The association between quality of connections and diagnostic accuracy in student-generated concept maps for clinical reasoning education with virtual patients

Objectives

Concept maps are a learning tool that fosters clinical reasoning skills in healthcare education. They can be developed by students in combination with virtual patients to create a visual representation of the clinical reasoning process while solving a case. However, in order to optimize feedback, there is a need to better understand the role of connections between concepts in student-generated maps. Therefore, in this study we investigated whether the quality of these connections is indicative of diagnostic accuracy.

Methods

We analyzed 40 concept maps created by fifth-year medical students in the context of four virtual patients with commonly encountered diagnoses. Half of the maps were created by students who made a correct diagnosis on the first attempt; the other half were created by students who made an error in their first diagnosis. The connections in the maps were rated by two reviewers using a relational scoring system. Analysis of covariance was employed to examine the difference in mean connection scores among groups while controlling for the number of connections.

Results

There were no differences between the groups in the number of concepts or connections in the maps; however, maps made by students who made a correct first diagnosis had higher scores for the quality of connections than those created by students who made an incorrect first diagnosis (12.13 vs 9.09; p=0.03). We also observed students' general reluctance to use connections in their concept maps.

Conclusion

Our results suggest that the quality, not the quantity, of connections in concept maps is indicative of their diagnostic accuracy.

Extracorporeal Rewarming Is Associated With Increased Survival Rate in Severely Hypothermic Patients With Preserved Spontaneous Circulation

Treatment recommendations for rewarming patients in severe accidental hypothermia with preserved spontaneous circulation have a weak evidence due to the absence of randomized clinical trials. We aimed to compare the outcomes of extracorporeal versus less-invasive rewarming of severely hypothermic patients with preserved spontaneous circulation. We conducted a multicenter retrospective study. The patient population was compiled based on data from the HELP Registry, the International Hypothermia Registry, and a literature review. Adult patients with a core temperature <28°C and preserved spontaneous circulation were included. Patients who underwent extracorporeal rewarming were compared with patients rewarmed with less-invasive methods, using a matched-pair analysis. The study population consisted of 50 patients rewarmed extracorporeally and 85 patients rewarmed with other, less-invasive methods. Variables significantly associated with survival included: lower age; outdoor cooling circumstances; higher blood pressure; higher PaCO 2 ; higher BE; higher HCO 3 ; and the absence of comorbidities. The survival rate was higher in patients rewarmed extracorporeally ( p = 0.049). The relative risk of death was twice as high in patients rewarmed less invasively. Based on our data, we conclude that patients in severe accidental hypothermia with circulatory instability can benefit from extracorporeal rewarming without an increased risk of complications.

Perceptions of clinical teachers acting as examiners regarding the value of Objective Structured Clinical Examinations

OBJECTIVES

OSCE (Objective Structured Clinical Examination) is a common method of assessing clinical skills used at many universities. An important and at the same time difficult aspect of good examination preparation is obtaining a properly trained and well-motivated group of assessors. To effectively recruit and maintain cooperation with assessors, it is worth to know their opinion. The aim of this study was to investigate the opinions of teacher-examiners about OSCE and to identify the factors that could shape this opinion and influence on motivation.

METHODS

A cross-sectional study was conducted using a questionnaire on teachers who participated as OSCE examiners. This questionnaire consisted of 21 questions about their perceptions. Answers were rated in a five-point Likert-type scale. Chi-square or Fisher's exact test was used to analyze the data.

RESULTS

A total of 49 (out of 52) teachers participated in this study. Nearly 90% of examiners believed that it is fair, more than 90% that it is transparent. Despite the fact that 67% of examiners believe the examination is difficult to organize and 71% believe it is stressful for students, according to 72% of respondents the OSCE has a positive effect on learning. More than 91% of examiners believed that the OSCE is an appropriate test to assess students' skills. Opinions about examination were independent of specialty, seniority, gender or taking the OSCE as students.

CONCLUSION

Teacher-examiners viewed the OSCE as a fair and transparent examination, adequate for assessment of skills and, despite it being difficult to organize, worth doing as it is appropriate to assess practical skills and positively influences students' motivation to learn tested skills.

Clinical communication course and other factors affecting patient-centered attitudes among medical students

OBJECTIVES

Patient-centered care (PCC) is associated with better relationships, resulting in a decrease in symptoms, hospitalizations and health costs. However, studies analyzing factors influencing patient-centered attitudes show ambiguous results. The purpose was to assess the impact of the Clinical Communication Course (CCC) in Jagiellonian University, Cracow and other factors on Patient-Centered Attitudes (PCA) and Attitude toward Clinical Skills Learning (CSLA).

METHODS

We retrospectively compared Polish-speakers (CCC+, n = 160), English-speakers (CCCen+, n = 55) after the CCC and upperclassmen Polish-speakers without it (CCC-, n = 122). Validated questionnaires to measure PCA (Leeds Attitude Toward Concordance II and Patient-Practitioner Orientation Scale (PPOS)) and for CSLA (Communication Skills Attitude Scale with negative subscale (CSAS-N)) were used. The higher the scores, the more PCA, and negative CSLA respectively. Students completed questionnaires and answered questions regarding age, sex, motivation to study (coded as humanitarian - MotHUM, financial - MotFIN, combination - MotMIX) and considered specialization - coded as with more human contact (family medicine, psychiatry, pediatrics - SpecHUM) and others (SpecNHUM). Statistics were prepared in R.

RESULTS

CCC+ scored higher in PPOS (2.91 vs. 2.74; p = 0.003) than CCC- and higher in CSAS-N than CCCen+ (31.22 vs. 28.32; p = 0.004). In CCC+ SpecHUM scored lower than SpecNHUM in PPOS (2.65 vs. 2.94, p = 0.012). MotFIN scored higher then MotMIX in PPOS (3.01 vs. 2.7, p = 0.036). Correlations were statistically significant.

CONCLUSION

CCC improved PCA in CCC+. They showed more negative CSLA than CCCen+. Among CCC+, surprisingly, SpecNHUM presented more PCA than SpecHUM as well as MotFIN compared to MotMIX.

The "Wholesome Contact" non-pharmacological, volunteer-delivered multidisciplinary programme to prevent hospital delirium in elderly patients: study protocol for a randomised controlled trial

Background

In hospital settings, delirium affects as many as 50% of older patients, aggravating their symptoms and worsening their condition, and therefore increasing the risk of in-hospital complications and death. The aim of this study is to assess the efficacy of structured, non-pharmacological care, delivered to older hospitalised patients by trained volunteers (students of medical fields), on the reduction of incidence of adverse health-related outcomes.

Methods/design

This trial will be a randomised, investigator-blind, controlled trial conducted in an internal medicine and geriatric ward in Poland. We aim to include 416 patients who are 70 years of age and have been hospitalised for medical reasons. Eligible patients will be randomised 1:1 to receive structured, non-pharmacological care delivered by students of medicine, psychology and nursing, together with standard medical treatment or standard medical care alone. The protocol of interventions has been designed to cover nine main risk factors for delirium, with the scope of multidisciplinary interventions being individualised and tailored. The protocol will be aimed at immobilisation, vision and hearing impairment, cognitive impairment and disorientation, stress and anxiety, sleep–wake cycle disturbances, dehydration and malnutrition, and pain. A structured evaluation of patients’ cognition, mood, anxiety and functional performance is planned to be carried out twice, on the day of group allocation and at discharge; structured screening assessment for delirium will be conducted daily using the Confusion Assessment Method. The primary outcome will be the incidence of delirium in hospital; secondary outcomes will be in-hospital changes in cognition, mood and anxiety, and functional status, occurrence of falls and death.

Discussion

Delirium prevention programmes are being introduced worldwide. A particular novelty of our project, however, is that invitations for voluntary work with older patients at risk for delirium will be addressed to medical students. With the use of the service learning method, the students will shape their attitudes, increase their knowledge and understanding of hospital care, and master competencies to work within interdisciplinary teams, which establishes the originality and practicality of the project.

Trial registration

Polish Science Database, 317484. Registered on 23 October 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2781-6) contains supplementary material, which is available to authorized users.

Identification of Seniors at Risk scale as a simple tool of elderly patients' assessment in an acute hospital department

INTRODUCTION

e aim of the study was to evaluate the usefulness of Identification of Seniors at Risk (ISAR) scale among elderly patients admitted to the department of internal medicine.

MATERIAL AND METHODS

The ISAR score was performed among patients aged >59 years a er admission to the hospital ward. Data from medical history about diseases, taken medicines, falls, length of hospital stay and mortality were compared in patients with ISAR score of 0-1 and over 1 and in subjects with and without history of falls. Regression analysis was used to detect predictors of the length of hospital stay or death.

RESULTS

The sample consisted of 102 subjects aged 80.9 ± 7.9 years, 45.5% of men, 34.6% had history of falls. The number of diseases was 11.3 ± 3.9 and number of medicines - 8.9 ± 3.7. The score of ISAR ≥2 was found in 90.2% of patients, length of hospital stay was 10.3 ± 8.4 days, mortality rate was 9.9%. Patients with ISAR score <2 were younger, showed a smaller number of diseases, used less drugs and had less frequency of falls than those with score ≥2. Patients with history of falls had higher mean ISAR score, higher number of diseases and medicines than the others. The increased number of diseases and higher ISAR score significantly influenced the length of hospital stay. None of the analyzed factors had any impact on mortality.

CONCLUSION

The score of ISAR scale together with number of diseases have a positive impact on the length of hospital stay.

The Objective Structured Clinical Examination (OSCE) from the perspective of 3rd year's medical students - a pilot study

BACKGROUND

In 2015 Department of Medical Education in Medical College of Jagiellonian University in Cracow performed a new format of integrated multidisciplinary skills assessment of third year students of medicine a er completing initial courses in internal medicine, surgery, pediatrics and gynecology.

AIM

OSCE assessed from the perspective of 3rd year medical students.

METHODS

Students of 3rd year's study of Faculty of medicine were evaluated by OSCE, which assessed their internal medicine, surgery, gynecology, pediatric skills. OSCE consisted of 12 stations. In order to assess student's opinions on OSCE, we used method of diagnostic survey; Statistica 12.0.

RESULTS

OSCE passed 255 (98.83%) of the students in thefirst term. We analyzed 221 questionnaires, in which students expressed their opinion. 93.7% of the students considered OSCE as a well organized exam. 87.8% of students claimed that OSCE is fair and 95.5% that the exam is clear. 86.4% students are pleased with the introduction information about OSCE that was given before the examination. 78.6% students believe, that OSCE allows to properly identify skills that require improvement. Students, who didn't pass all stations with positive result, more o en (Chi^2 Pearsona, p = 0.01990) indicated improper balance between quantity of stations that check communication skills and these checking other clinical skills.

CONCLUSIONS

is study confirms that OSCE in the students' opinions was well organized and fair. It proves that OSCE correctly selects students who need to improve their knowledge and skills. Students' preparing to the exams, their knowledge and skills, influences on the students' perception of OSCE.

Prognostic factors of left ventricle function deterioration in patients with coronary disease and normal results of echocardiographic examination in a 2-year observation - prospective cohort study

INTRODUCTION

Coronary disease is one of the strongest risk factors of developing heart failure. Identification of the predictive factors of left ventricle (LV) function deterioration in patients with stable angina pectoris and normal systolic function of LV, is a challenge for clinicians.

OBJECTIVE

Identification of prognostic factors: clinical, echocardiographic, biochemical (NT-proBNP, hsCRP) and spiroergometric of left ventricle function deterioration in patients with coronary disease and normal results of baseline echocardiographic examination in a 2-year observation.

PATIENTS AND METHODS

The study group comprised of 32 patients with stable angina pectoris and normal heart function, aged 50.9 ± 4 years; 23 men (71.8%). At baseline we performed echocardiography, cardiopulmonary exercise testing and determined serum levels of B-type natriuretic peptide and C-reactive protein. 24 months later we performed echocardiography and cardiopulmonary exercise testing.

RESULTS

Patients with stable angina pectoris and normal LV function are at risk of developing the impairment of LV function. Diastolic dysfunctions of LV are a crucial element of the whole clinical picture. 53.1% developed of LV diastolic dysfunction: 37% isovolumetric relaxation disorders and 15% pseudonormalization. The analysis of the tests carried out after a 2-year observation indicated a relation-ship between developing diastolic dysfunction of LV and the presence of type II diabetes (p = 0.01). Peak oxygen consumption (VO2peak) at baseline was significantly lower in patients who developed diastolic dysfunction of LV a er 2 years (p = 0.03).

CONCLUSIONS

The predictors of LV diastolic function deterioration in a 2-year observation in this group of patients include type II diabetes and peak oxygen consumption VO2peak.

[Nailfold videocapillaroscopy - a useful tool for screening patients with juvenile idiopathic arthritis at the risk of development of premature atherosclerosis]

Inflammation of the vascular wall with endothelial dysfunction and subsequent activation of inflammatory immune response play pivotal roles in the early development of the atherosclerotic process not only in adults with rheumatoid arthritis (RA), but also in children with juvenile idiopathic arthritis (JIA). This hypothesis was supported by our findings from autopsy examination, revealing atherosclerosis lesions in about 30% children with JIA. The established methods of assessing pre-clinical atherosclerosis include measurement of biochemical markers of endothelium impairment and ultrasonographic examination of vessels (FMD, IMT). The authors suggest that revealing structural and functional impairment of peripheral microvessels by means of static and dynamic videocapillaroscopy can give clinicians a chance to identify even younger patients with JIA/RA at high risk of atherosclerosis.

[Visceral leishmaniasis as a threat for non-endemic countries]

Global warming, globalisation, and constantly increasing number of people involved in long-distance tourism and travel to exotic destinations are likely to increase the number of cases of exotic diseases "imported" to nonendemic countries. One of the often forgotten and neglected diseases has been visceral leishmaniasis (VL or kala-azar). The disease is endemic to 62 countries, with India and Sudan accounting for the majority of the cases. It is typically fatal if left untreated. Each year about 500 000 new cases are reported worldwide, and 50 000 die as a result of the disease. Kala-azar is present in the Mediterranean Europe and 70% of cases are imported to non-endemic countries of European Union from that area. Immunocompromised status of patients, like HIV carriers are the principal prospective target for kala-azar. HIV/VL-coinfected patients have significantly higher relapse rates and decreased life expectancy. There is no formal system of reporting imported cases in Europe, except from Germany. In non-endemic countries, including Poland, there is usually the substantial delay between the onset of symptoms and the final diagnosis, with an average exceeding 3 months. This fact suggests that physicians are not familiar with leishmania infections. Despite progress in vaccine development, the only way to prevent the infection is avoiding sandfly bites. Mosquito nets, wearing appropriate clothes and repellents containing DEET (diethyl toluamide) can reduce number of bites and protect also from the other vector-borne diseases like malaria or dengue. Education concerning kala-azar risk and ways of the disease prevention is a needed for tourists and the other travelers.

[Relationship between bone mineral content and growth disorders in children with juvenile idiopathic arthritis]

In chronic inflammatory processes in children efforts are made to evaluate bone mineral content (BMC) with the use of densitometric parameters, which at the same time determine equivalent of lean body mass (LBM). This functional analysis of the musculoskeletal system by using DXA method seems to be particularly useful for the examination of bone mass in children suffering from juvenile idiopathic arthritis (JIA). THE AIM OF THE STUDY was to assess body mass content having regard of the BMC/LBM ratio in JIA children, depending on the degree of growth inhibition, disease advancement phase and the therapy applied.

MATERIAL AND METHODS

The study comprised 97 children aged 5-18 (mean age 12.7+/-3.8 years), 45 girls and 52 boys with diagnosed JIA according to ILAR criteria of 1997. The average duration of disease was 4.1+/-3.1 years. Antropometric and densitometric measurement was made in every child. Body height was defined by Standard Deviation Height Velocity Score - SDHVS (SDS). Patients were divided into 2 groups: I - 28-group with SDS ratio < -2.0; 11 - 69 children with normal height. For the evaluation of disease development and advancement of anatomic changes in joints criteria of Steinbrocker were applied: I grade - without joint damage, II - insignificant or moderate joints damage, III-IV - established deformation. The densitometric research was conducted with the use of double-energy X-ray absorptiometry (DXA) method. Bone mineral density (BMD) was assessed in the whole skeleton (TB BMD), in the vertebras L2-L4 (SB MD), Z-score index for SBMD and BMC, LBM, TB BMC/LBM defined by the Z-score index and compared to norms for age and growth.

RESULTS

Bone mineral density defined as Z-score index for SBMD <-2.0 was reported in 21 children (21.6%). Muscle-skeletal Z-score index for TB BMC/LBM in relation to norms of gender and growth lower than -1.0 was proved in 23 children (23.6%). Considerably lower Z-score index for TB BMC/LBM (p < 0.01) characterized children with growth inhibition and children with significant joints damage (p < 0.02). There was no significant correlation between densitometric parameters and applied treatment with glucocorticoids and without glucocorticoids.

CONCLUSIONS

Decrease of bone mineral mass defined as muscle-skeletal Z-score index for TB BMC/LBM was found in almost quarter of patients within the group of JIA children. In the group of children with growth deficiency and with larger joints damage bone mass was significantly lower.

[Growth disorders in the course of chronic juvenile arthritis]

INTRODUCTION

Juvenile idiopathic arthritis (JIA) is the most common chronic arthropathy, in witch an inflammatory process may lead not only to fixed deformities but also to developmental disturbances, including growth inhibition. The study objective of the current study was to assess the relationship of the degree of physical development disturbances in children with JIA with disease duration, clinical type, the Steinbrocker class of the disease and the therapy applied.

MATERIAL AND METHODS

Anthropometric parameters were analysed in 97 children aged 2-18 years (45 girls and 52 boys) with JIA. Bone densitometry (DXA) was performed in 51 children to assess the mineral mass of the whole skeleton (Total BMD) and L2-L4 vertebrae. Results Growth deficiency below -2.0 SDHS--Standard Deviation Height Score (group I) was found in 25 children (25.8%), with the predominance of older children (p<0.05) suffering from a polyarticular type. Children with considerable joint destruction (class III and IV according to Steinbrocker) exhibited lower height (p<0.002) as compared to the group of children without growth disorders (group II) and with early or moderate anatomical joint damage. Significant differences in BMI were noted between group I and II (16.05 and 18.12, respectively; p<0.02). A significant reduction in total bone mineral mass were found in group I as compared to group II (total BMD 0.736 g/cm2 and 0.922 g/cm2; p<0.05).

CONCLUSIONS

Growth deficiencies which strongly correlated with the degree of joint destruction and thus with inflammatory activity were found in 25% of the study children and adolescents with JIA. Growth retardation was accompanied by a significant bone mass reduction.

[Bone mineral density in children and adolescents with idiopathic chronic musculoskeletal pain syndromes]

PURPOSE

There is a limited information regarding associations between bone mineral density (BMD) and idiopathic musculoskeletal pain in pediatric subjects. The aim of this cross-sectional study was to assess whether children and adolescents with pain syndrome have lower BMD than healthy subjects.

MATERIAL AND METHODS

Eighty-nine subjects (49 girls, 40 boys) aged 5-18 years with chronic non-rheumatic musculoskeletal pain and daily calcium consumption below 500 mg were involved in the study. The subjects were divided in three groups: I--prepubertal (5-9 years), II--pubertal (9-15 years) and III--adolescents (15-18 years). Bone mineral density in the total skeleton (total BMD) and lumbar spine (spine BMD) was examined using dual energy x-ray absorptiometry (DXA) and compared to reference data. Serum calcium, ionized calcium, phosphate, alkaline phosphatase and its bone-fraction were estimated.

RESULTS

Low BMD (below the 5th percentile) was found in about 50% of the participants with pain syndromes in each measurement site. A significantly decreased Spine BMD was observed in those children who reported pain symptoms in the spine region and lower limbs (Z-score for Spine BMD was = -1.55; -1.41) compared to subjects with non-localized pain. The lowest mean Z-score (-1.85) for Spine BMD was found in the postpubertal group (III) compared with groups I and II.

CONCLUSIONS

As one-half of children and adolescents reporting musculoskeletal pain had low BMD it is possible that the symptoms are associated with an inadequate bone mass accrual during growth. Pain localized in the spine region and in lower extremities may be a selective and site-specific symptom of juvenile osteoporosis without fractures. The chronic musculoskeletal pain suggests a rationale for bone density testing during growth.

[Composition of linoleic and arachidonic acids in phosphatidylcholine of erythrocytes membrane and IL-6 and TNF-alpha in serum and C-reactive protein concentration in children with juvenile idiopathic arthritis]

The study objective was to determine the relationship, if any, between the levels of arachidonic and linoleic acids in erythrocyte membrane phosphatidylcholine (PCH), serum interleukin 6 (IL-6) and TNFalpha levels and C-reactive protein (CRP) in juvenile idiopathic arthritis (JIA).

MATERIALS AND METHODS

The study involved 49 children with JIA, aged 3-18 years (mean 11.3 +/- 3.9), and 29 healthy subjects. The JIA children were divided into 2 groups: group I--24 children (in exacerbation period) with mean CRP level of 15.6 mg/L +/- 13.3 and group II--25 children (in remission period--joint swelling-free) with CRP of 7.8 mg/L +/- 5.8 on average. Lipids were extracted according to a modified Folch's method. Fatty acids in erythrocyte membrane PCH were identified using gas chromatography (Hewlett-Packard 5890). The levels of IL-6 and TNFalpha were determined by ELISA, using Quantikine sets: R&D System (USA), while CRP was measured by nephelometric method on a BN II apparatus (Behring).

RESULTS

We found a significant decrease in the level of linoleic acid (p < 0.05) and a statistically insignificant reduction in arachidonic acid in JIA patients as compared to the controls. The decrease in linoleic acid was more pronounced in the active phase of JIA (p < 0.001. The higher serum CRP level was accompanied by a significantly elevated level of IL 6 (p < 0.05). The concentration of TNFa was elevated, but the difference had no statistical significance.

CONCLUSIONS

The levels of linoleic and arachidonic acids in erythrocyte PCH decreased and the concentrations of IL-6 and TNF-alpha increased in JIA children in the active phase of the disease. The differences intensified with a rise in CRP.

Double pattern of relationship between skin temperature, thermoregulation and sensory nerve conduction

Electroneurographic and thermographic investigations were done in 32 persons. Sensory nerve conduction velocity, amplitude of sensory nerve potential, subjective and objective sensory thresholds were determined during stimulation of each finger. The maximal and minimal skin temperatures for each finger were evaluated from thermograms taken from the dorsal and palmar surface of the hand before and after standard cooling test. The measurements were done in a thermostabilised room at 19-21 degrees C effective ambient temperature. The second degree correlations between the electroneurographic and thermographic parameters were calculated. The statistical analysis revealed the presence of a double correlation pattern depending on the homoiothermic or poikilothermic thermoregulatory ability of the finger. The differentiation threshold criterion for the poikilo- and homoiothermic group assignment was the minimal rest temperature of the finger equal to 28 degrees C. The correlations in the poikilothermic fingers were very strong and much stronger than in the homoiothermic fingers. Correlations with temperatures were strong both at rest as well as after cooling. Correlations for the sensory nerve potential amplitude likewise for the objective and subjective thresholds were stronger than for the conduction velocity. Sensory nerve potential amplitude increases and subjective and objective thresholds decrease with finger temperature. The obtained results suggest that sensory nerve conduction is related not only to the actual tissue temperature but also to local thermoregulatory ability.

Relationship between sensory nerve conduction and temperature of the hand

Electroneurographic and thermographic investigations were carried out in 32 persons. Sensory nerve conduction velocity, the amplitude of sensory nerve potential, subjective and objective electrical threshold were determined during the stimulation of each finger. Thermograms were taken before and after the standard cooling test. Statistical analysis has revealed that all the results of electroneurographic and thermographic parameters obtained from the fingers of the same person as well as of all investigated persons are directly connected. Highly significant (p = 0.001 and 0.01) correlations of second degree were found between electroneurographic and temperature parameters.