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A retrospective study was done to determine the effect of potassium (K+) infusions on serum levels in children admitted to the pediatric intensive care unit (PICU) with diabetic ketoacidosis (DKA). Eighty-two percent of 92 cases studied received 40 mEq/L K+ infusion over the treatment period of median 13.0 (interquartile range [IQR]: 7–18) hours. The median K+ value at the end of this period was 3.9 (IQR: 3.4–4.2) mEq/L. There were 31 data points of low K+ values (5.5 mEq/L) during this treatment period. The K+ infusions of 40 mEq/L may be sufficient to normalize serum K+ when treating DKA.

PURPOSE: This study examined medical students’ stress and certification exam preparation practices in a reformed clerkship curriculum that excluded high-stakes knowledge testing from end-of-rotation performance evaluation. METHOD: Stress and exam preparation practices were assessed via a survey comprising locally developed questions, three subscales of the Motivated Strategies for Learning Questionnaire, and two subscales of the Medical Student Stressor Questionnaire. The association between stress, learning self-regulation, and certification exam scores was evaluated retrospectively using non-parametric tests of association (Spearman’s rho). RESULTS: Forty students responded to the survey and consented to use of academic performance data (57% participation rate). Mean certification exam scores were indistinguishable from historical controls. Exam preparation practices resembled those of pre-clinical students: exam-related worrying and time devoted to studying were high, increasing as the exam drew near; preferred study resources were directly analogous to exam questions; and study involved relatively few generative strategies (e.g., concept mapping). Sustaining effort and creating time and space to study were associated with better exam performance, as was participation in this study. DISCUSSION: On the surface, the absence of regularly spaced, high-stakes testing from clerkship performance evaluation appears to “do no harm” to students’ certification exam scores. Students already performing better academically may excel due in part to effective learning self-regulation strategies. However, a clerkship curriculum that does not scaffold self-regulation via cumulative knowledge assessment could further disadvantage students already earning lower scores. Evaluating the impact of curriculum reforms should continuously examine changes to learners’ experience in context.

A retrospective data analysis was conducted to evaluate enteral nutrition practices for children admitted with status asthmaticus in a single-center pediatric intensive care unit. Of 406 charts, 315 were analyzed (63% male); 135 on bilevel positive airway pressure ventilation (BIPAP) and 180 on simple mask. Overall median age and weight were 6.0 (interquartile range [IQR]: 6.0) years and 24.8 (IQR: 20.8) kg, respectively. All children studied were on full feeds while still on BIPAP and simple mask; 99.3 and 100% were fed per oral, respectively. Median time to initiation of feeds and full feeds was longer in the BIPAP group, 11.0 (IQR: 20) and 23.0 hours (IQR: 26), versus simple mask group, 4.3 (IQR: 7) and 12.0 hours (IQR: 15), p = 0.001. The results remained similar after adjusting for gender, weight, clinical asthma score at admission, use of adjunct therapy, and duration of continuous albuterol. By 24 hours, 81.5% of patients on BIPAP and 96.6% on simple mask were started on feeds. Compared with simple mask, patients on BIPAP were sicker with median asthma score at admission of 4 (IQR: 2) versus 3 (IQR: 2) on simple mask, requiring more adjunct therapy (80.0 vs. 43.9%), and a longer median length of therapy of 41.0 (IQR: 41) versus 20.0 hours (IQR: 29), respectively, p = 0.001. There were no complications such as aspiration pneumonia, and none required invasive mechanical ventilation in either group. Enteral nutrition was effectively and safely initiated and continued for children admitted with status asthmaticus, including those on noninvasive bilevel ventilation therapy.

Racial disparities in the outcomes after intervention for aortic valve disease remain understudied. We stratified patients by race who underwent surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) in the Medicare database. The TAVI cohort consisted of 17,973 patients (3.9% were black and 1.0% were Hispanic). The SAVR cohort consisted of 95,078 patients, (4.8% were black and 1.3% were Hispanic). Most comorbidities were more common in blacks. After TAVI, 30-day mortality was not significantly different in races with both unadjusted and adjusted data. There were no significant racial differences in readmission rates or discharge to home after TAVI. After SAVR, black patients had worse unadjusted 30-day and 1-year mortality than whites or Hispanics (30-day mortality, 4.7% vs 6.2% vs 4.7% for whites, blacks, and Hispanics, respectively, p = 0.0001; 1-year mortality 11.7% vs 16.1% vs 12.5%, respectively, p = 0.0001); however, after adjustment, there were no differences in mortality. Black patients had higher 30-day readmission rates after SAVR (20.1% vs 25.2% vs 21.7% for whites, blacks, and Hispanics, respectively, p = 0.0001), which persisted after adjustment for comorbidities. Minorities were underrepresented in both SAVR and TAVI relative to what would be predicted by population prevalence. In conclusion, while blacks have worse outcomes in SAVR compared with whites or Hispanics, race did not impact mortality, readmission, or discharge to home in TAVI. Both blacks and Hispanics were underrepresented compared with what would be predicted by population prevalence.

Objectives To determine the effects of the 3-month multicomponent Better Exercise Adherence after Treatment for Cancer (BEAT Cancer) physical activity behavior change intervention on fatigue, depressive symptomatology, and anxiety. Methods Postprimary treatment breast cancer survivors (n = 222) were randomized to BEAT Cancer or usual care. Fatigue Symptom Inventory and Hospital Anxiety and Depression Scale were assessed at baseline, postintervention (month 3; M3), and follow-up (month 6; M6). Results Adjusted linear mixed-model analyses demonstrated significant effects of BEAT Cancer vs usual care on fatigue intensity (M3 mean between group difference [M] = −0.6; 95% confidence interval [CI] = −1.0 to −0.2; effect size [d] = −0.32; P = .004), fatigue interference (M3 M = −0.8; CI = −1.3 to −0.4; d = −0.40; P

To determine whether the location of the superior and inferior epigastric vessels (deep epigastric vessels) change with abdominal insufflation.Descriptive study (Canadian Task Force classification III).Tertiary care academic institution.Patients undergoing gynecologic laparoscopic surgery were recruited. A total of 35 subjects were enrolled.Subjects underwent color Doppler ultrasound assessment of deep epigastric vessel location preoperatively and intraoperatively following abdominal insufflation. The deep epigastric vessels were identified at 5 points along the abdomen (pubic symphysis, anterior superior iliac spine [ASIS], umbilicus, xiphoid, and midpoint from umbilicus to xiphoid), with the distance from vessels to midline measured. Paired t tests and split-plot analysis of variance were used as appropriate.The mean patient age was 45.6 ± 16.5 years, and mean BMI was 29.8 ± 7.2. A significant difference between vessel location in the resting abdomen and insufflated abdomen was noted bilaterally at the ASIS, umbilicus, and midpoint from the umbilicus to the xiphoid. At each of these points, the deep epigastric vessels were found more laterally after insufflation on average, ranging from 0.6 ± 0.9 cm (p .001) more laterally at the midpoint between the umbilicus and xiphoid to 1.1 ± 0.8 cm (p .001) more laterally at the umbilicus. The most lateral location of the deep vessels after insufflation was seen at the ASIS (10.6 cm) and the umbilicus (10.9 cm). In a subanalysis of subjects grouped by body mass index (obese vs nonobese), deep epigastric vessels were more lateral in the insufflated abdomen of obese subjects compared with that of nonobese subjects at the ASIS, umbilicus, and midpoint from umbilicus to xiphoid (p .05 for each point bilaterally).The deep epigastric vessels shift laterally with abdominal insufflation, and may be found as far as 10.9 cm from the midline; this is more lateral than previously described and is clinically significant. Obesity is associated with a more lateral location of the deep epigastric vessels.

Data from large randomized controlled trials confirming sleep quality improvements with aerobic physical activity have heretofore been lacking for post-primary treatment breast cancer survivors. Our primary purpose for this report was to determine the effects of a physical activity behavior change intervention, previously reported to significantly increase physical activity behavior, on sleep quality in post-primary treatment breast cancer survivors.Post-primary treatment breast cancer survivors (n = 222) were randomized to a 3-month physical activity behavior change intervention (Better Exercise Adherence after Treatment for Cancer [BEAT Cancer]) or usual care. Self-report (Pittsburgh Sleep Quality Index [PSQI]) and actigraphy (latency and efficiency) sleep outcomes were measured at baseline, 3 months (M3), and 6 months (M6).After adjusting for covariates, BEAT Cancer significantly improved PSQI global sleep quality when compared with usual care at M3 (mean between-group difference [M] = -1.4, 95% confidence interval [CI] = -2.1 to -0.7, P0.001) and M6 (M = -1.0, 95% CI = -1.7 to -0.2, P = 0.01). BEAT Cancer improved several PSQI subscales at M3 (sleep quality M = -0.3, 95% CI = -0.4 to -0.1, P = 0.002; sleep disturbances M = -0.2, 95% CI = -0.3 to -0.03, P = 0.016; daytime dysfunction M = -0.2, 95% CI = -0.4 to -0.02, P = 0.027) but not M6. A nonsignificant increase in percent of participants classified as good sleepers occurred. No significant between-group difference was noted for accelerometer latency or efficiency.A physical activity intervention significantly reduced perceived global sleep dysfunction at 3 and 6 months, primarily because of improvements in sleep quality aspects not detected with accelerometer.

Most breast cancer survivors do not meet physical activity recommendations. Understanding mediators of physical activity behavior change can improve interventions designed to increase physical activity in this at-risk population. Study aims were to determine the 3-month Better Exercise Adherence after Treatment for Cancer (BEAT Cancer) behavior change intervention effects on social cognitive theory constructs and the mediating role of any changes on the increase in accelerometer-measured physical activity previously reported. Post-treatment breast cancer survivors (N = 222) were randomized to BEAT Cancer or usual care. Assessments occurred at baseline, 3 months (M3), and 6 months (M6). Adjusted linear mixed model analysis of variance determined intervention effects on walking self-efficacy, outcome expectations, goal setting, and perceived barrier interference at M3. Path analysis determined mediation of intervention effects on physical activity at M6 by changes in social cognitive constructs during the intervention (i.e., baseline to M3). BEAT Cancer significantly improved self-efficacy, goals, negative outcome expectations, and barriers. Total path analysis model explained 24 % of the variance in M6 physical activity. There were significant paths from randomized intervention group to self-efficacy (β = 0.15, p

Background: Racial disparities in the outcomes after intervention for aortic valve disease remain understudied. Methods: Data of patients who underwent surgical (SAVR) and transcatheter aortic valve replacement (TAVR) were obtained from the Medicare database from Nov 2011 through 2013. Comparisons were performed stratifying by race. Results: In the TAVR group, there were 17,081 (95.0%) white patients and 706 (3.9%) African Americans (AAs). In SAVR, there were 89,265 (93.9%) whites and 4,562 (4.8%) AAs. Compared to whites, AAs were substantially younger in both TAVR and SAVR groups. Otherwise, most comorbidities were more common among AA (Table 1). In TAVR, mortality at 30 days and 1 year was similar for AA patients and whites (6.1% and 6.3%, p=NS, and 20.5% vs. 22.3%, p=NS), respectively, while it remained higher in the SAVR cohort among AAs (6.2% vs. 4.7%, p=.0001, and 16.1% vs. 11.7%, p=.0001). Similarly, in TAVR, 30-day readmission was similar for AAs compared to whites (22.8% vs. 23.8%, p=NS) but remained higher for AAs after SAVR (25.2% vs. 20.1%, p=.0001). After adjustment for baseline characteristics, there was no statistically significant difference in 30-day mortality after SAVR between, races, however, AAs continued to have higher adjusted odds of readmission (OR 1.14, 95% CI 1.04-1.22). Compared to whites, AA patients were less likely to be discharged home after SAVR (52.1% vs. 57.7%, p=.0001), but not after TAVR. Conclusions: While AAs have worse outcomes in SAVR, it appears that race does not impact mortality, readmission, or discharge to home in TAVR. While these results may be influenced by patient selection and incomplete adjustment, they are representative of outcomes observed in current clinical practice.

Most breast cancer survivors (BCS) are not meeting recommended physical activity guidelines. Here, we report the effects of the Better Exercise Adherence after Treatment for Cancer (BEAT Cancer) behavior change intervention on physical activity, aerobic fitness, and quality of life (QoL). We randomized 222 post-primary treatment BCS to the 3-month intervention (BEAT Cancer) or usual care (UC). BEAT Cancer combined supervised exercise, face-to-face counseling, and group discussions with tapering to home-based exercise. Assessments at baseline, immediately post-intervention (month 3; M3), and 3 months post-intervention (month 6; M6) included accelerometer and self-reported physical activity, submaximal treadmill test, and QoL [Functional Assessment of Cancer Therapy (FACT)-Breast scale]. Adjusted linear mixed-model analyses demonstrated significant effects of BEAT Cancer compared to UC on weekly minutes of ≥moderate intensity physical activity at M3 by accelerometer [mean between group difference (M) = +41; 95 % confidence interval (CI) = 10–73; p = 0.010] and self-report (M = +93; CI = 62–123; p < 0.001). Statistical significance remained at M6 for self-reported physical activity (M = +74; CI = 43–105; p < 0.001). BEAT Cancer participants were significantly more likely to meet physical activity recommendations at both time points [accelerometer M3 adjusted odds ratio (OR) = 2.2; CI = 1.0–4.8 and M6 adjusted OR = 2.4; CI = 1.1–5.3; self-report M3 adjusted OR = 5.2; CI = 2.6–10.4 and M6 adjusted OR = 4.8; CI = 2.3–10.0]. BEAT Cancer significantly improved fitness at M6 (M = +1.8 ml/kg/min; CI = 0.8–2.8; p = 0.001) and QoL at M3 and M6 (M = +6.4; CI = 3.1–9.7; p < 0.001 and M = +3.8; CI = 0.5–7.2; p = 0.025, respectively). The BEAT Cancer intervention significantly improved physical activity, fitness, and QoL with benefits continuing 3 months post-intervention.

Objective To improve mechanistic understanding, this pilot randomized controlled trial examined mediators of an exercise intervention effects on sleep in breast cancer survivors (BCS).

Background Survival and other outcomes of nonagenarians undergoing transcatheter aortic valve replacement (TAVR) in the Medicare population are unclear. Methods Patients aged 65 years and older who underwent TAVR from November 2011 through 2013 were considered for inclusion. Results The study consisted of 18,283 patients and 19.3% were aged 90 years or older. Compared with patients younger than 90 years, patients 90 years or older were less likely to have a number of comorbidities, including previous myocardial infarction (17.5% versus 21.8%), previous coronary artery bypass grafting (20.0% versus 35.0%), and chronic obstructive pulmonary disease (25.4% versus 39.0%) among others. The 30-day and 1-year mortality rates were 8.4% versus 5.9% ( p = 0.0001) and 25.4% versus 21.5% ( p = 0.0001) in the older and younger groups, respectively (odds ratio [OR] 1.47, 95% confidence interval [CI]: 1.28 to 1.70, p = 0.0001). Patients 90 years and older were more likely to undergo pacemaker insertion (11.1% versus 8.3%, p = 0.0001). Among nonagenarians, compared with the transapical group, patients undergoing transfemoral TAVR had lower 30-day (7.2% versus 13.6%, p = 0.0001) and 1-year (23.8% versus 31.6%, p = 0.0001) mortality rates, were more likely to be discharged home (54.4% versus 34.1%, p = 0.0001), and had lower 30-day readmission rates (23.8% versus 31.8%, p = 0.0001). After adjustment for patient characteristics, transapical TAVR was an independent predictor of 30-day mortality rate (OR 1.94, 95% CI: 1.48 to 2.56, p = 0.0001) and readmission (OR 1.46, 95% CI: 1.19 to 1.80, p = 0.0003). Conclusions In patients undergoing TAVR, although 30-day and 1-year mortality rates were slightly worse for nonagenarians than their younger counterparts, long-term survival was still encouraging, with 75% of nonagenarians living to 1 year. Transapical TAVR was associated with worse outcomes in nonagenarians.

Little is known about the effects of physical activity behavior change interventions on health outcomes such as lower extremity dysfunction and SF-36 physical health (predictor of mortality) in breast cancer survivors. Furthermore, effect moderators are rarely reported. Therefore, we report the effects of the 3-month BEAT Cancer physical activity behavior change intervention on global health status and health indicators along with moderators of intervention outcomes. Postprimary treatment breast cancer survivors (n = 222) were randomized to BEAT Cancer or usual care (UC). SF-36, muscle strength, body mass index, lower extremity dysfunction (WOMAC), and life satisfaction were measured at 3 months (M3) and 6 months (M6). At M3, adjusted linear mixed-model analyses demonstrated statistically significant effects of BEAT Cancer versus UC on SF-36 physical health [mean between-group difference (M) = 2.1; 95 % confidence interval (CI) 0.3–3.9; p = 0.023], SF-36 mental health (M = 5.2; CI 2.8–7.6; p < 0.001), and all SF-36 subscores. Intervention benefits occurred for lower extremity physical dysfunction (M = −2.7; CI −5.0 to −0.5; p = 0.018), WOMAC total (M = −3.7; CI −6.7 to −0.6; p = 0.018), and life satisfaction (M = 2.4; CI 0.9–3.9; p = 0.001). Statistically significant effects persisted at M6 for mental health and vitality. Baseline value, income, marital status, cancer treatment, cancer stage, and months since diagnosis moderated one or more outcomes. BEAT Cancer improves SF-36, WOMAC, and life satisfaction outcomes with improvements in vitality and mental well-being continuing 3 months postintervention. Several moderators with potential to guide targeting individuals for optimal intervention benefit warrant further study.

Social cognitive theory (SCT) measures related to exercise adherence in head and neck cancer (HNCa) patients were developed. Enrolling 101 HNCa patients, psychometric properties and associations with exercise behavior were examined for barriers self-efficacy, perceived barriers interference, outcome expectations, enjoyment, and goal setting. Cronbach's alpha ranged from.84 to.95; only enjoyment demonstrated limited test-retest reliability. Subscales for barriers self-efficacy (motivational, physical health) and barriers interference (motivational, physical health, time, environment) were identified. Multiple SCT constructs were cross-sectional correlates and prospective predictors of exercise behavior. These measures can improve the application of the SCT to exercise adherence in HNCa patients.

This is the first systematic investigation of the very long-term effects of severe closed head injury (CHI) on objective measures of memory, and the first to employ both a normal control group and an 'other injury' control group consisting of spinal cord injury (SCI) patients. The CHI group displayed significantly poorer performance on every memory measure, and the effect sizes were large. This impairment in episodic memory is neither due to pre-injury nor post-injury differences between CHI and normal control subjects because the same differences were found when the CHI group was compared to a group of SCI patients. The findings demonstrate severe impairment in learning and retention many years after sustaining a severe CHI, which is likely in part due to the bilateral hippocampal damage shown in neuropathological studies. This life-long memory impairment needs to be addressed by community service programs.

Context: Ethnicity has been a continuing concern for the valid assessment of clinical performance with standardized patients (SPs). The concern is that examinee ethnicity and SP ethnicity might interact, such that examinees might score higher in encounters with SPs of the same ethnicity. Objective: To test for an interaction of examinee ethnicity and SP ethnicity on clinical performance in an SP examination. Main Outcome Measures: History-taking andphysical-examination scores and interpersonal-and communication-skills scores, both based on checklists completed by SPs. Poststation scores for answers to case-related questions concerning pathophysiology, diagnosis, test selection, and test interpretation. Setting And Participants: Two graduating classes of over 1,000 fourth-year medical students each in the New York City Consortium were tested on the SP assessment administered at The Morchand Centerof Mount Sinai School of Medicine. Design And Analysis: The primary analyses were two-way (2 × 2) analyses, to test the main and interaction effects of examinee ethnicity and SP ethnicity. Effect-size measures (standardized mean differences, d) were computed to provide a sharper picture of the effects. Results: Of the 24 interaction analyses, only three were statistically significant (notsignificantly more than expected by chance) and the results were mixed: one analysis showed better examinee performance in encounters with SPs of thesame ethnic background and the other two showed the opposite. For all 24 interactions, significant or not, the results showed weak effects and no consistent pattern. White examinees scored on average 0.12 standard deviations above black examinees in encounters with white SPs, and 0.11 standard deviations higher in encounters with black SPs. Conclusions: These initial results are encouraging and should dispel some of the concern about ethnicity in SP assessment, at least about the operation of an examinee-by-SP-ethnicity interaction that would pose a serious threat to the validity of the examination scores.

Word fluency in 45 medicated non-demented Parkinson’s disease (PD) patients and 45 normal control subjects was studied with a Phonemic Word Fluency (PWF) task using the letters F, A, and S, a Semantic Word Fluency (SWF) task using the categories animals, boys’ names, and states, and an Alternating Word Fluency (AWF) task requiring the person to alternate between colors and occupations, animals and states, and words beginning with C and P. The number of words generated did not differ for trials with F, A, S, or states, but PD patients generated significantly fewer animal names and boys’ names. PD patients also generated significantly fewer words on each of the three AWF trials. The PD patients scored 21% lower than the normal control group on the total AWF score, but only 10% lower for the PWF and SWF scores. The greater impairment on the AWF task which requires the use of internal attentional control to rapidly shift mental set can be considered a type of executive functioning deficit. This is consistent with the growing literature suggesting frontal systems dysfunction in PD and with the view that dopaminergic treatment only incompletely restores functioning in the frontostriatal system.

We report ease of conversion, effect on equivalent efficacy and frequency of dosing when immediate-release carbidopa/levodopa (Sinemet, IR-CL, DuPont Pharma, Wilmington, DE, U.S.A.) is replaced with controlled-release carbidopa/levodopa (Sinemet CR, CR-CL, DuPont Pharma, Wilmington, DE, U.S.A.) in patients with Parkinson's disease (PD). One-step conversion through the application of a mathematical formula was utilized. Fifty-two patients (35 men, 17 women) with a mean +/- SD age of 72 +/- 8 years participated in this open-label study. All patients were taking IR-CL prior to conversion. The Unified Parkinson's Disease Rating Scale (UPDRS) was used for efficacy assessment. Pharmacokinetic studies were undertaken in five patients while they were on IR-CL, and repeated after they were switched to CR-CL. Dosage adjustment was not required either immediately after converting or during the 6-month follow-up. No significant changes occurred in efficacy scores during follow-up visits, indicating the effectiveness of the conversion. There were substantial differences in the level of plasma DOPA, dopamine, 3-O-methyldopa, homovanillic acid, and dihydroxyphenylacetic acid between patients receiving IR-CL and those receiving CR-CL, but the differences did not correlate with clinical changes, suggesting that plasma levels do not reflect tissue levels at the site of action for levodopa. This study demonstrates that conversion from IR-CL to CR-CL for optimal dosing may be achieved in one step through the application of a mathematical formula with ease of conversion and reduction of number of doses.

Background: Many, many studies, including three major reviews, that compare problem-based curricula to more traditional curricula, have been published in the last 10 years. No study, however, has looked specifically at a closed-loop or reiterative problem-based approach. Purpose: A 3-year retrospective study was done to compare the academic performance of students in a reiterative problem-based learning (PBL)curriculum with that of their counterparts in the standard curriculum to ensure that the PBL students were not disadvantaged. Methods: Three graduating classes' performance on a number of outcome measures, including the United States Medical Licensing Examination, clinical clerkship, and clinical practice examination performance, were compared. Results: Analyses indicate that students in the PBL curriculum performed at least as well as, and in some instances better than, their counterparts in the standard curriculum. Conclusion: Students in the PBL curriculum, a student-directed curriculum, were not d...

Background: Empathy has long been thought to be an important characteristic of a good physician, and a measure of empathy is needed to provide feedback to medical students, residents, and physicians on this important aspect of their clinical performance. The standardized-patient-testing format provides a simple but intuitively convincing approach to the assessment of empathy. Purpose: To determine the extent to which 4th-year medical students were checked "empathic" by standardized patients (SPs) on a performance-based examination, to evaluate the psychometric properties of this simple empathy measure, and to see whether empathy was related to clinical performance on history taking and physical examination. Method: Analyses were performed on examination data for 1,048 senior medical students in the 8 member schools of the New York City Consortium tested at The Morch and Center of Mount Sinai School ofMedicine. Results: The percentage of students who were checked "empathic" ranged from 59% to 98% (M = 79%)...

This study aimed to examine mediators of fatigue response to an exercise intervention for breast cancer survivors in a pilot randomized controlled trial.Postmenopausal breast cancer survivors (n = 46; ≤stage 2), off primary treatment, and reporting fatigue and/or sleep dysfunction were randomized to a 3-month exercise intervention (160 min·wk of moderate-intensity aerobic walking, twice weekly resistance training with resistance bands) or control group. Six discussion group sessions provided behavioral support to improve adherence. Fatigue, serum cytokines, accelerometer physical activity, cardiorespiratory fitness, sleep dysfunction, and psychosocial factors were assessed at baseline and 3 months.The exercise intervention effect sizes for fatigue were as follows: fatigue intensity d = 0.30 (P = 0.34), interference d = -0.38 (P = 0.22), and general fatigue d = -0.49 (P = 0.13). Using the Freedman-Schatzkin difference-in-coefficients tests, increase in fatigue intensity was significantly mediated by interleukin 6 (IL-6) (82%), IL-10 (94%), IL-6/IL-10 (49%), and tumor necrosis factor-α (TNF-α):IL-10 (78%) with reduced sleep dysfunction increasing the relationship between intervention and fatigue intensity rather than mediating intervention effects (-88%). Decrease in fatigue interference was mediated by sleep dysfunction (35%), whereas IL-10 and pro-anti-inflammatory cytokine ratios increased the relationship between intervention and interference (-25% to -40%). The reduction in general fatigue was significantly mediated by minutes of physical activity (76%), sleep dysfunction (45%), and physical activity enjoyment (40%), with IL-10 (-40%) and IL-6/IL-10 (-11%) increasing the intervention-fatigue relationship. In the intervention group, higher baseline fatigue, anxiety, depression, and perceived exercise barrier interference predicted a greater decline in fatigue interference and/or general fatigue during the intervention.Biobehavioral factors mediated and enhanced intervention effects on fatigue, whereas psychosocial factors predicted fatigue response. Further study is warranted to confirm our results and to improve understanding of relationships that mediate and strengthen the intervention-fatigue association.

To improve mechanistic understanding, this pilot randomized controlled trial examined mediators of an exercise intervention effects on sleep in breast cancer survivors (BCS).Forty-six postmenopausal BCS (≤Stage II, off primary treatment) were randomized to a 3-month exercise intervention or control group. Intervention included 160 min/week of moderate intensity aerobic walking, twice weekly resistance training (resistance bands), and six discussion groups (to improve adherence). Blinded assessments at baseline and post-intervention included sleep disturbance (PSQI and PROMIS®), objective sleep quality (accelerometer), serum cytokines, accelerometer physical activity, cardiorespiratory fitness, body composition, fatigue, and psychosocial factors. Mediation was tested using Freedman-Schatzkin difference-in-coefficients tests.When compared with control, the intervention group demonstrated a significant increase in PSQI sleep duration (i.e., fewer hours of sleep/night) (d = 0.73, p = .03). Medium to large but non-significant standardized effect sizes were noted for PSQI daytime somnolence (d = -0.63, p = .05) and accelerometer latency (d = -0.49, p = .14). No statistically significant mediators were detected for PSQI sleep duration score or accelerometer latency. Daytime somnolence was mediated by tumor necrosis factor-alpha (mediated 23% of intervention effect, p .05), interleukin (IL)-6:IL-10 (16%, p .01), IL-8:IL-10 (26%, p .01), and fatigue (38%, p .05). Mediating or enhancing relationships for several of the sleep outcomes were noted for accelerometer physical activity, PROMIS® fatigue, exercise social support, and/or physical activity enjoyment.Inflammation and psychosocial factors may mediate or enhance sleep response to our exercise intervention. Further study is warranted to confirm our results and translate our findings into more effective interventions aimed at improving sleep quality in BCS.

A seven case clinical performance examination was administered ten times throughout an academic year in a required Ambulatory Care Clerkship. Three of the cases were developed at Saint Louis University School of Medicine (SLU); four of the cases were developed by the National Board of Medical Examiners (NBME). Immediately following each examination, the examinees participated in a feedback session where checklists for the three SLU cases were displayed, and details of the cases were discussed. No feedback on the four NBME cases was provided. Student performance on cases in which students were given detailed feedback by the faculty was compared with performance on cases in which no feedback was given. Data were collected from 119 students.

Performance‐based examinations that use standardized‐patient (SP) cases have been used to assess the clinical competence of senior medical students in eight classes (1986 to 1993) at Southern Illinois University School of Medicine. Two or more (multiple) SPs have been used to simulate about half the cases in each examination. This study was conducted to assess the effect of multiple SPs on the intercase reliability of SP ratings of interpersonal and communication skills. In general, results showed little effect of multiple SPs on reliability of ratings of interpersonal and communication skills. For example, for ratings on overall patient satisfaction, the generalizability coefficient computed without including measurement error due to multiple SPs was .78, whereas the coefficient computed with measurement error due to multiple SPs included was. 73—suggesting that use of multiple SP raters on the same case reduced reliability by about .05. Similar results were obtained for ratings on the other dimensions. ...

To assess the effects of examinee gender, standardized-patient (SP) gender, and, in particular, their interaction on ratings made by SPs of examinees' interpersonal and communication skills in a performance-based examination of clinical competence.The examination was administered to four classes of senior medical students (about 70 per class) at Southern Illinois University School of Medicine, 1988-1991. The skill dimensions tested were clarity of communication, thoroughness of explanation, professional manner, personal manner, and overall patient satisfaction. Split-plot analyses of variance were used.There was no interaction of examinee gender and SP gender for any of the five rating scales. There was no main effect of examinee gender for four of the five scales; however, for personal manner, women students were rated slightly higher than men students. There was a main effect of SP gender, but the effect was not consistent from rating scale to rating scale or from class to class. Nevertheless, differences in ratings given by men and women SPs should not be of psychometric concern, since the ratings of men and women examinees are necessarily affected alike.Except for the women examinee's higher performance in personal manner, the men and women examinees generally performed equally well with respect to interpersonal and communication skills, and they performed equally well regardless of the gender of the SP.

Standardized‐patient (SP) examinations are being used increasingly for the identification of examinees who have mastered the clinical competencies deemed necessary for the practice of clinical medicine. Hence, it is of critical importance to evaluate the psychometric properties of the mastery decisions—in particular, the false‐negative and false‐positive rates associated with these pass‐fail decisions. In this article, methods are described for estimating the false‐negative and false‐positive rates resulting from measurement error for a mastery examination. These rates, as well as the reliabilities of the pass‐fail decisions based on a recently adopted standard‐setting procedure, are reported for data for six classes of senior medical students. The methods for determining the false‐negative rate, in particular, provided valuable information for our faculty about the effectiveness of the new standard‐setting procedure for minimizing false‐negative decisions for our SP‐based examination.

The Alzheimer Disease Assessment Scale (ADAS) was administered to 61 patients with dementia of the Alzheimer type (DAT) and 52 elderly controls. The DAT group was subdivided into different severity levels of dementia based on scores from the Mini-Mental State Exam: very mild (greater than or equal to 24), mild (20 to 23), moderate (10 to 19), and severe (0 to 9). The mean scores on the ADAS Cognitive subscale for the four levels of dementia (very mild = 23.1 +/- 7.7, mild = 22.9 +/- 8.9, moderate = 38.6 +/- 9.8, severe = 54.8 +/- 7.6) were statistically different from one another (p less than 0.0001, except very mild vs. mild) and were significantly worse than the scores of the elderly control group (5.5 +/- 2.7, p less than 0.0001, ANOVA). Furthermore, the ADAS Cognitive subscale was highly effective in discriminating individual Alzheimer patients from elderly controls. The ADAS Cognitive score correctly classified 100% of the very mild group, 91% of the entire mild group, and 100% of the moderate and severe groups when a cutoff score of 2 SDs above the control group mean was used. Age and education had only minimal effects on the ADAS Cognitive score. The ADAS is a valuable screening test that only takes 30 min to administer and has utility in both early detection and staging of DAT.

Purpose To compare the characteristics and outcome data of students from a single institution with a two-track, problem based learning (PBL) and standard (STND) curriculum. Method PBL and STND students from nine graduating classes at Southern Illinois University School of Medicine were compared using common medical school performance outcomes (USMLE Step 1, USMLE Step 2, clerkship mean ratings, number of clerkship honors and remediation designations, and the senior clinical competency exam), as well as common admission and demographic variables. Results PBL students were older, and the cohort had a higher proportion of women. The two tracks had similar USMLE Step 1 and 2 mean scores and pass rates. Performance differences were significant for PBL students in two clerkships as well as in the clerkship subcategories of clinical performance, knowledge and clinical reasoning, and noncognitive behaviors. In addition, the proportion of PBL students earning honors was greater. Conclusions The traditional undergraduate educational outcomes for the PBL and STND students are very positive. In several of the clerkship performance measures, the PBL students performed significantly better, and in no circumstance did they perform worse than the STND students.

gynecologic surgeons (odds ratio [OR] 10.117, 95% confidence interval [CI] 1.341-76.354). Premenarchal status (p1⁄4.0240), ischemic appearing adnexa (p

The effects of using two or more standardized patients (multiple SPs) to simulate the same case in a performance-based examination were studied at the case level by comparing case means and case failure rates for multiple SPs simulating the same case, using data from the classes of 1988, 1989, and 1990 at the Southern Illinois University School of Medicine. For total scores and scores on the students' written answers, the effects on means and failure rates were negligible and could be explained as due to sampling error. For scores on the checklists completed by the SPs, there were more significant differences than would be expected by chance alone, even though the number of significant differences was relatively small. The results demonstrate a need for caution in the interpretation of scores obtained from a case checklist completed by multiple SPs, particularly in regard to making pass-fail decisions.

Acetylcholinesterase (AChE; EC 3.1.1.7) is present in both primitive and mature erythroid cells, and a role has been suggested for the enzyme in regulation of differentiation in the human erythron. AChE is also a major enzyme in the central nervous system; alteration of its activity has been proposed as a therapeutic strategy in Alzheimer disease. We recently treated 18 Alzheimer disease patients with metrifonate, a long-acting AChE inhibitor, over periods up to 7 months, with resulting erythrocyte AChE inhibition as high as 82 per cent of baseline values. Despite chronic reduction of enzyme activity, no significant alterations were noted in erythrocyte, leukocyte or platelet characteristics or numbers that would suggest a deleterious effect of AChE inhibition on normal differentiation. Thus, any modification of developmental pathways appears to be compensated by other regulatory mechanisms in the intact organism.

To evaluate the relationship between clinical competence and interpersonal and communication skills, in an attempt to clarify current thinking about these two dimensions as measured with standardized-patient (SP) examinations.Simple Pearson correlations were computed between total examination scores for clinical competence and interpersonal and communication skills. Three sets of different types of data involving 15 separate examinations were used to explore the generality of the findings. To control for a within-case halo effect and measurement error, corrected cross-half correlations and corrected cross-case correlations were also computed.The simple correlations and the corrected cross-half and cross-case correlations showed moderate and above relationships between these two dimensions in the clinical context. The simple correlations centered around .50, and the corrected cross-half and cross-case correlations were slightly higher, centering around .65 and .70, respectively.The authors' thinking is that the moderate relationship between clinical competence and interpersonal and communication skills is not due to a flaw in the measurement of clinical competence, as has been suggested, but rather is a natural consequence of the clinical encounter, which exacts an interdependence of these two dimensions. At least, this possibility must be seriously considered so medical educators can think and act appropriately in the assessment of clinical performance.

Checklists and rating scales are both used for assessing examinees in standardized patient (SP) examinations. The common presumption, though, is that checklists are more objective than and hence superior to rating scales with respect to such psychometric properties as reliability. Two related articles, however, have warned that “objectified methods do not inherently provide more reliable scores,” and our recent study of interpersonal and communication skills supports this claim with checklist and rating-scale reliabilities of. 65 and. 76, respectively, and an intercorrelation of. 82. The present study extended this research to different aspects or components of interpersonal and communication skills, using a 26-item checklist consisting of five sections of 3 to 7 items each, with each section representing a different component of interpersonal and communication skills. At the end of each section, the SP was asked to provide a global rating of the component indicated by the items in that section. Analyses were performed on data for 1,048 fourth-year medical students at the eight-school New York City Consortium, tested on the 7-case SP examination administered by The Morchand Center at Mount Sinai School of Medicine. The intercase reliabilities for the checklist scores and ratings, respectively, were:. 33 and. 39 for eliciting information,. 33 and. 39 for nonverbal behaviour,. 55 and. 52 for patient education,. 48 and. 45 for professional manner, and. 49 and. 52 for patient satisfaction. The correlations between the checklist scores and ratings for the five components were. 66,. 60,. 80,. 69, and. 75, respectively. The pattern of these results provides further support for the claim that “objectified” measures, like check lists, “do not inherently provide more reliable scores.”

The results are disappointing, providing little support for the validity of the case-passing decisions based on this simple approach to scoring and standard setting. The case-passing decisions predicted what the case author intended for about only 73% or 74% of the students on average and, with agreement expected by chance removed, predicted what the case author intended for about only 25% of the students. Even with the use of the optimal pass/fail cutoffs and the dropping of students with ambiguous borderline global ratings, the case-passing decisions failed to agree with the case authors' global ratings for 15% to 30% of the students. The findings might be dismissed as simply due to low reliabilities of passing decisions and global ratings based on a single case. Although this concern would apply to intercase reliabilities, which would be subject to case specificity, the appropriate reliabilities here would seem to be intracase (i.e., intrarater), which should be fairly high (if they could be computed). Nevertheless, it seems reasonable to expect much better agreement between results of case scoring and of standard setting developed by the case author and the case author's global ratings of performance on that case, given that the case author might recall the checklist, assign a weight to each item, and so forth. Also, case-passing decisions would possibly agree more with global ratings of live or videotaped performances than with ratings of written summaries of performance; however, that question remains a challenge for further research. In conclusion, the study provides only weak evidence, at best, for the validity of the scoring and standard setting commonly used with SP assessment. The results do not undermine claims about the realism of the SP approach, however, nor do they call into question the standardization afforded by this method of assessing clinical competence. The results do raise serious concerns about this simple approach to scoring and standard setting for SP-based assessments and suggest that we should focus more on the observation and evaluation of actual student performance on SP cases in the development of valid scoring and standard setting.

To compare two methods of rating students' performances on history and physical examination: (1) by using checklists completed by standardized patients (SPs) and databases completed by students, and (2) by using ratings of students by three physicians for each SP-student encounter.Four cases were chosen for the study, and 30 students were examined per case. The students were all in their fourth year at the Southern Illinois University School of Medicine in the spring of 1991. Two of the cases had both checklists and databases, and the remaining two had databases only. Each SP-student encounter was videotaped and was viewed independently by three physicians unfamiliar with the contents of the checklists and databases. The physicians' pooled ratings were then compared with the checklist and database scores. Uncorrected and corrected correlations were obtained, with the generalizability coefficient used as the index of reliability.Interrater generalizability of physicians' ratings was very good, ranging from .65 to .93 for overall ratings. Generalizability of physicians' ratings pooled across the four cases was .85. Checklist scores tended to correlate higher with physicians' ratings than did database scores: across the cases, correlation coefficients between physicians' ratings and checklist scores and database scores were .65 and .39, respectively.The checklist scores correlated strongly with the physicians' ratings of history and physical-examination skills, providing some evidence of validity for their use. The checklist scores correlated much better with the physicians' ratings than did the database scores. Possible explanations for this finding are discussed.