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Introduction: The number of young adults (youth) living with childhood-onset disabilities, and requiring transitional support to adult community and rehabilitation services, is increasing. We explored facilitators and barriers to accessing and sustaining community and rehabilitation services during the transition from pediatric to adult care. Methods: A qualitative descriptive study was conducted in Ontario, Canada. Data were collected through interviews with youth (n = 11) and family caregivers (n = 7). The data were coded and analyzed using thematic analysis. Results: Youth and caregivers face many types of transitions from pediatric to adult community and rehabilitation services, e.g., those related to education, living arrangements, and employment. This transition is marked by feelings of isolation. Supportive social networks, continuity of care (i.e., same care providers), and advocacy all contribute to positive experiences. Lack of knowledge about resources, changing parental involvement without preparation, and a lack of system responses to evolving needs were barriers to positive transitions. Financial circumstances were described as either a barrier or facilitator to service access. Conclusions: This study demonstrated that continuity of care, support from providers, and social networks all contribute markedly to the positive experience of transitioning from pediatric to adult services for individuals with childhood-onset disabilities and family caregivers. Future transitional interventions should incorporate these considerations.

Introduction: Functional heterogeneity, defined as variations between and within tumours, is the underlying cause for malignant tumour processes such as tumour progression, metastasis and treatment resistance. In particular, cancer stem cells (CSCs) could be important contributors to functional heterogeneity within tumours, as CSCs can differentiate into different tumorous cells. This study aims to identify models for the genesis of functional heterogeneity among cancer cells and strategies for targeting CSCs. Methods: Using an integrated review process, various models for functional heterogeneity genesis in cancer and cancer stem cell treatments were explored. Papers that explicitly focused on either explaining a model for the genesis of functional heterogeneity in cancer or on describing targeting strategies for CSCs were included. To conduct our search the following databases were used: PubMed, OVID (Medline), and Web of Science. Results: Several prominent models for genesis of cancer functional heterogeneity were identified, including the hierarchy model, stochastic model, and plasticity model. There is no definitive model as different types of cancer may follow different models of functional heterogeneity. However, multiple models suggest that CSCs, tumor cells with acquired or innate multipotency, are responsible for enhancing tumour progression. Hence, many therapeutic methods have been explored to target CSCs including: interfering with signalling pathways, targeting biomarkers, exerting transcriptional control, damaging quiescence, disrupting the microenvironment and immunotherapy. Discussion: This study identified a gap in current literature to be the lack of clinical studies, with the majority of experiments being conducted on mice models or in vitro. As such the applicability of the findings on a human in vivo level are unclear. Strengths of this paper include the extensive scope of literature reviewed, while limitations include the lack of a quality assessment stage. Conclusion: This study suggests that CSCs are involved in the development of functional heterogeneity in tumours and identifies some preliminary strategies to target them. However, more clinical trials are needed to further validate current proposed treatments. By developing CSC-specific therapies, functional heterogeneity amongst cancer cells can be decreased, which will prevent cancer cells from continuing to progress. As a result, these treatments will be more likely to effectively treat cancer.

Objectives: A wealth of literature has established risk factors for social isolation among older people; however, much of this research has focused on community-dwelling populations. Relatively little is known about how risk of social isolation is experienced among those living in long-term care (LTC) homes. We conducted a scoping review to identify possible risk factors for social isolation among older adults living in LTC homes. Methods: A systematic search of five online databases retrieved 1535 unique articles. Eight studies met the inclusion criteria. Results: Thematic analyses revealed that possible risk factors exist at three levels: individual (e.g., communication barriers), systems (e.g., location of LTC facility), and structural factors (e.g., discrimination). Discussion: Our review identified several risk factors for social isolation that have been previously documented in literature, in addition to several risks that may be unique to those living in LTC homes. Results highlight several scholarly and practical implications.

We investigate the question of dynamic allocation across a diversified range of alternative risk premia. By using a set of point-in-time indicators across macro, sentiment and valuation dimensions, we find that a majority of indicators deliver a positive information ratio for a majority of alternative risk premia over the period 2005-2020. In our empirical simulations, the macro dimension seems to have worked well, notably during recession periods. Sentiment (based on market stress and momentum) struggled during recovery periods, but added value elsewhere. Valuation has worked well from 2005 to 2013 and lost part of its appeal since then. The combination of indicators allows to deliver a higher information ratio thanks to the low correlation among them. Our research also finds that point-in-time macroeconomic variables (“nowcasters”) can add value over traditional indicators, while this improvement is not significant in the case of the market stress indicator. Forthcoming in Journal of Systematic Investing.

Introduction: Antibiotic resistance is a major global health concern as many fatalities occur each year due to severe infections associated with it, such as sepsis. This research protocol hopes to address the issue of antibiotic resistance in methicillin-resistant Staphylococcus aureus (MRSA) by using an alternative antibiotic therapy. Silver nanoparticles (AgNPs), which have antibiotic properties and low antibiotic resistance potential, will be administered in conjunction with stable and biocompatible branched amphiphilic peptide capsules (BAPCs). Surface functionalized ligands will be attached to the peptide capsules to target iron receptors essential to MRSA survival. By targeting its iron receptors, the bacteria will be unable to mutate in such a way that would attenuate its uptake of this antibiotic. Methods: Testing will begin in vitro on MRSA cultures to assess the minimum inhibitory concentration of the various AgNP treatment groups. Constraints determining the minimum inhibitory concentration include a minimum 3-hour delay in bactericidal effect from application, and a 95% eradication efficacy. Drug efficacy will be evaluated via ex vivo and in vivo mice experiments, with off-target toxicity effects measured via BAPC targeted immunohistochemistry, and both serological and organ-based tests. Repeated in vivo treatments will be performed against a control to measure the relative antibiotic resistance advantages this treatment proposes. As this protocol requires the use of mice, ethics approval from the Canadian Council on Animal Care will be obtained prior to experimentation. Results: It is expected that the AgNPs will be successfully encapsulated within the structurally-sound BAPCs and that the AgNPs will eradicate a significant amount of the MRSA present in the human body with minimal side effects. The in vitro, ex vivo and in vivo tests are likely to yield results that demonstrate that the most effective protocol in eradicating MRSA is to use AgNPs in BAPCs in conjunction with a vancomycin treatment. The proposal will likely satisfy the criteria for appropriate AgNP doses, which includes bactericidal effect in a time frame of hours, over 95% efficacy, and statistically significant reproducibility. Discussion: Successful BAPC mediated delivery of AgNPs prove the potential for targeted antibiotic application against multidrug bacteria with lower risk of antibiotic resistance compared to conventional antibiotics. This proof of concept protocol demonstrates the potential for applying rational design of BAPCs as a delivery vector. Certain limitations, including off-target toxicity and redundant targeting are issues to be cognizant of and controlled. Conclusion: This novel therapy can be considered as a preliminary step in overcoming antibiotic resistance. With appropriate modifications to the functional ligands attached to the BAPCs, the proposed drug mechanism could be applied to treat other bacterial strains.

Objectives This study prospectively evaluated endomyocardial biopsies in patients with heart failure with preserved ejection fraction (HFpEF) to identify histopathologic phenotypes and their association with clinical characteristics. Background Myocardial tissue analysis from a prospectively defined HFpEF cohort reflecting contemporary comorbidities is lacking. Methods Patients with HFpEF (EF ≥50%) referred to the Johns Hopkins HFpEF Clinic between August 2014 and September 2018 were enrolled for right heart catheterization and endomyocardial biopsy. Clinical features, echocardiography, hemodynamics, and tissue histology were determined and compared with controls (unused donor hearts) and HF with reduced EF (HFrEF). Results Of the 108 patients enrolled, median age was 66 years (25th to 75th percentile: 57 to 74 years), 61% were women, 57% were African American, 62% had a previous HF hospitalization, median systolic blood pressure was 141 mm Hg (25th to 75th percentile: 125 to 162 mm Hg), body mass index (BMI) was 37 kg/m2 (25th to 75th percentile: 32 to 45 kg/m2), and 97% were on a loop diuretic. Myocardial fibrosis and myocyte hypertrophy were often present (93% and 88%, respectively); however, mild in 71% with fibrosis and in 52% with hypertrophy. Monocyte infiltration (CD68+ cells/mm2) was greater in patients with HFpEF versus controls (60.4 cells/mm2 [25th to 75th percentile: 36.8 to 97.8] vs. 32.1 cells/mm2 [25th to 75th percentile: 22.3 to 59.2]; p = 0.02) and correlated with age and renal disease. Cardiac amyloidosis (CA) was diagnosed in 15 (14%) patients (HFpEF-CA: 7 patients with wild-type transthyretin amyloidosis [ATTR], 4 patients with hereditary ATTR, 3 patients with light-chain amyloidosis, and 1 patient with AA (secondary) amyloidosis), of which 7 cases were unsuspected. Patients with HFpEF-CA were older, with lower BMI, higher left ventricular mass index, and higher N-terminal pro−B-type natriuretic peptide and troponin I levels. Conclusions In this large, prospective myocardial tissue analysis of HFpEF, myocardial fibrosis and hypertrophy were common, CD68+ inflammation was increased, and CA prevalence was 14%. Tissue analysis in HFpEF might improve precision therapies by identifying relevant myocardial mechanisms.

Many transcription factors contain intrinsically disordered transcription activation domains (TADs), which mediate interactions with coactivators to activate transcription. Historically, DNA-binding domains and TADs have been considered as modular units, but recent studies have shown that TADs can influence DNA binding. Whether these results can be generalized to more TADs is not clear. Here, we biophysically characterized the NFκB p50/RelA heterodimer including the RelA TAD and investigated the TAD's influence on NFκB-DNA interactions. In solution, we show the RelA TAD is disordered but compact, with helical tendency in two regions that interact with coactivators. We determined that the presence of the TAD increased the stoichiometry of NFκB-DNA complexes containing promoter DNA sequences with tandem κB recognition motifs by promoting the binding of NFκB dimers in excess of the number of κB sites. In addition, we measured the binding affinity of p50/RelA for DNA containing tandem κB sites and single κB sites. While the presence of the TAD enhanced the binding affinity of p50/RelA for all κB sequences tested, it also increased the affinity for nonspecific DNA sequences by over 10-fold, leading to an overall decrease in specificity for κB DNA sequences. In contrast, previous studies have generally reported that TADs decrease DNA-binding affinity and increase sequence specificity. Our results reveal a novel function of the RelA TAD in promoting binding to nonconsensus DNA, which sheds light on previous observations of extensive nonconsensus DNA binding by NFκB invivo in response to strong inflammatory signals.

Many transcription factors contain intrinsically disordered transcription activation domains (TADs), which mediate interactions with co-activators to activate transcription. Historically, DNA-binding domains and TADs have been considered as modular units, but recent studies have shown that TADs can influence DNA binding. We biophysically characterized the NFκB p50/RelA heterodimer including the RelA TAD and investigated the TAD’s influence on NFκB-DNA interactions. In solution the RelA TAD is disordered but compact, with helical tendency in two regions that interact with co-activators. The presence of the TAD increased the stoichiometry of NFκB-DNA complexes containing promoter DNA sequences with tandem κB recognition motifs by promoting the binding of NFκB dimers in excess of the number of κB sites. We measured the binding affinity of p50/RelA for DNA containing tandem κB sites and single κB sites. While the presence of the TAD enhanced the binding affinity of p50/RelA for all κB sequences tested, it increased the affinity for non-specific DNA sequences by over 10-fold, leading to an overall decrease in specificity for κB DNA sequences. Our results reveal a novel function of the RelA TAD in promoting binding to non-consensus DNA previously observed by in vivo studies of NFκB-DNA binding in response to strong inflammatory signals.

Sustainable Agriculture Research wishes to acknowledge the following individuals for their assistance with peer review of manuscripts for this issue. Their help and contributions in maintaining the quality of the journal are greatly appreciated. Sustainable Agriculture Research is recruiting reviewers for the journal. If you are interested in becoming a reviewer, we welcome you to join us. Please contact us for the application form at: sar@ccsenet.org Reviewers for Volume 12, Number 1 Bed Mani Dahal, Kathmandu University, Nepal Chaterina Agusta Paulus, Universitas Nusa Cendana, Indonesia Minfeng Tang, Kansas State University, USA Murtazain Raza, Hamdard University, Pakistan Nehemie Tchinda Donfagsiteli, Institute of Medical Research and Medicinal Plants Studies, Cameroon Olabisi Omodara, Obafemi Awolowo University, Ife, Nigeria Omnia Mohamed Mohamed Helmy Arief, Benha University, Egypt Ram Niwas, Swami Keshwanand Rajasthan Agricultural University, India Sait Engindeniz, Ege University Faculty of Agriculture, Turkey Waqar Majeed, University of Agriculture, Pakistan

Adiponectin receptor 1 (ADIPOR1) is a lipid and glucose metabolism regulator that possesses intrinsic ceramidase activity. Mutations of the ADIPOR1 gene have been associated with nonsyndromic and syndromic retinitis pigmentosa. Here, we show that the absence of AdipoR1 in mice leads to progressive photoreceptor degeneration, significant reduction of electroretinogram amplitudes, decreased retinoid content in the retina, and reduced cone opsin expression. Single-cell RNA-Seq results indicate that ADIPOR1 encoded the most abundantly expressed ceramidase in mice and one of the 2 most highly expressed ceramidases in the human retina, next to acid ceramidase ASAH1. We discovered an accumulation of ceramides in the AdipoR1-/- retina, likely due to insufficient ceramidase activity for healthy retina function, resulting in photoreceptor death. Combined treatment with desipramine/L-cycloserine (DC) lowered ceramide levels and exerted a protective effect on photoreceptors in AdipoR1-/- mice. Moreover, we observed improvement in cone-mediated retinal function in the DC-treated animals. Lastly, we found that prolonged DC treatment corrected the electrical responses of the primary visual cortex to visual stimuli, approaching near-normal levels for some parameters. These results highlight the importance of ADIPOR1 ceramidase in the retina and show that pharmacological inhibition of ceramide generation can provide a therapeutic strategy for ADIPOR1-related retinopathy.

Background: Gastrostomy tube (g-tube) complications are typically minor and site related with major complications related to dislodgment before tract establishment. With the recent adoption of 12F ...

Univentricular heart with common atrioventricular (AV) valve and aortopulmonary window (APW) are rare cardiac defects. This association has not been reported and there are only 2 cases published prior with univentricular heart and AP window. In addition, our patient has CHARGE syndrome and genetic testing was positive for CHD7 mutation supportive of this.

Sustainable Agriculture Research wishes to acknowledge the following individuals for their assistance with peer review of manuscripts for this issue. Their help and contributions in maintaining the quality of the journal are greatly appreciated. Sustainable Agriculture Research is recruiting reviewers for the journal. If you are interested in becoming a reviewer, we welcome you to join us. Please contact us for the application form at: sar@ccsenet.org Reviewers for Volume 11, Number 4 Boutheina Zougari, Regional Research Centre of Oasis Agriculture-Degache, Tunisia Darwin Pangaribuan, Lampung University, Indonesia Jiban Shrestha, Nepal Agricultural Research Council, Nepal Luciano Chi, Sugar Industry Research and Development Institute, Belize Luis F. Pina, Universidad de Chile, Chile Minfeng Tang, Kansas State University, USA Momin Momin, Istanbul University, Bangladesh Nehemie Tchinda Donfagsiteli, Institute of Medical Research and Medicinal Plants Studies, Cameroon Patrice Ngatsi Zemko, University of Yaoundé I, Cameroon Tenaw Workayehu, Hawassa Research Center, Southern Agricultural Research Institute, Ethiopia

Accounting professionals today operate in an increasingly complex world, which increases the likelihood that they will encounter multiple dilemmas, both technical and ethical, over the course of their careers. Recent researchers have expressed concern that the pressures associated with these complexities have led to a decrease in professionalism among accountants. Thus, it is critical to the future of the profession that accountants address ethical dilemmas with the same degree of professionalism with which they address technical accounting challenges. In this chapter, we review and critique the extant ethical decision-making models in accounting, and share a new model, dubbed the ‘RADAR’ model. The letters in the acronym ‘RADAR’ refer to the five steps at the core of the model: Research, Analyze, Decide, Act, Reflect. The ‘RADAR’ model provides a more complete model for addressing ethical dilemmas, and explicitly incorporates affect, something lacking in the prior models. As such, the “RADAR” model provides a robust framework to navigate ethical potholes in an accounting context.

Sustainable Agriculture Research wishes to acknowledge the following individuals for their assistance with peer review of manuscripts for this issue. Their help and contributions in maintaining the quality of the journal are greatly appreciated. Sustainable Agriculture Research is recruiting reviewers for the journal. If you are interested in becoming a reviewer, we welcome you to join us. Please contact us for the application form at: sar@ccsenet.org Reviewers for Volume 11, Number 3 Bed Mani Dahal, Kathmandu University, Nepal Boutheina Zougari, Regional Research Centre of Oasis Agriculture-Degache, Tunisia Jiban Shrestha, Nepal Agricultural Research Council, Nepal Katarzyna Panasiewicz, Poznan University of Life Sciences, Poland Luciano Chi, Sugar Industry Research and Development Institute, Belize Luis F. Pina, Universidad de Chile, Chile Manuel Teles Oliveira, University Tras os Montes Alto Douro (UTAD), Portugal Minfeng Tang, Kansas State University, USA Patrice Ngatsi Zemko, University of Yaoundé I, Cameroon Tenaw Workayehu, Hawassa Research Center, Southern Agricultural Research Institute, Ethiopia Waqar Majeed, University of Agriculture, Pakistan

The purpose of this research was to use direct observation of the physical examination to elucidate the role physical examination technique plays in diagnostic accuracy. Physical examination is important for quality clinical care and requires multiple interrelated skills. The relationship of physical examination technique to related skills is poorly understood. Current methods of teaching and assessing physical examination skills provide few opportunities to evaluate physical examination technique and accuracy.The authors developed a clinical examination assessment using volunteer patients and direct observation. Trained faculty preceptors rated resident performance in 7 domains: 1) physical examination technique, 2) identification of physical signs, 3) clinical communication, 4) differential diagnosis, 5) clinical judgment, 6) managing patient concerns, and 7) maintaining patient welfare. The Pearson correlation coefficient was used to determine relationships between performance in each of these domains. Data on residents' self-assessed competency in the physical examination and perceptions of feedback received during the assessment were collected.From December 2018 to February 2020, 113 interns from 2 internal medicine residency programs participated in the assessment. Physical examination technique was significantly correlated with accurate identification of physical signs, differential diagnosis and clinical judgment. Time spent in graduate medical education was negatively correlated with performance. Interns more highly rated the feedback received from this assessment than traditional clinical skills feedback.Our findings emphasize the necessity of multi-dimensional physical examination assessment. Observed deterioration of physical examination skill during internship may reflect contemporary practice patterns, which deprioritize the physical examination. Future research on physical examination education should focus on the interface between physical examination technique and related clinical skills.

Objectives: A wealth of literature has established risk factors for social isolation among older people, however much of this research has focused on community-dwelling populations. Relatively little is known about how risk of social isolation is experienced among those living in long-term care (LTC) homes. We conducted a scoping review to identify possible risk factors for social isolation among older adults living in LTC homes. Methods: A systematic search of five online databases retrieved 1535 unique articles. Eight studies met the inclusion criteria. Results: Thematic analyses revealed that possible risk factors exist at three levels: individual (e.g., communication barriers), systems (e.g., location of LTC facility), and structural factors (e.g., discrimination). Discussion: Our review identified several risk factors for social isolation that have been previously documented in literature, in addition to several risks that may be unique to those living in LTC homes. Results highlight several scholarly and practical implications.

INTRODUCTION Cranial vault surgery in children with ventricular shunts is more complex due to the possible interference of shunt location with surgical planning and increased risk of shunt related complications. The study evaluated the management of ventricular shunts during cranial vault remodeling (CVR) and subsequent outcomes and complications following CVR. METHODS An IRB-approved retrospective chart review was performed including patients who underwent CVR in presence of a ventricular shunt. Measured outcomes were number of shunt revisions following CVR, 30-day complication rate, 3-month complication rate, and post-CVR Whitaker classification. Finally, a review of the literature was performed, and our results were compared to previous reports. RESULTS Eleven patients met the inclusion criteria. Ventricular shunt was not exposed in 18%; exposed and not revised in 54%; exposed and left on a bone peninsula in 18% and simultaneously exposed and revised in 18%. Two patients experienced complications within 30-days. Three additional patients experienced complications within 3-months. An average of 2.2 shunt revisions per patient were performed following CVR. Whitaker classification was I in 7 patients, II in 1 patient and III in 2 patients. Shunt revision rate for patients undergoing CVR for hydrocephalic macrocephaly was on average of 1.2 and 1.9 for shunt-induced craniosynostosis in literature. CONCLUSIONS Cranial vault abnormalities in the presence of a ventricular shunt can be effectively treated with CVR. The presence of a shunt does not seem to interfere with final head shape. While leaving the shunt unexposed may appear less morbid, shunt related complications can still occur with this approach.

Sustainable Agriculture Research wishes to acknowledge the following individuals for their assistance with peer review of manuscripts for this issue. Their help and contributions in maintaining the quality of the journal are greatly appreciated. Sustainable Agriculture Research is recruiting reviewers for the journal. If you are interested in becoming a reviewer, we welcome you to join us. Please contact us for the application form at: sar@ccsenet.org Reviewers for Volume 11, Number 2 Aaron Norris, Texas Tech University, USA Bed Mani Dahal, Kathmandu University, Nepal Darwin Pangaribuan, Lampung University, Indonesia Jiban Shrestha, Nepal Agricultural Research Council, Nepal Katarzyna Panasiewicz, Poznan University of Life Sciences, Poland Luciano Chi, Sugar Industry Research and Development Institute, Belize Manuel Teles Oliveira, University Tras os Montes Alto Douro (UTAD), Portugal Nehemie Tchinda Donfagsiteli, Institute of Medical Research and Medicinal Plants Studies, Cameroon Patrice Ngatsi Zemko, University of Yaoundé I, Cameroon Ram Niwas, Swami Keshwanand Rajasthan Agricultural University, India Roberto José Zoppolo, Instituto Nacional de Investigación Agropecuaria (Uruguay), Uruguay Tenaw Workayehu, Hawassa Research Center, Southern Agricultural Research Institute, Ethiopia Waqar Majeed, University of Agriculture, Pakistan

Sustainable Agriculture Research wishes to acknowledge the following individuals for their assistance with peer review of manuscripts for this issue. Their help and contributions in maintaining the quality of the journal are greatly appreciated. Sustainable Agriculture Research is recruiting reviewers for the journal. If you are interested in becoming a reviewer, we welcome you to join us. Please contact us for the application form at: sar@ccsenet.org Reviewers for Volume 11, Number 1 Aaron Norris, Texas Tech University, USA Bed Mani Dahal, Kathmandu University, Nepal Darwin Pangaribuan, Lampung University, Indonesia Jiban Shrestha, Nepal Agricultural Research Council, Nepal Katarzyna Panasiewicz, Poznan University of Life Sciences, Poland Luciano Chi, Sugar Industry Research and Development Institute, Belize Manuel Teles Oliveira, University Tras os Montes Alto Douro (UTAD), Portugal Patrice Ngatsi Zemko, University of Yaoundé I, Cameroon Ram Niwas, Swami Keshwanand Rajasthan Agricultural University, India Roberto José Zoppolo, Instituto Nacional de Investigación Agropecuaria (Uruguay), Uruguay Tenaw Workayehu, Hawassa Research Center, Southern Agricultural Research Institute, Ethiopia Waqar Majeed, University of Agriculture, Pakistan

Sustainable Agriculture Research wishes to acknowledge the following individuals for their assistance with peer review of manuscripts for this issue. Their help and contributions in maintaining the quality of the journal are greatly appreciated. Sustainable Agriculture Research is recruiting reviewers for the journal. If you are interested in becoming a reviewer, we welcome you to join us. Please contact us for the application form at: sar@ccsenet.org Reviewers for Volume 10, Number 4 Aaron Norris, Texas Tech University, USA Bed Mani Dahal, Kathmandu University, Nepal Darwin Pangaribuan, Lampung University, Indonesia Jiban Shrestha, Nepal Agricultural Research Council, Nepal Katarzyna Panasiewicz, Poznan University of Life Sciences, Poland Luciano Chi, Sugar Industry Research and Development Institute, Belize Manuel Teles Oliveira, University Tras os Montes Alto Douro (UTAD), Portugal Patrice Ngatsi Zemko, University of Yaoundé I, Cameroon Roberto José Zoppolo, Instituto Nacional de Investigación Agropecuaria (Uruguay), Uruguay Tenaw Workayehu, Hawassa Research Center, Southern Agricultural Research Institute, Ethiopia Waqar Majeed, University of Agriculture, Pakistan

Reviewer Acknowledgements for Journal of Plant Studies, Vol. 10, No. 2, 2021.

Background Feedback based on direct observation of the physical examination (PE) is associated with enhanced educational outcomes, yet attending physicians do not frequently observe graduate trainees performing the PE. Methods We recruited volunteer patients (VPs), each with an abnormality of the cardiovascular, respiratory, or neurological system. Interns examined each VP, then presented a differential diagnosis and management plan to two clinician educators, who, themselves, had independently examined the VPs. The clinician educators assessed interns along five domains and provided post-examination feedback and teaching. We collected data on intern performance, faculty inter-rater reliability, correlation with a simulation-based measure of clinical skill, and resident and VP perceptions of the assessment. Results A total of 72 PGY-1 interns from a large academic training program participated. Performance on the cardiovascular and respiratory system was superior to performance on the neurologic exam. There was no correlation between results of an online test and directly observed cardiovascular skill. Interns preferred feedback from the direct observation sessions. VPs and faculty also rated the experience highly. Inter-rater reliability was good for the respiratory exam, but poor for the cardiovascular and neurologic exams. Conclusions Direct observation of trainees provides evidence about PE skill that cannot be obtained via simulation. Clinician educators’ ability to provide reliable PE assessment may depend on the portion of the PE being assessed. Our experience highlights the need for ongoing training of clinician educators in direct observation, standard setting, and assessment protocols. This assessment can inform summative or formative assessments of physical exam skill in graduate medical education.