Search

Abstract Background Age-dependent immune responses to coronavirus disease 2019 (COVID-19) vaccinations and breakthrough infections (BIs) in young and middle-aged individuals are unclear. Methods This nationwide multicenter prospective cohort study analyzed immune responses in participants of the ChAdOx1 (ChAd)-ChAd-mRNA vaccine group using cytometry by time-of-flight, anti-spike protein antibody (Sab) and anti-nucleocapsid antibody (Nab) titers, plaque reduction neutralization tests (PRNTs), and interferon-gamma (IFN-γ) release assays at various time points. Results We evaluated 347 participants with an average age of 38.9 ± 9.4 years (range: 21–63). There was a significant inverse correlation between age and Sab levels after the second dose (slope − 14.96, P = 0.032), and this was more pronounced after the third dose (slope − 208.9, P

Purpose This study aims to evaluate the incidence and management of venous ruptures after percutaneous transluminal angioplasty (PTA) for dysfunctional arteriovenous (AV) access. Materials and Methods From January 1998 to December 2015, 13506 PTA, mechanical thrombectomy, and thrombolysis procedures were performed in 6732 patients. The venous rupture rate following PTA was obtained, and access circuit primary patency (ACPP) was compared according to the etiology (PTA, thrombotic occlusion, and treatment type) of the venous rupture present. Results Venous rupture developed in 604 of the 13506 procedures. Venous ruptures were more frequent in female, AV graft cases, and in cases accompanied by thrombosis. Balloon tamponade was performed in 604 rupture cases, and stents were deployed in 119 cases where contrast extravasation and flow stasis persisted. ACPP was significantly better in the non-ruptured AV access circuits than in the ruptured group. However, AV access type and thrombosis was not associated with primary patency. In ruptured cases, ACPP is 8.4 months for prolonged balloon tamponade and 11.2 months for bare-metal stent insertion, showing statistically significant difference. Conclusion Balloon tamponade and bare-metal stent placement are effective treatment for PTA-induced venous ruptures. In particular, stent placement showed a similar ACPP to that of non-ruptured AV access circuits.

Abstract Background Despite the prevalence of non-English languages in the US population, existing medical training to teach communication with linguistically diverse communities is limited to electives or solely focuses on medical interpreting. Language-appropriate communication skills are seldom comprehensively integrated in medical education. This study describes the development and evaluation of an intervention to teach foundational language equity concepts. Methods The authors implemented a pre-clinical language equity course at three medical school campuses between August 2020 and March 2022. Sessions focused on the impact of language in health, physician language proficiency standards, and working with medical interpreters. The study sought to (1) understand students’ language skills and prior clinical experiences with patients with non-English language preference and (2) evaluate the curriculum’s impact. Students self-reported their language skills and experiences as part of a voluntary pre-questionnaire. Pre and post-questionnaires evaluated knowledge, attitudes, and intent to apply language equity concepts. Descriptive statistics and chi-squared tests were used to examine trends; themes were identified from free-text responses. Results Overall, 301 students completed the course, 252 (83%) completed at least one questionnaire; for each session, between 35% and 46% of learners completed both pre and post-questionnaires. Three quarters (189/252) reported non-English languages. Over half (138/252) reported previous non-English language patient care, and 28% (62/224) had served as ad hoc (untrained) interpreters. Only two students (

Considering patient room shortages and prevalence of other communicable diseases, reassessing the isolation of patients with Clostridioides difficile infection (CDI) is imperative. We conducted a retrospective study to investigate the secondary CDI transmission rate in a hospital in South Korea, where patients with CDI were not isolated. Using data from a real-time locating system and electronic medical records, we investigated patients who had both direct and indirect contact with CDI index patients. The primary outcome was secondary CDI transmission, identified by whole-genome sequencing. Among 909 direct and 2,711 indirect contact cases, 2 instances of secondary transmission were observed (2 [0.05%] of 3,620 cases), 1 transmission via direct contact and 1 via environmental sources. A low level of direct contact (113 minutes) was required for secondary CDI transmission. Our findings support the adoption of exhaustive standard preventive measures, including environmental decontamination, rather than contact isolation of CDI patients in nonoutbreak settings.

BackgroundThe long-term mortality and morbidity of patients with severe fever with thrombocytopenia syndrome (SFTS) remain unclear.MethodsThis retrospective cohort study was conducted using the National Health Insurance Service dataset on hospitalized patients with SFTS aged ≥20 years between 2016 and 2021 (n = 1,217). Each SFTS case was matched with three controls hospitalized for non-SFTS-related diseases using propensity score matching. The all-cause mortality of patients with SFTS was evaluated during the one-year follow-up and compared with that of controls. Post-discharge events were investigated to determine the effects of SFTS on post-acute sequelae.ResultsFinally, 1,105 patients with SFTS and 3,315 controls were included. Patients with SFTS had a higher risk of death during the one-year follow-up than that of controls (hazard ratio [HR], 2·26; 95% confidence interval [CI], 1·82-2·81). Thirty-day mortality was significantly higher in the SFTS group (HR, 3·99; 95% CI, 3·07-5·19) than in the control group. An increased risk of death after 31-365 days was observed among controls, though this difference was significant only among patients in their 80s (HR, 0·18; 95% CI, 0·06-0·57). For post-discharge events, patients in the SFTS group exhibited a higher risk of readmission (HR, 1·17; 95% CI, 1·04-1·32) and emergency room visit (HR, 2·32; 95% CI, 1·96-2·76) than those in the control group.ConclusionSFTS induces a higher risk of short-term mortality and post-acute sequelae in hospitalized patients during a one-year follow-up than non-SFTS-related diseases. Our results provide guidance for the management of SFTS.

Abstract Background Equitable assessment is critical in competency-based medical education. This study explores differences in key characteristics of qualitative assessments (i.e., narrative comments or assessment feedback) of internal medicine postgraduate resident performance associated with gender and race and ethnicity. Methods Analysis of narrative comments included in faculty assessments of resident performance from six internal medicine residency programs was conducted. Content analysis was used to assess two key characteristics of comments- valence (overall positive or negative orientation) and specificity (detailed nature and actionability of comment) – via a blinded, multi-analyst approach. Differences in comment valence and specificity with gender and race and ethnicity were assessed using multilevel regression, controlling for multiple covariates including quantitative competency ratings. Results Data included 3,383 evaluations with narrative comments by 597 faculty of 698 residents, including 45% of comments about women residents and 13.2% about residents who identified with race and ethnicities underrepresented in medicine. Most comments were moderately specific and positive. Comments about women residents were more positive (estimate 0.06, p 0.045) but less specific (estimate − 0.07, p 0.002) compared to men. Women residents were more likely to receive non-specific, weakly specific or no comments (adjusted OR 1.29, p 0.012) and less likely to receive highly specific comments (adjusted OR 0.71, p 0.003) or comments with specific examples of things done well or areas for growth (adjusted OR 0.74, p 0.003) than men. Gendered differences in comment specificity and valence were most notable early in training. Comment specificity and valence did not differ with resident race and ethnicity (specificity: estimate 0.03, p 0.32; valence: estimate − 0.05, p 0.26) or faculty gender (specificity: estimate 0.06, p 0.15; valence: estimate 0.02 p 0.54). Conclusion There were significant differences in the specificity and valence of qualitative assessments associated with resident gender with women receiving more praising but less specific and actionable comments. This suggests a lost opportunity for well-rounded assessment feedback to the disadvantage of women.

Abstract Introduction Evidence suggests gender disparities in medical education assessment, including differences in ratings of competency and narrative comments provided in resident performance assessments. This study explores how gender manifests within the content of qualitative assessments (i.e., narrative comments or performance feedback) of resident performance. Methods Qualitative content analysis was used to explore gender-based differences in narrative comments included in faculty assessments of resident performance during inpatient medicine rotations at six Internal Medicine residency programs, 2016–2017. A blinded, multi-analyst approach was employed to identify themes across comments. Patterns in themes with resident gender and post-graduate year (PGY) were explored, focusing on PGY2 and PGY3 when residents are serving in the team leader role. Results Data included 3,383 evaluations with narrative comments of 385 men (55.2%) and 313 women residents (44.8%). There were thematic differences in narrative comments received by men and women residents and how these themes manifested within comments changed with training time. Compared to men, comments about women had a persistent relationship-orientation and emphasized confidence over training including as interns and in PGY2 and PGY3, when serving as team leader. The relationship-orientation was characterized not only by the residents’ communal attributes but also their interpersonal and communication skills, including efforts supporting others and establishing the tone for the team. Comments about women residents often highlighted confidence, including recommendations around behaviors that convey confidence in decision-making and team leadership. Discussion There were gender-based thematic differences in qualitative assessments. Comments about women resident team leaders highlight relationship building skills and urge confidence and actions that convey confidence as team leader. Persistent attention to communal skills suggests gendered expectations for women resident team leaders and a lost opportunity for well-rounded feedback to the disadvantage of women residents. These findings may inform interventions to promote equitable assessment, such as providing feedback across the competencies.

Abstract Background Safe and effective physician-to-physician patient handoffs are integral to patient safety. Unfortunately, poor handoffs continue to be a major cause of medical errors. Developing a better understanding of challenges faced by health care providers is critical to address this continued patient safety threat. This study addresses the gap in the literature exploring broad, cross-specialty trainee perspectives around handoffs and provides a set of trainee-informed recommendations for both training programs and institutions. Methods Using a constructivist paradigm, the authors conducted a concurrent/embedded mixed method study to investigate trainees’ experiences with patient handoffs across Stanford University Hospital, a large academic medical center. The authors designed and administered a survey instrument including Likert-style and open-ended questions to solicit information about trainee experiences from multiple specialties. The authors performed a thematic analysis of open-ended responses. Results 687/1138 (60.4%) of residents and fellows responded to the survey, representing 46 training programs and over 30 specialties. There was wide variability in handoff content and process, most notably code status not being consistently mentioned a third of the time for patients who were not full code. Supervision and feedback about handoffs were inconsistently provided. Trainees identified multiple health-systems level issues that complicated handoffs and suggested solutions to these threats. Our thematic analysis identified five important aspects of handoffs: (1) handoff elements, (2) health-systems-level factors, (3) impact of the handoff, (4) agency (duty), and (5) blame and shame. Conclusions Health systems, interpersonal, and intrapersonal issues affect handoff communication. The authors propose an expanded theoretical framework for effective patient handoffs and provide a set of trainee-informed recommendations for training programs and sponsoring institutions. Cultural and health-systems issues must be prioritized and addressed, as an undercurrent of blame and shame permeates the clinical environment.

Introduction. The effectiveness of spaced and massed strategies can be evaluated by examining how educational experts (faculty members) transfer their learning skills to real-life educational contexts, such as with their undergraduate students in Saudi Arabia. It is necessary to consider the respective benefits of these strategies for faculty members to maintain standards and capabilities, fulfilling their learning and development needs. Aim. This study aimed to compare the effectiveness of spaced and massed practice programs for faculty members in transferring their acquired assessment skills to their students. To achieve this goal, we used a mixed methodological approach, integrating both qualitative and quantitative methods into the study design. Methods. This study was carried out at the Faculty of Medicine, King Abdul-Aziz University (KAU), Jeddah, Saudi Arabia. Focus group discussions were employed for the qualitative approach, while the paired-sample t-test and Chi-square test of independence were used for the quantitative approach. Results. The results of the focus group discussion indicated that participants from both groups preferred the spaced learning approach, considering the busy schedules of medical doctors and students. In terms of cost effectivity, both group participants preferred the massed learning technique. Two (25%) participants from the spaced technique group and five (62.5%) participants from the massed technique group succeeded in applying all parts of the assessment cycle without significant help from other experts. Three (37.5%) participants in the spaced groups agreed that the pathway of applying the standards was confusing and entailed extra work requirements, while five (62.5%) participants in the massed group responded that it increased the feeling of being overwhelmed. Furthermore, the statistical results did not provide a clear indication of which program faculty members should adopt to facilitate their students in a better way. The lack of statistically significant differences between the findings of both programs suggests that the results do not confirm the superiority of spaced or massed practice, as is often assumed in medical education. Conclusions. Both spaced and massed learning strategies were found to be broadly effective in transferring assessment skills, with no significant qualitative and qualitative differences. Their effectiveness depended on the specification of modules.

Introduction Medical Spanish courses in US medical schools aim to teach patient-centered communication, yet many existing resources focus on technical vocabulary and may inadvertently increase jargon use with patients. Graphic medicine presents an opportunity for interactive learning that centers the patient experience, yet it has never been explored in medical Spanish education. Methods We developed a Medical Spanish Graphic Activity (MeGA) for medical student deliberate practice of patient-centered verbal communication focused on three aspects: diagnosis, treatment, and follow-up care. Each 30-minute activity included a comics handout depicting a patient with a common problem. Students used voice-to-text technology to record their explanations in response to prompts. Transcripts were analyzed for jargon use, including total jargon, unexplained jargon, and problem words (non-Spanish words plus unexplained jargon), utilizing a previously published, reliable protocol for Spanish medical jargon classification. Participants voluntarily provided postactivity feedback. Results Twenty-nine fourth-year students with intermediate or greater Spanish skills participated in a series of 10 MeGA activities between January and April 2022. Unexplained jargon use and problem words progressively decreased for all transcripts (diagnosis, treatment, and follow-up; all ps < .001). Total jargon use also decreased, but this was not significant in follow-up transcripts (p = .38). All students agreed that MeGA helped them enhance communication skills applicable to patient care and self-identify strengths and limitations. Discussion MeGA is realistic to implement, engages students' active participation in the speaking domain, and reduces unexplained jargon use. Future studies should explore the broader application of this model and engage patient perspectives.

Despite the efforts made to minimize the illegal trafficking of hazardous waste and prevent environmental pollution worldwide in accordance with the 1989 Basel Convention (BC), the illegal transboundary movement of waste and associated environmental pollution are ongoing. This study proposes a three-stage theoretical approach to effectively managing this waste. In stage one, the Convention, including its 2019 revisions, stipulates six primary requirements: clear declaration, hazardous waste, onsite inspection, responsibility, transport management, and final disposal after import. In stage two, the export and import management system is divided into four facets: customs preprocessing, customs processing, follow-up, and law. The challenges are presented of how to align the waste disposal with the Basel Convention's main requirements. Stage three presents a discussion of the effectiveness of the countermeasures derived in stage two for disposing of waste both within individual nations and internationally. Then, the theoretical approach was applied to analyzing South Korea Ministry of Environment's Act on the Transboundary Movement of Hazardous Waste and Their Disposal (revised in 2017). The strategy was demonstrated to be an improvement, and these study results can be foundational data to newly establish laws or revise existing acts on transboundary movement of waste (TMW) in each country.

Abstract Background Effective teamwork in interdisciplinary healthcare teams is necessary for patient safety. Psychological safety is a key component of effective teamwork. The baseline psychological safety on pediatric inpatient healthcare teams is unknown. The purpose of this study is to determine the baseline psychological safety between pediatric nurses and residents and examine the impact of an interdisciplinary nighttime simulation curriculum. Methods A convergent, multistage mixed methods approach was used. An interprofessional simulation curriculum was implemented fall 2020 to spring 2021. Qualitative focus group data and quantitative survey data on team psychological safety were collected and compared, both pre- and post-intervention and across nurses and residents. Thematic analysis of the qualitative data was conducted, and themes integrated with survey findings. Results Data were collected from 30 nurses and 37 residents pre-intervention and 32 and 38 post-intervention, respectively. Residents and nurses negatively rated psychological safety (pre-intervention mean = 3.40 [SD = 0.72]; post-intervention mean = 3.35 [SD = 0.81]). At both times psychological safety was rated significantly lower for residents (pre-intervention mean = 3.11 [SD = 0.76], post-intervention mean = 2.98 [SD = 0.84]) than nurses (pre-intervention mean = 3.76 [SD = 0.45], post-intervention mean = 3.79 [SD = 0.50]), all P

Blood transfusion services maintain quality practice through adherence to guidelines but are faced with blood component wastage due to multiple factors. One factor, in particular, is poor ordering and utilization practices followed by physicians who may not be familiar with the indications and the optimal conditions for the handling of blood products. This study evaluates whether an educational intervention would help reduce ordering of plasma and improve wastage rates after thawing. The study followed a quasi-experimental pre-test post-test design. A multifaceted educational intervention was introduced at a tertiary hospital-based combining predisposing, enabling, and reinforcing activities, based on the literature of effective continuous professional development. The activities included a brief survey to evaluate participant knowledge about indications of plasma and its storage condition, a lecture, and periodic reports and reminders sent to all department heads in the hospital. Respondents to the survey and lecture attendees included physicians in adult critical care and anesthesia departments. Monthly plasma utilization and wastage rates were compared before and after introducing the intervention. Sixty physicians participated in the survey. The questions were answered correctly by less than half. After introducing the intervention, monthly plasma transfusion rates decreased; however, wastage rates did not improve. There is a knowledge gap among physicians who order plasma. The educational intervention resulted in lower plasma transfusion rates but did not affect wastage rates. Future interventions would benefit from including physicians in other departments as well as nurses.

Abstract Background Nearly all U.S. medical students engage in a 4–8 week period of intense preparation for their first-level licensure exams, termed a “dedicated preparation period” (DPP). It is widely assumed that student well-being is harmed during DPPs, but evidence is limited. This study characterized students’ physical, intellectual, emotional, and social well-being during DPPs. Methods This was a cross-sectional survey sent electronically to all second-year students at four U.S. medical schools after each school’s respective DPP for USMLE Step 1 or COMLEX Level 1 in 2019. Survey items assessed DPP characteristics, cost of resources, and perceived financial strain as predictors for 18 outcomes measured by items with Likert-type response options. Open-ended responses on DPPs’ influence underwent thematic analysis. Results A total of 314/750 (42%) students completed surveys. DPPs lasted a median of 7 weeks (IQR 6–8 weeks), and students spent 70 h/week (IQR 56–80 h/week) studying. A total of 62 (20%) reported experiencing a significant life event that impacted their ability to study during their DPPs. Most reported 2 outcomes improved: medical knowledge base (95%) and confidence in ability to care for patients (56%). Most reported 9 outcomes worsened, including overall quality of life (72%), feeling burned out (77%), and personal anxiety (81%). A total of 25% reported paying for preparation materials strained their finances. Greater perceived financial strain was associated with worsening 11 outcomes, with reported amount spent associated with worsening 2 outcomes. Themes from student descriptions of how DPPs for first-level exams influenced them included (1) opportunity for synthesis of medical knowledge, (2) exercise of endurance and self-discipline required for professional practice, (3) dissonance among exam preparation resource content, formal curriculum, and professional values, (4) isolation, deprivation, and anguish from competing for the highest possible score, and (5) effects on well-being after DPPs. Conclusions DPPs are currently experienced by many students as a period of personal and social deprivation, which may be worsened by perceived financial stress more than the amount of money they spend on preparation materials. DPPs should be considered as a target for reform as medical educators attempt to prevent student suffering and enhance their well-being.

Abstract Background Diagnosing Clostridioides difficile infection (CDI) is complicated. There have been reports on effects of compliance with anti-C. difficile prescription guidelines on patient outcomes. However, the causes of non-adherence and their impact on outcomes have rarely been explored. Therefore, an investigation on the risk factors for non-adherence with treatment guidelines and their influence on recurrence is important. Methods This case–control study was conducted with patients with a positive C. difficile culture from March 2020 to April 2021. We conducted analysis based on treatment categories using factors associated with recurrent CDI as variables. Univariate and multivariable analyses were conducted to identify risk factors for non-adherence with treatment guidelines. Results In total, culture positive stool samples from 172 patients were analyzed. Having positive glutamate dehydrogenase antigen (GDH Ag), negative toxin enzyme immunoassay (EIA), and positive nucleic acid amplification test (NAAT) (GDH+/toxin EIA−/NAAT +) results were associated with both under- (adjusted odds ratio [aOR] 3.49 [95% CI 1.62–7.51], p = 0.001) and over-treatment (aOR 0.17 [95% CI 0.06–0.48], p = 0.001). Patients with refractory diarrhea were over treated (aOR 2.71 [95% CI 1.02–7.20], p = 0.046). Patients with an increased risk of CDI recurrence were not over treated. Conclusions Our results suggest that non-adherence with CDI treatment guidelines depends on the duration of symptoms and rapid EIA test results. Patients with an increased risk of recurrence were neglected.

Introduction In psychiatry, several converging factors are impacting the recruitment of residents: the increased competitiveness of the specialty, the national trend to take active steps to improve diversity and inclusion, and the decision from USMLE to change Step 1 to a pass/fail result. Methods We developed a workshop for psychiatry residency program directors to meet these challenges and transition into using a holistic review model during recruitment. The workshop included (1) a didactic session providing background on the AAMC holistic review model; (2) a small-group exercise to determine and prioritize experiences, attributes, competencies, and metrics (EACMs) aligned with the program's mission and aims; (3) a review of the rankings from the previous exercise, selection of two “very important” criteria for each of the four domains of the EACM model, and operationalization of these criteria based on the recruitment process; and (4) a discussion focused on application of program criteria with example applicants. Results The holistic review workshop was conducted at the American Association of Psychiatry Residency Directors conference in 2021 with 48 self-selected attendees. Following the workshop, 74% of attendees reported a likelihood of implementing holistic applications during their next application cycle, 78% were able to leave with at least one actionable item, 100% thought that the session was interactive, and 78% felt that the session met their expectations. Discussion Implementing a holistic review for psychiatry residency recruitment can assist programs in responding to the rapidly changing landscape and achieve aims for improving diversity and inclusion.

Understanding the risk factors and microbiological features in recurrent Escherichia coli BSI is helpful for clinicians. Data of patients with E. coil BSI from 2017 to 2018 were collected. Antimicrobial resistance rates of E. coli were determined. We also identified the ST131 and ESBL genotype to evaluate the molecular epidemiology of E. coli. Whole genome sequencing was conducted on the available ESBL-producing E. coli samples. Of 808 patients with E. coli BSI, 57 (6.31%) experienced recurrence; 29 developed at 4-30 days after initial BSI (early onset recurrence) and 28 at 31-270 days after initial BSI (late onset recurrence). One hundred forty-nine patients with single episode, whose samples were available for determining the molecular epidemiology, were selected for comparison. Vascular catheterization (adjusted odds ratio [aOR], 4.588; 95% confidence interval [CI], 1.049-20.068), ESBL phenotype (aOR, 2.037; 95% CI, 1.037-3.999) and SOFA score ≥9 (aOR, 3.210; 95% CI, 1.359-7.581) were independent risk factors for recurrence. The proportion of ST131 and ESBL genotype was highest in early onset recurrent BSI (41.4% and 41.4%, respectively), from which E. coil had the highest resistance rates to most antimicrobial agents. Whole genome sequencing on 27 of ESBL-producing E. coli (11 from single episode, 11 from early onset recurrence, and 5 from late onset recurrence) demonstrated that various virulence factors, resistant genes, and plasmid types existed in isolates from all types of BSI. Risk factors contributing to the recurrence and microbiological features of E. coli causing recurrent BSI may be helpful for management planning in the clinical setting.

BackgroundEffective collaboration is the foundation for delivering safe, high quality patient care. Health sciences curricula often include interprofessional collaboration training but may neglect conflicts that occur within a profession (intraprofessional). We describe the development of and validity evidence for an assessment of intraprofessional conflict management.Methods and findingsWe designed a 22-item assessment, the Intraprofessional Conflict Exercise, to evaluate skills in managing intraprofessional conflicts based on a literature review of conflict management. Using Messick's validity framework, we collected evidence for content, response process, and internal structure during a simulated intraprofessional conflict from 2018 to 2019. We performed descriptive statistics, inter-rater reliability, Cronbach's alpha, generalizability theory, and factor analysis to gather validity evidence. Two trained faculty examiners rated 82 trainees resulting in 164 observations. Inter-rater reliability was fair, weighted kappa of 0.33 (SE = 0.03). Cronbach's alpha was 0.87. The generalizability study showed differentiation among trainees (19.7% person variance) and was highly reliable, G-coefficient 0.88, Phi-coefficient 0.88. The decision study predicted that using one rater would have high reliability, G-coefficient 0.80. Exploratory factor analysis demonstrated three factors: communication skills, recognition of limits, and demonstration of respect for others. Based on qualitative observations, we found all items to be applicable, highly relevant, and helpful in identifying how trainees managed intraprofessional conflict.ConclusionsThe Intraprofessional Conflict Exercise provides a useful and reliable way to evaluate intraprofessional conflict management skills. It provides meaningful and actionable feedback to trainees and may help health educators in preparing trainees to manage intraprofessional conflict.

BackgroundSituational judgments tests have been increasingly used to help training programs for the health professions incorporate professionalism attributes into their admissions process. While such tests have strong psychometric properties for testing professional attributes and are feasible to implement in high-volume, high-stakes selection, little is known about constructed-response situational judgment tests and their validity.MethodsWe will conduct a systematic review of primary published or unpublished studies reporting on the association between scores on constructed-response situational judgment tests and scores on other tests that measure personal, interpersonal, or professional attributes in training programs for the health professions. In addition to searching electronic databases, we will contact academics and researchers and undertake backward and forward searching. Two reviewers will independently screen the papers and decide on their inclusion, first based on the titles and abstracts of all citations, and then according to the full texts. Data extraction will be done independently by two reviewers using a data extraction form to chart study details and key findings. Studies will be assessed for the risk of bias and quality by two reviewers using the "Quality In Prognosis Studies" tool. To synthesize evidence, we will test the statistical heterogeneity and conduct a psychometric meta-analysis using a random-effects model. If adequate data are available, we will explore whether the meta-analytic correlation varies across different subgroups (e.g., race, gender).DiscussionThe findings of this study will inform best practices for admission and selection of applicants for training programs for the health professions and encourage further research on constructed-response situational judgment tests, in particular their validity.Trial registrationThe protocol for this systematic review has been registered in PROSPERO [CRD42022314561]. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022314561.

ABSTRACT: Objectives: This study was designed to investigate the molecular epidemiology of Clostridioides difficile isolates in South Korea and to evaluate risk factors for rifaximin-non-susceptible C. difficile infection (CDI). Methods: A total of 413 patients with CDI from two sentinel hospitals in South Korea were enrolled in this study. Putative clinical risk factors for CDI were identified using digital medical records of the patients. Pathogen profiles, including antimicrobial susceptibility, toxin production and ribotype, were evaluated for each of the causative C. difficile isolates. Results: Of the 413 C. difficile isolates, 81 (19.6%) were shown to be rifaximin-non-susceptible, with the most common ribotypes being 018 (56.8%; 46/81), 017 (16.0%; 13/81) and 027 (6.2%; 5/81). Rifaximin-non-susceptible C. difficile isolates exhibited higher non-susceptibility rates to most of the other drugs tested in this study compared with rifaximin-susceptible isolates. Previous history of pulmonary tuberculosis and prior rifaximin treatment were shown to be associated with the occurrence of rifaximin-non-susceptible CDI compared with susceptible CDI. Conclusion: Non-susceptibility rates to rifaximin for the C. difficile isolates identified in this study were reasonably high with most of the resistant strains belonging to either ribotype 018 or 017. Widespread dissemination of these clones may be the result of antimicrobial selection pressure introduced by the widespread use of rifaximin. These results suggest that a sustainable surveillance programme for CDI and C. difficile resistance is needed in order to better control CDIs and to improve therapeutic efficacy.

ABSTRACT Estimating neutralizing activity in vaccinees is crucial for predicting the protective effect against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As the plaque reduction neutralization test (PRNT) requires a biosafety level 3 facility, it would be advantageous if surrogate virus neutralization test (sVNT) assays and binding assays could predict neutralizing activity. Here, five different assays were evaluated with respect to the PRNT in vaccinees: three sVNT assays from GenScript, Boditech Med, and SD Biosensor and two semiquantitative binding assays from Roche and Abbott. The vaccinees were subjected to three vaccination protocols: homologous ChAdOx1, homologous BNT162b2, and heterologous administration. The ability to predict a 50% neutralizing dose (ND50) of ≥20 largely varied among the assays, with the binding assays showing substantial agreement (kappa, ~0.90) and the sVNT assays showing relatively poor performance, especially in the ChAdOx1 group (kappa, 0.33 to 0.97). The ability to predict an ND50 value of ≥118.25, indicating a protective effect, was comparable among different assays. Applying optimal cutoffs based on Youden’s index, the kappa agreements were greater than 0.60 for all assays in the total group. Overall, relatively poor performance was demonstrated in the ChAdOx1 group, owing to low antibody titers. Although there were intra-assay differences related to the vaccination protocols, as well as interassay differences, all assays demonstrated fair performance in predicting the protective effect using the new cutoffs. This study demonstrates the need for a different cutoff for each assay to appropriately determine a higher neutralizing titer and suggests the clinical feasibility of using various assays for estimation of the protective effect. IMPORTANCE The coronavirus disease 2019 (COVID-19) pandemic continues to last, despite high COVID-19 vaccination rates. As many people experience breakthrough infection after prior infection and/or vaccination, estimating the neutralization activity and predicting the protective effect are major issues of concern. However, since standard neutralization tests are not available in most clinical laboratories, it would be beneficial if commercial assays could predict these aspects. In this study, we evaluated the performance of three sVNT assays and two semiquantitative binding assays targeting the receptor-binding domain with respect to the PRNT. Our results suggest that these assays could be used for predicting the protective effect by adjusting the cutoffs.

BackgroundThere has been an increasing demand for new technologies regarding infection control in hospital settings to reduce the burden of contact tracing. ObjectiveThis study aimed to compare the validity of a real-time locating system (RTLS) with that of the conventional contact tracing method for identifying high-risk contact cases associated with the secondary transmission of SARS-CoV-2. MethodsA retrospective case-control study involving in-hospital contact cases of confirmed COVID-19 patients, who were diagnosed from January 23 to March 25, 2022, was conducted at a university hospital in South Korea. Contact cases were identified using either the conventional method or the RTLS. The primary endpoint of this study was secondary transmission of SARS-CoV-2 among contact cases. Univariate and multivariable logistic regression analysis comparing test positive and versus negative contact cases were performed. ResultsOverall, 509 and 653 cases were confirmed by the conventional method and the RTLS, respectively. Only 74 contact cases were identified by both methods, which could be attributed to the limitations of each method. Sensitivity was higher for the RTLS tracing method (653/1088, 60.0%) than the conventional tracing method (509/1088, 46.8%) considering all contact cases identified by both methods. The secondary transmission rate in the RTLS model was 8.1%, while that in the conventional model was 5.3%. The multivariable logistic regression model revealed that the RTLS was more capable of detecting secondary transmission than the conventional method (adjusted odds ratio 6.15, 95% CI 1.92-28.69; P=.007). ConclusionsThis study showed that the RTLS is beneficial when used as an adjunctive approach to the conventional method for contact tracing associated with secondary transmission. However, the RTLS cannot completely replace traditional contact tracing.

IntroductionDespite vaccine development, the COVID-19 pandemic is ongoing due to immunity-escaping variants of concern (VOCs). Estimations of vaccine-induced protective immunity against VOCs are essential for setting proper COVID-19 vaccination policy.MethodsWe performed plaque-reduction neutralizing tests (PRNTs) using sera from healthcare workers (HCWs) collected from baseline to six months after COVID-19 vaccination and from convalescent COVID-19 patients. The 20.2% of the mean PRNT titer of convalescent sera was used as 50% protective value, and the percentage of HCWs with protective immunity for each week (percent-week) was compared among vaccination groups. A correlation equation was deduced between a PRNT 50% neutralizing dose (ND50) against wild type (WT) SARS-CoV-2 and that of the Delta variant.ResultsWe conducted PRNTs on 1,287 serum samples from 297 HCWs (99 HCWs who received homologous ChAdOx1 vaccination (ChAd), 99 from HCWs who received homologous BNT162b2 (BNT), and 99 from HCWs who received heterologous ChAd followed by BNT (ChAd-BNT)). Using 365 serum samples from 116 convalescent COVID-19 patients, PRNT ND50 of 118.25 was derived as 50% protective value. The 6-month cumulative percentage of HCWs with protective immunity against WT SARS-CoV-2 was highest in the BNT group (2297.0 percent-week), followed by the ChAd-BNT (1576.8) and ChAd (1403.0) groups. In the inter-group comparison, protective percentage of the BNT group (median 96.0%, IQR 91.2–99.2%) was comparable to the ChAd-BNT group (median 85.4%, IQR 15.7–100%; P =0.117) and significantly higher than the ChAd group (median 60.1%, IQR 20.0–87.1%; P

This study aimed to investigate the clinical implications and prognostic value of artificial intelligence (AI)-based results for chest radiographs (CXR) in coronavirus disease 2019 (COVID-19) patients. Patients who were admitted due to COVID-19 from September 2021 to March 2022 were retrospectively included. A commercial AI-based software was used to assess CXR data for consolidation and pleural effusion scores. Clinical data, including laboratory results, were analyzed for possible prognostic factors. Total O2 supply period, the last SpO2 result, and deterioration were evaluated as prognostic indicators of treatment outcome. Generalized linear mixed model and regression tests were used to examine the prognostic value of CXR results. Among a total of 228 patients (mean 59.9 ± 18.8 years old), consolidation scores had a significant association with erythrocyte sedimentation rate and C-reactive protein changes, and initial consolidation scores were associated with the last SpO2 result (estimate −0.018, p = 0.024). All consolidation scores during admission showed significant association with the total O2 supply period and the last SpO2 result. Early changing degree of consolidation score showed an association with deterioration (odds ratio 1.017, 95% confidence interval 1.005–1.03). In conclusion, AI-based CXR results for consolidation have potential prognostic value for predicting treatment outcomes in COVID-19 patients.

With the emergence and rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Delta and Omicron variants, escaping vaccine-induced immunity is a concern. Three vaccination schedules, homologous or heterologous, have been initially applied due to an insufficient supply of vaccines in Korea. We investigated neutralizing activities against Omicron and Delta variants in each schedule. Three schedules using three doses of the BNT162b2 (BNT) or the ChAdOx1 (ChAd) vaccines include ChAd-ChAd-BNT, ChAd-BNT-BNT, and BNT-BNT-BNT. Neutralizing activities were evaluated using plaque-reduction neutralization test (PRNT) against wild type (WT) SARS-CoV-2, Delta variant, and Omicron variant. A total of 170 sera from 75 participants were tested, and the baseline characteristics of participants were not significantly different between groups. After the 2nd vaccine dose, geometric mean titers of PRNT ND50 against WT, Delta, and Omicron were highest after ChAd-BNT vaccination (2,463, 1,097, and 107) followed by BNT-BNT (2,364, 674, and 38) and ChAd-ChAd (449, 163, and 25). After the 3rd dose of BNT, the increase of PRNT ND50 against WT, Delta, and Omicron was most robust in ChAd-ChAd-BNT (4,632, 988, and 260), while the BNT-BNT-BNT group showed the most augmented neutralizing activity against Delta and Omicron variants (2,315 and 628). ChAd-BNT-BNT showed a slight increase of PRNT ND50 against WT, Delta, and Omicron (2,757, 1,279, and 230) compared to the 2nd dose. The results suggest that a 3rd BNT booster dose induced strengthened neutralizing activity against Delta and Omicron variants. The waning of cross-reactive neutralizing antibodies after the 3rd dose and the need for additional boosting should be further investigated.

Abstract Kikuchi-Fujimoto disease (KFD) is usually self-limiting, but prolonged systemic symptoms often result in frequent hospital visits, long admission durations, or missed workdays. We investigated the role of fluorine-18 fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) in assessing KFD severity. We reviewed the records of 31 adult patients with pathologically confirmed KFD who underwent 18F-FDG PET/CT between November 2007 and April 2018 at a tertiary-care referral hospital. Disease severity was assessed using criteria based on clinical manifestations of advanced KFD. Systemic activated lymph nodes and severity of splenic activation were determined using semi-quantitative and volumetric PET/CT parameters. The median of the mean splenic standardized uptake value (SUVmean) was higher in patients with severe KFD than those with mild KFD (2.38 ± 1.18 vs. 1.79 ± 0.99, p = 0.058). Patients with severe KFD had more systemically activated volume and glycolytic activity than those with mild KFD (total lesion glycolysis: 473.5 ± 504.4 vs. 201.6 ± 363.5, p = 0.024). Multivariate logistic regression showed that myalgia (odds ratio [OR] 0.035; 95% confidence interval [CI] 0.001–0.792; p = 0.035), total lymph node SUVmax (cutoff 9.27; OR 24.734; 95% CI 1.323–462.407; p = 0.032), and spleen SUVmean (cutoff 1.79; OR 37.770; 95% CI 1.769–806.583; p = 0.020) were significantly associated with severe KFD. 18F-FDG PET/CT could be useful in assessing KFD severity.

Abstract Background Examining the predictors of summative assessment performance is important for improving educational programs and structuring appropriate learning environments for trainees. However, predictors of certification examination performance in pediatric postgraduate education have not been comprehensively investigated in Japan. Methods The Pediatric Board Examination database in Japan, which includes 1578 postgraduate trainees from 2015 to 2016, was analyzed. The examinations included multiple-choice questions (MCQs), case summary reports, and an interview, and the predictors for each of these components were investigated by multiple regression analysis. Results The number of examination attempts and the training duration were significant negative predictors of the scores for the MCQ, case summary, and interview. Employment at a community hospital or private university hospital were negative predictors of the MCQ and case summary score, respectively. Female sex and the number of academic presentations positively predicted the case summary and interview scores. The number of research publications was a positive predictor of the MCQ score, and employment at a community hospital was a positive predictor of the case summary score. Conclusion This study found that delayed and repeated examination taking were negative predictors, while the scholarly activity of trainees was a positive predictor, of pediatric board certification examination performance.

Introduction Hispanic/Latinx patients experience health disparities in endocrine disease, such as higher rates of mortality due to diabetes mellitus, worse outcomes in the surgical treatment of thyroid cancer, and lack of knowledge about bone health and osteoporotic fracture prevention. Educational strategies to teach cultural and linguistic medical Spanish knowledge to medical students have the potential to improve Hispanic/Latinx endocrine health. Methods We created an 8-hour medical Spanish endocrine module targeting language and cultural skills acquisition. Specifically, students practiced obtaining a past medical history, obtaining a medications history, providing and explaining a diagnosis, explaining discharge instructions, and discussing sociocultural aspects of endocrine health. We divided the module into four 2-hour sessions: (1) preclass self-study, (2) class period, (3) role-play/interviewing practice session, and (4) case/cultural activity assignment. Participants completed a pre- and postassessment to measure student confidence level and knowledge. Results We implemented the module four times at one medical school, with 47 fourth-year medical students with intermediate or higher general Spanish skills. Confidence increased for all learners in the endocrine-focused interview and exam in Spanish. Heritage Spanish learners, who were exposed to Spanish at home as children, reported higher postmodule confidence in eliciting the past medical history of endocrine problems. Discussion The medical Spanish endocrine module improved the communication skills of medical students with intermediate through advanced Spanish proficiency. Future study should evaluate learner clinical performance metrics and applications to other groups of learners, such as resident physicians or health professions involved in the care of patients with endocrine disease.

Objectives: The aim of this study was to elucidate patterns of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) clearance in the natural course of asymptomatic coronavirus disease 2019 (COVID-19). Methods: Consecutive patients with non-severe COVID-19 were included retrospectively. Asymptomatic patients with a normal body temperature and no evidence of pneumonia throughout the disease course were assigned to the asymptomatic group. The reverse transcription PCR (RT-PCR) assay was repeated every two to five days after the first follow-up RT-PCR assay. Negative conversion was defined as two consecutive negative RT-PCR assay results within a 24-h interval. Rebound of the cycle threshold (Ct) value was defined as negative from the single RT-PCR assay and positive from the following assay. Results: Among a total of 396 patients identified (median age 42.5 years (interquartile range (IQR) 25.0–55.0 years), 35.6% male), 68 (17.2%) were assigned to the asymptomatic group and 328 (82.8%) to the symptomatic group. The time until negative conversion was significantly shorter in the asymptomatic group than in the symptomatic group: median 14.5 days (IQR 11.0–21.0 days) and 18.0 days (IQR 15.0–22.0 days), respectively (p = 0.001). Rebound of Ct values was observed in 78 patients (19.7%). Conclusions: Time until negative conversion is shorter in asymptomatic COVID-19 than in symptomatic COVID-19. Rebound of Ct values is not uncommon.

We reviewed the clinical efficacy of chloroquine for Plasmodium vivax malaria, the changing trend of parasite clearance time, and fever clearance time during 2000–2016 in South Korea. Median parasite clearance time and fever clearance time increased significantly over the study period. Chloroquine was mostly underdosed when used to treat P. vivax malaria.

Predicting factors of diagnostic yield in electromagnetic navigation bronchoscopy (ENB) have been explored in a number of previous studies based on data from experienced operators. However, little is known about predicting factors when the procedure is carried out by operators in the beginning of their learning curve. We here aim to identify the role of operators’ experience as well as lesion– and procedure characteristics on diagnostic yield of ENB procedures in the hands of novice ENB operators. Four operators from three centers without prior ENB experience were enrolled. The outcome of consecutive ENB procedures was assessed and classified as either diagnostic or non-diagnostic and predicting factors of diagnostic yield were assessed. A total of 215 procedures were assessed. A total of 122 (57%) of the ENB procedures resulted in diagnostic biopsies. Diagnostic ENB procedures were associated with a minor yet significant difference in tumor size compared to non-diagnostic/inconclusive ENB procedures (28 mm vs. 24 mm; p = 0.03). Diagnostic ENB procedures were associated with visible lesions at either fluoroscopy (p = 0.003) or radial endobronchial ultrasound (rEBUS), (p = 0.001). In the logistic regression model, lesion visibility on fluoroscopy, but none of operator experience, the presence of a bronchus sign, lesion size, or location nor visibility on rEBUS significantly impacted the diagnostic yield. In novice ENB operators, lesion visibility on fluoroscopy was the only factor found to increase the chance of obtaining a diagnostic sample.

This non-experimental quantitative study investigated medical school faculty members' behavioral intention to use and actual usage behavior of technology in inquiry-based learning activities in medical schools in the United States by applying the unified theory of acceptance and use of technology (UTAUT). In medical education, situational problems for students to solve typically incorporate instructive clinical cases to guide problem-solving and prepare them for their professional lives as clinicians. Technology-infused inquiry-based learning pedagogy can require significant paradigm shifts for both students and instructors. It can impact the level of responsibility students take upon themselves for their own learning, and use of a pedagogy instructors may find unfamiliar, to deliver content. Major findings demonstrated performance expectancy, effort expectancy, and social influence had a significant relationship with behavioral intention to use technology for teaching medical education inquiry-based activities. Gender and voluntariness of use were both found to have significant effects on the relationship between performance expectancy and behavioral intention to use technology. The results of this study can aid stakeholders in providing support mechanisms for faculty to adopt technology for teaching and learning. This is possibly the first of its kind on the application of this theoretical model to address medical educators' behavioral intention to use and actual usage behavior of educational technologies for the delivery of inquiry-based learning activities.

Abstract Background Effective communication has been linked to a reduction in adverse events and improved patient compliance. Currently in Otolaryngology – Head and Neck Surgery (OTL-HNS) residency programs, there is limited explicit teaching of communication skills. Our objective was to implement an educational program on communication skills for residents using multisource assessment in several simulation-based contexts throughout residency. Methods For three consecutive years, OTL-HNS residents were recruited to participate in a total of nine simulation-based clinical scenarios in which communication skills could be honed. This educational program was designed to provide instruction and practice of challenging ethics scenarios, with communication efficacy as a secondary goal. To facilitate this goal, a multisource assessment was paired with a debriefing process that involved attending staff, observing and participating residents, standardized patients, and invited content experts. Results Seventeen residents completed the curriculum for at least two consecutive years from 2009 to 2011. The internal-consistency reliability of the scenarios ranged from 0.88 to 0.96. The intraclass correlation was 0.19, as expected in this context. There was no statistical difference in the mean ratings of performance across post-graduate year (PGY) level (p = 0.201). Results from the random-intercept regression indicated that, on average, a learner’s mean rating at baseline was 3.6/5 and increased significantly by 0.25 points per year (p

Abstract Background To prevent the problems of traditional clinical evaluation, the “Objective Structured Clinical Examination (OSCE)” was presented by Harden as a more valid and reliable assessment instrument. However, an essential condition to guarantee a high-quality and effective OSCE is the assurance of evidence to support the validity of its scores. This study examines the psychometric properties of OSCE scores, with an emphasis on consequential and internal structure validity evidence. Methods Fifty-three first year medical students took part in a summative OSCE at the Lebanese American University-School of Medicine. Evidence to support consequential validity was gathered by using criterion-based standard setting methods. Internal structure validity evidence was gathered by examining various psychometric measures both at the station level and across the complete OSCE. Results Compared to our actual method of computing results, the introduction of standard setting resulted in lower students’ average grades and a higher cut score. Across stations, Cronbach’s alpha was moderately low. Conclusion Gathering consequential and internal structure validity evidence by multiple metrics provides support for or against the quality of an OSCE. It is critical that this analysis be performed routinely on local iterations of given tests, and the results used to enhance the quality of assessment.

Introduction While many medical schools provide opportunities in medical Spanish for medical students, schools often struggle with identifying a structured curriculum. The purpose of this module was to provide a flexible, organ system-based approach to teaching and learning musculoskeletal and dermatologic Spanish terminology, patient-centered communication skills, and sociocultural health contexts. Methods An 8-hour educational module for medical students was created to teach musculoskeletal and dermatologic medical communication skills in Spanish within the Hispanic/Latinx cultural context. Participants included 47 fourth-year medical students at an urban medical school with a starting minimum Spanish proficiency at the intermediate level. Faculty provided individualized feedback on speaking, listening, and writing performance of medical Spanish skills, and learners completed a written pre- and postassessment testing skills pertaining to communication domains of vocabulary, grammar, and comprehension as well as self-reported confidence levels. Results Students demonstrated improvement in vocabulary, grammar, comprehension, and self-confidence of musculoskeletal and dermatologic medical Spanish topics. While students with overall lower starting proficiency levels (intermediate) scored lower on the premodule assessment compared to higher proficiency students (advanced/native), the postmodule assessment did not show significant differences in skills performance among these groups. Discussion An intermediate Spanish level prerequisite for this musculoskeletal and dermatologic module can result in skills improvement for all learners despite starting proficiency variability. Future study should evaluate learner clinical performance and integration of this module into other educational settings such as graduate medical education (e.g., orthopedic, rehabilitation, and dermatology residency programs) and other health professions (e.g., physical therapy and nursing).

Some communities recover more quickly after a disaster than others. Some differentials in recovery are explained by variation in the level of disaster-related community damage and differences in pre-disaster community characteristics, e.g., the quality of housing stock. But distinct communities that are similar on the above characteristics may experience different recovery trajectories, and, if so, these different trajectories must be due to more subtle differences among them. Our principal objective is to assess short-term and long-term post-disaster mental health for Vietnamese and African Americans living in two adjacent communities in eastern New Orleans that were similarly flooded by Hurricane Katrina. We employ data from two population-based cohort studies that include a sample of African American adults (the Gulf Coast Child and Family Health [GCAFH study]) and a sample of Vietnamese American adults (Katrina Impacts on Vietnamese Americans [KATIVA NOLA study]) living in adjacent neighborhoods in eastern New Orleans who were assessed near the second and thirteenth anniversaries of the disaster. Using the 12-Item Short Form Survey (SF-12) as the basis of our outcome measure, we find in multivariate analysis a significant advantage in post-disaster mental health for Vietnamese Americans over their African American counterparts at the two-year mark, but that this advantage had disappeared by the thirteenth anniversary of the Katrina disaster.

BackgroundAll healthcare workers (HCWs) in Yongin Severance Hospital were allocated to receive the ChAdOx1 nCov-19 vaccine according to national policy. A report of thrombosis and thrombocytopenia syndrome (TTS) associated with ChAdOx1 nCoV-19 led to hesitancy about receiving the second dose among HCWs who had received the first dose.MethodsFrom 7 to 14 May, 2021, we performed a survey to identify the factors associated with hesitancy about receiving the second vaccine dose among HCWs at the hospital who had received the first dose of the vaccine. Based on survey results, a hospital-wide campaign was implemented on 18 May 2021 to improve vaccine coverage. HCWs who completed the second dose completed a self-administered questionnaire to evaluate the effect of the campaign.FindingsOf 1,171 HCWs who had received the first dose of the vaccine, 71.5% completed the online survey, of whom 3.7% refused to take the second dose and 22.3% showed hesitancy. Hesitancy to receive a second dose was significantly associated with age under 30 years and concerns about TTS, and was less common among those who trusted effectiveness and safety of the vaccine. Among HCWs who received the first dose, 96.2% completed vaccination with the second dose between 27 May and 4 June, 2021. Of those who answered the questionnaire asked about the timing of their decision to receive the second dose, 57.1% reported that they were motivated by the hospital-wide campaign.ConclusionA tailored intervention strategy based on a survey can improve COVID-19 vaccination uptake among HCWs.

During the past decade, cognitive diagnostic models (CDMs) have become prevalent in providing diagnostic information for learning. Cognitive diagnostic models have generally focused on single cross-sectional time points. However, longitudinal assessments have been commonly used in education to assess students’ learning progress as well as evaluating intervention effects. Thus, it becomes natural to identify longitudinal growth in skills profiles mastery, which can yield meaningful inferences on learning. This study proposes longitudinal CDMs that incorporate latent growth curve modeling and covariate extensions, with the aim to measure the growth of skills mastery and to evaluate attribute-level intervention effects over time. Using real-world data, this study demonstrates applications of unconditional and conditional latent growth CDMs. Simulation studies show stable parameter recovery and classification of latent classes for different sample sizes. These findings suggest that building on the well-established growth modeling frameworks, applications of covariate-based longitudinal CDM can help understand the effect of explanatory factors and intervention on the change of attribute mastery.

Background and study aims Patient safety during a colonoscopy highly depends on endoscopist competence. Endoscopic societies have been calling for an objective and regular assessment of the endoscopists, but existing assessment tools are time-consuming and prone to bias. We aimed to develop and gather evidence of validity for a computerized assessment tool delivering automatic and unbiased assessment of colonoscopy based on 3 dimensional coordinates from the colonoscope. Methods Twenty-four participants were recruited and divided into two groups based on experience: 12 experienced and 12 novices. Participants performed twice on a physical phantom model with a standardized alpha loop in the sigmoid colon. Data was gathered directly from the Olympus ScopeGuide system providing XYZ-coordinates along the length of the colonoscope. Five different motor skill measures were developed based on the data, named: Travel Length, Tip Progression, Chase Efficiency, Shaft movement without tip progression, and Looping. Results The experinced had a lower travel length (P

Background: Risk factors affecting early morality of patients with Escherichia coli bloodstream infection (BSI) were investigated including the host-pathogen-treatment tripartite components. Methods: Six general hospitals in South Korea participated in this multicentre prospective observational study from May 2016 to April 2017 and a total of 1492 laboratory-confirmed E. coli BSI cases were studied. Cox regression was used to estimate risks of the primary endpoint, i.e., all-cause mortality within 30 days from the initial blood culture. Six multivariate analysis models were constructed in accordance to the clinical importance and intra- and inter-component multicollinearity. Findings: Among the 1492 E. coli BSI cases, 9.5% (n = 141) patients expired within 30 days. Six models of multivariate analysis indicated risk factors of critical illness, primary infection of peritoneum, and chronic liver disease including cirrhosis for host variables; of phylogenetic group B2, ST131-sublineage H30Rx, multidrug resistance, group 1 CTX-M extended-spectrum beta-lactamase production, and having either of fyuA, afa, and sfa/foc virulence genes for causative E. coli pathogen variables; and of delayed definitive therapy for antimicrobial treatment variables. In addition, as a protective factor, primary urinary tract infection was identified. Interpretation: Despite decades' effort searching for the risk factors for E. coli BSI, systemic understanding covering the entire tripartite component is still lacking. This study detailed the organic impact of host-pathogen-treatment tripartite components for early mortality in patients with E. coli BSI. Keywords: Escherichia coli, Bloodstream infection, Early mortality, ST131, CTX-M ESBL, Delayed definitive treatment

Abstract Background Trainees in medical subspecialties lack validated assessment scores that can be used to prepare for their licensing examination. This paper presents the development, administration, and validity evidence of a constructed-response preparatory test (CRPT) administered to meet the needs of nephrology trainees. Methods Learning objectives from the licensing examination were used to develop a test blueprint for the preparatory test. Messick’s unified validity framework was used to gather validity evidence for content, response process, internal structure, relations to other variables, and consequences. Questionnaires were used to gather data on the trainees’ perception of examination preparedness, item clarity, and curriculum adequacy. Results There were 10 trainees and 5 faculty volunteers who took the test. The majority of trainees passed the constructed-response preparatory test. However, many scored poorly on items assessing renal pathology and physiology knowledge. We gathered the following five sources of validity evidence: (1) Content: CRPT mapped to the licensing examination blueprint, with items demonstrating clarity and range of difficulty; (2) Response process: moderate rater agreement (intraclass correlation = .58); (3) Internal structure: sufficient reliability based on generalizability theory (G-coefficient = .76 and Φ-coefficient = .53); (4) Relations to other variables: CRPT scores reflected years of exposure in nephrology and clinical practice; (5) Consequences: post-assessment survey revealed that none of the test takers felt “poorly prepared” for the upcoming summative examination and that their studying would increase in duration and be adapted in terms of content focus. Conclusions Preparatory tests using constructed response items mapped to licensure examination blueprint can be developed and used at local program settings to help prepare learners for subspecialty licensure examinations. The CRPT and questionnaire data identified shortcomings of the nephrology training program curriculum. Following the preparatory test, trainees expressed an improved sense of preparedness for their licensing examination.

Background: In the present study, the prevalence and risk factors for acquisition of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli in intensive care unit (ICU) settings without outbreak in the situation of widespread sequence type (ST) 131 ESBL-producing E. coli in a Korean community was investigated.Methods: Consecutive and prospective screening of ESBL-producing E. coli colonization was performed in all patients admitted to surgical or medical ICUs within 48 hours for two months. ESBL genotype was determined based on PCR and sequencing. PCR for O16-ST131/O25-ST131 was performed for all ESBL producers. Clinical information was obtained from a review of electronic medical record to determine the risk factors for ESBL-producing E. coli colonization.Results: The colonization rate of ESBL-producing E. coli at ICU admission was 14.9% (42/281). CTX-M-15 (N=15), CTX-M-14 (N=12), and CTX-M-27 (N=10) were commonly detected using PCR of ESBL genes. Approximately half (45.2%, 19/42) of ESBL producers were ST131 clone with 14 ST131-O25 and 5 ST131- O16. In univariate analysis, independent risk factor for acquisition of ESBL-producing E. coli compared with controls was ICU type (odds ratio, 2.05; P

Abstract Background Students evaluations of their learning experiences can provide a useful source of information about clerkship effectiveness in undergraduate medical education. However, low response rates in clerkship evaluation surveys remain an important limitation. This study examined the impact of increasing response rates using a compulsory approach on validity evidence. Methods Data included 192 responses obtained voluntarily from 49 third-year students in 2014–2015, and 171 responses obtained compulsorily from 49 students in the first six months of the consecutive year at one medical school in Lebanon. Evidence supporting internal structure and response process validity was compared between the two administration modalities. The authors also tested for potential bias introduced by the use of the compulsory approach by examining students’ responses to a sham item that was added to the last survey administration. Results Response rates increased from 56% in the voluntary group to 100% in the compulsory group (P

Objective: To provide validity evidence for a multifaceted organizational program for assessing physician performance and evaluate the practical and psychometric consequences of 2 approaches to scoring (mean vs top box scores). Participants and Methods: Participants included physicians with a predominantly outpatient practice in general internal medicine (n=95), neurology (n=99), and psychiatry (n=39) at Mayo Clinic from January 1, 2013, through December 31, 2014. Study measures included hire year, patient complaint and compliment rates, note-signing timeliness, cost per episode of care, and Likert-scaled surveys from patients, learners, and colleagues (scored using mean ratings and top box percentages). Results: Physicians had a mean ± SD of 0.32±1.78 complaints and 0.12±0.76 compliments per 100 outpatient visits. Most notes were signed on time (mean ± SD, 96%±6.6%). Mean ± SD cost was 0.56±0.59 SDs above the institutional average. Mean ± SD scores were 3.77±0.25 on 4-point and 4.06±0.31 to 4.94±0.08 on 5-point Likert-scaled surveys. Mean ± SD top box scores ranged from 18.6%±16.8% to 90.7%±10.5%. Learner survey scores were positively associated with patient survey scores (r=0.26; P=.003) and negatively associated with years in practice (r=−0.20; P=.02). Conclusion: This study provides validity evidence for 7 assessments commonly used by medical centers to measure physician performance and reports that top box scores amplify differences among high-performing physicians. These findings inform the most appropriate uses of physician performance data and provide practical guidance to organizations seeking to implement similar assessment programs or use existing performance data in more meaningful ways.

Abstract Background Breaking bad news (BBN) to patients and their relatives is a complex and stressful task. The ideal structure, training methods and assessment instruments best used to teach and assess BBN for anesthesiology residents remain unclear. The purpose of this study is to evaluate the effectiveness of an education intervention for BBN based on immersive experiences with a high fidelity simulator and role-play with standardized patients (SPs). A secondary purpose is to gather validity evidence to support the use of a GRIEV_ING instrument to assess BBN skills. Methods The communication skills for BBN of 16 residents were assessed via videotaped SP encounters at baseline and immediately post-intervention. Residents’ perceptions about their ability and comfort for BBN were collected using pre and post workshop surveys. Results Posttest scores were significantly higher than the pretest scores for the GRIEV_ING checklist, as well as on the communication global rating. The GRIEV_ING checklist had acceptable inter-rater and internal-consistency reliabilities. Performance was not related to years of training, or previous BBN experience. Conclusion Anesthesiology residents’ communication skills when BBN in relation to a critical incident may be improved with educational interventions based on immersive experiences with a high fidelity simulator and role-play with SPs.

This study was conducted to evaluate the possible clinical and bacteriologic features associated with 30-day mortality from Acinetobacter baumannii (A. baumannii) bloodstream infections (BSIs). We conducted a prospective, multicenter, observational study of 181 entire episodes of A. baumannii BSI from six general hospitals between May 2016 and April 2017 in South Korea. Cox proportional-hazards regression model was used to estimate risks of the primary endpoint, i.e., all-cause mortality within 30 days from the initial blood culture. Most (84.5%) of the A. baumannii blood isolates belonged to the international clonal lineage II (ICLII) and 89.5% of the isolates were either multidrug- or extensively-drug resistant. We identified three risk factors including the old age of patient {hazard ratio, 1.033; [95% Confidential Interval (CI), 1.010–1.056]}, the sequential organ failure assessment score [1.133 (1.041–1.233)], and causative A. baumannii sequence type (ST) 191 belonging to ICLII [1.918 (1.073–3.430)], and three protective factors including causative A. baumannii ST451 belonging to ICLII [0.228 (0.078–0.672)], platelet count [0.996 (0.993–0.999)], and definitive therapy within 72 h [0.255 (0.125–0.519)]. Differing 30-day mortality rate in the dominant ICLII was observed by ST, which was much high in ST191 and low in ST451 and it was likely associated with the molecular traits, rather than the drug resistance.

Background Health education can benefit people with chronic diseases. However, in previous research those benefits were small, and reinforcement to maintain them was not effective. A possible explanation is that the benefits appeared to be small and reinforcement appeared to be ineffective because those analyses mixed data from two latent groups: one group of people who needed reinforcement and one group of people who did not. The hypothesis is that mixing the data from those two different groups caused the true effects to be “diluted.” Methods To test that hypothesis we used data from the Chronic Disease Self-Management Program in Japan, focusing on anxiety, depression, and patient-physician communication. To identify latent trajectories of change after the program, we used growth-mixture modeling. Then, to find out which baseline factors were associated with trajectory-group membership, we used logistic regression. Results Growth-mixture modeling revealed two trajectories—two groups that were defined by distinct patterns of change after the program. One of those patterns was improvement followed by backsliding: decay of impact. On anxiety and depression the decay of impact was large enough to be clinically important, and its prevalence was as high as 50%. Next, logistic regression analysis revealed that being in the decay-of-impact group could be predicted from multimorbidity, low self-efficacy, and high scores on anxiety or depression at baseline. In addition, one unexpected finding was an association between multimorbidity and better patient-physician communication. Conclusions These results support the hypothesis that previous findings (i.e., apparently small effect sizes and apparently ineffective reinforcement) actually reflect “dilution” of large effects, which was caused by mixing of data from distinct groups. Specifically, there was one group with decay of impact and one without. Thus, evaluations of health education should include analyses of trajectory-defined groups. These results show how the group of people who are most likely to need reinforcement can be identified even before the educational program begins. Extra attention and reinforcement can then be tailored. They can be focused specifically to benefit the people with the greatest need.

A vancomycin-intermediate Staphylococcus aureus (VISA) outbreak occurred in an intensive care unit (ICU) in South Korea. We aimed to investigate the condition that led to the VISA outbreak and seek measures to prevent further spread of the multidrug-resistant organism. A total of three VISA isolates were obtained from two patients and a health care worker (HCW) in a newly built 450-bed secondary hospital. Extensive screening of close contacts for VISA in terms of space sharing and physical contact, irrespective of contact time, was performed. Furthermore, multilocus sequence type, staphylococcal cassette chromosome mec type, and spa type profiles were determined for all VISA isolates. The relationship between vancomycin use and the minimum inhibitory concentration (MIC) of S. aureus was also investigated. Molecular typing showed that the strains of the three VISA isolates were identical, indicating horizontal hospital transmission. We assumed that VISA colonised in the HCW could have transmitted to the two patients, which resulted in one infection and one colonisation. The affected HCW was excused from work and was decolonised with mupirocin. Five weeks after the interventions, no additional VISA isolates were identified. No relationship between vancomycin use and MIC of S. aureus was identified. Extensive screening of contacts in addition to decolonisation is crucial in preventing the further spread of VISA.

The purpose of this study is to identify the factors related to the infection and/or colonization of carbapenemase-producing Enterobacterales (CPE) based on clinical and microbiological data for patients in the intensive care unit (ICU). All patients admitted to medical ICU were screened for CPE on admission and weekly, and this 1:2 case–control study included patients with CPE identified by screening or clinical cultures from 2017 to 2018. The clonal relatedness was evaluated by pulsed-field gel electrophoresis (PFGE). A total of 45 CPE patients were identified with a prevalence of 3.8%. The most frequent organism was Klebsiella pneumoniae (69%) and the carbapenemases belonged to the class A Klebsiella pneumoniae Carbapenemase (KPC-2) (87%), class B New Delhi Metallo-β-lactamase (NDM) (11%), and Imipenemase (IMP-1) (2%) strains. The PFGE profiles showed two large clustered groups of KPC-2-producing K. pneumoniae. In the multivariate analysis, pneumonia/chronic pulmonary disease, previous fluoroquinolone use, and previous use of nasogastric tube were the significant risk factors for CPE infection or colonization in ICU-admitted patients. Critical illness and underlying medical conditions such as pneumonia/chronic pulmonary disease, antimicrobial selective pressure, and the use of a medical device are identified as risk factors for CPE infection or colonization in ICU. Person to person transmission also contributed.