A comprehensive approach to identify challenges for clinical reasoning development in undergraduate dental students and their potential solutions.

INTRODUCTION: Clinical reasoning is a core competence in health professions that impacts the ability to solve patients' health problems. Due to its relevance, it is necessary to identify difficulties arising from different sources that affect clinical reasoning development in students. The aim of this study was to explore a comprehensive approach to identify challenges for clinical reasoning development in undergraduate dental students and their potential solutions. METHODS: Mixed methods were used in four stages: (1) students and clinical teachers focus groups to identify challenges to clinical reasoning development; (2) literature review to explore potential solutions for these challenges; (3) Delphi technique for teacher consensus on pertinence and feasibility of solutions (1-5 scale); and (4) teachers' self-perception of their ability to implement the solutions. RESULTS: Three categories and seven subcategories of challenges were identified: (I) educational context factors influencing the clinical reasoning process; (II) teacher's role in clinical reasoning development; and (III) student factors influencing the clinical reasoning process. From 134 publications identified, 53 were selected for review, resulting in 10 potential solutions. Through two Delphi rounds, teachers rated the potential solutions very highly in terms of relevance (4.50-4.85) and feasibility (3.50-4.29). Finally, a prioritisation ranking of these solutions was generated using their scores for relevance, feasibility, and teachers' self-perception of their ability to implement them. CONCLUSIONS: The present comprehensive approach identified challenges for clinical reasoning development in dental students and their potential solutions, perceived as relevant and feasible by teachers, requiring further research and follow-up actions to address them.

Mycobacterium abscessus pulmonary infection during hepatitis C treatment with telaprevir, peginterferon and ribavirin.

The first generation protease inhibitors has been the mainstay of hepatitis C treatment for the last couple of years, showing marked improvement in sustained virological response, but also increased side effects. Infection has emerged as a common complication of telaprevir and boceprevir in combination with peginterferon and ribavirin, usually caused by common pathogens. We present the case of a 65 years old man who developed a Mycobacterium abscessus pulmonary infection during treatment with telaprevir, peginterferon and ribavirin. The patient was successfully treated with amikacin, imipenem and chlarithromycin. The present case is relevant for increasing awareness for recognition of opportunistic infections and particularly nontuberculous mycobacterial infections in patients receiving triple therapy for chronic hepatitis C, especially in cirrhotic subjects who develop significant lymphopenia.

Effects of bile acid sequestration on hepatic steatosis in obese mice.

BACKGROUND. Bile acid sequestration (BAS) with resins has shown antidiabetic effects in both humans and animals. Since hepatic steatosis is commonly associated with type 2 diabetes mellitus and the effects of BAS on steatosis have not been explored in detail, we evaluated the effects of cholestyramine (CTM) administration on fatty liver development in the leptin-deficient obese mice. AIM. To study the effects of BAS on fatty liver development in obese (ob/ob) mice. MATERIAL AND METHODS. 4 week-old ob/ob mice (B6.V-Lepob/J, n = 4-6 per group) were fed with or without CTM (control group) during 8 weeks. Serum and biliary parameters, glucose tolerance test (GTT), hepatic triglyceride content, liver histology and hepatic gene expression of relevant genes related to bile secretion, lipid and glucose metabolism were assessed. RESULTS. Control 12-week-old mice exhibited marked obesity and hepatic steatosis. CTM administration expectedly determined a marked de-repression of 7-α-hydroxylase and decreased biliary bile acid secretion as well as improved GTT. CTM feeding showed no effects on hepatic triglyceride content or in the degree of steatosis on liver histology. CTM was associated with increased levels of serum alanine-aminotransferase. CONCLUSION. Although CTM administration positively affects glucose tolerance it does not prevent hepatic steatosis development in obese mice. Moreover, CTM feeding was associated to liver enzyme elevation in this model of NAFLD. Thus, the effects BAS on NAFLD need to be specifically addressed since this therapy might not be beneficial for this condition.

The best mirror of the students' longitudinal performance: Portfolio or structured oral exam assessment at clerkship?

OBJECTIVE: This study aimed to compare the strength of association (i.e., explained variability) of the cumulative grade point average (GPA) with the grades obtained in the clerkship portfolio and the final structured oral exam by dental students. METHODS: A prospective longitudinal study was designed to analyze quantitative data from three cohorts of dental school students. Univariate and multivariate linear regression models were built to evaluate the association between the students' cumulative GPA with the grades obtained in their clerkship portfolio and the final structured oral exam. RESULTS: In total, 171 students in the last year of the undergraduate program were considered (76% women, age average 24.8 ± 1.6 years). The dental students' grades of both portfolio and structured oral exam were significantly associated with the GPA score but with different strengths of association. The clerkship portfolio was more strongly associated with cumulative GPA than the structured oral exam (R2  = 19.6% versus R2  = 7.6%). On the opposite, the association between the structured oral exam and GPA can be interpreted as a lower precision in its practical significance and thus reflecting different concurrent validity. CONCLUSIONS: Considering the results of this study, it could probably incline the balance toward the portfolio because it may be closer to a programmatic assessment model, with timely feedback, development of metacognition, and the achievement of formative process measurement rather than evidence of a single instance of examination.

Adaptation, psychometric properties, and implementation of the Mini-CEX in dental clerkship.

BACKGROUND: Workplace-based assessment is a key component of dental-student clerkships, allowing students to demonstrate clinical proficiency. PURPOSE: This study adapts the Mini-Clinical Evaluation Exercise (Mini-CEX) to a dentistry-program clerkship, analyzing the results and examining the psychometric properties of Mini-CEX. METHODS: First, Delphi panel methodology was used to ensure content validity. Mini-CEX was then piloted in the dental-clerkship program, with each student assessed by at least 2 supervisors and a peer student. Subsequently, psychometric properties, acceptability, and observation time were analyzed. RESULTS: The study was conducted between July and November 2019. Overall, 140 Mini-CEX evaluation exercises were carried out on 30 students by 84 supervisors and 56 peers. The adapted instrument was found to be unidimensional, obtaining an acceptable internal consistency (α = 0.74). As the assessor type changed, there were differences in observation time; the medians (Q1-Q3) were 10 minutes (5-15) for supervisors and 30 minutes (20-45) for peer students (P < 0.001). This difference was also observed in assessor perceptions (P < 0.001), with supervisors scoring a median of 6 (6-6.75) and peer students scoring a median of 7 (6-7). No differences were found between supervisor and peer scores. CONCLUSION: The adapted version of Mini-CEX can objectively assess the clinical performance of dental students, achieving validity and reliability values similar to those obtained in the original instrument.

Measuring the educational environment in health professions studies: a systematic review.

BACKGROUND: One of the determinants of the medical student's behaviour is the medical school learning environment. AIM: The aim of this research was to identify the instruments used to measure the educational environment in health professions education and to assess their validity and reliability. METHODS: We performed an electronic search in the medical literature analysis and retrieval system online (MEDLINE) and Timelit (Topics in medical education) databases through to October 2008. The non-electronic search (hand searching) was conducted through reviewing the references of the retrieved studies and identifying the relevant ones. Two independent authors read, rated and selected studies for the review according to the pre-specified criteria. The inter-rater agreement was measured with Kappa coefficient. RESULTS: Seventy-nine studies were included with the Kappa coefficient of 0.79, which demonstrated a reliable process, and 31 instruments were extracted. The Dundee Ready Education Environment Measure, Postgraduate Hospital Educational Environment Measure, Clinical Learning Environment and Supervision and Dental Student Learning Environment Survey are likely to be the most suitable instruments for undergraduate medicine, postgraduate medicine, nursing and dental education, respectively. CONCLUSIONS: As a valid and reliable instrument is available for each educational setting, a study to assess the educational environment should become a part of an institution's good educational practice. Further studies employing a wider range of databases with more elaborated search strategies will increase the comprehensiveness of the systematic review.