T1(Gd) gives comparable information as Delta T1 relaxation rate in dGEMRIC evaluation of cartilage repair tissue

OBJECTIVES: To evaluate the relationship between T1 after intravenous contrast administration (T1Gd) and Delta relaxation rate (DeltaR1) = (1/T1(Gd) - 1/T1o) in the delayed Gadolinium-Enhanced MRI of cartilage (dGEMRIC) evaluation of cartilage repair tissue. MATERIALS AND METHODS: Thirty single MR examinations from 30 patients after matrix-associated autologous chondrocyte transplantations of the knee joint with different postoperative intervals were examined using an 8-channel knee-coil at 3T. T1 mapping using a 3D GRE sequence with a 35/10 degrees flip angle excitation pulse combination was performed before and after contrast administration (dGEMRIC technique). T1 postcontrast (T1(Gd)) and the DeltaR1 (relative index of pre- and postcontrast R1 value) were calculated for repair tissue and the weight-bearing normal appearing control cartilage. For evaluation of the different postoperative intervals, MR exams were subdivided into 3 groups (up to 12 months, 12-24 months, more than 24 months). For statistical analysis Spearman correlation coefficients were calculated. RESULTS: The mean value for T1 postcontrast was 427 +/- 159 ms, for DeltaR1 1.85 +/- 1.0; in reference cartilage 636 +/- 181 ms for T1 postcontrast and 0.83 +/- 0.5 for DeltaR1.The correlation coefficients were highly significant between T1 (Gd) and DeltaR1 for repair tissue (0.969) as well as normal reference cartilage (0.928) in total, and for the reparative cartilage in the early, middle postoperative, and late postoperative interval after surgery (R values: -0.986, -0.970, and -0.978, respectively). Using either T1(Gd) or DeltaR1, the 2 metrics resulted in similar conclusions regarding the time course of change of repair tissue and control tissue, namely that highly significant (P > 0.01) differences between cartilage repair tissue and reference cartilage were found for all follow-up groups. Additionally, for both metrics highly significant differences (P < 0.01) between early follow up and the 2 later postoperative groups for cartilage repair tissue were found. No statistical differences were found between the 2 later follow-up groups of reparative cartilage either for T1 (Gd) or DeltaR1. CONCLUSION: The high correlation between T1 (Gd) and DeltaR1 and the comparable conclusions reached utilizing metric implies that T1 mapping before intravenous administration of MR contrast agent is not necessary for the evaluation of repair tissue. This will help to reduce costs, inconvenience for the patients, simplifies the examination procedure, and makes dGEMRIC more attractive for follow-up of patients after cartilage repair surgeries.

Issues of spectral quality in clinical 1H-magnetic resonance spectroscopy and a gallery of artifacts

In spite of the facts that magnetic resonance spectroscopy (MRS) is applied as clinical tool in non-specialized institutions and that semi-automatic acquisition and processing tools can be used to produce quantitative information from MRS exams without expert information, issues of spectral quality and quality assessment are neglected in the literature of MR spectroscopy. Even worse, there is no consensus among experts on concepts or detailed criteria of quality assessment for MR spectra. Furthermore, artifacts are not at all conspicuous in MRS and can easily be taken for true, interpretable features. This article aims to increase interest in issues of spectral quality and quality assessment, to start a larger debate on generally accepted criteria that spectra must fulfil to be clinically and scientifically acceptable, and to provide a sample gallery of artifacts, which can be used to raise awareness for potential pitfalls in MRS.

Jackson County Heifer Development Project Update

The heifer development project took place the past four years on the site of the former Jackson County Farm north of Andrew, Iowa. Heifers arrived around December 1 with 38 heifers delivered for 1992, 44 for 1993, 46 for 1994, and 47 for 1995. After a 30+ day warm-up period, the heifers were put on a 112-day test from early January to late April. They were fed a shelled corn and legume-grass hay ration consisting of between 13% and 14% crude protein and .48, .58, .44, and .54 megacal/pound of NEg respectively for the years 1992 - 1995. During the 112-day test heifers gained 1.86, 1.78, 1.5, and 1.63 pounds per day respectively for years 1992 through 1995. The 1995 heifers averaged 853 pounds at breeding (22 pounds under target weight). This compares with previous years in which the breeding weight was less than target weight in two years by 5 and 12 pounds and exceeded the target weight in one year by 17 pounds. Estrus synchronization used a combination of MGA feeding and Lutalyse injection. Heifers were heatdetected and bred 12 hours later for a three-day period. On the fourth day, all heifers not bred were mass inseminated. Heifers then ran with the cleanup bull for 58 days. The synchronization response rate in 1995 was 83%, which compares with the three year previous average of 77%. The overall pregnancy rates based on September pregnancy exams were 94.6% in 1992, 93% in 1993, 91% in 1994, and 91.5% in 1995. Development costs for the 326 days in 1995 totaled $269.14 per heifer. This compares with the average of $286. 92 for the three previous years. The four-year average total cost per head for heifer development was $282.48, or about $.84 per day. Feed and pasture costs represented 58% of the total costs, or $.49 per day.

Sensitive Questions in Online Surveys: An Experimental Comparison of the RRT and the Crosswise Model

Self-administered online surveys provide a higher level of privacy protection to respondents than surveys administered by an interviewer. Yet, studies show that asking sensitive questions is problematic also in self-administered mode. Because respondents might not be willing to reveal the truth and provide answers that are subject to social desirability bias, the validity of prevalence estimates of sensitive behaviors gained via online surveys can be challenged. A wellknown method to combat these problems is the Randomized Response Technique (RRT). However, convincing evidence that the RRT provides more valid estimates than direct questioning in online mode is still lacking. Moreover, an alternative approach called the Crosswise Model (CM) has recently been suggested to overcome some of the deficiencies of the RRT. We therefore conducted an experimental study in which different implementations of the RRT and the CM have been tested and compared to direct questioning. Our study is a large-scale online survey on sensitive behaviors by students such as cheating in exams and paper plagiarism. The results of the study reveal poor per-formance of the RRT, while the CM yielded significantly higher estimates of sensitive behaviors than direct questioning. We conclude that the CM is a promising approach for asking sensitive questions in self-administered surveys.

Asking Sensitive Questions in Online Surveys: An Experimental Comparison of the Randomized Response Technique and the Crosswise Model

Self-administered online surveys provide a higher level of privacy protection to respondents than surveys administered by an interviewer. Yet, studies show that asking sensitive questions is problematic also in self-administered mode. Because respondents might not be willing to reveal the truth and provide answers that are subject to social desirability bias, the validity of prevalence estimates of sensitive behaviors gained via online surveys can be challenged. A well-known method to combat these problems is the Randomized Response Technique (RRT). However, convincing evidence that the RRT provides more valid estimates than direct questioning in online mode is still lacking. Moreover, an alternative approach called the Crosswise Model (CM) has recently been suggested to overcome some of the deficiencies of the RRT. In the context of an online survey on plagiarism and cheating on exams among students of two Swiss universities (N = 6,494), we tested different implementations of the RRT and the CM and compared them to direct questioning using a randomized experimental design. Results reveal a poor performance of the RRT, which failed to elicit higher prevalence estimates than direct questioning. Using the CM however, significantly higher prevalence estimates were obtained making it a promising new alternative to the conventional RRT.

Quality Control for SP Performance Regarding Patient Portrayal in a High-Stakes OSCE

Introduction Since the quality of patient portrayal of standardized patients (SPs) during an Objective Structured Clinical Exam (OSCE) has a major impact on the reliability and validity of the exam, quality control should be initiated. Literature about quality control of SP’s performance focuses on feedback [1, 2] or completion of checklists [3, 4]. Since we did not find a published instrument meeting our needs for the assessment of patient portrayal, we developed such an instrument after being inspired by others [5] and used it in our high-stakes exam. Methods SP trainers from all five Swiss medical faculties collected and prioritized quality criteria for patient portrayal. Items were revised with the partners twice, based on experiences during OSCEs. The final instrument contains 14 criteria for acting (i.e. adequate verbal and non-verbal expression) and standardization (i.e. verbatim delivery of the first sentence). All partners used the instrument during a high-stakes OSCE. Both, SPs and trainers were introduced to the instrument. The tool was used in training (more than 100 observations) and during the exam (more than 250 observations). FAIR_OSCE The list of items to assess the quality of the simulation by SPs was primarily developed and used to provide formative feedback to the SPs in order to help them to improve their performance. It was therefore named “Feedbackstruckture for the Assessment of Interactive Role play in Objective Structured Clinical Exams (FAIR_OSCE). It was also used to assess the quality of patient portrayal during the exam. The results were calculated for each of the five faculties individually. Formative evaluation was given to the five faculties with individual feedback without revealing results of other faculties other than overall results. Results High quality of patient portrayal during the exam was documented. More than 90% of SP performances were rated to be completely correct or sufficient. An increase in quality of performance between training and exam was noted. In example the rate of completely correct reaction in medical tests increased from 88% to 95%. 95% completely correct reactions together with 4% sufficient reactions add up to 99% of the reactions meeting the requirements of the exam. SP educators using the instrument reported an augmentation of SPs performance induced by the use of the instrument. Disadvantages mentioned were high concentration needed to explicitly observe all criteria and cumbersome handling of the paper-based forms. Conclusion We were able to document a very high quality of SP performance in our exam. The data also indicate that our training is effective. We believe that the high concentration needed using the instrument is well invested, considering the observed augmentation of performance. The development of an iPad based application for the form is planned to address the cumbersome handling of the paper.

Sensitive Questions in Online Surveys: An Experimental Evaluation of the Randomized Response Technique and the Crosswise Model

Self-administered online surveys provide a higher level of privacy protection to respondents than surveys administered by an interviewer. Yet, studies indicate that asking sensitive questions is problematic also in self-administered surveys. Because respondents might not be willing to reveal the truth and provide answers that are subject to social desirability bias, the validity of prevalence estimates of sensitive behaviors from online surveys can be challenged. A well-known method to overcome these problems is the Randomized Response Technique (RRT). However, convincing evidence that the RRT provides more valid estimates than direct questioning in online surveys is still lacking. A new variant of the RRT called the Crosswise Model has recently been proposed to overcome some of the deficiencies of existing RRT designs. We therefore conducted an experimental study in which different implementations of the RRT, including two implementations of the crosswise model, were tested and compared to direct questioning. Our study is a large-scale online survey (N = 6,037) on sensitive behaviors by students such as cheating in exams and plagiarism. Results indicate that the crosswise-model RRT---unlike the other variants of RRT we evaluated---yields higher prevalence estimates of sensitive behaviors than direct questioning. Whether higher estimates are a sufficient condition for more valid results, however, remains questionable.

Rigor mortis at the myocardium investigated by post-mortem magnetic resonance imaging

INTRODUCTION Post-mortem cardiac MR exams present with different contraction appearances of the left ventricle in cardiac short axis images. It was hypothesized that the grade of post-mortem contraction may be related to the post-mortem interval (PMI) or cause of death and a phenomenon caused by internal rigor mortis that may give further insights in the circumstances of death. METHOD AND MATERIALS The cardiac contraction grade was investigated in 71 post-mortem cardiac MR exams (mean age at death 52y, range 12-89y; 48 males, 23 females). In cardiac short axis images the left ventricular lumen volume as well as the left ventricular myocardial volume were assessed by manual segmentation. The quotient of both (LVQ) represents the grade of myocardial contraction. LVQ was correlated to the PMI, sex, age, cardiac weight, body mass and height, cause of death and pericardial tamponade when present. In cardiac causes of death a separate correlation was investigated for acute myocardial infarction cases and arrhythmic deaths. RESULTS LVQ values ranged from 1.99 (maximum dilatation) to 42.91 (maximum contraction) with a mean of 15.13. LVQ decreased slightly with increasing PMI, however without significant correlation. Pericardial tamponade positively correlated with higher LVQ values. Variables such as sex, age, body mass and height, cardiac weight and cause of death did not correlate with LVQ values. There was no difference in LVQ values for myocardial infarction without tamponade and arrhythmic deaths. CONCLUSION Based on the observation in our investigated cases, the phenomenon of post-mortem myocardial contraction cannot be explained by the influence of the investigated variables, except for pericardial tamponade cases. Further research addressing post-mortem myocardial contraction has to focus on other, less obvious factors, which may influence the early post-mortem phase too.

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

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

Improving the Assessment of Communication Skills at the Swiss Federal Licensing Exam: Results of a Student's Needs Assessment

Introduction With a three year project the assessment of communication skills within the Swiss Federal Licensing Examinations (FLE) shall be improved. As a first step a needs assessment among communication experts and medical students of the Swiss Medical Faculties will be performed. In this presentation the results of the students’ needs assessment will be presented. Methods A bilingual student’s online questionnaire will be developed by an expert panel taking relevant literature, the Swiss Catalogue of Learning Objectives and other consensus statements for communication (e.g., the European and Basler consensus statements) into account. With a think aloud study response process validity evidence will be sought. The questionnaire will focus on the following topics related to communication skills: (1) What has been taught?, (2) What has been assessed in the faculty exams?, (3) What has been assessed in the FLE?, (4) What should have been assessed in the FLE and how should the assessment be improved? Results Results of the students’ needs assessment will be available by the end of 2015 and be presented. Conclusions/ Take-home message We hope for valuable input for improving the assessment of communications skills within the FLE also from the students’ side. Results of the needs assessment from the students and experts will be combined and taken as input for an international expert symposium on how to improve the communication skills assessment within the FLE.

Is the Cheating Risk Always Higher in Online Instruction Compared to Face-to-Face Instruction?

This article analyzes the exposure to cheating risk of online courses relative to face-to-face courses at a single institution. For our sample of 20 online courses we report that the cheating risk is higher than for equivalent face-to-face courses because of reliance on un-proctored multiple choice exams. We conclude that the combination of a proctored final exam, and strategic use cheating deterrents in the administration of un-proctored multiple choice exams, would significantly reduce the cheating risk differential without substantially altering the assessment design of online instruction.

The identification and prevalence of veterinary clinical events in U.S. military working dogs deployed to Iraq between March 20, 2003, and December 31, 2007

Objective. The purpose of this study was to identify the medical issues experienced by Military Working Dogs during their period of deployment in Iraq.^ Design. This study was a retrospective cross-sectional survey based on database and medical record abstraction.^ Population. Military Working Dogs (MWDs) that were deployed to Iraq at any time between 20 March 2003 and 31 December 2007 were the inclusive population of interest. Seven hundred ninety-five (795) MWDs were identified as having been deployed to Iraq during the inclusive dates. Four hundred ninety-six (496) MWDs were identified that had medical events during the deployment period. ^ Procedures. Eligible MWDs were identified through several sources, to include database query, medical record abstraction questionnaire, and medical record abstraction. Demographic information collected for each MWD included tattoo, name, age, gender, breed, Branch of Service, and duty certification. Information on each veterinary/medical clinical event (VCE) was collected. This information was coded, and data entered into a database for organization. Frequency and prevalence information were determined for each category of VCE.^ Results. The top four VCEs experienced by MWDs while deployed in Iraq were gastrohepatic, dermatologic, traumatic injury, and appendicular musculoskeletal issues.^ Conclusions. Training, equipment, and supplies for veterinary personnel who care for the deployed MWDs should be tailored accordingly to suit the identified medical needs of the MWDs. ^

Secondary data analysis of lead screening compliance in high-risk children

Introduction. Despite the ban of lead-containing gasoline and paint, childhood lead poisoning remains a public health issue. Furthermore, a Medicaid-eligible child is 8 times more likely to have an elevated blood lead level (EBLL) than a non-Medicaid child, which is the primary reason for the early detection lead screening mandate for ages 12 and 24 months among the Medicaid population. Based on field observations, there was evidence that suggested a screening compliance issue. Objective. The purpose of this study was to analyze blood lead screening compliance in previously lead poisoned Medicaid children and test for an association between timely lead screening and timely childhood immunizations. The mean months between follow-up tests were also examined for a significant difference between the non-compliant and compliant lead screened children. Methods. Access to the surveillance data of all childhood lead poisoned cases in Bexar County was granted by the San Antonio Metropolitan Health District. A database was constructed and analyzed using descriptive statistics, logistic regression methods and non-parametric tests. Lead screening at 12 months of age was analyzed separately from lead screening at 24 months. The small portion of the population who were also related were included in one analysis and removed from a second analysis to check for significance. Gender, ethnicity, age of home, and having a sibling with an EBLL were ruled out as confounders for the association tests but ethnicity and age of home were adjusted in the nonparametric tests. Results. There was a strong significant association between lead screening compliance at 12 months and childhood immunization compliance, with or without including related children (p<0.00). However, there was no significant association between the two variables at the age of 24 months. Furthermore, there was no significant difference between the median of the mean months of follow-up blood tests among the non-compliant and compliant lead screened population for at the 12 month screening group but there was a significant difference at the 24 month screening group (p<0.01). Discussion. Descriptive statistics showed that 61% and 56% of the previously lead poisoned Medicaid population did not receive their 12 and 24 month mandated lead screening on time, respectively. This suggests that their elevated blood lead level may have been diagnosed earlier in their childhood. Furthermore, a child who is compliant with their lead screening at 12 months of age is 2.36 times more likely to also receive their childhood immunizations on time compared to a child who was not compliant with their 12 month screening. Even though there was no statistical significant association found for the 24 month group, the public health significance of a screening compliance issue is no less important. The Texas Medicaid program needs to enforce lead screening compliance because it is evident that there has been no monitoring system in place. Further recommendations include a need for an increased focus on parental education and the importance of taking their children for wellness exams on time.^

A cross-sectional study of human symptomatology and residential formaldehyde concentrations

The cross-sectional study was performed to quantify the prevalence of symtomatology in residents of mobile homes as a function of indoor formaldehyde concentration. Formaldehyde concentrations were monitored for a seven hour period with an automated wet-chemical colorimetric analyzer. The health status of family members was ascertained by administration of questionnaires and physical exams. This is the first investigation to perform clinical assessments on residents undergoing concurrent exposure assessment in the home.^ Only 22.8% of households eligible for participation chose to cooperate. Monitoring data and health evaluations were obtained from 155 households in four Texas counties. A total of 428 residents (86.1%) were available for examination during the sampling hours. The study population included 45 infants, 126 children, and 257 adults.^ Formaldehyde concentration was not found to be significantly associated with increased risks for symptoms and signs of ocular irritation, dermal anomalies, or malaise. Three associations were identified that warrant further investigation. The relative odds associated with a doubling of formaldehyde concentration was significantly associated with parenchymal rales in adults and children. However, risk was modified by log respirable suspended particulate concentrations. Due to the presence of modification by a continuous variable, prevalence odds ratios (POR) and 95% confidence intervals (95% CI) for these associations are presented in tables. A doubling of formaldehyde concentration was also associated with an increased risk of perceived tightness in the chest in adults. Prevalence odds ratios are presented in a table due to effect modification by the average number of hours spent indoors on weekdays. Furthermore, a doubling of formaldehyde concentration was associated with an increased risk of drowsiness in children (POR = 2.60; 95% CI 1.04-6.51) and adults (POR = 1.94; 95% CI 1.20-3.14). ^

"I understood what she meant when she said '21st century medicine'": A qualitative analysis of patient responses for plans for colorectal cancer screening following a recommendation from their physician

Although physician recommendation has been significantly associated with colorectal cancer screening (CRCS), it still does not motivate all patients to get CRCS. Although improved physician recommendation for CRCS has been shown to increase patient CRCS screening, questions remain about what elements of that discussion may lead to screening. The objective of this study is to describe patients' perceptions and interpretations about their physician's recommendation for CRCS during their annual wellness exam. A subset of patients (n=51) participating in a supplement study of a behavioral intervention trial designed to increase CRCS completed a follow-up, open-ended interview two to four weeks after their annual wellness visit. Using qualitative methods, transcripts of these interviews were analyzed. Findings suggest that most patients would follow their physician's recommendation for CRCS despite not engaging in much discussion. Patients may refrain from CRCS discussion because of a commitment to CRCS, awareness of screening guidelines, and trust in physician's honesty and beneficence. Yet many patients left their wellness exams with questions, refraining because of future plans to consult with their physicians, perceived time constraints or a lack of a patient-physician relationship. If patients are leaving their wellness exams with unanswered questions, interventions should prepare physicians for patient reticence, teaching physicians how to assure patients that CRCS is a primary care activity where all questions and concerns, including cost and scheduling, may be resolved.^