Using student feedback to construct an assessment rubric for a concept map in physiology

Constructing quality assessment rubrics can be challenging, especially when they are used for integrated, group-centered, applied learning. We describe a collaborative assessment task in which groups of second-year dentistry students developed a complex concept map. In groups of four, the students were given a written, simulated, medical history of a patient and required to construct a concept map illustrating relevant pathophysiological concepts and pharmacological interventions. This report describes a research project aimed at making educational goals of the task more explicit through investigating student and faculty member understandings of the criteria that might be used to assess the concept map. Information was gathered about the perceptions of students in relation to the learning goals associated with the task. These were compared with faculty member perceptions. The findings were used to develop an assessment rubric intended to be more accessible to learners. The new rubric used the language of both faculty members and students to more clearly represent expectations of each criterion and standard. This assessment rubric will be used in 2005 for the next phase of the project.

Common causes of sleep disruption and daytime sleepiness: childhood sleep disorders II

There are strong associations between childhood sleep disorders and behavioural, concentration and mood problems. Sleep disorders caused and maintained by behavioural factors (eg, sleep-onset association disorder) are common in young children, and have a significant impact on families. Evaluation should include a medical history, a physical, neurological and developmental examination, a description of any nocturnal events or daytime effects of the child's disturbed sleep, and a good understanding of the family situation and parental management of the child. Management involves recognising the developmental age of the child and the family dynamics, and educating and supporting families in applying behavioural techniques to establish good sleep hygiene. Children with parasomnias (eg, night terrors) also benefit from good sleep hygiene, while those with respiratory or neurological causes of sleep disturbance should be referred for specialist treatment.

Cryotherapy for treatment of oral lesions

Cryotherapy is the deliberate destruction of tissue by application of extreme cold. It is well received by patients due to a relative lack of discomfort, the absence of bleeding and minimal to no scarring after healing. It has many applications in oral medicine and clinical oral pathology, and is extremely useful in patients for whom surgery is contra-indicated due to either age or medical history. In this paper we outline the principles, mechanisms of action, and current applications of cryotherapy in the treatment of oral lesions, and present some clinical cases.

Successful mental health aging: Results from a longitudinal study of older Australian men

Objective: The authors investigated the associations of medical and lifestyle factors with the mental health of men in their 80s. Methods: This was a prospective study of a community-representative cohort of older men. Successful mental health aging was defined as reaching age 80 years with Mini-Mental State Examination score (MMSE) of 24 or more and Geriatric Depression Scale-15 items (GDS-15) score of 5 or less. Results: Of 601 men followed for 4.8 years, 76.0% enjoyed successful mental health aging. Successful mental health aging was inversely associated with age (hazard ratio [HR] = 0.87; 95% confidence interval [CI]: 0.81 - 0.94), non-English-speaking background (HR = 0.42; 95% CI: 0.21 - 0.85), and the consumption of full-cream milk (HR = 0.63; 95% CI: 0.45 - 0.89), and directly associated with high school or university education (HR = 1.92; 95% CI: 1.34 - 2.75) and vigorous (HR = 1.89; 95% CI: 1.17 - 3.05) and nonvigorous physical activity (HR = 1.50; 95% CI: 1.05 - 2.14). Marital status, smoking and alcohol use, weekly consumption of meat or fish, and a medical history of hypercholesterolemia, hypertension, diabetes, myocardial infarction, and stroke were not associated with mental health outcomes in men aged 80 years or over. Conclusion: Three in four men who reach age 80 years undergo successful mental health aging. Factors associated with successful mental health aging include education and lifestyle behaviors such as physical activity. Lifestyle modification by means of increasing physical activity and reducing saturated fat intake may prove to be a safe, inexpensive, and readily available strategy to help maximize the successful mental health aging of the population.

Hypertension, glomerular number, and birth weight in African Americans and white subjects in the southeastern United States

Low nephron number has been related to low birth weight and hypertension. In the southeastern United States, the estimated prevalence of chronic kidney disease due to hypertension is five times greater for African Americans than white subjects. This study investigates the relationships between total glomerular number (N-glom), blood pressure, and birth weight in southeastern African Americans and white subjects. Stereological estimates of N-glom were obtained using the physical disector/fractionator technique on autopsy kidneys from 62 African American and 60 white subjects 30-65 years of age. By medical history and recorded blood pressures, 41 African Americans, and 24 white subjects were identified as hypertensive and 21 African Americans and 36 white subjects as normotensive. Mean arterial blood pressure ( MAP) was obtained on 81 and birth weights on 63 subjects. For African Americans, relationships between MAP, N-glom, and birth weight were not significant. For white subjects, they were as follows: MAP and N-glom ( r = -0.4551, P = 0.0047); Nglom and birth weight ( r = 0.5730, P = 0.0022); MAP and birth weight ( r = -0.4228, P = 0.0377). For African Americans, average N-glom of 961 840 +/- 292 750 for normotensive and 867 358 +/- 341 958 for hypertensive patients were not significantly different ( P = 0.285). For white subjects, average N-glom of 923 377 +/- 256 391 for normotensive and 754 319 +/- 329 506 for hypertensive patients were significantly different ( P = 0.03). The data indicate that low nephron number and possibly low birth weight may play a role in the development of hypertension in white subjects but not African Americans.

Watermarking biomedical time series data

This thesis addresses the problem of information hiding in low dimensional digital data focussing on issues of privacy and security in Electronic Patient Health Records (EPHRs). The thesis proposes a new security protocol based on data hiding techniques for EPHRs. This thesis contends that embedding of sensitive patient information inside the EPHR is the most appropriate solution currently available to resolve the issues of security in EPHRs. Watermarking techniques are applied to one-dimensional time series data such as the electroencephalogram (EEG) to show that they add a level of confidence (in terms of privacy and security) in an individual’s diverse bio-profile (the digital fingerprint of an individual’s medical history), ensure belief that the data being analysed does indeed belong to the correct person, and also that it is not being accessed by unauthorised personnel. Embedding information inside single channel biomedical time series data is more difficult than the standard application for images due to the reduced redundancy. A data hiding approach which has an in built capability to protect against illegal data snooping is developed. The capability of this secure method is enhanced by embedding not just a single message but multiple messages into an example one-dimensional EEG signal. Embedding multiple messages of similar characteristics, for example identities of clinicians accessing the medical record helps in creating a log of access while embedding multiple messages of dissimilar characteristics into an EPHR enhances confidence in the use of the EPHR. The novel method of embedding multiple messages of both similar and dissimilar characteristics into a single channel EEG demonstrated in this thesis shows how this embedding of data boosts the implementation and use of the EPHR securely.

Provision of primary care to patients with chronic cough in the community pharmacy setting

BACKGROUND: Community pharmacies are at the forefront of primary care providers and have an important role in the referral of patients to a medical practitioner for review when necessary. Chronic cough is a common disorder in the community and requires medical assessment. The proficiency of community pharmacy staff to refer patients with chronic cough is currently unknown. OBJECTIVE: To assess the ability of community pharmacy staff to recognize and medically refer patients with a chronic nonproductive cough. METHODS: Following ethics approval, a simulated patient study of 156 community pharmacies in Perth, Western Australia, was conducted over a 3-month period. Simulated patients presented to the pharmacy requesting treatment for a cough. The simulated patient required a referral based on a designated scenario. Demographic details, assessment questions, and advice provided were recorded by the simulated patient immediately postvisit. A logistic regression analysis was performed, with referral for medical assessment as the dependent variable. RESULTS: Of the 155 community pharmacies included in the analysis, 38% provided appropriate medical referral. Cough suppressants were provided as therapy in 72% of all visits. Predictors of medical referral were assessment of symptom duration, medical history, current medications being taken, frequency of reliever use, and the position of the pharmacy staff member conducting the consultation. A third of community pharmacies provided appropriate primary care by recommending medical referral advice to patients with chronic cough. The majority of pharmacy staff members acquired information from the patient that suggested a need for medical referral, yet did not provide referral advice. CONCLUSIONS: Appropriate medical referral is more likely when adequate assessment is undertaken and when a pharmacist is directly involved in the consultation. This highlights the need for pharmacies to ensure that processes are in place for patients to access the pharmacist.

Health promotion for chronic obstructive pulmonary disease

Peter, a 45 year old male, enters the pharmacy and asks, 'do you have something to stop a cough?' On questioning you find out that Peter has an irritating cough that has been off and on for the past few weeks since winter started. He coughs up phlegm every now and then, mostly upon waking. He has tried some cough mixture that he bought at the supermarket but is looking for something stronger. He states that he does not have any medical history or allergies and does not take any medication. He does feel that he can't exercise as much as he used to as he gets more breathless these days.

A review of the information-gathering process for the provision of medicines for self-medication via community pharmacies in developing countries

Background: Currently, no review has been completed regarding the information-gathering process for the provision of medicines for self-medication in community pharmacies in developing countries. Objective: To review the rate of information gathering and the types of information gathered when patients present for self-medication requests. Methods: Six databases were searched for studies that described the rate of information gathering and/or the types of information gathered in the provision of medicines for self-medication in community pharmacies in developing countries. The types of information reported were classified as: signs and symptoms, patient identity, action taken, medications, medical history, and others. Results: Twenty-two studies met the inclusion criteria. Variations in the study populations, types of scenarios, research methods, and data reporting were observed. The reported rate of information gathering varied from 18% to 97%, depending on the research methods used. Information on signs and symptoms and patient identity was more frequently reported to be gathered compared with information on action taken, medications, and medical history. Conclusion: Evidence showed that the information-gathering process for the provision of medicines for self-medication via community pharmacies in developing countries is inconsistent. There is a need to determine the barriers to appropriate information-gathering practice as well as to develop strategies to implement effective information-gathering processes. It is also recommended that international and national pharmacy organizations, including pharmacy academics and pharmacy researchers, develop a consensus on the types of information that should be reported in the original studies. This will facilitate comparison across studies so that areas that need improvement can be identified. © 2013 Elsevier Inc.

Multiple component patient safety intervention in English hospitals:controlled evaluation of second phase

Objective: To independently evaluate the impact of the second phase of the Health Foundation's Safer Patients Initiative (SPI2) on a range of patient safety measures. Design: A controlled before and after design. Five substudies: survey of staff attitudes; review of case notes from high risk (respiratory) patients in medical wards; review of case notes from surgical patients; indirect evaluation of hand hygiene by measuring hospital use of handwashing materials; measurement of outcomes (adverse events, mortality among high risk patients admitted to medical wards, patients' satisfaction, mortality in intensive care, rates of hospital acquired infection). Setting: NHS hospitals in England. Participants: Nine hospitals participating in SPI2 and nine matched control hospitals. Intervention The SPI2 intervention was similar to the SPI1, with somewhat modified goals, a slightly longer intervention period, and a smaller budget per hospital. Results: One of the scores (organisational climate) showed a significant (P=0.009) difference in rate of change over time, which favoured the control hospitals, though the difference was only 0.07 points on a five point scale. Results of the explicit case note reviews of high risk medical patients showed that certain practices improved over time in both control and SPI2 hospitals (and none deteriorated), but there were no significant differences between control and SPI2 hospitals. Monitoring of vital signs improved across control and SPI2 sites. This temporal effect was significant for monitoring the respiratory rate at both the six hour (adjusted odds ratio 2.1, 99% confidence interval 1.0 to 4.3; P=0.010) and 12 hour (2.4, 1.1 to 5.0; P=0.002) periods after admission. There was no significant effect of SPI for any of the measures of vital signs. Use of a recommended system for scoring the severity of pneumonia improved from 1.9% (1/52) to 21.4% (12/56) of control and from 2.0% (1/50) to 41.7% (25/60) of SPI2 patients. This temporal change was significant (7.3, 1.4 to 37.7; P=0.002), but the difference in difference was not significant (2.1, 0.4 to 11.1; P=0.236). There were no notable or significant changes in the pattern of prescribing errors, either over time or between control and SPI2 hospitals. Two items of medical history taking (exercise tolerance and occupation) showed significant improvement over time, across both control and SPI2 hospitals, but no additional SPI2 effect. The holistic review showed no significant changes in error rates either over time or between control and SPI2 hospitals. The explicit case note review of perioperative care showed that adherence rates for two of the four perioperative standards targeted by SPI2 were already good at baseline, exceeding 94% for antibiotic prophylaxis and 98% for deep vein thrombosis prophylaxis. Intraoperative monitoring of temperature improved over time in both groups, but this was not significant (1.8, 0.4 to 7.6; P=0.279), and there were no additional effects of SPI2. A dramatic rise in consumption of soap and alcohol hand rub was similar in control and SPI2 hospitals (P=0.760 and P=0.889, respectively), as was the corresponding decrease in rates of Clostridium difficile and meticillin resistant Staphylococcus aureus infection (P=0.652 and P=0.693, respectively). Mortality rates of medical patients included in the case note reviews in control hospitals increased from 17.3% (42/243) to 21.4% (24/112), while in SPI2 hospitals they fell from 10.3% (24/233) to 6.1% (7/114) (P=0.043). Fewer than 8% of deaths were classed as avoidable; changes in proportions could not explain the divergence of overall death rates between control and SPI2 hospitals. There was no significant difference in the rate of change in mortality in intensive care. Patients' satisfaction improved in both control and SPI2 hospitals on all dimensions, but again there were no significant changes between the two groups of hospitals. Conclusions: Many aspects of care are already good or improving across the NHS in England, suggesting considerable improvements in quality across the board. These improvements are probably due to contemporaneous policy activities relating to patient safety, including those with features similar to the SPI, and the emergence of professional consensus on some clinical processes. This phenomenon might have attenuated the incremental effect of the SPI, making it difficult to detect. Alternatively, the full impact of the SPI might be observable only in the longer term. The conclusion of this study could have been different if concurrent controls had not been used.

Large scale organisational intervention to improve patient safety in four UK hospitals:mixed method evaluation

Objectives: To conduct an independent evaluation of the first phase of the Health Foundation's Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals. Design: Mixed method evaluation involving five substudies, before and after design. Setting: NHS hospitals in United Kingdom. Participants: Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals. Intervention: The SPI1 was a compound (multicomponent) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change. Results: Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P<0.01) effect in favour of the SPI1 hospitals in one of 11 dimensions of the staff questionnaire (organisational climate). Qualitative evidence showed only modest penetration of SPI1 at medical ward level. Although SPI1 was designed to engage staff from the bottom up, it did not usually feel like this to those working on the wards, and questions about legitimacy of some aspects of SPI1 were raised. Of the five components to identify patients at risk of deterioration - monitoring of vital signs (14 items); routine tests (three items); evidence based standards specific to certain diseases (three items); prescribing errors (multiple items from the British National Formulary); and medical history taking (11 items) - there was little net difference between control and SPI1 hospitals, except in relation to quality of monitoring of acute medical patients, which improved on average over time across all hospitals. Recording of respiratory rate increased to a greater degree in SPI1 than in control hospitals; in the second six hours after admission recording increased from 40% (93) to 69% (165) in control hospitals and from 37% (141) to 78% (296) in SPI1 hospitals (odds ratio for "difference in difference" 2.1, 99% confidence interval 1.0 to 4.3; P=0.008). Use of a formal scoring system for patients with pneumonia also increased over time (from 2% (102) to 23% (111) in control hospitals and from 2% (170) to 9% (189) in SPI1 hospitals), which favoured controls and was not significant (0.3, 0.02 to 3.4; P=0.173). There were no improvements in the proportion of prescription errors and no effects that could be attributed to SPI1 in non-targeted generic areas (such as enhanced safety culture). On some measures, the lack of effect could be because compliance was already high at baseline (such as use of steroids in over 85% of cases where indicated), but even when there was more room for improvement (such as in quality of medical history taking), there was no significant additional net effect of SPI1. There were no changes over time or between control and SPI1 hospitals in errors or rates of adverse events in patients in medical wards. Mortality increased from 11% (27) to 16% (39) among controls and decreased from17%(63) to13%(49) among SPI1 hospitals, but the risk adjusted difference was not significant (0.5, 0.2 to 1.4; P=0.085). Poor care was a contributing factor in four of the 178 deaths identified by review of case notes. The survey of patients showed no significant differences apart from an increase in perception of cleanliness in favour of SPI1 hospitals. Conclusions The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening.

Application of Naïve Bayesian sequential analysis to primary care optometry

The objective of this study was to investigate the effects of circularity, comorbidity, prevalence and presentation variation on the accuracy of differential diagnoses made in optometric primary care using a modified form of naïve Bayesian sequential analysis. No such investigation has ever been reported before. Data were collected for 1422 cases seen over one year. Positive test outcomes were recorded for case history (ethnicity, age, symptoms and ocular and medical history) and clinical signs in relation to each diagnosis. For this reason only positive likelihood ratios were used for this modified form of Bayesian analysis that was carried out with Laplacian correction and Chi-square filtration. Accuracy was expressed as the percentage of cases for which the diagnoses made by the clinician appeared at the top of a list generated by Bayesian analysis. Preliminary analyses were carried out on 10 diagnoses and 15 test outcomes. Accuracy of 100% was achieved in the absence of presentation variation but dropped by 6% when variation existed. Circularity artificially elevated accuracy by 0.5%. Surprisingly, removal of Chi-square filtering increased accuracy by 0.4%. Decision tree analysis showed that accuracy was influenced primarily by prevalence followed by presentation variation and comorbidity. Analysis of 35 diagnoses and 105 test outcomes followed. This explored the use of positive likelihood ratios, derived from the case history, to recommend signs to look for. Accuracy of 72% was achieved when all clinical signs were entered. The drop in accuracy, compared to the preliminary analysis, was attributed to the fact that some diagnoses lacked strong diagnostic signs; the accuracy increased by 1% when only recommended signs were entered. Chi-square filtering improved recommended test selection. Decision tree analysis showed that accuracy again influenced primarily by prevalence, followed by comorbidity and presentation variation. Future work will explore the use of likelihood ratios based on positive and negative test findings prior to considering naïve Bayesian analysis as a form of artificial intelligence in optometric practice.

Relação entre a cárie precoce da infância com o índice de Apgar e outros fatores de risco

The aim of this cross-sectional study was to investigate the association of early childhood caries (ECC) with the Apgar score (AS) and other variables related to the child (conditions at birth and medical history) and related to the child and parents and / or guardians and family (demographic, socioeconomic and behavioral). One hundred and twenty healthy children aged between 3-5 years-old treated by Pediatric Dentistry Area of Dentistry College of the Federal University of Uberlandia during 2015 were selected. To obtain qualitative and quantitative variables a questionnaire was applied as an interview to the parents and/or guardians. The 5-minute AS (interest exposure) was obtained through the record in the Child Health Handbook. To assess the prevalence of caries (clinical dependent variable), a single calibrated researcher conducted the clinical examination, according to the criteria of the World Health Organization. Caries experience was measured using the indexes dmft and dmfs. The children were classified into three groups, according to age and dmfs index: no caries (NC), with ECC and with severe early childhood caries (S-ECC). Data were tabulated and submitted to statistical analysis using the SPSS software (IBM, Inc, Chicago, Illinois, USA) 17th version. Three logistics models were carried out having the following classifications: NC and ECC, NC and S-ECC, ECC and S-ECC (p<0.05). The overall ECC prevalence, considering children with ECC and S-ECC, was 55,8% (n= 67). The AS was not a statistically significant variable. The child’s age, weaning age and recent hospitalization were variables associated with the ECC prevalence. The age of brush start and the educational level of the mother were variables associated with the S-ECC prevalence. Considering the ECC and the S-ECC groups, the child's age and the beginning of the use of fluoride toothpaste, recent hospitalization, the educational level of the mother and the father's income were associated with the S-ECC prevalence. Considering the methodology employed and the analysis of results, it was concluded that there was no association between the ECC with the AS in healthy children. However, an association was found of ECC and S-ECC with some variables related to birth and to medical history of the child (recent hospitalization), demographic (child’s age), socioeconomic (educational level of the mother and father's income) and behavioral (age of brush start, weaning age and use of fluoride toothpaste) related to children and to the parents and/or guardians.

Psychosocial Functioning in Women with Symptoms of Persistent Genital Arousal

Persistent genital arousal disorder (PGAD) is characterized by physiological sexual arousal (vasocongestion, sensitivity of the genitals and nipples) that is described as distressing, and sometimes painful. Although awareness of PGAD is growing, there continues to be a lack of systematic research on this condition. The vast majority of published reports are case studies. Little is known about the symptom characteristics, biological factors, or psychosocial functioning associated with the experience of persistent genital arousal (PGA) symptoms. This study sought to characterize a sample of women with PGA (Study One); compare women with and without PGA symptoms on a series of biopsychosocial factors (Study Two); and undertake an exploratory comparison of women with PGA, painful PGA, and genital pain (Study Three)—all within a biopsychosocial framework. Symptom-free women, women with PGA symptoms, painful PGA, and genital pain, completed an online survey of biological factors (medical history, symptom profiles), psychological factors (depression, anxiety) and social factors (sexual function, relationship satisfaction). Study One found that women report diverse symptoms associated with PGA, with almost half reporting painful symptoms. In Study Two, women with symptoms of PGA reported significantly greater impairment in most domains of psychosocial functioning as compared to symptom-free women. In particular, catastrophizing of vulvar sensations was related to symptom ratings (i.e., greater severity, distress) and psychosocial outcomes (i.e., greater depression and anxiety). Finally, Study Three found that women with PGA symptoms reported some overlap in medical comorbidities and symptom expression as those with combined PGA and vulvodynia and those with vulvodynia symptoms alone; however, there were also a number of significant differences in their associated physical symptoms. These studies indicate that PGA symptoms have negative consequences for the psychosocial functioning of affected women. As such, future research and clinical care may benefit from a biopsychosocial approach to PGA symptoms. These studies highlight areas for more targeted research, including the role of catastrophizing in PGA symptom development and maintenance, and the potential conceptualization of both PGA and vulvodynia (and potentially other conditions) under a general umbrella of ‘genital paraesthesias’ (i.e., disorders characterized by abnormal sensations, such as tingling and burning).

Of Marx and Makers: an Historical Perspective on Generative Justice

In Marxist frameworks “distributive justice” depends on extracting value through a centralized state. Many new social movements—peer to peer economy, maker activism, community agriculture, queer ecology, etc.—take the opposite approach, keeping value in its unalienated form and allowing it to freely circulate from the bottom up. Unlike Marxism, there is no general theory for bottom-up, unalienated value circulation. This paper examines the concept of “generative justice” through an historical contrast between Marx’s writings and the indigenous cultures that he drew upon. Marx erroneously concluded that while indigenous cultures had unalienated forms of production, only centralized value extraction could allow the productivity needed for a high quality of life. To the contrary, indigenous cultures now provide a robust model for the “gift economy” that underpins open source technological production, agroecology, and restorative approaches to civil rights. Expanding Marx’s concept of unalienated labor value to include unalienated ecological (nonhuman) value, as well as the domain of freedom in speech, sexual orientation, spirituality and other forms of “expressive” value, we arrive at an historically informed perspective for generative justice.