Basic science knowledge underlies clinical science knowledge and clinical problem solving: evidence from veterinary medicine.

Medical sciences education emphasizes basic science learning as a prerequisite to clinical learning. Studies exploring relationships between achievement in the basic sciences and subsequent achievement in the clinical sciences generally suggest a significant positive relationship. Basic science knowledge and clinical experience are theorized to combine to form encapsulated knowledge- a dynamic mix of information that is useful for solving clinical problems. This study explores the relationship between basic science knowledge (BSK), clinical science knowledge (CSK), and clinical problem-solving ability, as measured within the context of four veterinary colleges using both college-specific measures and professionally validated, standardized measures of basic and clinical science knowledge and problem-solving ability. Significant correlations existed among all variables. Structural equation modeling and confirmatory factor analysis were used to produce models showing that newly acquired BSK directly and significantly predicted BSK retained over time and newly acquired CSK, as well as indirectly predicted clinical problem-solving ability (mediated by newly acquired CSK and BSK retained over time). These findings likely suggest a gradual development of schema (encapsulated knowledge) and not an isolated development of biomedical versus clinical knowledge over time. A broader implication of these results is that explicitly teaching basic science knowledge positively and durably affects subsequent clinical knowledge and problem-solving ability independent of instructional strategy or curricular approach. Furthermore, for veterinary colleges specifically, student performance as measured by both course-level and standardized tests are likely to prove useful for predicting subsequent academic achievement in classroom and clinical settings, licensing examination performance, and/or for identifying students likely in need of remediation in clinical knowledge.

Amyotrophic lateral sclerosis-specific quality of life-short form (ALSSQOL-SF): A brief, reliable, and valid version of the ALSSQOL-R.

INTRODUCTION: The Amyotrophic Lateral Sclerosis (ALS)-Specific Quality of Life instrument and its revised version (ALSSQOL and ALSSQOL-R) have strong psychometric properties, and have demonstrated research and clinical utility. In this study we aimed to develop a short form (ALSSQOL-SF) suitable for limited clinic time and patient stamina. METHODS: The ALSSQOL-SF was created using Item Response Theory and confirmatory factor analysis on 389 patients. A cross-validation sample of 162 patients assessed convergent, divergent, and construct validity of the ALSSQOL-SF compared with psychosocial and physical functioning measures. RESULTS: The ALSSQOL-SF consisted of 20 items. Compared with the ALSSQOL-R, optimal precision was retained, and completion time was reduced from 15-25 minutes to 2-4 minutes. Psychometric properties for the ALSSQOL-SF and its subscales were strong. DISCUSSION: The ALSSQOL-SF is a disease-specific global QOL instrument that has a short administration time suitable for clinical use, and can provide clinically useful, valid information about persons with ALS. Muscle Nerve 58: 646-654, 2018.

Examining the Validity of the North American Veterinary Licensing Examination (NAVLE) Time Constraints.

Individuals who want to become licensed veterinarians in North America must complete several qualifying steps including obtaining a passing score on the North American Veterinary Licensing Examination (NAVLE). Given the high-stakes nature of the NAVLE, it is essential to provide evidence supporting the validity of the reported test scores. One important way to assess validity is to evaluate the degree to which scores are impacted by the allotted testing time which, if inadequate, can hinder examinees from demonstrating their true level of proficiency. We used item response data from the November-December 2014 and April 2015 NAVLE administrations (n =5,292), to conduct timing analyses comparing performance across several examinee subgroups. Our results provide evidence that conditions were sufficient for most examinees, thereby supporting the current time limits. For the relatively few examinees who may have been impacted, results suggest the cause is not a bias with the test but rather the effect of poor pacing behavior combined with knowledge deficits.

Hospital-acquired conditions after bariatric surgery: we can predict, but can we prevent?

BACKGROUND: Centers for Medicare and Medicaid Services initiated a non-payment policy for certain hospital-acquired conditions (HACs) in 2008. This study aimed to determine the rate of the three most common HACs (surgical site infection (SSI), urinary tract infection (UTI), and venous thromboembolism (VTE)) among bariatric surgery patients. Additionally, the association of HACs with patient factors and the effect of HACs on post-operative outcomes were investigated. METHODS: Patients over 18 years with a body mass index (BMI) ≥ 35 who underwent bariatric surgery were identified using the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2012). Patients were grouped into two categories: HAC versus no HAC patients and baseline characteristics and outcomes, including 30-day mortality, reoperation, and mean length of stay (LOS) were compared. Multivariable logistic regression analysis was performed to identify the risk factors for developing a HAC. RESULTS: 98,553 patients were identified, 2,809 (2.9%) developed at least one HACs. SSI was the most common HAC (1.8%), followed by UTI (0.7%) and VTE (0.4%). The rate of these HACs significantly decreased from 4.6% in 2005-2006 to 2.5% in 2012 (p < 0.001). Laparoscopic gastric banding was associated with the lowest rates of HAC (1.3%) and open gastric bypass with the highest (8.0%). HAC patients had significantly higher rates of in-hospital mortality (0.8 vs. 0.1%, p < 0.001) and LOS (3.9 vs. 2.1 days, p < 0.001). On adjusted analysis, open GBP patients had 5.36-fold higher odds of developing a HAC. Interestingly, the presence of a resident surgeon 7-11 years post graduation was associated with significantly increased odds of HACs (1.86, 1.50-2.31, p < 0.001). CONCLUSION: Our data demonstrate a strong correlation between these three HACs following bariatric surgery and factors intrinsic to the bariatric patient population. This calls into question the non-payment policy for inherent patient factors on which they cannot have impact. These findings are important to help inform health care policy decisions regarding access to care for bariatric surgery patients.

The impact of postgraduate training on USMLE® step 3® and its computer-based case simulation component.

BACKGROUND: The United States Medical Licensing Examination® (USMLE®) Step 3® examination is a computer-based examination composed of multiple choice questions (MCQ) and computer-based case simulations (CCS). The CCS portion of Step 3 is unique in that examinees are exposed to interactive patient-care simulations. OBJECTIVE: The purpose of the following study is to investigate whether the type and length of examinees' postgraduate training impacts performance on the CCS component of Step 3, consistent with previous research on overall Step 3 performance. DESIGN: Retrospective cohort study PARTICIPANTS: Medical school graduates from U.S. and Canadian institutions completing Step 3 for the first time between March 2007 and December 2009 (n = 40,588). METHODS: Post-graduate training was classified as either broadly focused for general areas of medicine (e.g. pediatrics) or narrowly focused for specific areas of medicine (e.g. radiology). A three-way between-subjects MANOVA was utilized to test for main and interaction effects on Step 3 and CCS scores between the demographic characteristics of the sample and type of residency. Additionally, to examine the impact of postgraduate training, CCS scores were regressed on Step 1 and Step 2 Clinical Knowledge (CK) scores. Residuals from the resulting regressions were plotted. RESULTS: There was a significant difference in CCS scores between broadly focused (µ = 216, σ = 17) and narrowly focused (µ=211, σ = 16) residencies (p < 0.001). Examinees in broadly focused residencies performed better overall and as length of training increased, compared to examinees in narrowly focused residencies. Predictors of Step 1 and Step 2 CK explained 55% of overall Step 3 variability and 9% of CCS score variability. CONCLUSIONS: Factors influencing performance on the CCS component may be similar to those affecting Step 3 overall. Findings are supportive of the validity of the Step 3 program and may be useful to program directors and residents in considering readiness to take this examination.

Congestive heart failure and chronic obstructive pulmonary disease predict poor surgical outcomes in older adults undergoing elective diverticulitis surgery.

BACKGROUND: Diverticulitis is a common medical condition that disproportionately affects older adults. The ideal management of recurrent diverticulitis, including the role of prophylactic colectomy, remains uncertain. OBJECTIVE: This study aimed to investigate the outcomes among older patients undergoing elective surgery for diverticulitis and examine subgroups of patients with comorbid congestive heart failure and chronic obstructive pulmonary disease to determine whether outcomes in these patients are worse than in other groups. DESIGN: This article reports a retrospective cohort study of patients undergoing elective surgery for diverticulitis. SETTING: Data were derived from the 100% Medicare Provider Analysis and Review inpatient files from 2004 to 2007. PATIENTS: Included were 22,752 patients, age 65 years and older, with a primary diagnosis of diverticulitis that underwent elective left-colon resection, colostomy, or ileostomy. MAIN OUTCOME MEASURE: The primary outcome measure was in-hospital mortality. The secondary outcome measures were intestinal diversion rates (colostomy and ileostomy) and postoperative complications. RESULTS: Overall mortality, intestinal diversion (colostomy and ileostomy), and postoperative complication rate were 1.2%, 11.3%, and 22.1%. Patients with congestive heart failure had increased odds of in-hospital mortality (OR 3.5, 95% CI 2.59-4.63), colostomy (OR 1.9, 95% CI 1.69-2.27), and all postoperative complications, including hemorrhagic (OR 1.5, 95% CI 1.01-2.11), wound (OR 1.9, 95% CI 1.50-2.39), pulmonary (OR 4.2, 95% CI 3.59-4.85), cardiac (OR 4.6, 95% CI 3.68-5.74), postoperative shock/sepsis (OR 3.2, 95% CI 2.53-4.35), renal (OR 4.1, 95% CI 3.22-5.12), and thromboembolic (OR 1.6, 95% CI 1.00-2.43) complications. Patients with chronic obstructive pulmonary disease had significantly increased odds of wound (OR 1.4, 95% CI 1.19-1.67) and pulmonary (OR 2.2, 95% CI 1.94-2.50) complications. Advancing age, congestive heart failure, and chronic obstructive pulmonary disease were significantly associated with increased morbidity and mortality. LIMITATIONS: Medicare data are limited by the potential for lack of generalizability to patients <65 years and the potential for coding errors. CONCLUSIONS: Elective diverticular surgery in older patients carries substantial morbidity, especially in those patients with comorbid congestive heart failure and chronic obstructive pulmonary disease. The rate of perioperative complications that we document in this patient population may attenuate some of the expected benefit of surgery.

Morbidity and mortality associated with antireflux surgery with or without paraesophogeal hernia: a large ACS NSQIP analysis.

BACKGROUND: Surgical repair of paraesophageal hernias (PEH) represents a considerable technical challenge in patients who are older and have multiple comorbidities. We sought to identify factors associated with increased rates of mortality and morbidity in these patients. METHODS: We performed a retrospective analysis of the National Surgical Quality Improvement Program from 2005 through 2007. Patients who underwent an antireflux operation or repair of PEH and with a primary diagnosis of PEH or GERD were included. Primary outcome was 30-day mortality. Secondary outcomes included intraoperative blood transfusion (BT) and standard comorbidities. Multivariate analyses were performed, adjusting for factors of age and BMI. RESULTS: A total of 3518 patients were identified, including 1290 PEH patients. Compared to GERD patients, PEH patients were significantly older and had more comorbidities. On adjusted analysis for PEH patients only, BT and age ≥70 years were significantly associated with multiple outcome variables, including pulmonary complications and venous thromboembolism (VTE), but had no association with mortality. BMI was not found to be associated with any of our outcome measures. CONCLUSION: Despite higher rates of complications, notably pulmonary and VTE, PEH can be repaired in the elderly with mortality rates comparable to those in younger populations. BMI does not adversely impact any short-term outcome measures in patients undergoing PEH repair.

Effects and Unforeseen Consequences of Accessing References on a Maintenance of Certification Examination: Findings From a National Study.

PURPOSE: Increasing criticism of maintenance of certification (MOC) examinations has prompted certifying boards to explore alternative assessment formats. The purpose of this study was to examine the effect of allowing test takers to access reference material while completing their MOC Part III standardized examination. METHOD: Item response data were obtained from 546 physicians who completed a medical subspecialty MOC examination between 2013 and 2016. To investigate whether accessing references was related to better performance, an analysis of covariance was conducted on the MOC examination scores with references (access or no access) as the between-groups factor and scores from the physicians' initial certification examination as a covariate. Descriptive analyses were conducted to investigate how the new feature of accessing references influenced time management within the test day. RESULTS: Physicians scored significantly higher when references were allowed (mean = 534.44, standard error = 6.83) compared with when they were not (mean = 472.75, standard error = 4.87), F(1, 543) = 60.18, P < .001, ω(2) = 0.09. However, accessing references affected pacing behavior; physicians were 13.47 times more likely to finish with less than a minute of test time remaining per section when reference material was accessible. CONCLUSIONS: Permitting references caused an increase in performance, but also a decrease in the perception that the test has sufficient time limits. Implications for allowing references are discussed, including physician time management, impact on the construct assessed by the test, and the importance of providing validity evidence for all test design decisions.

Can Item Keyword Feedback Help Remediate Knowledge Gaps?

BACKGROUND: In graduate medical education, assessment results can effectively guide professional development when both assessment and feedback support a formative model. When individuals cannot directly access the test questions and responses, a way of using assessment results formatively is to provide item keyword feedback. OBJECTIVE: The purpose of the following study was to investigate whether exposure to item keyword feedback aids in learner remediation. METHODS: Participants included 319 trainees who completed a medical subspecialty in-training examination (ITE) in 2012 as first-year fellows, and then 1 year later in 2013 as second-year fellows. Performance on 2013 ITE items in which keywords were, or were not, exposed as part of the 2012 ITE score feedback was compared across groups based on the amount of time studying (preparation). For the same items common to both 2012 and 2013 ITEs, response patterns were analyzed to investigate changes in answer selection. RESULTS: Test takers who indicated greater amounts of preparation on the 2013 ITE did not perform better on the items in which keywords were exposed compared to those who were not exposed. The response pattern analysis substantiated overall growth in performance from the 2012 ITE. For items with incorrect responses on both attempts, examinees selected the same option 58% of the time. CONCLUSIONS: Results from the current study were unsuccessful in supporting the use of item keywords in aiding remediation. Unfortunately, the results did provide evidence of examinees retaining misinformation.

Prevalence, impact, and risk factors for hospital-acquired conditions after major surgical resection for cancer: a NSQIP analysis.

BACKGROUND: The effectiveness of the CMS nonpayment policy for certain hospital-acquired conditions (HAC) is debated, since their preventability is questionable in several groups of patients. This study aimed to determine the rate of the three most common HAC in major surgical resections for cancer: surgical site infection (SSI), urinary tract infection (UTI), and venous thromboembolism (VTE). Additionally, the association of HAC with patients' characteristics and their effect on post-operative outcomes were investigated. METHODS: Patients who underwent surgical resection for esophageal, gastric, hepato-biliary, pancreatic, colorectal, and lung cancer were identified using the ACS-NSQIP database (2005-2012). Early surgical outcomes were compared between HAC and non-HAC patients. Modified Poisson regression was used to identify risk factors for developing HAC. RESULTS: Seventy-four thousand three hundred eighty-one patients were identified, of whom 9,479 (12.74%) developed one or more HAC. HAC patients had significantly higher rates of 30-day mortality, return to operating room, 30-day readmission, had longer LOS, and were less likely to be discharged home. Several peri-operative patients' factors were significantly associated with HAC. CONCLUSION: Our data show that the development of HAC is strongly associated to pre-operative patients' characteristics and not only to sub-optimal peri-operative care, therefore suggesting that the nonpayment policy might be excessively penalizing.

Outcomes of esophagectomy for esophageal achalasia in the United States.

BACKGROUND: While the outcomes after Heller myotomy have been extensively reported, little is known about patients with esophageal achalasia who are treated with esophagectomy. METHODS: This was a retrospective analysis using the Nationwide Inpatient Sample over an 11-year period (2000-2010). Patients admitted with a primary diagnosis of achalasia who underwent esophagectomy (group 1) were compared to patients with esophageal cancer who underwent esophagectomy (group 2) during the same time period. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay, postoperative complications, and total hospital charges. A propensity-matched analysis was conducted comparing the same outcomes between group 1 and well-matched controls in group 2. RESULTS: Nine hundred sixty-three patients with achalasia and 18,003 patients with esophageal cancer underwent esophagectomy. The propensity matched analysis showed a trend toward a higher mortality in group 2 (7.8 vs. 2.9 %, p = 0.08). Postoperative length of stay and complications were similar in both groups. Total hospital charges were higher for the achalasia group ($115,087 vs. $99, 654.2, p = 0.006). CONCLUSION: This is the largest study to date examining outcomes after esophagectomy in patients with achalasia. Based on our findings, esophagectomy can be considered a safe option, and surgeons should not be hindered by a perceived notion of prohibitive operative risk in this patient population.

Outcomes of operations for benign foregut disease in elderly patients: a National Surgical Quality Improvement Program database analysis.

BACKGROUND: The development of minimally invasive operative techniques and improvement in postoperative care has made surgery a viable option to a greater number of elderly patients. Our objective was to evaluate the outcomes of laparoscopic and open foregut operation in relation to the patient age. METHODS: Patients who underwent gastric fundoplication, paraesophageal hernia repair, and Heller myotomy were identified via the National Surgical Quality Improvement Program (NSQIP) database (2005-2011). Patient characteristics and outcomes were compared between five age groups (group I: ≤65 years, II: 65-69 years; III: 70-74 years; IV: 75-79 years; and V: ≥80 years). Multivariable logistic regression analysis was used to predict the impact of age and operative approach on the studied outcomes. RESULTS: A total of 19,388 patients were identified. Advanced age was associated with increased rate of 30-day mortality, overall morbidity, serious morbidity, and extended length of stay, regardless of the operative approach. After we adjusted for other variables, advanced age was associated with increased odds of 30-day mortality compared with patients <65 years (III: odds ratio 2.70, 95% confidence interval 1.34-5.44, P = .01; IV: 2.80, 1.35-5.81, P = .01; V: 6.12, 3.41-10.99, P < .001). CONCLUSION: Surgery for benign foregut disease in elderly patients carries a burden of mortality and morbidity that needs to be acknowledged.

Thirty-day outcomes of paraesophageal hernia repair using the NSQIP database: should laparoscopy be the standard of care?

BACKGROUND: Although surgical repair is universally recognized as the gold standard for treatment of paraesophageal hernia (PEH), the optimal surgical approach is still the subject of debate. To determine which surgical technique is safest, we compared the outcomes of laparoscopic (lap), open transabdominal (TA), and open transthoracic (TT) PEH repair using the NSQIP database. STUDY DESIGN: From 2005 to 2011, we identified 8,186 patients who underwent a PEH repair (78.4% lap, 19.2% TA, 2.4% TT). Primary outcome measured was 30-day mortality. Secondary outcomes included hospital length of stay, and NSQIP-measured postoperative complications. Multivariable analyses were performed to compare the odds of each outcome across procedure type (lap, TA, and TT) while adjusting for other factors. RESULTS: Transabdominal patients had the highest 30-day mortality rate (2.6%), compared with 0.5% in the lap patients (p < 0.001) and 1.5% in TT patients. Mean length of stay was statistically significantly longer for TA and TT patients (7.8 days and 6.5 days, respectively) compared with lap patients (3.3 days). After adjusting for age, American Society of Anesthesiologists score, emergency cases, functional status, and steroid use, TA patients were nearly 3 times as likely as lap patients to experience 30-day mortality (odds ratio [OR], 2.97; 95% CI, 1.69 to 5.20; p < 0.001). Moreover, TA and TT patients had significantly increased odds of overall (OR 2.12; 95% CI 1.79 to 2.51; p < 0.001; OR 2.73; 95% CI 1.88 to 3.96; p < 0.001; respectively) and serious morbidity (OR 1.90; 95% CI 1.53 to 2.37, p < 0.001; OR 2.49; 95% CI 1.54 to 4.00; p < 0.001; respectively). CONCLUSIONS: In the absence of published data indicating improved long-term outcomes after open TA or TT approach, our findings support the use of laparoscopy, whenever technically feasible, because it yields improved short-term outcomes.

Older patients with diverticulitis have low recurrence rates and rarely need surgery.

BACKGROUND: In a cohort of older patients with newly diagnosed diverticulitis, we aimed to describe diverticulitis recurrence and need for an operation based on patient age and site of initial care. METHODS: This retrospective, longitudinal, cohort study used data from the 5% Medicare Provider Analysis and Review inpatient and outpatient files from January 1, 2003, through December 31, 2007. An incident cohort of patients with diverticulitis was identified. Patients undergoing left colectomy, colostomy, or ileostomy were considered to have undergone diverticulitis surgery. The primary outcomes of interest were need for operative intervention and number of recurrences. RESULTS: We included 16,048 individuals and followed them for an average of 19.2 months; their mean age was 77.8 years. Among those with initial inpatient care, 14.0% underwent operations and 82.5% had no further recurrences. Of patients initially managed nonoperatively, 97% did not go on to have surgery. Individuals treated as outpatients upon first presentation, and patients ≥ 80, were significantly less likely to have recurrent episodes and were less likely to require an operation. CONCLUSION: The majority of elderly patients newly diagnosed with diverticulitis did not have an operation or experience recurrent episodes. The apparent benign course of this disease in this population suggests that a conservative approach to the management may be appropriate.

Elective surgery for diverticulitis is associated with high risk of intestinal diversion and hospital readmission in older adults.

PURPOSE: This study seeks to compare outcomes (in-hospital mortality, colostomy rates, and 30-day readmission rates) in older adult patients undergoing emergency/urgent versus elective surgery for diverticulitis. METHODS: Data were derived from the 100% Medicare Provider Analysis and Review (MEDPAR) inpatient file from 2004-2007. All patients 65 years of age and above with a primary diagnosis of diverticulitis that underwent left colon resection, colostomy, or ileostomy were included. The primary outcome variable was in-hospital mortality. Secondary outcome variables included intestinal diversion, 30-day post-discharge readmission rates, discharge destination, length of stay, and total charges. Patients were grouped in two categories for comparison: emergent/urgent (EU) versus elective surgery, as defined by admission type. Multivariate analysis was performed adjusting for age (categorized by five groups), gender, race, and medical comorbidity as measured by Charlson Index. RESULTS: Fifty-three thousand three hundred sixteen individuals were eligible for inclusion, with 23,764 (44.6%) in the elective group. On average, EU patients were older (76.8 vs. 73.9 years of age, p < 0.001) and less likely to be female (65.4% vs. 71.1%, p < 0.001). EU patients had higher in-hospital mortality (8.0% vs. 1.4%, p < 0.001), higher intestinal diversion rates (64.2% vs. 12.7%, p < 0.001), and higher 30-day readmission rates (21.4% vs. 11.9%, p < 0.001) and the worse outcomes persisted even after adjustment for risk factors. Unadjusted and adjusted mortality rates dramatically increased by age, although the affect of age on mortality was more pronounced in the elective group where mortality rates ranged from 0.56% in patients 65-69 years old to 6.5% in patients 85+ years old. The rates of ostomy and 30-day readmission generally increased with age, with worse outcomes noted particularly in the elective group. CONCLUSIONS: As expected, older adults undergoing emergent/urgent surgical treatment for diverticulitis have significantly increased risks of poor outcomes compared with elective patients. While advancing age is associated with a substantial increase in mortality, intestinal diversion and 30-day readmission after surgery for diverticulitis, this affect is especially evident among patients undergoing elective colectomy. Our data suggest that given the considerable risk of prophylactic colon resection in elderly patients with sigmoid diverticulitis, a reappraisal of the proper role of elective colectomy in this population may be warranted.

Economic reform in three Giants : U.S. foreign policy and the USSR, China and India / Economic reform in three Giants : U.S. foreign policy and the USSR, China and India

Three of the largest and strategically most important underdeveloped nations in the world--the Soviet Union, China and India--are simultaneously in the throes of historic changes. Economic reform in the Giants clearly has profound consequences for their own political ystems--and for the lives of the 2.2 billion people (nearly half the world's population) living in their societies. The reforms in the Giants are also prompting dramatic changes in the international policy and economic order

All three of the Giants are opening up their economies to foreign trade, technology, and investment. What consequences will their new outward-orientation have for international trade, and how should U.S. policy respond to these developments? What role can key international economic institutions like the GATT, the International Monetary Fund, and the World Bank play in helping to integrate the Giants more fully into the world economy?

While the ability of the U.S. and the other industrial democracies to influence the course of events within the Giants is limited, they have at their disposal multiple means to facilitate the progress of reform. The authors argue that the many uncertainties of the new international setting "underscore the need for clear-headed realism but should not stand in the way of bold action to help steer history in a forward direction." Their policy recommendations suggest ways to transform past threats into new opportunities (AU)