repair is a significant clinical problem. Distal aortic perfusion for organ and spinal cord protection requires cannulation of the left femoral artery. In 2006, we reported the finding that direct cannulation led to leg ischemia in some patients and was associated with increased renal failure. After this finding, we modified our perfusion technique to eliminate leg ischemia from cannulation. In this article, we present the effects of this change on postoperative renal function. METHODS: Between February 1991 and July 2008, we repaired 1464 thoracoabdominal aortic aneurysms. Distal aortic perfusion was used in 1088, and these were studied. Median patient age was 68 years, and 378 (35%) were women. In September 2006, we began to adopt a sidearm femoral cannulation technique that provides distal aortic perfusion while maintaining downstream flow to the leg. This was used in 167 patients (15%). We measured the joint effects of preoperative glomerular filtration rate (GFR) and cannulation technique on the highest postoperative creatinine level, postoperative renal failure, and death. Analysis was by multiple linear or logistic regression with interaction. RESULTS: The preoperative GFR was the strongest predictor of postoperative renal dysfunction and death. No significant main effects of sidearm cannulation were noted. For peak creatinine level and postoperative renal failure, however, strong interactions between preoperative GFR and sidearm cannulation were present, resulting in reductions of postoperative renal complications of 15% to 20% when GFR was <60 mL>/min/1.73 m(2). For normal GFR, the effect was negated or even reversed at very high levels of GFR. Mortality, although not significantly affected by sidearm cannulation, showed a similar trend to the renal outcomes. CONCLUSION: Use of sidearm cannulation is associated with a clinically important and highly statistically significant reduction in postoperative renal complications in patients with a low GFR. Reduced renal effect of skeletal muscle ischemia is the proposed mechanism. Effects among patients with good preoperative renal function are less clear. A randomized trial is needed.

Molluscan memory of injury: evolutionary insights into chronic pain and neurological disorders.

Molluscan preparations have yielded seminal discoveries in neuroscience, but the experimental advantages of this group have not, until now, been complemented by adequate molecular or genomic information for comparisons to genetically defined model organisms in other phyla. The recent sequencing of the transcriptome and genome of Aplysia californica, however, will enable extensive comparative studies at the molecular level. Among other benefits, this will bring the power of individually identifiable and manipulable neurons to bear upon questions of cellular function for evolutionarily conserved genes associated with clinically important neural dysfunction. Because of the slower rate of gene evolution in this molluscan lineage, more homologs of genes associated with human disease are present in Aplysia than in leading model organisms from Arthropoda (Drosophila) or Nematoda (Caenorhabditis elegans). Research has hardly begun in molluscs on the cellular functions of gene products that in humans are associated with neurological diseases. On the other hand, much is known about molecular and cellular mechanisms of long-term neuronal plasticity. Persistent nociceptive sensitization of nociceptors in Aplysia displays many functional similarities to alterations in mammalian nociceptors associated with the clinical problem of chronic pain. Moreover, in Aplysia and mammals the same cell signaling pathways trigger persistent enhancement of excitability and synaptic transmission following noxious stimulation, and these highly conserved pathways are also used to induce memory traces in neural circuits of diverse species. This functional and molecular overlap in distantly related lineages and neuronal types supports the proposal that fundamental plasticity mechanisms important for memory, chronic pain, and other lasting alterations evolved from adaptive responses to peripheral injury in the earliest neurons. Molluscan preparations should become increasingly useful for comparative studies across phyla that can provide insight into cellular functions of clinically important genes.

PURINERGIC SIGNALING REGULATES FILOPODIA-INDUCED ZIPPERING

The molecular mechanisms that mediate endometrial cancer invasion and metastasis remain poorly understood. This is a significant clinical problem, as there is no definitive cure for metastatic disease. The purinergic pathway’s generation of adenosine and its activation of the adenosine receptor A2B (A2BR) induces cell-cell adhesion to promote barrier function. This barrier function is known to be important in maintaining homeostasis during hypoxia, trauma, and sepsis. Loss of this epithelial barrier function provides a considerable advantage for carcinoma progression, as loss of cell-cell adhesions supports proliferation, aberrant signaling, epithelial-to-mesenchymal transition, invasion, and metastasis. The present work provides strong evidence that CD73-generated adenosine actively promotes cell-cell adhesion in carcinoma cells by filopodia-induced zippering. Adenosine-generating ecto-enzyme, CD73, was down-regulated in moderately- and poorly-differentiated, invasive, and metastatic endometrial carcinomas. CD73 expression and enzyme activity in normal endometrium and endometrial carcinomas was significantly correlated to the epithelial phenotype. Barrier function in normal epithelial cells of the endometrium was dependent on stress-induced generation of adenosine by CD73 and adenosine’s activation of A2BR. This same mechanism inhibited endometrial carcinoma cell migration and invasion. Finally, adenosine’s activation of A2BR induced the formation of filopodia that promoted the re-forming of cell-cell adhesions in carcinoma cells. Overall, these studies identified purinergic pathway-induced filopodia to be a novel mechanism of adenosine’s barrier function and a mechanism that has to be avoided/down-regulated by endometrial carcinoma cells attempting to lose attachment with their neighboring cells. These results provide insight into the molecular mechanisms of endometrial cancer invasion. In addition, because loss of cell-cell adhesions has been closely linked to therapy resistance in cancer, these results provide a rational clinical strategy for the re-establishment of cell-cell adhesions to potentially increase therapeutic sensitivity. In contrast to other molecular mechanisms regulating cell-cell adhesions, the purinergic pathway is clinically druggable, with agonists and antagonists currently being tested in clinical trials of various diseases.

The utility of rapid participatory appraisal for community assessment, diagnosis, and policy development

The selection of a model to guide the understanding and resolution of community problems is an important issue relating to the foundation of public health practice: assessment, policy development, and assurance. Many assessment models produce a diagnosis of community weaknesses, but fail to promote planning and interventions. Rapid Participatory Appraisal (RPA) is a participatory action research model which regards assessment as the first step in the problem solving process, and claims to achieve assessment and policy development within limited resources of time and money. Literature documenting the fulfillment of these claims, and thereby supporting the utility of the model, is relatively sparse and difficult to obtain. Very few articles discuss the changes resulting from RPA assessments in urban areas, and those that do describe studies conducted outside the U.S.A. ^ This study examines the utility of the RPA model and its underlying theories: systems theory, grounded theory, and principles of participatory change, as illustrated by the case study of a community assessment conducted for the Texas Diabetes Institute (TDI), San Antonio, Texas, and subsequent outcomes. Diabetes has a high prevalence and is a major issue in San Antonio. Faculty and students conducted the assessment by informal collaboration between two nursing and public health assessment courses, providing practical student experiences. The study area was large, and the flexibility of the model tested by its use in contiguous sub-regions, reanalyzing aggregated results for the study area. Official TDI reports, and a mail survey of agency employees, described policy development resulting from community diagnoses revealed by the assessment. ^ The RPA model met the criteria for utility from the perspectives of merit, worth, efficiency, and effectiveness. The RPA model best met the agencies' criteria (merit), met the data needs of TDI in this particular situation (worth), provided valid results within budget, time, and personnel constraints (efficiency), and stimulated policy development by TDI (effectiveness). ^ The RPA model appears to have utility for community assessment, diagnosis, and policy development in circumstances similar to the TDI diabetes study. ^

Stress and coping in African American grandparents who are raising grandchildren

Over the years, substantial increases have occurred in the number of children being raised by their grandparents. A small number of studies have reported that grandparents raising grandchildren experience an increase in stress due to the demands of caregiving. The primary objectives of this study were to: (1) determine the degree of stress in African American (AA) grandparents who are raising their grandchildren age 12 years or younger; (2) identify the variables pertaining to the demographic characteristics of the grandparent caregiver and characteristics of the caregiving situation; (3) identify the coping strategies reported by AA grandparents; and (4) identify the relative importance of demographic and situational variables pertaining to the grandparent caregiver and caregiving situation, and coping strategies in influencing the degree of stress experienced. ^ An exploratory, descriptive, cross sectional design was used to study stress and coping in 50 AA grandparents who ranged in age from 44–87 years (M = 63.12). Data were collected via one personal interview in January/February 2001 at area senior centers or churches which the grandparent attends in Harris County, Texas. Five home interviews were done as requested by grandparents. ^ The instruments used to measure stress and coping were the Parenting Stress Index developed by Abidin and Folkman and Lazarus' Ways of Coping Questionnaire. Results of the study found that the grandparents is this study were a highly stressed group. Ninety-four percent of the sample demonstrated a “clinically significant” level of stress. Situational variables associated with lower stress levels were use of counseling, use of special school programs such as tutoring and special education, and increased length of caregiving (>5 years). ^ The most frequently used coping strategies overall were seeking social support and positive reappraisal. Six coping strategies were significantly correlated to lower reported stress: positive reappraisal, accepting responsibility, confrontive coping, self-control, planful problem solving, and distancing. ^ The findings from this study have limited generalizability. Nonetheless, this study was useful in adding to the limited amount of literature on AA grandparents who are rearing their grandchildren. The results clearly suggest the need for affordable counseling, support groups, education related to available resources, stress management, and interventions that increase the use of coping strategies found to reduce perceived stress. Future research should investigate levels of stress in AA and other grandparent caregivers longitudinally, as well as focus on stress and coping in grandparents raising grandchildren with special needs. ^

Exploring professional orientations to community voice in professional practice settings: The IMAP process

The tension between technical experts and the populations they seek to serve is well established in the literature examining professional social problem solving. In this piece, I examine this tension as one between the distinct discursive worlds of technical expertise and community voice. I develop an analytic process, IMAP, for exploring this tension by looking at a wide variety of professional orientations around a relatively fixed concept of community voice. IMAP involves I&barbelow;dentifying social problem solvers, M&barbelow;apping social problem solvers' claims, A&barbelow;nalyzing professional orientations that arise from this mapping, and P&barbelow;redicting, diagnosing, and remediating conflicts. IMAP can be used by analysts external to social problem solving settings or by social problem solvers themselves. The use of IMAP by external experts poses questions of expert alignment with either of the discursive worlds. I examine two cases in public health practice settings: a mobile immunization service and the efforts of a foundation to improve health in an inner-city neighborhood. I develop four modal types that can be anticipated in social problem solving settings or, more specifically, in public health practice. Understanding of these “world views” can enhance mutual understanding between public health professionals and between public health professionals and the communities they seek to serve. IMAP might also address ongoing conflicts to clarify differences in unspoken normative commitments and the impact of these on social problem solving. I discuss implications of the research for public health practice and further research in the area. ^

Long-term hyperexcitability of sensory and motor axons in Aplysia californica: Induction by axotomy, serotonin, and transient depolarization

Neuropathic pain is a debilitating neurological disorder that may appear after peripheral nerve trauma and is characterized by persistent, intractable pain. The well-studied phenomenon of long-term hyperexcitability (LTH), in which sensory somata become hyperexcitable following peripheral nerve injury may be important for both chronic pain and long-lasting memory formation, since similar cellular alterations take place after both injury and learning. Though axons have previously been considered simple conducting cables, spontaneous afferent signals develop from some neuromas that form at severed nerve tips, indicating intrinsic changes in sensory axonal excitability may contribute to this intractable pain. Here we show that nerve transection, exposure to serotonin, and transient depolarization induce long-lasting sensory axonal hyperexcitability that is localized to the treated nerve segment and requires local translation of new proteins. Long-lasting functional plasticity may be a general property of axons, since both injured and transiently depolarized motor axons display LTH as well. Axonal hyperexcitability may represent an adaptive mechanism to overcome conduction failure after peripheral injury, but also displays key features shared with cellular analogues of memory including: site-specific changes in neuronal function, dependence on transient, focal depolarization for induction, and requirement for synthesis of new proteins for expression of long-lasting effects. The finding of axonal hyperexcitability after nerve injury sheds new light on the clinical problem of chronic neuropathic pain, and provides more support for the hypothesis that mechanisms of long-term memory storage evolved from primitive adaptive responses to injury. ^

Latino patients' desire to participate in informed decisions regarding colorectal cancer screening

Colorectal cancer (CRC) has become a public health concern due to the underutilization of the various screening methods. There is a need to understand a patient's decision making process in regards to their health and obtaining the appropriate screening. Previous research has defined patient autonomy in two dimensions: The patient's involvement in the decision making process and their desire to be informed (Ende, Kazis, Ash, & Moskowitz, 1989). Past research shows that patients have a high desire to be informed, but a low desire to be involved in the medical decision process. Deber, Kraetschmer, and Irvine (1996) developed a measure which consisted of two subscales that measures patients' involvement: Patient's desire to be involved in the problem solving (PS) and decision making (DM) process. Little research has examined the desire for involvement and decision making of Latino populations. The present study sought to investigate the psychometric properties of the Deber et al. (1996) measure. In general, Latino patients in the present sample had low desire for autonomy in health decisions or to be involved in the decision making processes of their health related issues. ^

A cross-sectional study of disparities in suicide ideation between Hispanic and non-Hispanic white female adolescents

Suicide is recognized as a major public health and clinical problem in the United States. One fifth of adolescents in the United States seriously consider suicide each year, and about 8% of high school students attempt suicide at least once. Hispanic ethnicity constitutes a risk factor for suicidal ideation and suicide attempts, with Hispanic females at highest risk. Nevertheless, published studies on suicidal behavior in Hispanic female adolescents are extremely limited and focus on suicidal ideation in school samples. Given the severity of the problem and the paucity of information on this topic, more research on ethnic differences in suicidal ideation in community samples of high-risk children is urgently needed. This cross-sectional study delineated differences in suicide ideation between Hispanic female adolescents and non-Hispanic white female adolescents attending a mental health clinic and examined the association of ethnicity with suicide ideation independent of other known risk factors. Data were accrued between June 2004 and December 2008 in a Harris County Mental Health and Mental Retardation Association (MHMRA) clinic. Data were limited to adolescents who were Harris County Residents between the ages of 10 to 17 years when they were admitted to the clinic. The objective of this study was to determine whether differences in socio-demographic and clinical variables play a significant role in ethnic disparities in suicide ideation. A series of logistic regressions were performed to estimate the association between ethnicity and suicide ideation after controlling for potentially confounding factors. ^ Results showed an interaction between Hispanic ethnicity and having a history of treatment: Hispanic girls having history of treatment had lower odds of having suicide ideation than Hispanic girls without such a history. After adjusting for treatment history, family problems, substance use, juvenile justice involvement, current treatment, and age, Hispanic girls had 1.86 times the odds of having suicide ideation than non Hispanic girls (OR=1.86, 95% CI=0.88-1.46). Although additional studies on community samples of high risk adolescents are needed to verify these findings, our study highlights the fact that Hispanic girls are at significantly higher risk and need to be targeted for prevention and treatment efforts. ^

THE DEVELOPMENT OF COMMUNITY COMPETENCE THROUGH A NEIGHBORHOOD ORGANIZATION (LOS ANGELES, MEXICAN-AMERICAN)

This investigation focused on how people cope with the demands of their environment in a competent manner. It sought to assess the effects of learning competent coping behaviors on self-reported well-being. The study chose a community-evolved, organized effort on the part of a group of neighborhoods to build competence in the Mexican-American community of East Los Angeles. This network was a citizen-action organization called the United Neighborhoods Organization. UNO was selected because it concentrated on developing community leaders by using spiritual beliefs and family values as shared community resources. Neighborhood leaders were encouraged to engage in risk-taking and confrontation maneuvers. They were also taught problem-solving skills and provided with social support.^ A survey instrument was developed to assess sociodemographic characteristics, acculturation history and status, willingness to engage in risk-taking and confrontation and self-perceived general well-being. The study relied on eight months of daily participant-observation of the organization, the East Los Angeles environment and the interaction between the two. At the end of the observation period, a sample of 150 UNO participants were given the survey questionnaire as was a matched group of 150 non-UNO participants who were ELA residents.^ The study sample was mostly women, in their middle age years who had lived in the area from 5 to more than 30 years. Significantly more single persons were found in the UNO group. The sample was almost equally divided into English and Spanish speaking respondents. Acculturatively almost all the sample fell in the Very Mexican and Mostly Mexican types. The survey found a trend of association between participating in UNO and reporting feeling well. A statistically significant association was found among UNO participants between taking risks and reporting feeling well, regardless of a tendency for all the sample to minimize risk. A trend was seen for married UNO participants to report feeling well. Slightly more UNO participants were willing to engage in confrontation and a substantial proportion of the participants who were confronters reported feeling well in comparison to their counterparts. Ethnic pride was positively associated with participation in UNO and showed a trend in the expected direction with reported self-perceived well-being. ^

QUALITY OF MATERNITY CARE IN RURAL TEXAS (MEXICAN-AMERICAN)

The purpose of the study was to describe regionalized systems of perinatal care serving predominantly low income Mexican-American women in rural underserved areas of Texas. The study focused upon ambulatory care; however, it provided a vehicle for examination of the health care system. The questions posed at the onset of the study included: (1) How well do regional organizations with various patterns of staffing and funding levels perform basic functions essential to ambulatory perinatal care? (2) Is there a relationship between the type of organization, its performance, and pregnancy outcome? (3) Are there specific recommendations which might improve an organization's future performance?^ A number of factors--including maldistribution of resources and providers, economic barriers, inadequate means of transportation, and physician resistance to transfer of patients between levels of care--have impeded the development of regionalized systems of perinatal health care, particularly in rural areas. However, studies have consistently emphasized the role of prenatal care in the early detection of risk and treatment of complications of pregnancy and childbirth, with subsequent improvement in pregnancy outcomes.^ This study has examined the "system" of perinatal care in rural areas, utilizing three basic regional models--preventive care, limited primary care, and fully primary care. Information documented in patient clinical records was utilized to compare the quality of ambulatory care provided in the three regional models.^ The study population included 390 women who received prenatal care in one of the seven study clinics. They were predominantly hispanic, married, of low income, with a high proportion of teenagers and women over 35. Twenty-eight percent of the women qualified as migrants.^ The major findings of the study are listed below: (1) Almost half of the women initiated care in the first trimester. (2) Three-fourths of the women had or exceeded the recommended number of prenatal visits. (3) There was a low rate of clinical problem recognition. Additional follow-up is needed to determine the reasons. (4) Cases with a tracer condition had significantly more visits with monitoring of the clinical condition. (5) Almost 90% of all referrals were completed. (6) Only 60% of mothers had postpartum follow-up, while almost 90% of their newborns received care. (7) The incidence of infants weighing 2500 grams or less was 4.2%. ^

InGen of creative production in the health sciences: A workbook companion to innovation generation

InGen of Creative Production in the Health Sciences is a compendium of innovative thinking exercises for individuals and groups, derived from an eclectic array of practical guides for professionals in a variety of fields. Segmented into five subcategories across twenty two chapters, the effort seeks to make techniques for increasing innovative problem solving more accessible to a diverse audience of problem solvers. The chapters of Roberta Ness. Innovation Generation (2012, Oxford University Press) provide the themes for each of the chapters in the workbook. It is intended that those who read Ness. Innovation Generation will benefit from practicing the constructs of innovative thinking exemplified in each exercise.^ The methods used to gather data, in this case mostly innovative thinking exercises, included literature reviews of existing innovative thinking tools, classroom materials, and theory-driven exploration of exercises to fill in gaps in extant materials. Specifically, Google.com and Amazon.com searches were conducted using the terms “innovation,” “innovative,” “innovator,” “creative,” “novelty,” “thinking,” together with some variance of “book,” “workbook,” and “exercise.” The results were sorted thematically to show correspondence with the themes in Ness (2012) and compared to suggested best practices of 50 years of scientific research on innovative thinking. Where themes were suggested by Ness (2012) and peer-reviewed research on innovation but unavailable in published innovation thinking workbooks, new exercises were developed. The five type subcategories into which these results were organized are: individual direct, individual indirect, group direct, group indirect and probing question. It is anticipated that the five type subcategories and spectrum of themes will equip problem solvers in a variety of capacities.^