Managing common ambulatory conditions: Exploring clinical decision making performance between pharmacists and family physicians.

Background: Prescribing is part of the expanded scope of practice for pharmacists in Alberta, Canada. Given these responsibilities, clinical decision making (the outcome from the diagnostic and therapeutic decision making process) is an essential skill for pharmacists. The current study compared diagnostic and therapeutic decision-making between Additional Prescribing Authority (APA) pharmacists and family physicians using a set of common ambulatory clinical cases that both practitioners could encounter in the community as part of their daily practice. Objectives: To explore clinical decision making performance and behaviors between APA pharmacists and family physicians during the assessment and prescribing of common ambulatory conditions. Methods: Eight written ambulatory clinical cases were developed by a panel of experts in both family medicine and pharmacy that were commonly encountered in both professions' daily practice. Participating APA pharmacists and family physicians reviewed the cases and responded with likely diagnoses, recommended treatments, and reported confidence in therapeutic choices. The responses of 18 APA pharmacists and 9 family physicians in community practices were analyzed. Results: There were no significant differences in diagnostic accuracy, therapeutic accuracy, confidence in diagnostic choices, and confidence in therapeutic choices between APA pharmacists and family physicians to these common ambulatory presentations. Conclusions: This study provides preliminary insights regarding the capabilities of pharmacists in the assessment of common ambulatory community conditions and suggests that APA pharmacists are making similar diagnostic and therapeutic decisions to family physicians. Future research could focus on examining the performance of pharmacists trained in different pharmacy education models, as well as their ability to provide clinical assessment in other specialties, or in more uncommon clinical scenarios.

Pathologists aren't pigeons: exploring the neural basis of visual recognition and perceptual expertise in pathology.

Visual (perceptual) reasoning is a critical skill in many medical specialties, including pathology, diagnostic imaging, and dermatology. However, in an ever-compressed medical curriculum, learning and practicing this skill can be challenging. Previous studies (including work with pigeons) have suggested that using reward-feedback-based activities, novices can gain expert levels of visual diagnostic accuracy in shortened training times. But is this level of diagnostic accuracy a result of image recognition (categorization) or is it the acquisition of diagnostic expertise? To answer this, the authors measured electroencephalographic data (EEG) and two components of the human event-related brain potential (reward positivity and N170) to explore the nature of visual expertise in a novice-expert study in pathology visual diagnosis. It was found that the amplitude of the reward positivity decreased with learning in novices (suggesting a decrease in reliance on feedback, as in other studies). However, this signal remained significantly different from the experts whose reward positivity signal did not change over the course of the experiment. There were no changes in the amplitude of the N170 (a reported neural marker of visual expertise) in novices over time. Novice N170 signals remained statistically and significantly lower in amplitude compared to experts throughout task performance. These data suggest that, while novices gained the ability to recognize (categorize) pathologies through reinforcement learning as quantified by the change in reward positivity, increased accuracy, and decreased time for responses, there was little change in the neural marker associated with visual expertise (N170). This is consistent with the multi-dimensional and complex nature of visual expertise and provides insight into future training programs for novices to bridge the expertise gap.

Development of and Validity Evidence for a Canine Ocular Model for Training Novice Veterinary Students to Perform a Fundic Examination.

Indirect fundoscopy is challenging for novice learners, as patients are often intolerant of the procedure, impeding development of proficiency. To address this, we developed a canine ocular simulator that we hypothesized would improve student learning compared to live dogs. Six board-certified veterinary ophthalmologists and 19 second-year veterinary students (novices) performed an indirect fundic examination on the model and live dog. Prior to assessment, novices were introduced to the skill with a standardized teaching protocol and practiced (without feedback) with either the model (n = 10) or live dog (n = 9) for 30 minutes. All participants evaluated realism and usefulness of the model using a Likert-type scale. Performance on the live dog and model was evaluated in all participants using time to completion of task, performance of fundic examination using a checklist and global score, identification of objects in the fundus of the model, and evaluation of time spent looking at the fundus of the model using eye tracking. Novices (trained on simulator or live dogs) were compared in fundic examination performance on the live dog and identification of shapes in the model. In general, experts performed the fundic examination faster (p ≤ .0003) and more proficiently than the novices, although there were no differences in eye tracking behavior between groups (p ≥ .06). No differences were detected between training on simulator versus live dog in development of fundoscopy skills in novices (p ≥ .20). These findings suggest that this canine model may be an effective tool to train students to perform fundoscopy.

Electroencephalography correlates of transcranial direct-current stimulation enhanced surgical skill learning: A replication and extension study.

Transcranial direct-current stimulation (tDCS), an increasingly applied form of non-invasive brain stimulation, can augment the acquisition of motor skills. Motor learning investigations of tDCS are limited to simple skills, where mechanisms are increasingly understood. Investigations of meaningful, complex motor skills possessed by humans, such as surgical skills, are limited. This replication and extension of our previous findings used electroencephalography (EEG) to determine how tDCS and complex surgical training alters electrical activity in the sensorimotor network to enhance complex surgical skill acquisition. In twenty-two participants, EEG was recorded during baseline performance of simulation-based laparoscopic surgical skills. Participants were randomized to receive 20 min of primary motor cortex targeting anodal tDCS or sham concurrent to 1 h of surgical skill training. EEG was reassessed following training, during a post-training repetition of the surgical tasks. Our results replicated our previous study suggesting that compared to sham, anodal tDCS enhanced the acquisition of unimanual surgical skill. Surgical training modulated delta frequency band activity in sensorimotor regions. Next, the performance of unimanual and bimanual skills evoked unique EEG profiles, primarily within the beta frequency-band in parietal regions. Finally, tDCS-paired surgical training independently modulated delta and alpha frequency-bands in sensorimotor regions. Application of tDCS during surgical skill training is feasible, safe and tolerable. In conclusion, we are the first to explore electrical brain activity during performance of surgical skills, how electrical activity may change during surgical training and how tDCS alters the brain to enhance skill acquisition. The results provide preliminary evidence of neural markers that can be targeted by neuromodulation to optimize complex surgical training.

Quantifying two-dimensional and three-dimensional stereoscopic learning in anatomy using electroencephalography.

Advances in computer visualization enabling both 2D and 3D representation have generated tools to aid perception of spatial relationships and provide a new forum for instructional design. A key knowledge gap is the lack of understanding of how the brain neurobiologically processes and learns from spatially presented content, and new quantitative variables are required to address this gap. The objective of this study was to apply quantitative neural measures derived from electroencephalography (EEG) to examine stereopsis in anatomy learning by comparing mean amplitude changes in N250 (related to object recognition) and reward positivity (related to responding to feedback) event related to potential components using a reinforcement-based learning paradigm. Health sciences students (n = 61) learned to identify and localize neuroanatomical structures using 2D, 3D, or a combination of models while EEG and behavioral (accuracy) data were recorded. Participants learning using 3D models had a greater object recognition (N250 amplitude) compared to those who learned from 2D models. Based on neurological results, interleaved learning incorporating both 2D and 3D models provided an advantage in learning, retention, and transfer activities represented by decreased reward positivity amplitude. Behavioral data did not have the same sensitivity as neural data for distinguishing differences in learning with and without stereopsis in these learning activities. Measuring neural activity reveals new insights in applied settings for educators to consider when incorporating stereoscopic models in the design of learning interventions.

Identification of Coding and Non-coding RNA Classes Expressed in Swine Whole Blood.

The advent of innovative and increasingly powerful next generation sequencing techniques has opened new avenues into the ability to examine the underlying gene expression related to biological processes of interest. These innovations not only allow researchers to observe expression from the mRNA sequences that code for genes that effect cellular function, but also the non-coding RNA (ncRNA) molecules that remain untranslated, but still have regulatory functions. Although researchers have the ability to observe both mRNA and ncRNA expression, it has been customary for a study to focus on one or the other. However, when studies are interested in both mRNA and ncRNA expression, many times they use separate samples to examine either coding or non-coding RNAs due to the difference in library preparations. This can lead to the need for more samples which can increase time, consumables, and animal stress. Additionally, it may cause researchers to decide to prepare samples for only one analysis, usually the mRNA, limiting the number of biological questions that can be investigated. However, ncRNAs span multiple classes with regulatory roles that effect mRNA expression. Because ncRNA are important to fundamental biologic processes and disorder of these processes in during infection, they may, therefore, make attractive targets for therapeutics. This manuscript demonstrates a modified protocol for the generation mRNA and non-coding RNA expression libraries, including viral RNA, from a single sample of whole blood. Optimization of this protocol, improved RNA purity, increased ligation for recovery of methylated RNAs, and omitted size selection, to allow capture of more RNA species.

A Reinforcement-Based Learning Paradigm Increases Anatomical Learning and Retention-A Neuroeducation Study.

In anatomy education, a key hurdle to engaging in higher-level discussion in the classroom is recognizing and understanding the extensive terminology used to identify and describe anatomical structures. Given the time-limited classroom environment, seeking methods to impart this foundational knowledge to students in an efficient manner is essential. Just-in-Time Teaching (JiTT) methods incorporate pre-class exercises (typically online) meant to establish foundational knowledge in novice learners so subsequent instructor-led sessions can focus on deeper, more complex concepts. Determining how best do we design and assess pre-class exercises requires a detailed examination of learning and retention in an applied educational context. Here we used electroencephalography (EEG) as a quantitative dependent variable to track learning and examine the efficacy of JiTT activities to teach anatomy. Specifically, we examined changes in the amplitude of the N250 and reward positivity event-related brain potential (ERP) components alongside behavioral performance as novice students participated in a series of computerized reinforcement-based learning modules to teach neuroanatomical structures. We found that as students learned to identify anatomical structures, the amplitude of the N250 increased and reward positivity amplitude decreased in response to positive feedback. Both on a retention and transfer exercise when learners successfully remembered and translated their knowledge to novel images, the amplitude of the reward positivity remained decreased compared to early learning. Our findings suggest ERPs can be used as a tool to track learning, retention, and transfer of knowledge and that employing the reinforcement learning paradigm is an effective educational approach for developing anatomical expertise.

Identification and differentiation of PDX1 ß-cell progenitors within the human pancreatic epithelium.

AIM: To minimize the expansion of pancreatic mesenchymal cells in vitro and confirm that ß-cell progenitors reside within the pancreatic epithelium. METHODS: Due to mesenchymal stem cell (MSC) expansion and overgrowth, progenitor cells within the pancreatic epithelium cannot be characterized in vitro, though ß-cell dedifferentiation and expansion of MSC intermediates via epithelial-mesenchymal transition (EMT) may generate ß-cell progenitors. Pancreatic epithelial cells from endocrine and non-endocrine tissue were expanded and differentiated in a novel pancreatic epithelial expansion medium supplemented with growth factors known to support epithelial cell growth (dexamethasone, epidermal growth factor, 3,5,3'-triiodo-l-thyronine, bovine brain extract). Cells were also infected with a single and dual lentiviral reporter prior to cell differentiation. Enhanced green fluorescent protein was controlled by the rat Insulin 1 promoter and the monomeric red fluorescent protein was controlled by the mouse PDX1 promoter. In combination with lentiviral tracing, cells expanded and differentiated in the pancreatic medium were characterized by flow cytometry (BD fluorescence activated cell sorting), immunostaining and real-time polymerase chain reaction (PCR) (7900HT Fast Realtime PCR System). RESULTS: In the presence of 10% serum MSCs rapidly expand in vitro while the epithelial cell population declines. The percentage of vimentin(+) cells increased from 22% ± 5.83% to 80.43% ± 3.24% (14 d) and 99.00% ± 0.0% (21 d), and the percentage of epithelial cells decreased from 74.71% ± 8.34% to 26.57% ± 9.75% (14 d) and 4.00% ± 1.53% (21 d), P < 0.01 for all time points. Our novel pancreatic epithelial expansion medium preserved the epithelial cell phenotype and minimized epithelial cell dedifferentiation and EMT. Cells expanded in our epithelial medium contained significantly less mesenchymal cells (vimentin(+)) compared to controls (44.87% ± 4.93% vs 95.67% ± 1.36%; P < 0.01). During cell differentiation lentiviral reporting demonstrated that, PDX1(+) and insulin(+) cells were localized within adherent epithelial cell aggregates compared to controls. Compared to starting islets differentiated cells had at least two fold higher gene expression of PDX1, insulin, PAX4 and RFX (P < 0.05). CONCLUSION: PDX1(+) cells were confined to adherent epithelial cell aggregates and not vimentin(+) cells (mesenchymal), suggesting that EMT is not a mechanism for generating pancreatic progenitor cells.

Rare cadaveric finding of a grossly enlarged mucocele appendix.

Appendicular mucoceles are rare clinical findings characterized by dilation and distention of the appendicular lumen by the accumulation of mucus. Their discovery is often incidental from abdominal imaging or more commonly as a secondary surgical finding. In this case study we report the first known recorded case of a cadaveric mucocele appendix discovered during routine dissection of the gastrointestinal system. The recorded cause of death for the 86-year-old female patient was congestive heart failure. We compared the gross anatomy and histology of this enormous appendix with another cadaveric appendix. A pathology report identified the appendicular mucocele as a mucinous cystadenoma.