The influence of students' prior clinical skills and context characteristics on mini-CEX scores in clerkships - a multilevel analysis.

BACKGROUND In contrast to objective structured clinical examinations (OSCEs), mini-clinical evaluation exercises (mini-CEXs) take place at the clinical workplace. As both mini-CEXs and OSCEs assess clinical skills, but within different contexts, this study aims at analyzing to which degree students' mini-CEX scores can be predicted by their recent OSCE scores and/or context characteristics. METHODS Medical students participated in an end of Year 3 OSCE and in 11 mini-CEXs during 5 different clerkships of Year 4. The students' mean scores of 9 clinical skills OSCE stations and mean 'overall' and 'domain' mini-CEX scores, averaged over all mini-CEXs of each student were computed. Linear regression analyses including random effects were used to predict mini-CEX scores by OSCE performance and characteristics of clinics, trainers, students and assessments. RESULTS A total of 512 trainers in 45 clinics provided 1783 mini-CEX ratings for 165 students; OSCE results were available for 144 students (87 %). Most influential for the prediction of 'overall' mini-CEX scores was the trainers' clinical position with a regression coefficient of 0.55 (95 %-CI: 0.26-0.84; p < .001) for residents compared to heads of department. Highly complex tasks and assessments taking place in large clinics significantly enhanced 'overall' mini-CEX scores, too. In contrast, high OSCE performance did not significantly increase 'overall' mini-CEX scores. CONCLUSION In our study, Mini-CEX scores depended rather on context characteristics than on students' clinical skills as demonstrated in an OSCE. Ways are discussed which focus on either to enhance the scores' validity or to use narrative comments only.

Prior knowledge of the clinical picture does not introduce bias in the histopathologic diagnosis of melanocytic skin lesions

A common debate among dermatopathologists is that prior knowledge of the clinical picture of melanocytic skin neoplasms may introduce a potential bias in the histopathologic examination. Histologic slides from 99 melanocytic skin neoplasms were circulated among 10 clinical dermatologists, all of them formally trained and board-certified dermatopathologists: 5 dermatopathologists had clinical images available after a 'blind' examination (Group 1); the other 5 had clinical images available before microscopic examination (Group 2). Data from the two groups were compared regarding 'consensus' (a diagnosis in agreement by ≥4 dermatopathologists/group), chance-corrected interobserver agreement (Fleiss' k) and level of diagnostic confidence (LDC: a 1-5 arbitrary scale indicating 'increasing reliability' of any given diagnosis). Compared with Group 1 dermatopathologists, Group 2 achieved a lower number of consensus (84 vs. 90) but a higher k value (0.74 vs. 0.69) and a greater mean LDC value (4.57 vs. 4.32). The same consensus was achieved by the two groups in 81/99 cases. Spitzoid neoplasms were most frequently controversial for both groups. The histopathologic interpretation of melanocytic neoplasms seems to be not biased by the knowledge of the clinical picture before histopathologic examination.

Partial lateralization of the nasopalatine nerve at the incisive foramen for ridge augmentation in the anterior maxilla prior to placement of dental implants: a retrospective case series evaluating self-reported data and neurosensory testing

The objective of this study was to assess implant therapy after a staged guided bone regeneration procedure in the anterior maxilla by lateralization of the nasopalatine nerve and vessel bundle. Neurosensory function following augmentative procedures and implant placement, assessed using a standardized questionnaire and clinical examination, were the primary outcome variables measured. This retrospective study included patients with a bone defect in the anterior maxilla in need of horizontal and/or vertical ridge augmentation prior to dental implant placement. The surgical sites were allowed to heal for at least 6 months before placement of dental implants. All patients received fixed implant-supported restorations and entered into a tightly scheduled maintenance program. In addition to the maintenance program, patients were recalled for a clinical examination and to fill out a questionnaire to assess any changes in the neurosensory function of the nasopalatine nerve at least 6 months after function. Twenty patients were included in the study from February 2001 to December 2010. They received a total of 51 implants after augmentation of the alveolar crest and lateralization of the nasopalatine nerve. The follow-up examination for questionnaire and neurosensory assessment was scheduled after a mean period of 4.18 years of function. None of the patients examined reported any pain, they did not have less or an altered sensation, and they did not experience a "foreign body" feeling in the area of surgery. Overall, 6 patients out of 20 (30%) showed palatal sensibility alterations of the soft tissues in the region of the maxillary canines and incisors resulting in a risk for a neurosensory change of 0.45 mucosal teeth regions per patient after ridge augmentation with lateralization of the nasopalatine nerve. Regeneration of bone defects in the anterior maxilla by horizontal and/or vertical ridge augmentation and lateralization of the nasopalatine nerve prior to dental implant placement is a predictable surgical technique. Whether or not there were clinically measurable impairments of neurosensory function, the patients did not report them or were not bothered by them.

Extreme River Floods in Western Switzerland and the Lake of Constance Region in the Period Prior to Instrumental Measurements

The floods that occurred on the Aare and Rhine rivers in May 2015 and the mostly successful handling of this event in terms of flood protection measures are a good reminder of how important it is to comprehend the causes and processes involved in such natural hazards. While the needed data series of gauge measurements and peak discharge calculations reach back to the 19th century, historical records dating further back in time can provide additional and useful information to help understanding extreme flood events and to evaluate prevention measures such as river dams and corrections undertaken prior to instrumental measurements. In my PhD project I will use a wide range of historical sources to assess and quantify past extreme flood events. It is part of the SNF-funded project “Reconstruction of the Genesis, Process and Impact of Major Pre-instrumental Flood Events of Major Swiss Rivers Including a Peak Discharge Quantification” and will cover the research locations Fribourg (Saane R.), Burgdorf (Emme R.), Thun, Bern (both Aare R.), and the Lake of Constance at the locations Lindau, Constance and Rorschach. My main goals are to provide a long time series of quantitative data for extreme flood events, to discuss the occurring changes in these data, and to evaluate the impact of the aforementioned human influences on the drainage system. Extracting information given in account books from the towns of Basel and Solothurn may also enable me to assess the frequency and seasonality of less severe river floods. Finally, historical information will be used for remodeling the historical hydrological regime to homogenize the historical data series to modern day conditions and thus make it comparable to the data provided by instrumental measurements. The method I will apply for processing all information provided by historical sources such as chronicles, newspapers, institutional records, as well as flood marks, paintings and archeological evidence has been developed and successfully applied to the site of Basel by Wetter et al. (2011). They have also shown that data homogenization is possible by reconstructing previous stream flow conditions using historical river profiles and by carefully observing and re-constructing human changes of the river bed and its surroundings. Taken all information into account, peak discharges for past extreme flood events will be calculated with a one-dimensional hydrological model.

Emerging Identities in Colonial Tunisia: "Alliancist" and Zionist Representations in Tunis prior to World War I

By 1900 the Jewish community of Tunisia witnessed the emergence of new competing identities: “assimilationist” of the Alliance Israelite Universelle, termed “Alliancist,” and Zionist. Strikingly, two members of the same family in Tunis, Raymond Valensi, President of the AIU Regional Committee, and Alfred Valensi, President of the Zionist Federation, led the struggle for their separate causes. In his discussion of identity in the modern world, Homi Bhabha asks, "How do strategies of representation or empowerment come to be formulated in the competing claims of communities…where, despite shared histories of …discrimination, the exchange of values, meanings and priorities…may be profoundly antagonistic…?" It is in this context that the claims of the Alliance and Zionism will be examined prior to World War I, based on the Archives of the AIU and on such secondary sources as the indispensable work of Paul Sebag. The tensions between the Alliancists and Zionists continued until the outbreak of World War II, as the French-speaking Jews of Tunisia sought to define their individual and collective identities.

Search, Seizure and (False?) Arrest: An Analysis of Fourth Amendment Remedies when Police can Plant Evidence

The Fourth Amendment prohibits unreasonable searches and seizures in criminal investigations. The Supreme Court has interpreted this to require that police obtain a warrant prior to search and that illegally seized evidence be excluded from trial. A consensus has developed in the law and economics literature that tort liability for police officers is a superior means of deterring unreasonable searches. We argue that this conclusion depends on the assumption of truth-seeking police, and develop a game-theoretic model to compare the two remedies when some police officers (the bad type) are willing to plant evidence in order to obtain convictions, even though other police (the good type) are not (where this type is private information). We characterize the perfect Bayesian equilibria of the asymmetric-information game between the police and a court that seeks to minimize error costs in deciding whether to convict or acquit suspects. In this framework, we show that the exclusionary rule with a warrant requirement leads to superior outcomes (relative to tort liability) in terms of truth-finding function of courts, because the warrant requirement can reduce the scope for bad types of police to plant evidence

De anima brutorum quae hominis vitalis ac sensitiva est exercitationes : 2. Prior physiologica eiusdem naturam, partes, petentias et affectiones tradit : altera pathologica morbos qui ipsam, & sedem eius primariam, ...

studio Thomae Willis

Prior history of atopy or autoimmunity increases risk for alopecia areata

Background. The association between a prior history of atopy or other autoimmune diseases and risk of alopecia areata is not well established. ^ Objective. Purpose of this study was to use the National Alopecia Areata Registry database to further investigate the association between history of atopy or other autoimmune diseases and risk of alopecia areata. ^ Methods. A total of 2,613 self-registered sporadic cases (n = 2,055) and controls (n = 558) were included in the present analysis. ^ Results. Possessing a history of any atopy (OR = 2.00; 95% CI 1.50-2.54) or autoimmune disease (OR = 1.73; 95% CI 1.10-2.72) was associated with an increased risk of alopecia areata. There was no trend for possessing a history of more than one atopy or autoimmune disease and increasing risk of alopecia areata. ^ Limitations. Recall, reporting, and recruiting bias are potential sources of limitations in this analysis. ^ Conclusion. This analysis revealed that a prior history of atopy and autoimmune disease was associated with an increased risk of alopecia areata and that the results were consistent for both the severe subtype of alopecia areata (i.e., alopecia totalis and alopecia universalis) and the localized subtype (i.e., alopecia areata persistent).^

A systematic review of selected birth outcomes in diabetic women who received preconception care and/or used multivitamins prior to pregnancy

Objective. To conduct a systematic review of published literature on preconception care in pre-existing diabetic women looking at the effect of glycemic control and multivitamin usage on the frequency of spontaneous abortion and birth defects.^ Methods. Articles were retrieved from Medline (1950–Dec 2007), Cochrane Library (1800–Dec 2007), Academic Search Complete (Ebsco) (Jan 1800–Dec 2007) and Maternal and Child Health Library (1965–Dec 2007). Studies included women with pre-existing, non-gestational diabetes and a comparison group. Participants must have either received preconception care and/or consumed a multivitamin as part of the study.^ Results. Overall, seven studies met the study criteria and applicability to the study objectives. Four of these reported the frequency of spontaneous abortion. Only one found a statistically significant increased risk of spontaneous abortion among pregnant women who did not receive preconception care compared with those who did receive care, odds ratio 4.32; 95% CI 1.34 to 13.9. Of the seven studies, six reported the frequency of birth defects. Five of these six studies found a significantly increased rate of birth defects among pregnant women who did not receive preconception care compared with those who did receive care, with odds ratios ranging from 1.53 to 10.16. All seven studies based their preconception care intervention on glycemic control. One study also used multivitamins as part of the preconception care.^ Conclusion. Glycemic control was shown to be useful in reducing the prevalence of birth defects, but not as useful in reducing the prevalence of spontaneous abortion. Insulin regimen options vary widely for the diabetic woman. No author excluded or controlled for women who may have been taking a multivitamin on their own. Due to the small amount of literature available, it is still not known which preconception care option, glucose control and/or multivitamin usage, provides better protection from birth defects and spontaneous abortion for the diabetic woman. An area for future investigation would be glycemic control and the use of folic acid started before pregnancy and the effects on birth defects and spontaneous abortion.^

Does prior receipt of a rifamycin antibiotic increase the risk of acquiring an infection due to a rifamycin-resistant strain of Clostridium difficile?

Objectives. To examine the association between prior rifamycin exposure and later development of C. difficile infection (CDI) caused by a rifamycin-resistant strain of C. difficile , and to compare patient characteristics between rifamycin-resistant strains of C. difficile infection and rifamycin-susceptible strains of C. difficile infection. ^ Methods. A case-control study was performed in a large university-affiliated hospital in Houston, Texas. Study subjects were patients with C. difficile infection acquired at the hospital with culture-positive isolates of C. difficile with which in vitro rifaximin and rifampin susceptibility has been tested. Prior use of rifamycin, demographic and clinical characteristics was compared between case and control groups using univariate statistics. ^ Results. A total of 49 C. difficile strains met the study inclusion criteria for rifamycin-resistant case isolates, and a total of 98 rifamycin-susceptible C. difficile strains were matched to case isolates. Of 49 case isolates, 12 (4%) were resistant to rifampin alone, 12 (4%) were resistant to rifaximin alone, and 25 (9%) were resistant to both rifampin and rifaximin. There was no significant association between prior rifamycin use and rifamycin-resistant CDI. Cases and controls did not differ according to demographic characteristics, length of hospital stay, known risk factors of CDI, type of CDI-onset, and pre-infection medical co-morbidities. Our results on 37 rifaximin-resistant isolates (MIC ≥32 &mgr;g/ml) showed more than half of isolates had a rifaximin MIC ≥256 &mgr;g/ml, and out of these isolates, 19 isolates had MICs ≥1024 &mgr;g/ml. ^ Conclusions. Using a large series of rifamycin-non-susceptible isolates, no patient characteristics were independently associated with rifamycin-resistant CDI. This data suggests that factors beyond previous use of rifamycin antibiotics are primary risk factors for rifamycin-resistant C. difficile. ^

A Logarithmic Image Prior for Blind Deconvolution

Blind Deconvolution consists in the estimation of a sharp image and a blur kernel from an observed blurry image. Because the blur model admits several solutions it is necessary to devise an image prior that favors the true blur kernel and sharp image. Many successful image priors enforce the sparsity of the sharp image gradients. Ideally the L0 “norm” is the best choice for promoting sparsity, but because it is computationally intractable, some methods have used a logarithmic approximation. In this work we also study a logarithmic image prior. We show empirically how well the prior suits the blind deconvolution problem. Our analysis confirms experimentally the hypothesis that a prior should not necessarily model natural image statistics to correctly estimate the blur kernel. Furthermore, we show that a simple Maximum a Posteriori formulation is enough to achieve state of the art results. To minimize such formulation we devise two iterative minimization algorithms that cope with the non-convexity of the logarithmic prior: one obtained via the primal-dual approach and one via majorization-minimization.

Effect of short-term fasting prior to slaughter on welfare and meat quality or rainbow trout (Oncorhynchus mykiss)

El manejo pre-sacrificio es de vital importancia en acuicultura, ya que afecta tanto a las reacciones fisiológicas como a los procesos bioquímicos post mortem, y por tanto al bienestar y a la calidad del producto. El ayuno pre-sacrificio se lleva a cabo de forma habitual en acuicultura, ya que permite el vaciado del aparato digestivo de restos de alimento y heces, reduciendo de esta manera la carga bacteriana en el intestino y la dispersión de enzimas digestivos y potenciales patógenos a la carne. Sin embargo, la duración óptima de este ayuno sin que el pez sufra un estrés innecesario no está clara. Además, se sabe muy poco sobre la mejor hora del día para realizar el sacrificio, lo que a su vez está regido por los ritmos diarios de los parámetros fisiológicos de estrés. Finalmente, se sabe que la temperatura del agua juega un papel muy importante en la fisiología del estrés pero no se ha determinado su efecto en combinación con el ayuno. Además, las actuales recomendaciones en relación a la duración óptima del ayuno previo al sacrificio en peces no suelen considerar la temperatura del agua y se basan únicamente en días y no en grados día (ºC d). Se determinó el efecto del ayuno previo al sacrificio (1, 2 y 3 días, equivalente a 11,1-68,0 grados día) y la hora de sacrificio (08h00, 14h00 y 20h00) en trucha arco iris (Oncorhynchus mykiss) de tamaño comercial en cuatro pruebas usando diferentes temperaturas de agua (Prueba 1: 11,8 ºC; Prueba 2: 19,2 ºC; Prueba 3: 11,1 ºC; y Prueba 4: 22,7 ºC). Se midieron indicadores biométricos, hematológicos, metabólicos y de calidad de la carne. En cada prueba, los valores de los animales ayunados (n=90) se compararon con 90 animales control mantenidos bajo condiciones similares pero nos ayunados. Los resultados sugieren que el ayuno tuvo un efecto significativo sobre los indicadores biométricos. El coeficiente de condición en los animales ayunados fue menor que en los controles después de 2 días de ayuno. El vaciado del aparato digestivo se produjo durante las primeras 24 h de ayuno, encontrándose pequeñas cantidades de alimento después de 48 h. Por otra parte, este vaciado fue más rápido cuando las temperaturas fueron más altas. El peso del hígado de los animales ayunados fue menor y las diferencias entre truchas ayunadas y controles fueron más evidentes a medida que el vaciado del aparato digestivo fue más rápido. El efecto del ayuno hasta 3 días en los indicadores hematológicos no fue significativo. Los niveles de cortisol en plasma resultaron ser altos tanto en truchas ayunadas como en las alimentadas en todas las pruebas realizadas. La concentración media de glucosa varió entre pruebas pero mostró una tendencia a disminuir en animales ayunados a medida que el ayuno progresaba. En cualquier caso, parece que la temperatura del agua jugó un papel muy importante, ya que se encontraron concentraciones más altas durante los días 2 y 3 de ayuno en animales mantenidos a temperaturas más bajas previamente al sacrificio. Los altos niveles de lactato obtenidos en sangre parecen sugerir episodios de intensa actividad muscular pero no se pudo encontrar relación con el ayuno. De la misma manera, el nivel de hematocrito no mostró efecto alguno del ayuno y los leucocitos tendieron a ser más altos cuando los animales estaban menos estresados y cuando su condición corporal fue mayor. Finalmente, la disminución del peso del hígado (índice hepatosomático) en la Prueba 3 no se vio acompañada de una reducción del glucógeno hepático, lo que sugiere que las truchas emplearon una estrategia diferente para mantener constantes los niveles de glucosa durante el periodo de ayuno en esa prueba. En relación a la hora de sacrificio, se obtuvieron niveles más bajos de cortisol a las 20h00, lo que indica que las truchas estaban menos estresadas y que el manejo pre-sacrificio podría resultar menos estresante por la noche. Los niveles de hematocrito fueron también más bajos a las 20h00 pero solo con temperaturas más bajas, sugiriendo que las altas temperaturas incrementan el metabolismo. Ni el ayuno ni la hora de sacrificio tuvieron un efecto significativo sobre la evolución de la calidad de la carne durante los 3 días de almacenamiento. Por el contrario, el tiempo de almacenamiento sí que parece tener un efecto claro sobre los parámetros de calidad del producto final. Los niveles más bajos de pH se alcanzaron a las 24-48 h post mortem, con una lata variabilidad entre duraciones del ayuno (1, 2 y 3 días) en animales sacrificados a las 20h00, aunque no se pudo distinguir ningún patrón común. Por otra parte, la mayor rigidez asociada al rigor mortis se produjo a las 24 h del sacrificio. La capacidad de retención de agua se mostró muy estable durante el período de almacenamiento y parece ser independiente de los cambios en el pH. El parámetro L* de color se incrementó a medida que avanzaba el período de almacenamiento de la carne, mientras que los valores a* y b* no variaron en gran medida. En conclusión, basándose en los resultados hematológicos, el sacrificio a última hora del día parece tener un efecto menos negativo en el bienestar. De manera general, nuestros resultados sugieren que la trucha arco iris puede soportar un período de ayuno previo al sacrificio de hasta 3 días o 68 ºC d sin que su bienestar se vea seriamente comprometido. Es probable que con temperaturas más bajas las truchas pudieran ser ayunadas durante más tiempo sin ningún efecto negativo sobre su bienestar. En cualquier caso, se necesitan más estudios para determinar la relación entre la temperatura del agua y la duración óptima del ayuno en términos de pérdida de peso vivo y la disminución de los niveles de glucosa en sangre y otros indicadores metabólicos. SUMMARY Pre-slaughter handling in fish is important because it affects both physiological reactions and post mortem biochemical processes, and thus welfare and product quality. Pre-slaughter fasting is regularly carried out in aquaculture, as it empties the viscera of food and faeces, thus reducing the intestinal bacteria load and the spread of gut enzymes and potential pathogens to the flesh. However, it is unclear how long rainbow trout can be fasted before suffering unnecessary stress. In addition, very little is known about the best time of the day to slaughter fish, which may in turn be dictated by diurnal rhythms in physiological stress parameters. Water temperature is also known to play a very important role in stress physiology in fish but the combined effect with fasting is unclear. Current recommendations regarding the optimal duration of pre-slaughter fasting do not normally consider water temperature and are only based on days, not degree days (ºC d). The effects of short-term fasting prior to slaughter (1, 2 and 3 days, between 11.1 and 68.0 ºC days) and hour of slaughter (08h00, 14h00 and 20h00) were determined in commercial-sized rainbow trout (Oncorhynchus mykiss) over four trials at different water temperatures (TRIAL 1, 11.8 ºC; TRIAL 2, 19.2 ºC; TRIAL 3, 11.1 ºC; and TRIAL 4, 22.7 ºC). We measured biometric, haematological, metabolic and product quality indicators. In each trial, the values of fasted fish (n=90) were compared with 90 control fish kept under similar conditions but not fasted. Results show that fasting affected biometric indicators. The coefficient of condition in fasted trout was lower than controls 2 days after food deprivation. Gut emptying occurred within the first 24 h after the cessation of feeding, with small traces of digesta after 48 h. Gut emptying was faster at higher water temperatures. Liver weight decreased in food deprived fish and differences between fasted and fed trout were more evident when gut clearance was faster. The overall effect of fasting for up to three days on haematological indicators was small. Plasma cortisol levels were high in both fasted and fed fish in all trials. Plasma glucose response to fasting varied among trials, but it tended to be lower in fasted fish as the days of fasting increased. In any case, it seems that water temperature played a more important role, with higher concentrations at lower temperatures on days 2 and 3 after the cessation of feeding. Plasma lactate levels indicate moments of high muscular activity and were also high, but no variation related to fasting could be found. Haematocrit did not show any significant effect of fasting, but leucocytes tended to be higher when trout were less stressed and when their body condition was higher. Finally, the loss of liver weight was not accompanied by a decrease in liver glycogen (only measured in TRIAL 3), suggesting that a different strategy to maintain plasma glucose levels was used. Regarding the hour of slaughter, lower cortisol levels were found at 20h00, suggesting that trout were less stressed later in the day and that pre-slaughter handling may be less stressful at night. Haematocrit levels were also lower at 20h00 but only at lower temperatures, indicating that higher temperatures increase metabolism. Neither fasting nor the hour of slaughter had a significant effect on the evolution of meat quality during 3 days of storage. In contrast, storage time seemed to have a more important effect on meat quality parameters. The lowest pH was reached 24-48 h post mortem, with a higher variability among fasting durations at 20h00, although no clear pattern could be discerned. Maximum stiffening from rigor mortis occurred after 24 h. The water holding capacity was very stable throughout storage and seemed to be independent of pH changes. Meat lightness (L*) slightly increased during storage and a* and b*-values were relatively stable. In conclusion, based on the haematological results, slaughtering at night may have less of a negative effect on welfare than at other times of the day. Overall, our results suggest that rainbow trout can cope well with fasting up to three days or 68 ºC d prior to slaughter and that their welfare is therefore not seriously compromised. At low water temperatures, trout could probably be fasted for longer periods without negative effects on welfare but more research is needed to determine the relationship between water temperature and days of fasting in terms of loss of live weight and the decrease in plasma glucose and other metabolic indicators.