Appraisal of the IADT fellowship - A member survey

BACKGROUND/AIM

The International Association of Dental Traumatology (IADT) is considered the foremost authority in Dental Traumatology. Fellowship status was introduced in 2015 and is considered an international standard of excellence. The Fellowship Committee of the IADT believed it was essential to survey members seeking information on the benefits of the IADT Fellowship and potential considerations for future development. This survey aimed to explore the perceptions of members of IADT surrounding the fellowship process in terms of interest, accessibility, equality, perceived prestige, and value to the membership.

MATERIAL AND METHODS

The survey was sent to 546 IADT members, of whom 89 were fellows (as of 31 July 2022) from 74 countries via an email invitation. Answers were analysed using the Chi2 and Fisher's exact test (p < .05).

RESULTS

The response rate to the survey was 20.69% (n = 113), including 28 fellows (24.78%). Forty-six respondents (40.71%) were female, and 67 (59.30%) were male. Dentists identified as specialists were significantly more likely to be involved in teaching dental trauma (p = .000008). A majority of respondents (87.76%; 86/98) expressed interest in obtaining fellowship, with increased interest from more recent graduates. Learning opportunities, obtaining expertise, networking and a sense of community and prestige, were key factors in considering fellowship. There was interest in alternate pathways other than examination alone, with 60.2% of 98 respondents suggesting a combination of publications /service to IADT/ reviewer for Dental Traumatology, 57.14% suggesting the submission of case reports, and 42.86% suggesting Honorary Fellowship. Respondents (73%) were willing to participate in online discussion forums and other professional development opportunities. This preference was more notable among non-fellows (75.29%) than fellows (67.85%).

CONCLUSIONS

The survey indicates the diverse motivations and perceptions regarding the IADT Fellowship, despite the low participation of IADT members. Achieving fellowship status is desired by 87.7% of non-fellows. The majority of respondents were aware of the process, but main concerns were identified as eligibility criteria and examination difficulty. Options for alternate pathways and other initiatives promoting engagement were identified. Further exploration of these issues is required to be representative of the entire IADT membership. Addressing these obstacles could significantly enhance fellowship participation and overall member satisfaction within the IADT community.

Authors' Reply: "Evaluating GPT-4's Cognitive Functions Through the Bloom Taxonomy: Insights and Clarifications"

Collapse

Performance of GPT-4V in Answering the Japanese Otolaryngology Board Certification Examination Questions: Evaluation Study

BACKGROUND

Artificial intelligence models can learn from medical literature and clinical cases and generate answers that rival human experts. However, challenges remain in the analysis of complex data containing images and diagrams.

OBJECTIVE

This study aims to assess the answering capabilities and accuracy of ChatGPT-4 Vision (GPT-4V) for a set of 100 questions, including image-based questions, from the 2023 otolaryngology board certification examination.

METHODS

Answers to 100 questions from the 2023 otolaryngology board certification examination, including image-based questions, were generated using GPT-4V. The accuracy rate was evaluated using different prompts, and the presence of images, clinical area of the questions, and variations in the answer content were examined.

RESULTS

The accuracy rate for text-only input was, on average, 24.7% but improved to 47.3% with the addition of English translation and prompts (P<.001). The average nonresponse rate for text-only input was 46.3%; this decreased to 2.7% with the addition of English translation and prompts (P<.001). The accuracy rate was lower for image-based questions than for text-only questions across all types of input, with a relatively high nonresponse rate. General questions and questions from the fields of head and neck allergies and nasal allergies had relatively high accuracy rates, which increased with the addition of translation and prompts. In terms of content, questions related to anatomy had the highest accuracy rate. For all content types, the addition of translation and prompts increased the accuracy rate. As for the performance based on image-based questions, the average of correct answer rate with text-only input was 30.4%, and that with text-plus-image input was 41.3% (P=.02).

CONCLUSIONS

Examination of artificial intelligence's answering capabilities for the otolaryngology board certification examination improves our understanding of its potential and limitations in this field. Although the improvement was noted with the addition of translation and prompts, the accuracy rate for image-based questions was lower than that for text-based questions, suggesting room for improvement in GPT-4V at this stage. Furthermore, text-plus-image input answers a higher rate in image-based questions. Our findings imply the usefulness and potential of GPT-4V in medicine; however, future consideration of safe use methods is needed.

Comprehensive literature review of oral and intravenous contrast-enhanced PET/CT: a step forward?

The integration of diagnostic CT scans into PET/CT facilitates a comprehensive single examination, presenting potential advantages for patients seeking a thorough one-shot check-up. The introduction of iodinated contrast media during PET scanning raises theoretical concerns about potential interference with uptake quantification, due to the modification of tissue density on CT. Nevertheless, this impact appears generally insignificant for clinical use, compared to the intrinsic variability of standardized uptake values. On the other hand, with the growing indications of PET, especially 18F-FDG PET, contrast enhancement increases the diagnostic performances of the exam, and provides additional information. This improvement in performance achieved through contrast-enhanced PET/CT must be carefully evaluated considering the associated risks and side-effects stemming from the administration of iodinated contrast media. Within this article, we present a comprehensive literature review of contrast enhanced PET/CT, examining the potential impact of iodinated contrast media on quantification, additional side-effects and the pivotal clinically demonstrated benefits of an all-encompassing examination for patients. In conclusion, the clinical benefits of iodinated contrast media are mainly validated by the large diffusion in PET protocols. Contrary to positive oral contrast, which does not appear to offer any major advantage in patient management, intravenous iodine contrast media provides clinical benefits without significant artifact on images or quantification. However, studies on the benefit-risk balance for patients are still lacking.

Capability of GPT-4V(ision) in the Japanese National Medical Licensing Examination: Evaluation Study

BACKGROUND

Previous research applying large language models (LLMs) to medicine was focused on text-based information. Recently, multimodal variants of LLMs acquired the capability of recognizing images.

OBJECTIVE

We aim to evaluate the image recognition capability of generative pretrained transformer (GPT)-4V, a recent multimodal LLM developed by OpenAI, in the medical field by testing how visual information affects its performance to answer questions in the 117th Japanese National Medical Licensing Examination.

METHODS

We focused on 108 questions that had 1 or more images as part of a question and presented GPT-4V with the same questions under two conditions: (1) with both the question text and associated images and (2) with the question text only. We then compared the difference in accuracy between the 2 conditions using the exact McNemar test.

RESULTS

Among the 108 questions with images, GPT-4V's accuracy was 68% (73/108) when presented with images and 72% (78/108) when presented without images (P=.36). For the 2 question categories, clinical and general, the accuracies with and those without images were 71% (70/98) versus 78% (76/98; P=.21) and 30% (3/10) versus 20% (2/10; P≥.99), respectively.

CONCLUSIONS

The additional information from the images did not significantly improve the performance of GPT-4V in the Japanese National Medical Licensing Examination.

Development of a Clinical Simulation Video to Evaluate Multiple Domains of Clinical Competence: Cross-Sectional Study

BACKGROUND

Medical students in Japan undergo a 2-year postgraduate residency program to acquire clinical knowledge and general medical skills. The General Medicine In-Training Examination (GM-ITE) assesses postgraduate residents' clinical knowledge. A clinical simulation video (CSV) may assess learners' interpersonal abilities.

OBJECTIVE

This study aimed to evaluate the relationship between GM-ITE scores and resident physicians' diagnostic skills by having them watch a CSV and to explore resident physicians' perceptions of the CSV's realism, educational value, and impact on their motivation to learn.

METHODS

The participants included 56 postgraduate medical residents who took the GM-ITE between January 21 and January 28, 2021; watched the CSV; and then provided a diagnosis. The CSV and GM-ITE scores were compared, and the validity of the simulations was examined using discrimination indices, wherein ≥0.20 indicated high discriminatory power and >0.40 indicated a very good measure of the subject's qualifications. Additionally, we administered an anonymous questionnaire to ascertain participants' views on the realism and educational value of the CSV and its impact on their motivation to learn.

RESULTS

Of the 56 participants, 6 (11%) provided the correct diagnosis, and all were from the second postgraduate year. All domains indicated high discriminatory power. The (anonymous) follow-up responses indicated that the CSV format was more suitable than the conventional GM-ITE for assessing clinical competence. The anonymous survey revealed that 12 (52%) participants found the CSV format more suitable than the GM-ITE for assessing clinical competence, 18 (78%) affirmed the realism of the video simulation, and 17 (74%) indicated that the experience increased their motivation to learn.

CONCLUSIONS

The findings indicated that CSV modules simulating real-world clinical examinations were successful in assessing examinees' clinical competence across multiple domains. The study demonstrated that the CSV not only augmented the assessment of diagnostic skills but also positively impacted learners' motivation, suggesting a multifaceted role for simulation in medical education.

Ankle Telemedicine Planning Considerations

A virtual medical visit, also known as telemedicine or telehealth, is a valuable alternative method of providing health care to patients who do not have easy access to a hospital, or during times when limited social interaction is crucial such as our current COVID-19 pandemic. A virtual approach to evaluating musculoskeletal system ailments is particularly challenging, for diagnosis of these conditions generally rely greatly on physical examination, which may be challenging. However, a properly planned and executed telemedicine visit will yield successful results in most cases. Our aim is to produce a document with instructions and suggestions, including physical examination maneuvers, to help physicians carry out a proper virtual medical visit with patients complaining of ankle musculoskeletal problems. Virtual visits should not be thought of as a replacement for traditional face-to-face medical consultations, but rather a complementary method to provide health care when deemed appropriate. By following this guide, and tailoring it to the specific case at hand, medical providers should be able to effectively carry out a successful telemedicine consultation for musculoskeletal ailments relating to the ankle.Levels of Evidence: Level V.

The shoulder joint complex in the throwing motion

The shoulder joint complex in the overhead athlete is organized to effectively transfer the proximally generated forces distally into the arm. The organization also protects the joints and anatomic structures against the repetitive high velocities, large ranges of motions, and compressive, shear, translational, and distraction loads in the overhead motion while placing the hand in the "launch window." Coupling of the movements of the scapula, clavicle, and humerus results in scapulohumeral rhythm (SHR). Effective SHR requires the clavicle and scapula-and, at times, the mechanically linked claviscapular segment-to move the arm into the task-specific position and motion and requires the humerus to move through the ranges of motion to achieve the specific task in the throwing motion. Alterations in SHR can negatively affect effective shoulder joint complex function in the overhead throwing motion and increase injury risk. There are 4 phases of clavicular, scapular, and claviscapular motion that are coupled with arm motion in SHR. The first 3 phases occur in arm elevation motions from 0°-90° and result in the claviscapula and humerus being placed in task-specific positions. The fourth phase is coupling of claviscapular motion with humeral motion to maintain ball-and-socket kinematics throughout the throwing motion. Alterations in this composite motion are termed "scapular dyskinesis." The dyskinesis is considered an impairment of the efficient mobility of the claviscapular segment of the shoulder complex. The most prevalent problem with scapular dyskinesis is the association of scapular protraction and consequent glenoid antetilt with alterations in humeral rotation and posterior humeral head translation to produce shoulder joint internal impingement. Task effectiveness in overhead throwing is also based on and determined by humeral range of motion, precision of humeral motion, and velocity of humeral motion, as well as humeral and arm position in 3-dimensional space. This activity requires maximum ball-and-socket kinematics to create the highest amount of concavity-compression that creates stability for the joint. There are bony and soft-tissue contributions to this stability. Injuries to the glenoid labrum are among the most common deficits that alter concavity-compression. Clinical evaluation of the shoulder joint complex in the injured throwing athlete should be comprehensive and systematic, following an evaluation pathway for proximal and distal causative factors and including observation of humeral motion. This type of evaluation can result in intervention protocols that address the pathoanatomic, pathophysiological, and pathomechanical deficits identified.

The effect of patient positioning on the accuracy and reliability of assessment of knee range of motion over a telemedicine platform

INTRODUCTION

Diagnostic accuracy is one of the key considerations of telemedicine usage in orthopedic surgery. The aim of this study was to determine the optimal patient positioning to achieve accurate and reliable visual estimation of the knee joint range of motion over a digital platform for telemedicine.

METHODS

A single volunteer was recruited to perform a total of 120 discrete and random knee range of motion angles in three patient positions: sitting, standing and supine. The patient image was broadcast over a digital platform to six raters. The raters recorded their visual estimation of each discrete knee flexion angle independently. After each discrete knee flexion angle, a physical goniometer was used to obtain the actual flexion angle of the knee.

RESULTS

A total of 120 discrete measurements (40 measurements in the sitting, standing, and supine positions each) were recorded by each of the six raters. The supine position resulted in the highest intraclass correlation of 0.97 (95% confidence interval: 0.98, 0.99). All three patient positions achieved low absolute difference between the goniometer and the raters with 5.6 degrees (95% limits of agreement: -21.0, 9.8) in sitting, 2.7 degrees (95% limits of agreement: -10.1, 15.4), and 1.2 degrees (95% limits of agreement: -9.8, 12.3) in the supine position. The supine position had the highest accuracy and reliability.

DISCUSSION

Visual estimation of the knee joint range of motion over telemedicine is clinically accurate and reliable. Patients should be assessed in a supine position to obtain the highest accuracy and reliability for visual estimation of the knee joint range of motion during telemedicine.

An Exploration of the Certified Health Informatician Australasia (CHIA) Participants

The Certified Health Informatician Australasian (CHIA) is an assessment of a candidate's capabilities measured using a core set of health informatics competencies. The aim of this paper is to describe the outcomes of the first eight years since the program's launch. This paper contributes to the competency framework and certification discourse, and knowledge of the increasing importance and recognition of health informaticians through certification. An analysis of results and possible contributing factors is discussed.

Assessing ChatGPT's Mastery of Bloom's Taxonomy Using Psychosomatic Medicine Exam Questions: Mixed-Methods Study

BACKGROUND

Large language models such as GPT-4 (Generative Pre-trained Transformer 4) are being increasingly used in medicine and medical education. However, these models are prone to "hallucinations" (ie, outputs that seem convincing while being factually incorrect). It is currently unknown how these errors by large language models relate to the different cognitive levels defined in Bloom's taxonomy.

OBJECTIVE

This study aims to explore how GPT-4 performs in terms of Bloom's taxonomy using psychosomatic medicine exam questions.

METHODS

We used a large data set of psychosomatic medicine multiple-choice questions (N=307) with real-world results derived from medical school exams. GPT-4 answered the multiple-choice questions using 2 distinct prompt versions: detailed and short. The answers were analyzed using a quantitative approach and a qualitative approach. Focusing on incorrectly answered questions, we categorized reasoning errors according to the hierarchical framework of Bloom's taxonomy.

RESULTS

GPT-4's performance in answering exam questions yielded a high success rate: 93% (284/307) for the detailed prompt and 91% (278/307) for the short prompt. Questions answered correctly by GPT-4 had a statistically significant higher difficulty than questions answered incorrectly (P=.002 for the detailed prompt and P<.001 for the short prompt). Independent of the prompt, GPT-4's lowest exam performance was 78.9% (15/19), thereby always surpassing the "pass" threshold. Our qualitative analysis of incorrect answers, based on Bloom's taxonomy, showed that errors were primarily in the "remember" (29/68) and "understand" (23/68) cognitive levels; specific issues arose in recalling details, understanding conceptual relationships, and adhering to standardized guidelines.

CONCLUSIONS

GPT-4 demonstrated a remarkable success rate when confronted with psychosomatic medicine multiple-choice exam questions, aligning with previous findings. When evaluated through Bloom's taxonomy, our data revealed that GPT-4 occasionally ignored specific facts (remember), provided illogical reasoning (understand), or failed to apply concepts to a new situation (apply). These errors, which were confidently presented, could be attributed to inherent model biases and the tendency to generate outputs that maximize likelihood.

A Novel Evaluation Model for Assessing ChatGPT on Otolaryngology-Head and Neck Surgery Certification Examinations: Performance Study

BACKGROUND

ChatGPT is among the most popular large language models (LLMs), exhibiting proficiency in various standardized tests, including multiple-choice medical board examinations. However, its performance on otolaryngology-head and neck surgery (OHNS) certification examinations and open-ended medical board certification examinations has not been reported.

OBJECTIVE

We aimed to evaluate the performance of ChatGPT on OHNS board examinations and propose a novel method to assess an AI model's performance on open-ended medical board examination questions.

METHODS

Twenty-one open-ended questions were adopted from the Royal College of Physicians and Surgeons of Canada's sample examination to query ChatGPT on April 11, 2023, with and without prompts. A new model, named Concordance, Validity, Safety, Competency (CVSC), was developed to evaluate its performance.

RESULTS

In an open-ended question assessment, ChatGPT achieved a passing mark (an average of 75% across 3 trials) in the attempts and demonstrated higher accuracy with prompts. The model demonstrated high concordance (92.06%) and satisfactory validity. While demonstrating considerable consistency in regenerating answers, it often provided only partially correct responses. Notably, concerning features such as hallucinations and self-conflicting answers were observed.

CONCLUSIONS

ChatGPT achieved a passing score in the sample examination and demonstrated the potential to pass the OHNS certification examination of the Royal College of Physicians and Surgeons of Canada. Some concerns remain due to its hallucinations, which could pose risks to patient safety. Further adjustments are necessary to yield safer and more accurate answers for clinical implementation.

Performance Comparison of ChatGPT-4 and Japanese Medical Residents in the General Medicine In-Training Examination: Comparison Study

BACKGROUND

The reliability of GPT-4, a state-of-the-art expansive language model specializing in clinical reasoning and medical knowledge, remains largely unverified across non-English languages.

OBJECTIVE

This study aims to compare fundamental clinical competencies between Japanese residents and GPT-4 by using the General Medicine In-Training Examination (GM-ITE).

METHODS

We used the GPT-4 model provided by OpenAI and the GM-ITE examination questions for the years 2020, 2021, and 2022 to conduct a comparative analysis. This analysis focused on evaluating the performance of individuals who were concluding their second year of residency in comparison to that of GPT-4. Given the current abilities of GPT-4, our study included only single-choice exam questions, excluding those involving audio, video, or image data. The assessment included 4 categories: general theory (professionalism and medical interviewing), symptomatology and clinical reasoning, physical examinations and clinical procedures, and specific diseases. Additionally, we categorized the questions into 7 specialty fields and 3 levels of difficulty, which were determined based on residents' correct response rates.

RESULTS

Upon examination of 137 GM-ITE questions in Japanese, GPT-4 scores were significantly higher than the mean scores of residents (residents: 55.8%, GPT-4: 70.1%; P<.001). In terms of specific disciplines, GPT-4 scored 23.5 points higher in the "specific diseases," 30.9 points higher in "obstetrics and gynecology," and 26.1 points higher in "internal medicine." In contrast, GPT-4 scores in "medical interviewing and professionalism," "general practice," and "psychiatry" were lower than those of the residents, although this discrepancy was not statistically significant. Upon analyzing scores based on question difficulty, GPT-4 scores were 17.2 points lower for easy problems (P=.007) but were 25.4 and 24.4 points higher for normal and difficult problems, respectively (P<.001). In year-on-year comparisons, GPT-4 scores were 21.7 and 21.5 points higher in the 2020 (P=.01) and 2022 (P=.003) examinations, respectively, but only 3.5 points higher in the 2021 examinations (no significant difference).

CONCLUSIONS

In the Japanese language, GPT-4 also outperformed the average medical residents in the GM-ITE test, originally designed for them. Specifically, GPT-4 demonstrated a tendency to score higher on difficult questions with low resident correct response rates and those demanding a more comprehensive understanding of diseases. However, GPT-4 scored comparatively lower on questions that residents could readily answer, such as those testing attitudes toward patients and professionalism, as well as those necessitating an understanding of context and communication. These findings highlight the strengths and limitations of artificial intelligence applications in medical education and practice.

Advanced biological ageing predicts future risk for neurological diagnoses and clinical examination findings

Age is a dominant risk factor for some of the most common neurological diseases. Biological ageing encompasses interindividual variation in the rate of ageing and can be calculated from clinical biomarkers or DNA methylation data amongst other approaches. Here, we tested the hypothesis that a biological age greater than one's chronological age affects the risk of future neurological diagnosis and the development of abnormal signs on clinical examination. We analysed data from the Swedish Adoption/Twin Study of Aging (SATSA): a cohort with 3175 assessments of 802 individuals followed-up over several decades. Six measures of biological ageing were generated: two physiological ages (created from bedside clinical measurements and standard blood tests) and four blood methylation age measures. Their effects on future stroke, dementia or Parkinson's disease diagnosis, or development of abnormal clinical signs, were determined using survival analysis, with and without stratification by twin pairs. Older physiological ages were associated with ischaemic stroke risk; for example one standard deviation advancement in baseline PhenoAgePhys or KDMAgePhys residual increased future ischaemic stroke risk by 29.2% [hazard ratio (HR): 1.29, 95% confidence interval (CI) 1.06-1.58, P = 0.012] and 42.9% (HR 1.43, CI 1.18-1.73, P = 3.1 × 10-4), respectively. In contrast, older methylation ages were more predictive of future dementia risk, which was increased by 29.7% (HR 1.30, CI 1.07-1.57, P = 0.007) per standard deviation advancement in HorvathAgeMeth. Older physiological ages were also positively associated with future development of abnormal patellar or pupillary reflexes, and the loss of normal gait. Measures of biological ageing can predict clinically relevant pathology of the nervous system independent of chronological age. This may help to explain variability in disease risk between individuals of the same age and strengthens the case for trials of geroprotective interventions for people with neurological disorders.

[The scientific conceptions of disability in the Soviet state in the 1930s]

The article analyzes development of scientific conceptions of disability in works of Soviet researchers during the period of forced construction of socialism. The materials of the dissertation abstract of employee of the North Caucasian Scientific and Research Institute of Labor Organization and Protection (1933), as well as publications of staff of the Leningrad Scientific and Research Institute of Medical and Labor Expertise and Professional Consultation (1935-1940) were explored. The positions of various authors concerning priority of medical examination in the process of disability expertise are considered. The article reveals ideas of "active employment" of the disabled, the organization of conditions for full-value functioning of the disabled capable of working in society, various employment opportunities for the disabled, including appeal to creative activity, causes of ineffective involvement of particular categories and groups of the disabled with various diseases into social and labor life. The conclusion is presented that ideas of scientists were not largely in demand in the 1930s, but became the basis of policy of employment of the disabled during the Great Patriotic War, significantly passing ahead of their time.

The use of post-exam feedback in oral radiology: A survey study of dental and dental hygienist schools in Europe

INTRODUCTION

A combination of summative assessments and post-exam feedback can create a formative environment to support student learning. It remains unknown to what extent feedback sessions are conducted after exams in oral radiology courses for dental and dental hygienist students in Europe. This survey study aimed to explore whether post-exam feedback sessions were conducted, and if so, in what format.

MATERIALS AND METHODS

A questionnaire was distributed to 76 dental schools in 26 countries and 34 dental hygienist schools in 14 countries in Europe. The questions addressed whether feedback was provided after exams in oral radiology, the feedback format, and whether feedback sessions were formalised or performed for other reasons.

RESULTS

Questionnaire responses were received from 33 dental schools in 18 countries, and 20 dental hygienist schools in 11 countries. Information about grades was provided in 23-30% of the schools. Post-exam feedback sessions including opportunities for discussion was provided at 39% of the schools, all with guidelines stating that these sessions should be carried out. The remaining schools provided feedback either on request by individual students or as written examples of correct answers.

CONCLUSION

Almost one third of the dental schools announced grades without providing any post-exam feedback that could support learning. Two fifth utilised feedback sessions to assist students in gaining knowledge and sorting out misconceptions, all according to guidelines. Given the possible learning potential in post-exam feedback with opportunity to discuss, further studies of this format would be valuable, including the role and use of feedback guidelines.

The importance of gynecological examination in adolescent girls and adult women with Prader-Willi syndrome

Current published guidelines for routine care of women with Prader-Willi syndrome (PWS) do not include recommendations for gynecologic examinations. We describe our experience with gynecological examinations in women with PWS and offer recommendations for routine health care for these patients. Data were collected on all 41 PWS females ages ≥12 year, followed in our national Israeli multidisciplinary clinic between the years 2011 and 2022. Menstrual data and findings on external gynecological examination, including evaluation of the vulva and hymen were recorded at yearly visits. During the gynecological evaluation the topic of sexual education was discussed. Pelvic ultrasound, specifically for antral follicular count, was performed for those visiting the clinic during 2020-2022. Blood samples for luteinizing hormone (LH), follicular stimulating hormone (FSH), and estradiol were obtained routinely and DEXA scans for bone density were done when indicated. Of the 41 women, (median age at start of follow-up 17 years, range [12.3-39], BMI 30.4 kg/m2 [IQR 23.5-37.1]), 39 women agreed to external gynecological examination. Eleven women (27%) had spontaneous menses, with menarche at the age of 14 to as late as 31 years. The hymen was intact in all except one. Poor hygiene was observed in eight women, three women with vulvovaginitis, and five with irritated vulva related to poor hygiene. Gynecological ultrasound was performed in 27 women. In 22, endometrial thickness was less than 5 mm. The median antral follicular count (AFC) was 6 (<10th percentile for age). No correlation between AFC and menstruation or BMI was found. Mean FSH level was 5.7 ± 3.6 IU, LH was 2.29 ± 2.23, and estradiol was 128 ± 76 pmol/L. Data on DEXA measurements were available in 25 women aged 16-39. Median spine T score was -1.3 (range between 0.5 and -3.7), and hip T score was -1.2 (range between 0.8 and -3.3). A negative correlation was found between endometrial thickness and the presence of osteopenia or osteoporosis (r = -0.5, p = 0.013). Despite our recommendations, only eight of 14 women agreed to hormonal treatment or contraception. One woman who received treatment had a thromboembolic event. Routine health care for women with PWS should include gynecological examinations. The gynecological evaluation should include external genital examination, assessment of hygiene, obtaining a blood sample for hormone levels, and documenting a history of sexual experience or sexual abuse. Hormonal treatment or contraception should be offered when appropriate.

Artificial intelligence in orthopaedics: can Chat Generative Pre-trained Transformer (ChatGPT) pass Section 1 of the Fellowship of the Royal College of Surgeons (Trauma & Orthopaedics) examination?

PURPOSE

Chat Generative Pre-trained Transformer (ChatGPT) is a large language artificial intelligence (AI) model which generates contextually relevant text in response to questioning. After ChatGPT successfully passed the United States Medical Licensing Examinations, proponents have argued it should play an increasing role in medical service provision and education. AI in healthcare remains in its infancy, and the reliability of AI systems must be scrutinized. This study assessed whether ChatGPT could pass Section 1 of the Fellowship of the Royal College of Surgeons (FRCS) examination in Trauma and Orthopaedic Surgery.

METHODS

The UK and Ireland In-Training Examination (UKITE) was used as a surrogate for the FRCS. Papers 1 and 2 of UKITE 2022 were directly inputted into ChatGPT. All questions were in a single-best-answer format without wording alterations. Imaging was trialled to ensure ChatGPT utilized this information.

RESULTS

ChatGPT scored 35.8%: 30% lower than the FRCS pass rate and 8.2% lower than the mean score achieved by human candidates of all training levels. Subspecialty analysis demonstrated ChatGPT scored highest in basic science (53.3%) and lowest in trauma (0%). In 87 questions answered incorrectly, ChatGPT only stated it did not know the answer once and gave incorrect explanatory answers for the remaining questions.

CONCLUSION

ChatGPT is currently unable to exert the higher-order judgement and multilogical thinking required to pass the FRCS examination. Further, the current model fails to recognize its own limitations. ChatGPT's deficiencies should be publicized equally as much as its successes to ensure clinicians remain aware of its fallibility.

KEY MESSAGES

Evaluating the performance of ChatGPT-4 on the United Kingdom Medical Licensing Assessment

Introduction

Recent developments in artificial intelligence large language models (LLMs), such as ChatGPT, have allowed for the understanding and generation of human-like text. Studies have found LLMs abilities to perform well in various examinations including law, business and medicine. This study aims to evaluate the performance of ChatGPT in the United Kingdom Medical Licensing Assessment (UKMLA).

Methods

Two publicly available UKMLA papers consisting of 200 single-best-answer (SBA) questions were screened. Nine SBAs were omitted as they contained images that were not suitable for input. Each question was assigned a specialty based on the UKMLA content map published by the General Medical Council. A total of 191 SBAs were inputted in ChatGPT-4 through three attempts over the course of 3 weeks (once per week).

Results

ChatGPT scored 74.9% (143/191), 78.0% (149/191) and 75.6% (145/191) on three attempts, respectively. The average of all three attempts was 76.3% (437/573) with a 95% confidence interval of (74.46% and 78.08%). ChatGPT answered 129 SBAs correctly and 32 SBAs incorrectly on all three attempts. On three attempts, ChatGPT performed well in mental health (8/9 SBAs), cancer (11/14 SBAs) and cardiovascular (10/13 SBAs). On three attempts, ChatGPT did not perform well in clinical haematology (3/7 SBAs), endocrine and metabolic (2/5 SBAs) and gastrointestinal including liver (3/10 SBAs). Regarding to response consistency, ChatGPT provided correct answers consistently in 67.5% (129/191) of SBAs but provided incorrect answers consistently in 12.6% (24/191) and inconsistent response in 19.9% (38/191) of SBAs, respectively.

Discussion and conclusion

This study suggests ChatGPT performs well in the UKMLA. There may be a potential correlation between specialty performance. LLMs ability to correctly answer SBAs suggests that it could be utilised as a supplementary learning tool in medical education with appropriate medical educator supervision.

Performance of ChatGPT on the Situational Judgement Test-A Professional Dilemmas-Based Examination for Doctors in the United Kingdom

BACKGROUND

ChatGPT is a large language model that has performed well on professional examinations in the fields of medicine, law, and business. However, it is unclear how ChatGPT would perform on an examination assessing professionalism and situational judgement for doctors.

OBJECTIVE

We evaluated the performance of ChatGPT on the Situational Judgement Test (SJT): a national examination taken by all final-year medical students in the United Kingdom. This examination is designed to assess attributes such as communication, teamwork, patient safety, prioritization skills, professionalism, and ethics.

METHODS

All questions from the UK Foundation Programme Office's (UKFPO's) 2023 SJT practice examination were inputted into ChatGPT. For each question, ChatGPT's answers and rationales were recorded and assessed on the basis of the official UK Foundation Programme Office scoring template. Questions were categorized into domains of Good Medical Practice on the basis of the domains referenced in the rationales provided in the scoring sheet. Questions without clear domain links were screened by reviewers and assigned one or multiple domains. ChatGPT's overall performance, as well as its performance across the domains of Good Medical Practice, was evaluated.

RESULTS

Overall, ChatGPT performed well, scoring 76% on the SJT but scoring full marks on only a few questions (9%), which may reflect possible flaws in ChatGPT's situational judgement or inconsistencies in the reasoning across questions (or both) in the examination itself. ChatGPT demonstrated consistent performance across the 4 outlined domains in Good Medical Practice for doctors.

CONCLUSIONS

Further research is needed to understand the potential applications of large language models, such as ChatGPT, in medical education for standardizing questions and providing consistent rationales for examinations assessing professionalism and ethics.

Retinal neurodegeneration in age-related macular degeneration

Age-related macular degeneration (AMD) is a complex and multifactorial disease characterized by the damage of the unit comprised of the photoreceptors, retinal pigment epithelium (RPE), Bruch's membrane, and choriocapillaris. Although the outer retina appears to be mainly affected in this disorder, several evidences exhibit that also the inner retina may be impaired. In this review we will provide a description of the prominent histologic and imaging findings suggesting an inner retinal loss in these eyes. In details, structural optical coherence tomography (OCT) technology proved either the inner and outer retina is impacted by AMD and that these two impairments are associated. Therefore, the purpose of this review is to provide a description of the role of neurodegeneration in AMD in order to better understand the relationship between neuronal loss and the outer retinal damage in this disease.

[The evolution of criteria of selection of citizen with mental disorders to Military Force]

The article presents the analysis of changes in official requirements to health of youths with mental disorders (the Regulation on military medical examination in version of 1995, 2003, 2013). The sections I and II of articles 14-20 of the Schedule of Diseases of this Regulation are considered from the point of view of the category of fitness for military service on conscription. The set of measures of leveling consequences of mitigation of requirements to health of future servicemen for particular nosologies is proposed.

Fellow of the European board of ophthalmology glaucoma examination and diploma (FEBOS-Gl): update on 8 years of experience and future perspectives

Glaucoma is the leading cause of irreversible blindness worldwide. Early diagnosis and appropriate management of the disease are essential to avoid a significant impact on the quality of life of millions of patients and the socioeconomic impact on societies. Education is the hallmark of good medical care. The European Glaucoma Society (EGS) has dedicated significant efforts to provide means of improving education, training, and testing knowledge in the field of glaucoma. The Fellow of the European Board of Ophthalmology Subspecialty (FEBOS)-Glaucoma examination, introduced and organized yearly by the EGS since 2015 in collaboration with the European Board of Ophthalmology (EBO), has become a valuable tool for increasing overall knowledge in the field. Over the 8 years of experience, several updates and new projects have emerged around the examination to further increase the overall quality of education, training, and knowledge in the field of glaucoma in Europe, particularly in UEMS and associated countries. This article discusses in detail the various projects and measures introduced by the EGS.

Scoring Single-Response Multiple-Choice Items: Scoping Review and Comparison of Different Scoring Methods

BACKGROUND

Single-choice items (eg, best-answer items, alternate-choice items, single true-false items) are 1 type of multiple-choice items and have been used in examinations for over 100 years. At the end of every examination, the examinees' responses have to be analyzed and scored to derive information about examinees' true knowledge.

OBJECTIVE

The aim of this paper is to compile scoring methods for individual single-choice items described in the literature. Furthermore, the metric expected chance score and the relation between examinees' true knowledge and expected scoring results (averaged percentage score) are analyzed. Besides, implications for potential pass marks to be used in examinations to test examinees for a predefined level of true knowledge are derived.

METHODS

Scoring methods for individual single-choice items were extracted from various databases (ERIC, PsycInfo, Embase via Ovid, MEDLINE via PubMed) in September 2020. Eligible sources reported on scoring methods for individual single-choice items in written examinations including but not limited to medical education. Separately for items with n=2 answer options (eg, alternate-choice items, single true-false items) and best-answer items with n=5 answer options (eg, Type A items) and for each identified scoring method, the metric expected chance score and the expected scoring results as a function of examinees' true knowledge using fictitious examinations with 100 single-choice items were calculated.

RESULTS

A total of 21 different scoring methods were identified from the 258 included sources, with varying consideration of correctly marked, omitted, and incorrectly marked items. Resulting credit varied between -3 and +1 credit points per item. For items with n=2 answer options, expected chance scores from random guessing ranged between -1 and +0.75 credit points. For items with n=5 answer options, expected chance scores ranged between -2.2 and +0.84 credit points. All scoring methods showed a linear relation between examinees' true knowledge and the expected scoring results. Depending on the scoring method used, examination results differed considerably: Expected scoring results from examinees with 50% true knowledge ranged between 0.0% (95% CI 0% to 0%) and 87.5% (95% CI 81.0% to 94.0%) for items with n=2 and between -60.0% (95% CI -60% to -60%) and 92.0% (95% CI 86.7% to 97.3%) for items with n=5.

CONCLUSIONS

In examinations with single-choice items, the scoring result is not always equivalent to examinees' true knowledge. When interpreting examination scores and setting pass marks, the number of answer options per item must usually be taken into account in addition to the scoring method used.

The Impact of Post-graduate Year and Program Accreditation Status on In-Training Examination Performance in Orthopaedic Surgery

Introduction  The progression of medical knowledge competency during surgical residency training is poorly understood. This study measures the acquisition of medical knowledge as orthopedic surgery residents advance during training and the impact of accreditation status on orthopedic in-training examination (OITE) performance. Methods  Orthopedic surgery residents taking the OITE during 2020 and 2021 were included. Residents were grouped into cohorts by post-graduate year (PGY) and Accreditation Council for Graduate Medical Education (ACGME) accreditation status. Comparisons were made with parametric tests. Results  Eight thousand eight hundred and seventy-one ACGME-accredited residents (89%) and 1,057 non-ACGME-accredited residents (11%) were evenly distributed by the PGY level (range, 19-21%). Residents in both ACGME- and non-ACGME-accredited residency programs had a significant increase in OITE performance at each PGY level (P<0.001). At ACGME-accredited programs, OITE performance increased from PGY1 (51%), PGY2 (59%), PGY3 (65%), PGY4 (68%), and PGY5 (70%) (P<0.001). There were progressively smaller percentage increases in OITE performance during accredited residency training (range, 2-8%), but this increase was linear in non-accredited residency training (range, 4%). At each PGY level, residents at accredited programs outperformed their counterparts at non-accredited programs (P<0.001). Conclusion OITE performance increases during residency training. Among ACGME-accredited residents, performance on the OITE progresses rapidly during junior years and plateaus during senior years. Residents in ACGME-accredited residency programs outperform their counterparts in non-accredited residency programs. More research is needed to understand optimal training environments that promote medical knowledge acquisition during orthopedic surgery residency.

The incidence of palmaris longus in the heterogeneous Israeli population

We evaluated the frequency of absence of the palmaris longus tendon in the heterogeneous Israeli population. Nine hundred and fifty wrists were evaluated using a modified Mishra/Schaeffer technique (thumb/little-finger opposition with resisted wrist flexion), which was validated by ultrasound scanning. The geographical and ethnic origin of volunteers was documented. When physical examination was equivocal, any vague, superficial structure was subsequently identified as the median nerve by ultrasound. Physical examination reliably identified palmaris longus only when a structure was clinically obvious (visually or by palpation). There was bilateral absence of the palmaris longus in 21% and unilateral absence in 15% of participants. Frequency of bilateral absence varied between 4.5% and 30%, depending on geographical origin (p = 0.0007). The incidence of palmaris longus tendon varied significantly by geographical, but not by ethnic origin.Level of evidence: II.

Use of Multiple-Select Multiple-Choice Items in a Dental Undergraduate Curriculum: Retrospective Study Involving the Application of Different Scoring Methods

BACKGROUND

Scoring and awarding credit are more complex for multiple-select items than for single-choice items. Forty-one different scoring methods were retrospectively applied to 2 multiple-select multiple-choice item types (Pick-N and Multiple-True-False [MTF]) from existing examination data.

OBJECTIVE

This study aimed to calculate and compare the mean scores for both item types by applying different scoring methods, and to investigate the effect of item quality on mean raw scores and the likelihood of resulting scores at or above the pass level (≥0.6).

METHODS

Items and responses from examinees (ie, marking events) were retrieved from previous examinations. Different scoring methods were retrospectively applied to the existing examination data to calculate corresponding examination scores. In addition, item quality was assessed using a validated checklist. Statistical analysis was performed using the Kruskal-Wallis test, Wilcoxon rank-sum test, and multiple logistic regression analysis (P<.05).

RESULTS

We analyzed 1931 marking events of 48 Pick-N items and 828 marking events of 18 MTF items. For both item types, scoring results widely differed between scoring methods (minimum: 0.02, maximum: 0.98; P<.001). Both the use of an inappropriate item type (34 items) and the presence of cues (30 items) impacted the scoring results. Inappropriately used Pick-N items resulted in lower mean raw scores (0.88 vs 0.93; P<.001), while inappropriately used MTF items resulted in higher mean raw scores (0.88 vs 0.85; P=.001). Mean raw scores were higher for MTF items with cues than for those without cues (0.91 vs 0.8; P<.001), while mean raw scores for Pick-N items with and without cues did not differ (0.89 vs 0.90; P=.09). Item quality also impacted the likelihood of resulting scores at or above the pass level (odds ratio ≤6.977).

CONCLUSIONS

Educators should pay attention when using multiple-select multiple-choice items and select the most appropriate item type. Different item types, different scoring methods, and presence of cues are likely to impact examinees' scores and overall examination results.

Are ChatGPT and other pretrained language models good parasitologists?

Large language models, such as ChatGPT, will have far-reaching impacts on parasitology, including on students. Authentic experiences gained during students' training are absent from these models. This is not a weakness of the models but rather an opportunity benefiting parasitology at large.

Predictive factors of academic success in neuromusculoskeletal anatomy among doctor of physical therapy students

Predictors of academic success in anatomy have been studied, but not in Doctor of Physical Therapy (DPT) students. The objectives of this study were to (1) explore predictors of academic success in a DPT anatomy course, (2) evaluate sex-based differences in the predictors of academic success and their influence on anatomy course grade, and (3) investigate the influence of the DPT anatomy course on visual-spatial ability. Forty-nine DPT students completed a demographic questionnaire, Learning and Study Strategies Inventory (LASSI), and Mental Rotations Test (MRT) before the ten-week anatomy course (MRT-1) and repeated the MRT at the end of the course (MRT-2). Anatomy course grade was determined based on quizzes and written and practical examinations. Multiple regression analysis showed significant associations between the predictor variables age (p = 0.010) and the LASSI anxiety subscale (p = 0.017), which measures anxiety coping, with the anatomy course grade. On the MRT-1, male DPT students attempted and correctly answered more questions than females (both, p < 0.0001). Female students had higher LASSI self-regulation and use of academic resources subscale scores (both, p < 0.05). In the 44 DPT students that completed the MRT-2, the number of correct and attempted responses increased following the anatomy course (p < 0.0001). Age and anxiety coping, but not sex, are predictors of anatomy course grades in DPT students. Mental rotations test scores improved following the anatomy course. The LASSI should be used in other cohorts to identify students with low anxiety subscale scores in order to provide targeted support.

Awareness of and Attitude to Breast Self-Examination and Breast Cancer Among Females in Jeddah, Saudi Arabia

Background Breast cancer is the most common of all female cancers worldwide. A large percentage are diagnosed at a late stage, which can be related to awareness and knowledge deficiency. We aimed to assess the level of knowledge of and attitude to breast cancer and breast self-examination in Jeddah, Saudi Arabia. Methodology A descriptive cross-sectional study was carried out among 392 women in Jeddah, Saudi Arabia. Using a non-probability sampling technique, a self-administered validated questionnaire was distributed via social media. Inclusion criteria were ages above 18 years old of all educational levels. Results Out of 392 participants, there were 146 in the age group of 19-25 (37.2%). Most of the participants are aware of breast cancer (94.9%). The mean knowledge score was 6.9 ± 3.36. Ninety-two percent (92%) of participants had poor knowledge. Most respondents reported that the main risk factor for breast cancer was family history (83.7%). About 37% believed that the purpose of the breast self-examination practice is advice from a health care professional followed by routine examination (37.3%). About 97% agreed that early detection of breast cancer increases the chance of recovery. Conclusion There is a lack of knowledge and awareness about the risk factors and symptoms of breast cancer. Despite a positive attitude toward breast self-examination, it is poorly practiced.

Teaching Medical Microbiology With a Web-Based Course During the COVID-19 Pandemic: Retrospective Before-and-After Study

BACKGROUND

The COVID-19 pandemic has imposed unprecedented hurdles on health care systems and medical faculties alike. Lecturers of practical courses at medical schools have been confronted with the challenge of transferring knowledge remotely.

OBJECTIVE

We sought to evaluate the effects of a web-based medical microbiology course on learning outcomes and student perceptions.

METHODS

During the summer term of 2020, medical students at Saarland University, Germany, participated in a web-based medical microbiology course. Teaching content comprised clinical scenarios, theoretical knowledge, and instructive videos on microbiological techniques. Test performance, failure rate, and student evaluations, which included open-response items, for the web-based course were compared to those of the on-site course from the summer term of 2019.

RESULTS

Student performance was comparable between both the online-only group and the on-site comparator for both the written exam (n=100 and n=131, respectively; average grade: mean 7.6, SD 1.7 vs mean 7.3, SD 1.8; P=.20) and the oral exam (n=86 and n=139, respectively; average grade: mean 33.6, SD 4.9 vs mean 33.4, SD 4.8; P=.78). Failure rate did not significantly differ between the online-only group and the comparator group (2/84, 2.4% vs 4/120, 3.3%). While lecturer expertise was rated similarly as high by students in both groups (mean 1.47, SD 0.62 vs mean 1.27, SD 0.55; P=.08), students who took the web-based course provided lower scores for interdisciplinarity (mean 1.7, SD 0.73 vs mean 2.53, SD 1.19; P<.001), opportunities for interaction (mean 1.46, SD 0.67 vs mean 2.91, SD 1.03; P<.001), and the extent to which the educational objectives were defined (mean 1.61, SD 0.76 vs mean 3.41, SD 0.95; P<.001). Main critiques formulated within the open-response items concerned organizational deficits.

CONCLUSIONS

Web-based courses in medical microbiology are a feasible teaching option, especially in the setting of a pandemic, leading to similar test performances in comparison to on-site courses. The lack of interaction and the sustainability of acquired manual skills warrant further research.

Losses along the tuberculosis sputum sample referral cascade for Mpongwe District, Zambia

BACKGROUND

In resource limited-settings, timely tuberculosis (TB) diagnosis depends upon referral of sputum samples from non-diagnostic to diagnostic facilities for examination. The TB programme data for 2018 suggested losses in Mpongwe District's sputum referral cascade.

AIM

This study aimed to identify the referral cascade stage where loss of sputum specimen occurred.

SETTING

Primary health care facilities in Mpongwe District, Copperbelt Province, Zambia.

METHODS

Data were retrospectively collected from one central laboratory and six referring health facilities between January and June 2019, using a paper-based tracking sheet. Descriptive statistics were generated in SPSS version 22.

RESULTS

Of the 328 presumptive pulmonary TB patients found in presumptive TB registers at referring facilities, 311 (94.8%) submitted sputum samples and were referred to the diagnostic facilities. Of these, 290 (93.2%) were received at the laboratory, and 275 (94.8%) were examined. The remaining 15 (5.2%) were rejected for reasons such as 'insufficient sample'. Results for all examined samples were sent back and received at referring facilities. Referral cascade completion rate was 88.4%. Median turnaround time was six days (IQR = 1.8).

CONCLUSION

Losses in the sputum referral cascade for Mpongwe District mainly occurred between dispatch of sputum samples and receipt at diagnostic facility. Mpongwe District Health Office needs to establish a system to monitor and evaluate the movement of sputum samples along the referral cascade to minimize losses and ensure timely TB diagnosis.Contribution: This study has highlighted, at primary health care level for resource limited settings, the stage in the sputum sample referral cascade where losses mainly occur.

Kinetic chain revisited: Consensus expert opinion on terminology, clinical reasoning, examination and treatment in people with shoulder pain

OBJECTIVES

To determine the most appropriate terminology and issues related to clinical reasoning, examination and treatment of the kinetic chain (KC) in people with shoulder pain by an international experts panel.

DESIGN

Delphi study METHODS: A three-round Delphi study that involved an international panel of experts with extensive clinical, teaching and research experience in the study topic was conducted. A search equation of terms related to KC in Web of Science and a manual search were used to find the experts. Participants were asked to rate items across five different domains (terminology, clinical reasoning, subjective examination, physical examination and treatment) using a 5-point Likert-type scale. An Aiken's Validity Index ≥ 0.7 was considered indicative of group consensus.

RESULTS

Participation rate was 30.2% (n=16) while retention rate was high throughout the 3 rounds (100%, 93.8%, 100%). A total of 15 experts from different fields and countries completed the study. After the three rounds, consensus was reached on 102 items: 3 items were included in the "terminology" domain, 17 items in the "rationale and clinical reasoning" domain, 11 items in the "subjective examination" domain, 44 items in the "physical examination" domain and 27 items in the "treatment" domain. "Terminology" was the domain with the highest level of more agreement with two items achieving an Aiken's V of 0.93, whereas "physical examination" and "treatment" of the KC where the two areas with less consensus. Together with "terminology" items, one item from the "treatment" and two items from the "rationale and clinical reasoning" domains reached the highest level of agreement (v=0.93 and 0.92, respectively).

CONCLUSION

This study defined a list of 102 items across five different domains (terminology, rationale and clinical reasoning, subjective examination, physical examination and treatment) regarding to KC in people with shoulder pain. The term KC was preferred and a definition for this concept agreed. Dysfunction of a segment in the chain (i.e., weak link) was agreed to result in altered performance or injury to distal segments. Experts considered important to assess and treat the KC in particular in throwing/overhead athletes and agreed that no one size fits all approach exist when implementing shoulder KC exercises within the rehabilitation process. Further research is now required to determine the validity of the identified items.

Comorbidities in Infants and Children with Neonatal Brachial Plexus Palsy: A Scoping Review to Inform Multisystem Screening

AIMS

The scoping review was undertaken to explore comorbidities in infants and children with neonatal brachial plexus palsy (NBPP). The purpose of the review was to inform physical and occupational therapy screening of multiple body systems during the examination of children with NBPP.

METHODS

EBSCO Discovery and EMBASE electronic databases were searched for reports published between January 1996 and September 2021 describing comorbidities in children with NBPP between birth and 18 years. Key data pertaining to comorbidity prevalence, risk factors, clinical features, and associated outcomes were extracted and charted by one researcher and confirmed by a second researcher.

RESULTS

Thirty-six articles were included in the scoping review. Fourteen comorbidities were identified across the musculoskeletal, neurological, cardiopulmonary, and integumentary systems and the communication domain. The most prevalent comorbidities were clavicle fractures, plagiocephaly, torticollis, high body mass index, and language delays. The least prevalent comorbidity was facial nerve palsy.

CONCLUSIONS

Physical and occupational therapists can use knowledge of comorbidities in infants and children with NBPP for multisystem screening during the examination. A thorough history can identify risk factors for comorbidities. Detection of comorbidities during screening allows for timely specialty referrals to optimize care.

Spontaneous Echo Contrast in the Left Atrium and Aortic-Arch Atheroma, Detected by Transesophageal Echocardiography, Was Negatively Correlated with Cognitive Function

BACKGROUND

The relationship between transesophageal echocardiography findings and cognitive function.

OBJECTIVE

This study aimed to establish an association between transesophageal echocardiography findings and cognitive function in stroke survivors.

METHODS

A single-center study was conducted between April 1, 2017 and March 31, 2022. All subjects that were included had a past history of ischemic stroke and were admitted after >21 days from onset. The participants underwent cognitive function tests including a Mini-Mental State Examination, Revised Hasegawa Dementia Scale, Frontal Assessment Battery, and transesophageal echocardiography.

RESULTS

The results of 126 participants were analyzed. The cognitive function of participants with a spontaneous echo contrast (+) in the left atrium including appendage or of those with an aorta-arch plaque with a maximum thickness ≥4 mm significantly worse while neither the patent foramen ovale nor the branch extending plaque influenced cognitive function (The median cognitive scores of the spontaneous echo contrast (-) versus (+) were 26 versus 22, p < 0.01**, 26 versus 21, p < 0.001***, and 14 versus 11, p < 0.01**. Those of the aortic-arch plaque max thickness (<4 mm) versus (≥4 mm) were 26 versus 25, p < 0.05*, 27 versus 24, p < 0.05*, and 15 versus 13, p < 0.05*).

CONCLUSION

Our findings show that spontaneous echo contrast in the left atrium and aortic-arch atheroma detected by transesophageal echocardiography, were negatively associated with cognitive function.

Identification of Clinical Measures to Use in a Virtual Concussion Assessment: Protocol for a Mixed Methods Study

BACKGROUND

Workplace concussions can have a significant impact on workers. The impact of concussion symptoms, combined with challenges associated with clinical environments that are loud, bright, and busy, create barriers to conducting effective in-person assessments. Although the opportunity for remote care in rural communities has long been recognized, the COVID-19 pandemic has catalyzed the transition to virtual assessments and care into the mainstream. With this rapid shift, many clinicians have been completing remote assessments. However, the approaches and measures used in these assessments have not yet been standardized. Furthermore, the psychometric properties of the assessments when completed remotely using videoconference have not yet been documented.

OBJECTIVE

Through this mixed methods study, we aim to (1) identify the concussion assessment measures clinicians are currently using in person and are most relevant to the following 5 physical domains: neurological examination (ie, cranial nerve, coordination, motor, and sensory skills), cervical spine, vestibular, oculomotor, and effort assessment; (2) document the psychometric properties of the measures identified; (3) identify measures that appear feasible in a virtual context; and (4) identify practical and technical barriers or challenges, facilitators, and benefits to conducting or engaging in virtual concussion assessments.

METHODS

This study will follow a sequential mixed methods design using a survey and Delphi approach, working groups with expert clinicians, and focus groups with experienced clinicians and people living with concussions. Our target sample sizes are 50 clinicians for the Delphi surveys, 4 clinician-participants for the working group, and 5-7 participants for each focus group (roughly 6-10 total groups being planned with at least two groups consisting of people living with concussions). The results from this study will inform the decision regarding the measures that should be included in a virtual assessment tool kit to be tested in a future planned prospective evaluation study.

RESULTS

The study is expected to be completed by January 2023.

CONCLUSIONS

This mixed methods study will document the clinical measures that are currently used in person and will identify those that are most relevant to assessing the physical domains impacted by concussions. Potential feasibility of using these measures in a virtual context will be explored.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40446.

Understanding the Female Physical Examination in Patients with Chronic Pelvic and Perineal Pain

(1) Background: The objective was to compare the exploration of chronic pelvic pain syndrome (CPPS) patients in different locations and establish the role of physical examination in CPPS patients. (2) Methods: We reviewed clinical data from 107 female patients with CPPS unresponsive to conventional therapies at Puerta de Hierro University Hospital Madrid, Spain, from May 2018 to June 2022. Patients were classified into three groups: (a) pelvic pain; (b) anorectal pain; or (c) vulvar/perineal pain. (3) Results: Although the demographics of patients with CPPS were different, their physical examinations were strikingly similar. Our study observed a comorbidity rate of 36% and 79% of central sensitization of pain. Seventy-one percent of patients had vulvar allodynia/hyperalgesia. Pain on examination was identified in any pelvic floor muscle, in any pelvic girdle structure, and neuropathic pain in 98%, 96%, and 89%, respectively. Patients with vulvar and perineal pain were more different from the other groups; these patients were younger and had fewer comorbidities and less central sensitization, less anorectal pain, more pain during intercourse, and greater nulliparity (p = 0.022; p = 0.040; p = 0.048; p = 0.000; p = 0.006; p = 0.005). (4) Conclusions: The findings of this study are related to the understanding of the pathophysiology of CPPS. The physical examination confirms the central sensitization of female patients with CPPS, helps us to determine the therapeutic management of the patient, and can be considered as a prognostic factor of the disease.

Creation of a novel course for the advanced emergency medicine ultrasound focused practice designation examination

Introduction

The American Board of Emergency Medicine recently established a new certification pathway in advanced emergency medicine ultrasound (AEMUS). Eligible applicants come from a wide range of experience but must pass the same examination to become certified. This study sought to evaluate a novel review course targeting a wide range of learners for a new examination.

Methods

This was a cross-sectional study evaluating the outcomes of the American College of Emergency Physicians (ACEP) AEMUS review course. The program evaluation survey was designed to collect outcomes across multiple Kirkpatrick levels, including overall satisfaction, topic-specific satisfaction, topic-specific coverage, topic-specific confidence before and after the course, topic-specific perceived knowledge before and after the course, and changes in practice.

Results

Seventy-four of 79 participants (93.7%) completed the survey. Mean course satisfaction was 4.59/5.00 (95% CI 4.47-4.72). Confidence to pass examination components increased for the following topics: administration, advanced left ventricle (LV), education, head and neck, hepatobiliary, male genitourinary, musculoskeletal, nonobstetric gynecology, pediatrics, physics, procedures, research, right ventricle, and venous/arterial. Perceived knowledge increased for the following topics: administration, advanced LV, education, head and neck, male genitourinary, musculoskeletal, pediatrics, physics, procedures, renal/bladder, research, right ventricle, and venous/arterial. Fifty-three of 74 participants (71.6%) stated they would change their practice based on the course. Examples of changes in practice include increased use of ultrasound for advanced abdominal, musculoskeletal, pediatric, and procedural applications. Future work will determine the impact on longer-term outcomes and focused practice designation (FPD) examination pass rates.

Conclusion

The ACEP AEMUS FPD review course demonstrated high levels of satisfaction, increased participant confidence, increased perceived knowledge, and several self-reported changes in participants' ultrasound practice.

The utilization of educational resources published by the Thoracic Surgery Residents Association

OBJECTIVE

The Thoracic Surgery Residents Association (TSRA) is a trainee-led cardiothoracic surgery organization in North America that has published a multitude of educational resources. However, the utilization of these resources remains unknown.

METHODS

Surveys were constructed, pilot-tested, and emailed to 527 current cardiothoracic trainees (12 questions) and 780 former trainees who graduated between 2012 and 2019 (16 questions). The surveys assessed the utilization of TSRA educational resources in preparing for clinical practice as well as in-training and American Board of Thoracic Surgery (ABTS) certification examinations.

RESULTS

A total of 143 (27%) current trainees and 180 (23%) recent graduates responded. A higher proportion of recent graduates compared with current trainees identified as male (84% vs 66%; P = .001) and graduated from 2- or 3-year traditional training programs (81% vs 41%; P < .001), compared with integrated 6-year (8% vs 49%; P < .001) or 4 + 3 (11% vs 10%; P = .82) pathways. Current trainees most commonly used TSRA resources to prepare for the in-training exam (75%) and operations (73%). Recent graduates most commonly used them to prepare for Oral and/or Written Board Exams (92%) and the in-training exam (89%). Among recent graduates who passed the ABTS Oral Board Exam on the first attempt, 82% (97/118) used TSRA resources to prepare, versus only 48% (25/52) of recent graduates who passed after multiple attempts, failed, have not taken the exam, or preferred not to answer (P < .001).

CONCLUSIONS

Current cardiothoracic trainees and recent graduates have utilized TSRA educational resources extensively, including to prepare for in-training and ABTS Board examinations.

Investigation and management of stillbirth: a descriptive review of major guidelines

Stillbirth is a common and devastating pregnancy complication. The aim of this study was to review and compare the recommendations of the most recently published guidelines on the investigation and management of this adverse outcome. A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynecologists (RCOG), the Perinatal Society of Australia and New Zealand (PSANZ), the Society of Obstetricians and Gynecologists of Canada (SOGC) on stillbirth was carried out. Regarding investigation, there is consensus that medical history and postmortem examination are crucial and that determining the etiology may improve care in a subsequent pregnancy. All guidelines recommend histopathological examination of the placenta, genetic analysis and microbiology of fetal and placental tissues, offering less invasive techniques when autopsy is declined and a Kleihauer test to detect large feto-maternal hemorrhage, whereas they discourage routine screening for inherited thrombophilias. RCOG and SOGC also recommend a complete blood count, coagulopathies' testing, anti-Ro and anti-La antibodies' measurement in cases of hydrops and parental karyotyping. Discrepancies exist among the reviewed guidelines on the definition of stillbirth and the usefulness of thyroid function tests and maternal viral screening. Moreover, only ACOG and RCOG discuss the management of stillbirth. They agree that, in the absence of coagulopathies, expectant management should be considered and encourage vaginal birth, but they suggest different labor induction protocols and different management in subsequent pregnancies. It is important to develop consistent international practice protocols, in order to allow effective determination of the underlying causes and optimal management of stillbirths, while identifying the gaps in the current literature may highlight the need for future research.

Dermatological manifestations of cardiac conditions

Various cardiac disorders seen in general and acute medicine have dermatological manifestations that may provide critical clues to the underlying disease. This review will discuss the important dermatological signs seen in cardiac conditions. We believe greater interdisciplinary liaison will improve our understanding of the link between the dermatological and cardiovascular systems and the underlying disease processes.

Determining Whether Pharmacy Students Can Accurately Recall Items on an Examination Using Their Collective Memory

Objective. To determine the extent to which students can recreate a recently completed examination from memory.Methods. After two mid-term examinations, students were asked, as a class, to recreate recently completed examinations. Students were given 48 hours to recreate the examination, including details about the questions and answer choices. The results were compared to the original examination to determine the accuracy of students' recall and reproduction of content.Results. The students were able to collectively recreate 90% of the questions on the two examinations. For the majority of questions (51%), students also recreated the question as well as the correct response and at least one incorrect response. The majority of questions that the students recreated were of medium to high accuracy as they contained detailed phrasing that aligned with the original question on the examination.Conclusion. The collective memory of a group of students may allow them to accurately recreate the majority of a completed examination from memory. Based on the findings of this study and tenets of social psychology, faculty should consider the potential implications for examination security, whether to provide feedback to students on examinations, and whether completed examinations should be released to students following the examination.

Practical Management: Telehealth Examination for Sport-Related Concussion in the Outpatient Setting

ABSTRACT

This article presents the telehealth version of the Buffalo Concussion Physical Examination (BCPE) (Tele-BCPE). It is a brief, focused telehealth PE for use in the outpatient setting by sports medicine physicians, pediatricians, neurologists, and primary care physicians. It is derived from the BCPE and includes general considerations for providers performing telehealth services and instructions for adapting traditional clinical tests for virtual use. The Tele-BCPE includes an orthostatic intolerance screen, examination of the cranial nerves, and tests of the oculomotor, vestibular, and cervical systems. It is meant to be used at initial and follow-up outpatient visits for patients acutely after concussion and in those with prolonged symptoms. This telehealth PE, when combined with other assessments, can help provide direct treatment to patients at any stage after concussion and reduce barriers to healthcare access posed by the COVID-19 pandemic and for patients living in rural or underserved areas.

Medical Students' Academic Achievement Differences in Annual and Semester-Based Examination Systems: Anatomy Subject Scores As an Example

INTRODUCTION

Various factors including the system of examination affect students' academic achievement. Annual or semester-based examinations are commonly observed practices. Students like semester system, as their academic performance is significantly higher in this system. Medical education in Pakistan has largely followed the British system of preclinical and clinical years of teaching followed by end-of-year examinations. In the wake of medical education reform, the semester system of examination having objective assessment was recently introduced in medical institutes of Pakistan. There is no empirical evidence regarding the effects of this change on medical students' academic achievement. This study aimed to assess whether the semester system has made any difference in the academic performance of medical students as compared to the annual system of examination.

METHOD

Anatomy percentage scores of two batches of students who sequentially took annual and semester examinations were collected from a medical university. The data were analyzed for normality and later descriptive and inferential statistical tests were carried.

RESULTS

The data of 748 students (semester = 319 and annual = 429) were entered for analysis. The students who took semester-based examination (N = 319, M = 72.30, SD = 8.25) performed better than the students who took annual examination (N = 429, M = 64.36, SD = 10.69). The difference in mean percentage scores was statistically significant (t-test = 11.04, degrees of freedom (df) = 746; p < 0.01; 95% CI, 6.53-9.35).

DISCUSSION

The results demonstrated the enhanced scores of students who sat the semester examination. The findings of this research supported the earlier studies that suggested the restructuring of course durations and examination system have enhanced students' achievement. Also, the objective assessments method showed improved academic performance.

CONCLUSION

The study found that anatomy knowledge assessment scores of students who sat semester examination were significantly higher than students who sat the end-of-year examination. Further studies are needed to understand if this difference is also observed in other basic sciences subjects and continues in the performance clinical years.

Perception of Students and Examiners about Objective Structured Clinical Examination in a Teaching Hospital in Ethiopia

INTRODUCTION

The objective structured clinical examination (OSCE) has become a standard assessment tool in undergraduate medical school training. It is considered an objective assessment of practical skill of students. OSCE is a resource demanding assessment method that can have numerous challenges. Comprehensive assessment of perception regarding OSCE can help identify areas that need improvement. The aim of this study was to assess the perception of students and examiners towards OSCE.

METHODS

A cross-sectional study was conducted on students and examiners undertaking OSCE from May 1 to July 30, 2021, using a structured questionnaire. Comparison of variables was done using Mann-Whitney U-Test and Chi-square test. P-value <0.05 was considered statistically significant.

RESULTS

A total of 141 students and 39 examiners participated in the study. The majority of the students and examiners had a positive response regarding the attributes, structure, organization and validity of OSCE. It was recommended to be used in future exams compared to other assessments by 38.3% of students and 51.3% of examiners. There were certain challenges reported by students and included stressfulness of the exam (51.1%), inadequate time (27.6%), and unsatisfactory orientation (30.5%). One-third of examiners considered it stressful, while 20.5% considered the time provided to be inadequate. Equipment to conduct the exam was considered inadequate by 39.1% and 56.4% of students and examiners, respectively. Around 80.1% of students recommended mock sessions and 23.1% of examiners did not have any prior training on OSCE.

CONCLUSION

An overall positive perception of OSCE by students and examiners was seen. Certain challenges that need improvements were identified. Continuing evaluation and refinement of OSCE by departments is needed. We recommend further wide-scale national evaluation of the OSCE examination system of medical students.

A National Survey on Safety Management at MR Imaging Facilities in Japan

PURPOSE

To investigate safety management at Japanese facilities performing human MRI studies.

METHODS

All Japanese facilities performing human MRI studies were invited to participate in a comprehensive survey that evaluated their MRI safety management. The survey used a questionnaire prepared with the cooperation of the Safety Committee of the Japanese Society for Magnetic Resonance in Medicine. The survey addressed items pertaining to the overall MRI safety management, questions on the occurrence of incidents, and questions specific to facility and MRI scanner or examination. The survey covered the period from October 2017 to September 2018. Automated machine learning was used to identify factors associated with major incidents.

RESULTS

Of 5914 facilities, 2015 (34%) responded to the questionnaire. There was a wide variation in the rate of compliance with MRI safety management items among the participating facilities. Among the facilities responding to this questionnaire, 5% reported major incidents and 27% reported minor incidents related to MRI studies. Most major incidents involved the administration of contrast agents. The most influential factor in major incidents was the total number of MRI studies performed at the facility; this number was significantly correlated with the risk of major incidents (P < 0.0001).

CONCLUSION

There were large variations in the safety standards applied at Japanese facilities performing clinical MRI studies. The total number of MRI studies performed at a facility affected the number of major incidents.

A guide to cranial nerve testing for musculoskeletal clinicians

BACKGROUND

Neurological examination in musculoskeletal practice is a key element of safe and appropriate orthopedic clinical practice. With physiotherapists currently positioning themselves as advanced first line practitioners, it is essential that those who treat patients who present with neck/head/orofacial pain and associated symptoms, should have an index of suspicion of cranial nerve (CN) dysfunction. They should be able to examine and determine if CN dysfunction is present, and make appropriate clinical decisions based upon those findings.

METHODS

This paper summarizes the functions, potential impairments of the nerves, associated conditions, and basic skills involved in cranial nerve examination.

RESULTS

A summary of cranial nerve examination is provided, which is based on the function of the nerves, This is intended to facilitate clinicians to feel more confident at understanding neural function/impairment, as well as performing and interpreting the examination.

CONCLUSION

This paper illustrates that CN testing can be performed quickly, efficiently and without the need for complicated or potentially unavailable equipment. An understanding of the CN's function and potential reasons for impairment is likely to increase the frequency of CN testing in orthopedic clinical practice and referral if positive findings are encountered.