Clinical prioritisation questions: A novel assessment tool to encourage tolerance of uncertainty?

Uncertainty is a common and increasingly acknowledged problem in clinical practice. Current single best answer (SBA) style assessments test areas where there is one correct answer, and as the approach to assessment impacts on the approach to learning, these exams may poorly prepare our future doctors to handle uncertainty. We therefore, need to modify our approach to assessment to emphasize reasoning and introduce the possibility of more than one 'correct' answer. We have developed clinical prioritization questions (CPQs), a novel formative assessment tool in which students prioritize possible responses in order of likelihood. This assessment format was piloted with a group of medical students and evaluated in comparison with the more traditional SBA question format in a team-based learning setting. Students reported that they felt ongoing use would help improve their tolerance of uncertainty (p < 0.01). Furthermore, over 80% of students felt that CPQs were more reflective of real-life clinical practice. Group based discussions were significantly longer when answering CPQs (p < 0.01), suggesting they may promote richer discourse. CPQs may have a role in formative assessment to help equip students with the skills to cope with ambiguity and strengthen clinical reasoning and decision-making. Institutions may find them more practical to implement compared with other clinical reasoning assessment tools.

Very-short-answer questions: reliability, discrimination and acceptability.

CONTEXT: Single-best-answer questions (SBAQs) have been widely used to test knowledge because they are easy to mark and demonstrate high reliability. However, SBAQs have been criticised for being subject to cueing. OBJECTIVES: We used a novel assessment tool that facilitates efficient marking of open-ended very-short-answer questions (VSAQs). We compared VSAQs with SBAQs with regard to reliability, discrimination and student performance, and evaluated the acceptability of VSAQs. METHODS: Medical students were randomised to sit a 60-question assessment administered in either VSAQ and then SBAQ format (Group 1, n = 155) or the reverse (Group 2, n = 144). The VSAQs were delivered on a tablet; responses were computer-marked and subsequently reviewed by two examiners. The standard error of measurement (SEM) across the ability spectrum was estimated using item response theory. RESULTS: The review of machine-marked questions took an average of 1 minute, 36 seconds per question for all students. The VSAQs had high reliability (alpha: 0.91), a significantly lower SEM than the SBAQs (p < 0.001) and higher mean item-total point biserial correlations (p < 0.001). The VSAQ scores were significantly lower than the SBAQ scores (p < 0.001). The difference in scores between VSAQs and SBAQs was attenuated in Group 2. Although 80.4% of students found the VSAQs more difficult, 69.2% found them more authentic. CONCLUSIONS: The VSAQ format demonstrated high reliability and discrimination and items were perceived as more authentic. The SBAQ format was associated with significant cueing. The present results suggest the VSAQ format has a higher degree of validity.

Validity of very short answer versus single best answer questions for undergraduate assessment.

BACKGROUND: Single Best Answer (SBA) questions are widely used in undergraduate and postgraduate medical examinations. Selection of the correct answer in SBA questions may be subject to cueing and therefore might not test the student's knowledge. In contrast to this artificial construct, doctors are ultimately required to perform in a real-life setting that does not offer a list of choices. This professional competence can be tested using Short Answer Questions (SAQs), where the student writes the correct answer without prompting from the question. However, SAQs cannot easily be machine marked and are therefore not feasible as an instrument for testing a representative sample of the curriculum for a large number of candidates. We hypothesised that a novel assessment instrument consisting of very short answer (VSA) questions is a superior test of knowledge than assessment by SBA. METHODS: We conducted a prospective pilot study on one cohort of 266 medical students sitting a formative examination. All students were assessed by both a novel assessment instrument consisting of VSAs and by SBA questions. Both instruments tested the same knowledge base. Using the filter function of Microsoft Excel, the range of answers provided for each VSA question was reviewed and correct answers accepted in less than two minutes. Examination results were compared between the two methods of assessment. RESULTS: Students scored more highly in all fifteen SBA questions than in the VSA question format, despite both examinations requiring the same knowledge base. CONCLUSIONS: Valid assessment of undergraduate and postgraduate knowledge can be improved by the use of VSA questions. Such an approach will test nascent physician ability rather than ability to pass exams.

Screening-guided spironolactone treatment of subclinical left ventricular dysfunction for heart failure prevention in at-risk patients.

AIMS: Subclinical left ventricular dysfunction (LVD) is a prelude to symptomatic heart failure (HF). We hypothesised that screening-guided treatment with spironolactone would prevent incident HF in at-risk patients. METHODS AND RESULTS: We randomised asymptomatic, community-dwelling subjects aged ≥65 years old, with at least one non-ischaemic HF risk factor (hypertension, type 2 diabetes mellitus or obesity) to echocardiography-guided therapy or usual care. Spironolactone therapy was triggered by the detection of subclinical LVD (global longitudinal strain [GLS] ≤16%) or diastolic abnormalities (at least one of E/e' >15, E/e' >10 with left atrial enlargement [LAE] or impaired relaxation [E/A < 0.8, IR], LAE with IR), or borderline GLS (17%) with IR or borderline GLS with LAE. The primary outcome was incident HF at 24 months. Secondary outcomes were change in 6-min walk test (6MWT) and change in left ventricular function. LVD was identified in 161 (46%) of 349 participants (age 70 [68-73] years, 201 [58%] women). The trial was stopped because of a 55% rate of spironolactone discontinuation, due primarily to decline in renal function. Incident HF developed in 11 (3.5%) of 310 participants completing follow-up, with no difference between usual care and intervention (4 [2.5%] vs. 7 [4.7%], p = 0.29), decline in 6MWT distance (p = 0.28), persistent or new LVD (p = 0.58), nor change in GLS with intervention (p = 0.15). A per-protocol analysis of 131 patients with baseline LVD and a follow-up echocardiogram, showed resolution of LVD with spironolactone therapy (59% vs. 33%, p = 0.01). CONCLUSION: The study was underpowered to determine whether screening-guided spironolactone therapy reduced incident HF because spironolactone was frequently discontinued due to renal function criteria. However, LVD resolved in more patients treated with spironolactone than in untreated patients. Future trials should use less conservative renal criteria for spironolactone discontinuation.

Validation of a focused echocardiographic training program in first opinion practice.

BACKGROUND: The EPIC study defines criteria, including echocardiographic assessments of left atrial to aortic ratio (LA: Ao) and left ventricular internal diameter in diastole normalized for body weight (LVIDdN), for dogs with preclinical myxomatous mitral valve disease (MMVD) likely to benefit from pimobendan therapy. Access to echocardiography by a cardiologist is not universally available. HYPOTHESIS/OBJECTIVES: Completion of a focused echocardiographic training program would result in accurate identification of dogs fulfilling the EPIC criteria by primary care veterinarians (PC). PARTICIPANTS: Six PCs with no previous echocardiographic experience. METHODS: Prospective diagnostic test accuracy study. After training, each PC evaluated ≤10 dogs that they believed to have preclinical MMVD. The evaluation was repeated by 1 of 3 cardiology diplomates, blinded to the PC's findings. Agreement between clinical assessments and echocardiographic measurements was assessed. RESULTS: Fifty-seven dogs were evaluated by PCs; 1 dog was withdrawn because of congestive heart failure. The median time between PC and cardiologist evaluation was 0 days (range, 0-8). One incorrect diagnosis of MMVD was made by a PC (this dog had dilated cardiomyopathy [DCM]); preclinical MMVD was confirmed by the cardiologist in 55 dogs. No difference in LA: Ao (P = .96; CV = 6.9%) was detected between PCs and cardiologists. LVIDdN (1.69 cm/kg0.294 (1.26-2.21) vs 1.73 cm/kg0.294 (1.32-2.73); P = .001; CV = 6.5%), was significantly lower when measured by PCs vs cardiologists. PCs and cardiologists agreed regarding assessment of EPIC criteria in 49/56 dogs (Alpha = .761, 95% confidence interval 0.697-0.922). CONCLUSIONS AND CLINICAL IMPORTANCE: The program effectively trained PCs to accurately assess EPIC criteria in dogs with preclinical MMVD.

Community immersion project to enhance medical students understanding of the health needs of the most vulnerable in the community.

AIM: A group of eight fourth year medical students formed the 'UBMS public health crew' to conduct a community immersion project within elderly ethnic minority communities. The aim of the study was to understand their health perceptions regarding influenza vaccinations and learn about the enablers and barriers in accessing the vaccination. METHODOLOGY: Interviews were held by the students at community lunch clubs with the help of questionnaires. RESULTS: 76 people participated in the focus groups of which 56.5% were Asians and 43% were Irish. Feedback was sought from the students in the form of an online survey. CONCLUSION: This project helped the medical students improve their public health knowledge, gave them an opportunity to interact with members of the community and learn about the health and social problems faced by underserved/vulnerable communities. The students were also able to appreciate the cultural, sociodemographic and psychological determinants of health in an underserved community. Providing such community immersion projects can enable future doctors to be better prepared for care closer to the community and have better insight into patient-centred care. RESULTS: 76 people participated in the focus groups of which 56.5% were Asians and 43% were Irish. Feedback was sought from the students in the form of an online survey. this project helped the medical students improve their public health knowledge, gave them an opportunity to interact with members of the community and learn about the health and social problems faced by underserved/vulnerable communities. The students were also able to appreciate the cultural, sociodemographic and psychological determinants of health in an underserved community. Providing such community immersion projects can enable future doctors to be better prepared for care closer to the community and have better insight into patient-centred care. METHODS: Interviews were held by the students at community lunch clubs with the help of questionnaires. 76 people participated in the focus groups of which 56.5% were Asians and 43% were Irish. Feedback was sought from the students in the form of an online survey which found that this project helped the medical students improve their public health knowledge, gave them an opportunity to interact with members of the community and learn about the health and social problems faced by underserved/vulnerable communities. The students were also able to appreciate the cultural, sociodemographic and psychological determinants of health in an underserved community. Providing such community immersion projects can enable future doctors to be better prepared for care closer to the community and have better insight into patient-centred care. AIM: A group of eight fourth year medical students formed the 'UBMS public health crew' to conduct a community immersion project within elderly ethnic minority communities. The aim of the study was to understand their health perceptions regarding influenza vaccinations and learn about the enablers and barriers in accessing the vaccination. Interviews were held by the students at community lunch clubs with the help of questionnaires. 76 people participated in the focus groups of which 56.5% were Asians and 43% were Irish. Feedback was sought from the students in the form of an online survey which found that this project helped the medical students improve their public health knowledge, gave them an opportunity to interact with members of the community and learn about the health and social problems faced by underserved/vulnerable communities. The students were also able to appreciate the cultural, sociodemographic and psychological determinants of health in an underserved community. Providing such community immersion projects can enable future doctors to be better prepared for care closer to the community and have better insight into patient-centred care.

The rOSCE: A remote clinical examination during COVID lockdown and beyond.

This article was migrated. The article was marked as recommended. The COVID-19 pandemic has created a challenge for all medical educators. There is a clear need to train the next generation of doctors whilst ensuring that patient safety is preserved. The OSCE has long been used as the gold standard for assessing clinical competency in undergraduates ( Khan et al., 2013a). However, social distancing rules have meant that we have had to reconsider our traditional assessment methods. We held a remote eight-station summative OSCE (rOSCE) for three final year resit students using Microsoft Teams. Apart from clinical examinations and practical procedures which are assessed elsewhere in our programme, the content was similar to our standard OSCE. Staff and student training ensured familiarity with the assessment modality. The rOSCE was found to be a feasible tool with high face validity. The rOSCE is a remote assessment tool that can offer an alternative to the traditional face to face OSCEs for use in high stakes examinations. Although further research is needed, we believe that the rOSCE is scalable to larger cohorts of students and is adaptable to the needs of most undergraduate clinical competency assessments.

Ambulatory electrocardiography and serum cardiac troponin I measurement in 21 dogs envenomated by the European adder (Vipera berus).

BACKGROUND: Envenomation by the European adder (Vipera berus) is common in dogs in Europe. Cardiac arrhythmias occur but clinical studies of envenomated dogs are limited. OBJECTIVES: To describe arrhythmias in dogs within 48 hours of envenomation, and investigate associations between arrhythmia grade, serum troponin I (cTnI), and snakebite severity score (SS score). ANIMALS: Twenty-one client-owned dogs bitten by V berus. METHODS: Prospective cohort study of envenomated dogs. Ambulatory electrocardiograms were recorded from presentation to 48 hours after snakebite, and arrhythmias graded 0 to 3 based on frequency and severity. Serum cTnI was measured at presentation, 12 hours, 24 hours, 36 hours, and 14 days after bite. An SS score of 1 to 3 was recorded at admission and based on clinical examination. RESULTS: All dogs survived. Twelve dogs (57%) developed arrhythmias, all of which were ventricular in origin. Severe complex ventricular arrhythmias (VAs) were observed in 6 dogs (29%). Eighty-one percent of dogs (n = 17) had increased cTnI concentrations at 1 or more time points. Dogs that developed arrhythmias had significantly higher concentrations of cTnI at 12 hours (1.67 [0.04-32.68] versus 0.03 [0.01-0.052]; P = .002), 24 hours (1.88 [0.2-14.23] versus 0.06 [0.01-2.06]; P = .009), and 36 hours (3.7 [0.02-16.62] versus 0.06 [0.01-1.33]; P = .006) after bite compared to those that did not. Contingency table analysis showed that SS score was not significantly associated with arrhythmia grade (P = .9). CONCLUSIONS AND CLINICAL IMPORTANCE: Myocardial cell injury, reflected by increased cTnI concentrations and VAs, is common after V berus envenomation in dogs. Prolonged electrocardiography monitoring is advised, particularly where cTnI is increased.

Consumer Neuroscience and Digital/Social Media Health/Social Cause Advertisement Effectiveness.

This research investigated the use of consumer neuroscience to improve and determine the effectiveness of action/emotion-based public health and social cause (HSC) advertisements. Action-based advertisements ask individuals to 'do something' such as 'act', 'share', make a 'pledge' or complete a 'challenge' on behalf of a brand, such as doing 'something good, somewhere, for someone else'. Public health messages as noncommercial advertisements attempt to positively change behavioural intent or increase awareness. Australian health expenditure was $180.7 billion AUD (Australian dollars) in 2016/17 with $17 million AUD spent on government health campaigns. However, evaluation of health advertisement effectiveness has been difficult to determine. Few studies use neuroscience techniques with traditional market research methods. A 2-part study with an exploratory design was conducted using (1) electroencephalography (EEG) using a 64 channel EEG wet cap (n = 47); and (2) a Qualtrics online psychometric survey (n = 256). Participants were asked to make a donation before and after viewing 7 HSC digital/social media advertisements and logos (6 action/emotion-based; 1 control) to measure changes in behavioural intent. Attention is considered a key factor in determining advertising effectiveness. EEG results showed theta synchronisation (increase)/alpha desynchronisation (decrease) indicating attention with episodic memory encoding. sLORETA results displayed approach responses to action/emotion-based advertisements with left prefrontal and right parietal cortex activation. EEG and survey results showed the greatest liking for the ManUp action/emotion-based advertisement which used male facial expressions of raw emotion and vulnerability. ManUp also had the highest increased amount donated after viewing. Lower theta amplitude results for the International Fund for Animal Welfare (IFAW) action/emotion-based advertisement indicated that novel (possessing distinct features) rather than attractive/conventional faces were more appealing, while the rapid presentation of faces was less effective. None of the highest peak amplitudes for each ad occurred when viewing brand logos within the advertisement. This research contributes to the academic consumer neuroscience, advertising effectiveness, and social media literature with the use of action/challenge/emotion-based marketing strategies, which remains limited, while demonstrating the value in combining EEG and neuroscientific techniques with traditional market research methods. The research provides a greater understanding of advertising effectiveness and changes in behavioural intent with managerial implications regarding the effective use of action/challenge/emotion-based HSC communications to potentially help save a life and reduce expenditure on ineffectual HSC marketing campaigns.

Effect of remote ischaemic preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery: a randomised controlled trial.

BACKGROUND: Whether remote ischaemic preconditioning, an intervention in which brief ischaemia of one tissue or organ protects remote organs from a sustained episode of ischaemia, is beneficial for patients undergoing coronary artery bypass graft surgery is unknown. We did a single-blinded randomised controlled study to establish whether remote ischaemic preconditioning reduces myocardial injury in these patients. METHODS: 57 adult patients undergoing elective coronary artery bypass graft surgery were randomly assigned to either a remote ischaemic preconditioning group (n=27) or to a control group (n=30) after induction of anaesthesia. Remote ischaemic preconditioning consisted of three 5-min cycles of right upper limb ischaemia, induced by an automated cuff-inflator placed on the upper arm and inflated to 200 mm Hg, with an intervening 5 min of reperfusion during which the cuff was deflated. Serum troponin-T concentration was measured before surgery and at 6, 12, 24, 48, and 72 h after surgery. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00397163. FINDINGS: Remote ischaemic preconditioning significantly reduced overall serum troponin-T release at 6, 12, 24, and 48 h after surgery. The total area under the curve was reduced by 43%, from 36.12 microg/L (SD 26.08) in the control group to 20.58 microg/L (9.58) in the remote ischaemic preconditioning group (mean difference 15.55 [SD 5.32]; 95% CI 4.88-26.21; p=0.005). INTERPRETATION: We have shown that adult patients undergoing elective coronary artery bypass graft surgery at a single tertiary centre could benefit from remote ischaemic preconditioning, using transient upper limb ischaemia.

(6R)-5,6,7,8-tetrahydro-L-biopterin and its stereoisomer prevent ischemia reperfusion injury in human forearm.

OBJECTIVE: 6R-5,6,7,8-tetrahydro-L-biopterin (6R-BH4) is a cofactor for endothelial nitric oxide synthase but also has antioxidant properties. Its stereo-isomer 6S-5,6,7,8-tetrahydro-L-biopterin (6S-BH4) and structurally similar pterin 6R,S-5,6,7,8-tetrahydro-D-neopterin (NH4) are also antioxidants but have no cofactor function. When endothelial nitric oxide synthase is 6R-BH4-deplete, it synthesizes superoxide rather than nitric oxide. Reduced nitric oxide bioavailability by interaction with reactive oxygen species is implicated in endothelial dysfunction (ED). 6R-BH4 corrects ED in animal models of ischemia reperfusion injury (IRI) and in patients with cardiovascular risks. It is uncertain whether the effect of exogenous 6R-BH4 on ED is through its cofactor or antioxidant action. METHODS AND RESULTS: In healthy volunteers, forearm blood flow was measured by venous occlusion plethysmography during intra-arterial infusion of the endothelium-dependent vasodilator acetylcholine, or the endothelium-independent vasodilator glyceryl trinitrate, before and after IRI. IRI reduced plasma total antioxidant status (P=0.03) and impaired vasodilatation to acetylcholine (P=0.01), but not to glyceryl trinitrate (P=0.3). Intra-arterial infusion of 6R-BH4, 6S-BH4 and NH4 at approximately equimolar concentrations prevented IRI. CONCLUSION: IRI causes ED associated with increased oxidative stress that is prevented by 6R-BH4, 6S-BH4, and NH4, an effect mediated perhaps by an antioxidant rather than cofactor function. Regardless of mechanism, 6R-BH4, 6S-BH4, or NH4 may reduce tissue injury during clinical IRI syndromes.

Effects of sample handling on serum N-terminal proB-type natriuretic peptide concentration in normal dogs and dogs with heart disease.

OBJECTIVES: To determine whether serum N-terminal B-type natriuretic peptide (NT-proBNP) concentration in normal dogs, and dogs with heart disease, is affected by freezing, or by sample ageing when stored at room temperature. ANIMALS, MATERIALS AND METHODS: Thirty six dogs with heart disease and ten normal dogs. Serum NT-proBNP was measured within 60 min of sample collection. Serum was also frozen at -20 degrees C and NT-proBNP measurement was repeated at 1, 24, 48, 72 and 96 h after thawing. RESULTS: Median NT-proBNP increased significantly after freezing (p<0.005) and then progressively decreased at all time points after thawing (p<0.005). CONCLUSIONS: Serum NT-proBNP concentration increases with freezing, and then rapidly decreases over time when stored at room temperature. Concentrations were sufficiently increased after freezing and decreased after 24h at room temperature to affect interpretation. The authors recommend that serum for NT-proBNP assay should be frozen within 1h of sampling and submitted frozen in cold packs.