Quality assurance of simulated patient feedback in communication training for fourth-year medical students

Introduction In our program, simulated patients (SPs) give feedback to medical students in the course of communication skills training. To ensure effective training, quality control of the SPs’ feedback should be implemented. At other institutions, medical students evaluate the SPs’ feedback for quality control (Bouter et al., 2012). Thinking about implementing quality control for SPs’ feedback in our program, we wondered whether the evaluation by students would result in the same scores as evaluation by experts. Methods Consultations simulated by 4th-year medical students with SPs were video taped including the SP’s feedback to the students (n=85). At the end of the training sessions students rated the SPs’ performance using a rating instrument called Bernese Assessment for Role-play and Feedback (BARF) containing 11 items concerning feedback quality. Additionally the videos were evaluated by 3 trained experts using the BARF. Results The experts showed a high interrater agreement when rating identical feedbacks (ICCunjust=0.953). Comparing the rating of students and experts, high agreement was found with regard to the following items: 1. The SP invited the student to reflect on the consultation first, Amin (= minimal agreement) 97% 2. The SP asked the student what he/she liked about the consultation, Amin = 88%. 3. The SP started with positive feedback, Amin = 91%. 4. The SP was comparing the student with other students, Amin = 92%. In contrast the following items showed differences between the rating of experts and students: 1. The SP used precise situations for feedback, Amax (=maximal agreement) 55%, Students rated 67 of SPs’ feedbacks to be perfect with regard to this item (highest rating on a 5 point Likert scale), while only 29 feedbacks were rated this way by the experts. 2. The SP gave precise suggestions for improvement, Amax 75%, 62 of SPs’ feedbacks obtained the highest rating from students, while only 44 of SPs’ feedbacks achieved the highest rating in the view of the experts. 3. The SP speaks about his/her role in the third person, Amax 60%. Students rated 77 feedbacks with the highest score, while experts judged only 43 feedbacks this way. Conclusion Although evaluation by the students was in agreement with that of experts concerning some items, students rated the SPs’ feedback more often with the optimal score than experts did. Moreover it seems difficult for students to notice when SPs talk about the role in the first instead of the third person. Since precision and talking about the role in the third person are important quality criteria of feedback, this result should be taken into account when thinking about students’ evaluation of SPs’ feedback for quality control. Bouter, S., E. van Weel-Baumgarten, and S. Bolhuis. 2012. Construction and Validation of the Nijmegen Evaluation of the Simulated Patient (NESP): Assessing Simulated Patients’ Ability to Role-Play and Provide Feedback to Students. Academic Medicine: Journal of the Association of American Medical Colleges

Age-dependent visual exploration during simulated day- and night driving on a motorway: a cross-sectional study

BACKGROUND: Central and peripheral vision is needed for object detection. Previous research has shown that visual target detection is affected by age. In addition, light conditions also influence visual exploration. The aim of the study was to investigate the effects of age and different light conditions on visual exploration behavior and on driving performance during simulated driving. METHODS: A fixed-base simulator with 180 degree field of view was used to simulate a motorway route under daylight and night conditions to test 29 young subjects (25-40 years) and 27 older subjects (65-78 years). Drivers' eye fixations were analyzed and assigned to regions of interests (ROI) such as street, road signs, car ahead, environment, rear view mirror, side mirror left, side mirror right, incoming car, parked car, road repair. In addition, lane-keeping and driving speed were analyzed as a measure of driving performance. RESULTS: Older drivers had longer fixations on the task relevant ROI, but had a lower frequency of checking mirrors when compared to younger drivers. In both age groups, night driving led to a less fixations on the mirror. At the performance level, older drivers showed more variation in driving speed and lane-keeping behavior, which was especially prominent at night. In younger drivers, night driving had no impact on driving speed or lane-keeping behavior. CONCLUSIONS: Older drivers' visual exploration behavior are more fixed on the task relevant ROI, especially at night, when driving performance becomes more heterogeneous than in younger drivers.

Teḥinnôt : ein gebeṭbuch fir gebildeṭe froientzimmer zum gebroich bai der effenṭlichen und haizlichen andachṭ ; nach forhandenen alṭ-daiṭšen teḥines in rain daiṭš abgedrukṭ ...

der ferfaser Jehošua Hešil Miro

Di bolšewisṭiše hagode : miṭ a sak šehne maiśes un mešolim, miṭ perušim un dinim ... oif rain ivri-ṭaiṭš ...

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Density-dependent dynamics of a dominant rain forest tree change with juvenile stage and time of masting

Although negative density dependence (NDD) can facilitate tree species coexistence in forests, the underlying mechanisms can differ, and rarely are the dynamics of seedlings and saplings studied together. Herein we present and discuss a novel mechanism based on our investigation of NDD predictions for the large, grove-forming ectomycorrhizal mast fruiting tree, Microberlinia bisulcata (Caesalpiniaceae), in an 82.5-ha plot at Korup, Cameroon. We tested whether juvenile density, size, growth and survival decreases with increasing conspecific adult basal area for 3245 ‘new’ seedlings and 540 ‘old’ seedlings (< 75-cm tall) during an approximately 4-year study period (2008–2012) and for 234 ‘saplings’ (≥ 75-cm tall) during an approximately 6-year study period (2008–2014). We found that the respective densities of new seedlings, old seedlings and saplings were positively, not and negatively related to increasing BA. Maximum leaf numbers and heights of old seedlings were negatively correlated with increasing basal areas, as were sapling heights and stem diameters. Whereas survivorship of new seedlings decreased by more than one-half with increasing basal area over its range in 2010–2012, that of old seedlings decreased by almost two-thirds, but only in 2008–2010, and was generally unrelated to conspecific seedling density. In 2010–2012 relative growth rates in new seedlings’ heights decreased with increasing basal area, as well as with increasing seedling density, together with increasing leaf numbers, whereas old seedlings’ growth was unrelated to either conspecific density or basal area. Saplings of below-average height had reduced survivorship with increasing basal area (probability decreasing from approx. 0.4 to 0.05 over the basal area range tested), but only sapling growth in terms of leaf numbers decreased with increasing basal area. These static and dynamic results indicate that NDD is operating within this system, possibly stabilizing the M. bisulcata population. However, these NDD patterns are unlikely to be caused by symmetric competition or by consumers. Instead, an alternative mechanism for conspecific adult–juvenile negative feedback is proposed, one which involves the interaction between tree phenology and ectomycorrhizal linkages.

Limitation of seedling growth by potassium and magnesium supply for two ectomycorrhizal tree species of a Central African rain forest and its implication for their recruitment

In the ectomycorrhizal caesalpiniaceous groves of southern Korup National Park, the dominant tree species, Microberlinia bisulcata, displays very poor in situ recruitment compared with its codominant, Tetraberlinia bifoliolata. The reported ex situ experiment tested whether availabilities of soil potassium and magnesium play a role. Seedlings of the two species received applications of K and Mg fertilizer in potted native soil in a local shade house, and their responses in terms of growth and nutrient concentrations were recorded over 2 years. Amended soil concentrations were also determined. Microberlinia responded strongly and positively in its growth to Mg, but less to K; Tetraberlinia responded weakly to both. Added Mg led to strongly increased Mg concentration for Microberlinia while added K changed that concentration only slightly; Tetraberlinia strongly increased its concentration of K with added K, but only somewhat its Mg concentration with added Mg. Additions of Mg and K had small but important antagonistic effects. Microberlinia is Mg-demanding and apparently Mg-limited in Korup soil; Tetraberlinia, whilst K-demanding, appeared not to be K-limited (for growth). Added K enhanced plant P concentrations of both species. Extra applied Mg may also be alleviating soil aluminum toxicity, and hence improving growth indirectly and especially to the benefit of Microberlinia. Mg appears to be essential for Microberlinia seedling growth and its low soil availability in grove soils at Korup may be an important contributing factor to its poor recruitment. Microberlinia is highly shade-intolerant and strongly light-responding, whilst Tetraberlinia is more shade-tolerant and moderately light-responding, which affords an interesting contrast with respect to their differing responses to Mg supply. The study revealed novel aspects of functional traits and likely niche-partitioning among ectomycorrhizal caesalps in African rain forests. Identifying the direct and interacting indirect effects of essential elements on tropical tree seedling growth presents a considerable challenge due the complex nexus of causes involved.

Effect of an intervertebral disk spacer on stiffness after monocortical screw/polymethylmethacrylate fixation in simulated and cadaveric canine cervical vertebral columns.

OBJECTIVE To determine the biomechanical effect of an intervertebral spacer on construct stiffness in a PVC model and cadaveric canine cervical vertebral columns stabilized with monocortical screws/polymethylmethacrylate (PMMA). STUDY DESIGN Biomechanical study. SAMPLE POPULATION PVC pipe; cadaveric canine vertebral columns. METHODS PVC model-PVC pipe was used to create a gap model mimicking vertebral endplate orientation and disk space width of large-breed canine cervical vertebrae; 6 models had a 4-mm gap with no spacer (PVC group 1); 6 had a PVC pipe ring spacer filling the gap (PCV group 2). Animals-large breed cadaveric canine cervical vertebral columns (C2-C7) from skeletally mature dogs without (cadaveric group 1, n = 6, historical data) and with an intervertebral disk spacer (cadaveric group 2, n = 6) were used. All PVC models and cadaver specimens were instrumented with monocortical titanium screws/PMMA. Stiffness of the 2 PVC groups was compared in extension, flexion, and lateral bending using non-destructive 4-point bend testing. Stiffness testing in all 3 directions was performed of the unaltered C4-C5 vertebral motion unit in cadaveric spines and repeated after placement of an intervertebral cortical allograft ring and instrumentation. Data were compared using a linear mixed model approach that also incorporated data from previously tested spines with the same screw/PMMA construct but without disk spacer (cadaveric group 1). RESULTS Addition of a spacer increased construct stiffness in both the PVC model (P < .001) and cadaveric vertebral columns (P < .001) compared to fixation without a spacer. CONCLUSIONS Addition of an intervertebral spacer significantly increased construct stiffness of monocortical screw/PMMA fixation.

Simulated heat waves affected alpine grassland only in combination with drought

The Alpine region is warming fast, and concurrently, the frequency and intensity of climate extremes are increasing. It is currently unclear whether alpine ecosystems are sensitive or resistant to such extremes. We subjected Swiss alpine grassland communities to heat waves with varying intensity by transplanting monoliths to four different elevations (2440–660 m above sea level) for 17 d. Half of these were regularly irrigated while the other half were deprived of irrigation to additionally induce a drought at each site. Heat waves had no significant impacts on fluorescence (Fv/Fm, a stress indicator), senescence and aboveground productivity if irrigation was provided. However, when heat waves coincided with drought, the plants showed clear signs of stress, resulting in vegetation browning and reduced phytomass production. This likely resulted from direct drought effects, but also, as measurements of stomatal conductance and canopy temperatures suggest, from increased high-temperature stress as water scarcity decreased heat mitigation through transpiration. The immediate responses to heat waves (with or without droughts) recorded in these alpine grasslands were similar to those observed in the more extensively studied grasslands from temperate climates. Responses following climate extremes may differ in alpine environments, however, because the short growing season likely constrains recovery.

Placental expression of the angiogenic placental growth factor is stimulated by both aldosterone and simulated starvation

Aldosterone is an important factor supporting placental growth and fetal development. Recently, expression of placental growth factor (PlGF) has been observed in response to aldosterone exposure in different models of atherosclerosis. Thus, we hypothesized that aldosterone up-regulates growth-adaptive angiogenesis in pregnancy, via increased placental PlGF expression. We followed normotensive pregnant women (n = 24) throughout pregnancy and confirmed these results in a second independent first trimester cohort (n = 36). Urinary tetrahydroaldosterone was measured by gas chromatography-mass spectrometry and corrected for creatinine. Circulating PlGF concentrations were determined by ELISA. Additionally, cultured cell lines, adrenocortical H295R and choriocarcinoma BeWo cells, as well as primary human third trimester trophoblasts were tested in vitro. PlGF serum concentrations positively correlated with urinary tetrahydroaldosterone corrected for creatinine in these two independent cohorts. This observation was not due to PlGF, which did not induce aldosterone production in cultured H295R cells. On the other hand, PlGF expression was specifically enhanced by aldosterone in the presence of forskolin (p < 0.01) in trophoblasts. A pronounced stimulation of PlGF expression was observed with reduced glucose concentrations simulating starvation (p < 0.001). In conclusion, aldosterone stimulates placental PlGF production, enhancing its availability during human pregnancy, a response amplified by reduced glucose supply. Given the crucial role of PlGF in maintaining a healthy pregnancy, these data support a key role of aldosterone for a healthy pregnancy outcome.

Litter nutrients and retranslocation in a central African rain forest dominated by ectomycorrhizal trees

In the strongly seasonal, but annually very wet, parts of the tropics, low-water availability in the short dry season leads to a semi-deciduous forest, one which is also highly susceptible to nutrient loss from leaching in the long wet season. Patterns in litterfall were compared between forest with low (LEM) and high (HEM) abundances of ectomycorrhizal trees in Korup National Park, Cameroon, over 26 months in 1990–92. Leaf litter was sorted into 26 abundant species which included six ectomycorrhizal species, and of these three were the large grove-forming trees Microberlinia bisulcata, Tetraberlinia bifoliolata and Tetraberlinia moreliana. Larger-tree species shed their leaves with pronounced peaks in the dry season, whereas other species had either weaker dependence, showed several peaks per year, or were wet-season shedders. Although total annual litterfall differed little between forest types, in the HEM forest (dominated by M. bisulcata) the dry-season peak was more pronounced and earlier than that in the LEMforest. Species differed greatly in their mean leaf litterfall nutrient concentrations, with an approx. twofold range for nitrogen and phosphorus, and 2.5–3.5-fold for potassium, magnesium and calcium. In the dry season, LEM and HEM litter showed similar declines in P and N concentration, and increases in K and Mg; some species, especially M. bisculcata, showed strong dry-wet season differences. The concentration of P (but not N) was higher in the leaf litter of ectomycorrhizal than nonectomycorrhizal species. Retranslocation of N and P was lower among the ectomycorrhizal than nonectomycorrhizal species by approx. twofold. It is suggested that, within ectomycorrhizal groves on this soil low in P, a fast decomposition rate with minimal loss of mineralized P is possible due to the relatively high litter P not limiting the cycle at this stage, combined with an efficient recapture of released P by the surface organic layer of ectomycorrhizas and fine roots. This points to a feedback between two essential controlling steps (retranslocation and mineralization) in a tropical rain forest ecosystem dominated by ectomycorrhizal trees.

Light and seed size affect establishment of grove-forming ectomycorrhizal rain forest tree species

• Regeneration of the dominant ectomycorrhizal tree Microberlinia bisulcata in groves in Korup, Central Africa, is very poor. The hypothesis was tested that this species is more shade intolerant than other co-occurring species. • In two 1-yr trials, each with M. bisulcata and four other species at a nursery close to Korup, growth was measured under five PAR levels, with ± added P and ± watering in the dry season. In parallel experiments the effects of PAR with two R : FR ratios were investigated. • Increasing PAR had a consistent effect on the rates of increase in plant mass and on changes in the other variables. Doubling soil P, watering and halving the R : FR ratio had almost no effect. However, across species, mass at low PAR and relative growth rate related positively and negatively, respectively, to seed mass. • One contributing factor for the poor recruitment of M. bisulcata is therefore its low survival and slow growth at low PAR, due to its small seed size. The two codominant ectomycorrhizal grove species of Tetraberlinia, with larger seeds, were less affected by low PAR.