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Purpose: Variable assessments of learner performances can occur when different assessors determine different elements to be differently important or salient. How assessors determine the importance of performance elements has historically been thought to occur idiosyncratically and thus be amenable to assessor training interventions. More recently, a main source of variation found among assessors was two underlying factors that were differently emphasised: medical expertise and interpersonal skills. This gave legitimacy to the theory that different interpretations of the same performance may represent multiple truths. A faculty development activity introducing assessors to entrustable professional activities in which they estimated a learner's level of readiness for entrustment provided an opportunity to qualitatively explore assessor variation in the context of an interaction and in a setting in which interpersonal skills are highly valued., Methods: Using a constructivist grounded theory approach, we explored variation in assessment processes among a group of palliative medicine assessors who completed a simulated direct observation and assessment of the same learner interaction., Results: Despite identifying similar learner strengths and areas for improvement, the estimated level of readiness for entrustment varied substantially among assessors. Those who estimated the learner as not yet ready for entrustment seemed to prioritise what information was exchanged and viewed missed information as performance gaps. Those who estimated the learner as ready for entrustment seemed to prioritise how information was exchanged and viewed the same missed information as personal style differences or appropriate clinical judgement. When presented with a summary, assessors expressed surprise and concern about the variation., Conclusion: A main source of variation among our assessors was the differential salience of performance elements that align with medical expertise and interpersonal skills. These data support the theory that when assessing an interaction, differential salience for these two factors may be an important and perhaps inevitable source of assessor variation., (© 2024 The Author(s). Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Faculty development (FD) is critical to the implementation of competency-based medical education (CBME) and yet evidence to guide the design of FD activities is limited. Our aim with this study was to describe and evaluate an FD activity as part of CBME implementation. Methods: Palliative medicine faculty were introduced to entrustable professional activities (EPAs) and gained experience estimating a learner's level of readiness for entrustment by directly observing a simulated encounter. The variation that was found among assessments was discussed in facilitated debrief sessions. Attitudes and confidence levels were measured 1 week and 6 months following debriefs. Results: Participants were able to use the EPA framework when estimating the learner's readiness level for entrustment. Significant improvements in attitudes and level of confidence for several knowledge, skill, and behavior domains were maintained over time. Conclusions: Simulated direct observation and facilitated debriefs contributed to preparing both faculty and learners for CBME and EPA implementation.

Background: Palliative care performed a central role in responding to the systemic suffering incurred by the COVID-19 pandemic. Yet, few studies have elucidated the inpatient palliative care specialists' experiences and perceptions., Objective: Systematically review and synthesize the evolving roles and expectations of inpatient palliative care specialists in response to COVID-19., Design: A systematic review and meta-synthesis informed by Thomas and Harden's framework and Pozzar et al.'s approach was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines., Data Sources: MEDLINE, EMBASE, CINAHL, and PubMed were systematically searched for articles published between December 2019 and March 2023. We included all peer-reviewed qualitative and mixed-method literature studying the roles and expectations of inpatient palliative care specialists. A mixed-method appraisal tool was used for quality assessment., Results: Of 3869 unique articles, 52 were included. Studies represented North American (n = 23), European (n = 16), South American (n = 4), Oceanic (n = 2), Asian (n = 2), West African (n = 1), Middle Eastern (n = 1), and inter-continental settings (n = 3). Most were reported in English (n = 50), conducted in 2020 (n = 28), and focused on the perspectives of inpatient palliative care clinicians (n = 28). Three descriptive themes captured the roles and expectations of inpatient palliative care specialists: shifting foundations, reorienting to relationships, and evolving identity. Two analytical themes were synthesized: palliative care propagates compassion through a healing presence, and palliative care enhances the systemic response to suffering through nimble leadership., Conclusion: Inpatient palliative care specialists responded to the COVID-19 pandemic by establishing their healing presence and leading with their adaptability. To develop institutionally tailored and collaborative responses to future pandemics, future studies are needed to understand how inpatient palliative care clinicians are recognized and valued within their institutions., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: Feedback on patient outcomes is invaluable to the practice of emergency medicine but examples of effective forms of feedback have not been well characterized in the literature. We describe one system of emergency department (ED) outcome feedback called the return visit report (RVR) and present the results of a survey assessing physicians' perceptions of this novel form of feedback., Methods: An Opinio web-based survey was conducted in 81 emergency physicians (EPs) at three EDs., Results: Of the 81 physicians surveyed, 40 (49%) responded. Most participants indicated that they frequently review their RVRs (83%), that RVRs are valuable to their practice of medicine (80%), and that RVRs alter their practice in future encounters (57%). Respondents reported seeking other forms of outcome feedback including speaking with other EPs (83%) and reviewing discharge summaries of admitted patients (87%). There was no correlation between demographic data and use of RVRs., Conclusion: EPs value RVRs as a form of feedback. RVRs could be improved by reducing the observational interval and optimizing report relevance and differential weighting., Competing Interests: Conflicts of interest: Authors have no financial or other conflicts of interest related to this submission.

When couples hold hands, one partner must take the lead hand and the other the following hand position. As potential correlates or predictors of handholding positions within lesbian couples, this article explored differences in height, age, income, who initiated the relationship, who usually initiates sexual intimacy, previous history of partnership with a male, and who has the most "say" in decision-making. Data revealed only 2 significant variables: The taller partner was more likely to have the lead hand, and a woman who had previously been partnered with a male was more likely to take the trailing hand position.

Three hundred-forty lesbians and 62 gay males, largely from North America and in partnered relationships, completed online surveys that explored what handholding means to same-sex couples. The data suggest that lesbians in the United States are more likely now than ¼ century ago to hold hands in public spaces. Younger lesbians are more likely to hold hands in public than older lesbians, and Canadian lesbians hold hands more often in public than American lesbians. In response to the question, "What does handholding mean to you?," 26% of the female respondents from North America overtly referred to public handholding as either a political act or a risky behavior. The number of comments of that nature was similar, regardless of whether the lesbians resided in the United States or Canada. Data suggest that full acceptance of same-sex couples in public spaces has not yet occurred, even in jurisdictions where same-sex couples have the same legal rights as heterosexual couples. Although the sample size for males was too small to analyze the influence of age or political jurisdiction on public handholding, males, in general, were significantly less likely than females to view handholding as a means of staying "connected" with their partners.

When neuraminidase-treated sera are analyzed by agarose gel isoelectric focusing, the factor B (BF) banding pattern is reduced to predominantly one major band without cathodically positioned bands. This not only makes unequivocal typing of BF allotypes possible but also the reliable distinction of all BF F subtype phenotypes with delimitation of "BF F subtype variants". With this new method, serum aging affects the BF determination to a lesser extent than when applying methods that separate native sera. We show that sialylation is not responsible for the BF F subtype polymorphism. All of the investigated BF allotype bands, including those characteristic of the subtypes, show functional hemolytic activity. The banding pattern after removal of neuraminic acid residues ranges from pH 6.8 to 7.3 for factor B, from pH 5.3 to 5.9 for the Ba fragment, and from pH 8.2 to 8.7 for the Bb fragment. The protein structure of factor B is also discussed. Eliminating the superimposition of bands in different BF allotypes, as demonstrated by these methods, proved to be necessary for the detection of hypomorphic BF gene products (BF QL), which are expressed by assumed BF*Q0 alleles in heterozygous genotypes. This allows investigation of BF*Q0 alleles on a protein level, which complements molecular genetic approaches.

In three families with an apparent non-expressed factor B (BF) allele (BF*Q0), advanced methods of isoelectric focusing for the determination of BF F subtypes revealed different hypomorphic BF products (BF QL) with functional hemolytic activity expressed by the assumed BF*Q0 allele. A Taq I and a Msp I restriction fragment length polymorphism as well as the Ba fragment of the expression products showed banding patterns for the BF*QL alleles corresponding to BF S types, whereas an altered Bb fragment was seen in two BF QL products. In one family an intragenic recombination site within the Bb part of the BF gene was assumed. Investigations of factor B and its conversion fragments, as demonstrated by the used methods, allow to complement molecular genetic investigations of BF*Q0 alleles in heterozygous genotypes on a protein level. We conclude that apparently non-expressed alleles of factor B code for hypomorphic but functionally active proteins.

The prevention of the pulmonary toxicity of bleomycin (BLM) has been investigated in experimental models where pulmonary damage was induced with one intra-tracheal dose of BLM. The present investigation was carried out as a pre-clinical study in which BLM was administered systemically. The non-steroid anti-inflammatory drug indomethacin (INDO) was chosen as a possible candidate for pulmonary protection. Twenty female Wistar rats were treated daily with 4 mg/kg (7.3 units) BLM intra-peritoneally for 50 days and 20 rats with BLM and with 1 mg/kg INDO subcutaneously for 62 days. There were 20 animals as controls. Histological examination revealed fibrosing alveolitis in the BLM-treated group which was markedly suppressed in the combination group. Quantitative morphological (stereological) parameters demonstrate that BLM induced alveolar wall thickening (+45%), pulmonary fibrosis (+110%), and an increase of alveolar wall nuclei and of intra-alveolar macrophages (volume densities +43% and +133%, P less than 0.001). In contrast, after combination with INDO significant differences to the control group could not be detected except for a slight increase of intra-alveolar macrophages (+62%). Thus, INDO is a highly efficient agent in the prevention of BLM-induced pulmonary damage.

In a factor B (BF) Reference Typing of the VIth Complement Genetics Workshop and Conference, Mainz, FRG, 1989, 99 samples from 13 laboratories, including 18 families, were investigated with the majority of presently known typing procedures. Among the major ('standard') allotypes BF SO4 was found to be new. For the group of common BF F subtypes samples from 11 laboratories including complete family data from 5 laboratories were compared. The subtypes BF FA and FB were recognized and confirmed to be identical in the samples from all groups. Within a third group rare subtype variants of F and S were compared and characterized. In samples submitted from individuals with assumed non-expressed (BF*QO) alleles unexpected and hypomorphic gene products were seen. The investigation of DNA samples for restriction fragment length polymorphisms from the same set of individuals revealed a correlation of the Msp I 0.7-kb fragment with BF F, and confirmed the correlation of a Taq I 6.6-kb fragment with BF FA.

A common nomenclature for factor B (BF) allotypes is recommended as a result of the BF Reference Typing of the VIth Complement Genetics Workshop and Conference, Mainz, FRG, 1989. It has generally been agreed that the alphanumeric BF nomenclature according to Mauff et al. should also be used in the future for all major BF allotypes distinguishable by standard agarose gel electrophoresis (AGE). The common BF F subtypes and further described rarer subtype variants are not detectable by standard AGE. Therefore, the nomenclature had to be extended. For the subtypes of BF F an alphabetical designation with capital letters will now be used: FA and FB. The designation of the five rarer subtype variants was modified after the reference typing to FB1, FB2, SB1, SB2, and SB3. Hyposynthetic variants detected in samples with previously assumed non-expressed (BF*Q0) alleles are now designated as SQL, M1QL, and M2QL, HQL' characterizing their lower concentration.

The segregation of factor B(BF)F subtypes was analyzed in conjunction with other MHC markers in 15 families with 89 offspring. Informative data for BF F subtypes were obtained from 11 families, 6 of them with known recombinant individuals for the HLA-B/DR/GLO region. The subtypes did not contribute further to the localization of the cross-overs, but followed the known segregation of conventional BF allotypes. In 2 families of one kinship, the recognition of heterozygous BF*FAFB individuals could be established following the inclusion of three generations. The rarer of the two BF F subtype alleles, BF*FA, is positively associated with the HLA haplotypes BW62, CW3, C4A*3 and A29, CWX, B44, C4A*3, B*1, DR7. BF F subtypes are regarded as a very useful additional tool for studies of MHC organization and disease association.

The unanimous recognition of the two subtypes FA and FB of the BF*F allele has repeatedly been challenged. In the present investigation we are reporting about the unequivocal and simple detection of the subtypes on the Ba fragment of factor B by immunofixation isoelectric focusing after conversion with inulin. The common BF phenotypes F, S, and FS could be diagnosed in addition to the subtypes of BF*F which were observed in two regions acidic of the F major band. By comparison of standard phenotypes the subtypes in the Ba fragment corresponded to those of native factor B. All BF bands could be attributed to the Ba fragment by developing Western Blots with monoclonal antibodies directed against Ba. The distribution of the major BF phenotypes and alleles and the BF F subtypes in a population sample of 527 unrelated individuals from F.R.G. was in Hardy-Weinberg equilibrium. The allele frequency was determined to be 0.0731 for BF*FA, and 0.1053 for BF*FB. The advantages of determining the subtypes on the Ba fragment are: broadening of the FA/FB corridor, a more reliable diagnosis of phenotypes, improved distinction between homozygous FA and heterozygous FAFB types, and recognition of common BF phenotypes as well as subtypes in aged sera. It is suggested that the problem in the designation of BF F subtypes by different groups should be resolved by an international reference typing.