Keeping fiction true to life.

Nurse Teresa Lynch spent a day on the set of the BBC television drama Silk, advising the programme makers on the portrayal of character with advanced prostate cancer. She ensured equipment and procedures were accurate, and encouraged the script writer to make the storyline more hopefull.

The Use of Virtual Standardized Patients for Practice in High Value Care.

INTRODUCTION: This study examined the influence of high value care (HVC)-focused virtual standardized patients (VSPs) on learner attitudes toward cost-conscious care (CCC), performance on subsequent standardized patient (SP) encounters, and the correlation of VSP performance with educational outcomes. METHOD: After didactic sessions on HVC, third-year medical students participated in a randomized crossover design of simulation modalities consisting of 4 VSPs and 3 SPs. Surveys of attitudes toward CCC were administered before didactics and after the first simulation method. Performance markers included automated VSP grading and, for SP cases, faculty-graded observational checklists and patient notes. Performance was compared between modalities using t tests and analysis of variance and then correlated with US Medical Licensing Examination performance. RESULTS: Sixty-six students participated (VSP first: n = 37; SP-first: n = 29). Attitudes toward CCC significantly improved after training (Cohen d = 0.35, P = 0.043), regardless of modality. Simulation order did not impact learner performance for SP encounters. Learners randomized to VSP first performed significantly better within VSP cases for interview (Cohen d = 0.55, P = 0.001) and treatment (Cohen d = 0.50, P = 0.043). The HVC component of learner performance on the SP simulations significantly correlated with US Medical Licensing Examination step 1 ( r = 0.26, P = 0.038) and step 2 clinical knowledge ( r = 0.33, P = 0.031). CONCLUSIONS: High value care didactics combined with either VSPs or SPs positively influenced attitudes toward CCC. The ability to detect an impact of VSPs on learner SP performance was limited by content specificity and sample size.

Explicating How Skill Determines the Qualities of User-Avatar Bonds.

Many frameworks exist that explain how people interact with avatars. Our core argument is that the primary theoretical mechanisms of a user-avatar bond (i.e., UAB) rest with the way people engage avatars and, thereby, the broader digital environment. To understand and predict such engagement, we identify a person's skill in handling/engaging the avatar in the digital environment as an ordering parameter (i.e., organizing predictor). Accordingly, we define skill as a person's ability to enact their agency successfully to achieve desired states. To explain how skill orders experience, we ground our theorizing in ecological perception and systems theory. In our explication, we describe how stable action coupling (i.e., the linking of action inputs to perceived outcomes) enables a state of embeddedness (i.e., when the environment facilitates and constrains behaviors) in the digital environment. Then, we explain how embeddedness promotes motivational attunement (i.e., orienting of motivational systems) and what the digital environment affords to users at different levels of skill. Throughout, we consider how our theoretical scaffolding generates tractable contentions regarding how skill influences UABs.

Hematological characteristics of patients in coronavirus 19 infection: a systematic review and meta-analysis.

Background COVID-19 infection has become a pandemic and a global health issue since its origin in Wuhan, China in December 2019. The present systematic review and meta-analysis aim to assess hematological changes seen in COVID-19 infection and their association with the severity of the disease. Methods Pooled proportions were calculated using both fixed effects model and random effects model. Weighted mean difference and 95% CI were calculated and reported. Results Initial search identified 84 reference articles, 23 relevant articles were selected and reviewed. Compared to general population, the weighted mean difference of WBC count in all COVID-19 patients was lower by 0.97 × 109 mm3 (95% CI = -1.29 to -0.66). In severe COVID-19 patients, the weighted mean difference of platelet count was lower by 23.85 × 109/liter (95% CI = -35.18 to -9.53), as compared to general population. The weighted mean difference of prothrombin time, D-Dimer, and fibrinogen in severe COVID-19 patients was higher by 1.92 seconds (95% CI = 0.01 to 3.84), 6.23 mg/liter (95% CI = 0.11 to 12.36) and 1.88 g/liter (95% CI = 1.18 to 2.48) respectively, as compared to general population. Pooled proportion showed D-Dimer to be elevated in 80.00% (95 % CI = 50.00 to 99.00) of severe patients. Conclusions Our meta-analysis shows that patients with COVID-19 have significant thrombocytopenia, leukopenia along with elevated D-dimer, fibrinogen and prothrombin time. These laboratory findings are marked in severe COVID-19 infections and could be helpful in early recognition of severe infection.

Virtual Standardized Patient Simulation: Case Development and Pilot Application to High-Value Care.

INTRODUCTION: High-value care (HVC) suggests that good history taking and physical examination should lead to risk stratification that drives the use or withholding of diagnostic testing. This study describes the development of a series of virtual standardized patient (VSP) cases and provides preliminary evidence that supports their ability to provide experiential learning in HVC. METHODS: This pilot study used VSPs, or natural language processing-based patient avatars, within the USC Standard Patient platform. Faculty consensus was used to develop the cases, including the optimal diagnostic testing strategies, treatment options, and scored content areas. First-year resident physician learners experienced two 90-minute didactic sessions before completing the cases in a computer laboratory, using typed text to interview the avatar for history taking, then completing physical examination, differential diagnosis, diagnostic testing, and treatment modules for each case. Learners chose a primary and 2 alternative "possible" diagnoses from a list of 6 to 7 choices, diagnostic testing options from an extensive list, and treatments from a brief list ranging from 6 to 9 choices. For the history-taking module, both faculty and the platform scored the learners, and faculty assessed the appropriateness of avatar responses. Four randomly selected learner-avatar interview transcripts for each case were double rated by faculty for interrater reliability calculations. Intraclass correlations were calculated for interrater reliability, and Spearman ρ was used to determine the correlation between the platform and faculty ranking of learners' history-taking scores. RESULTS: Eight VSP cases were experienced by 14 learners. Investigators reviewed 112 transcripts (4646 learner query-avatar responses). Interrater reliability means were 0.87 for learner query scoring and 0.83 for avatar response. Mean learner success for history taking was scored by the faculty at 57% and by the platform at 51% (ρ correlation of learner rankings = 0.80, P = 0.02). The mean avatar appropriate response rate was 85.6% for all cases. Learners chose the correct diagnosis within their 3 choices 82% of the time, ordered a median (interquartile range) of 2 (2) unnecessary tests and completed 56% of optimal treatments. CONCLUSIONS: Our avatar appropriate response rate was similar to past work using similar platforms. The simulations give detailed insights into the thoroughness of learner history taking and testing choices and with further refinement should support learning in HVC.

A qualitative study of youth living with Crohn disease.

Little is known about what it is like to live in adolescence with a chronic inflammatory bowel disease. This article reports the findings of a small qualitative study that explored the experience of four New Zealand youth aged between 16 and 21 years, who had been recently diagnosed with Crohn disease. Semistructured interviews focused on discovering the youth' thoughts, feelings, and perceptions of living with this condition. Analysis of the transcribed data is presented thematically. The findings reveal stress as integral to living with Crohn disease. They illuminate the paradoxical relationship between fear and hope and provide insight into what helps and what hinders young people's ability to cope with the disease and its treatments. Collectively, these three themes describe the ways in which the lives of young adults are drastically and almost irreparably changed by Crohn disease. The findings contribute to the "promoting wellness" literature and will inform those who support the increasing number of young people living and coping with a chronic inflammatory bowel disease.

The mental capacity act 2: patient advocacy and ethics.

This is the second of a two-part unit on the Mental Capacity Act 2005. Part 1 explored the concept and definition of mental capacity, advance treatment decisions, independent mental capacity advocates and the act's code of practice. This part discusses possible ethical and legal dilemmas in the interpretation of both the act and its code of practice.

The Mental Capacity Act 1: advance decisions.

This is the first of a two-part unit on the Mental Capacity Act 2005. Part 1 outlines the act's key principles and implications. Healthcare professionals' responsibilities are examined in relation to advance decisions.

Sphingomonas paucimobilis presenting as acute phlebitis: A case report.

Sphingomonas paucimobilis is a strictly aerobic, non-spore-forming Gram-negative bacillus, ubiquitous bacterium, thought to be an opportunistic pathogen and is rarely reported in clinical settings. Here in, is the first case report of Acute Sphingomonas phlebitis secondary to intravenous (IV) drug use. We present the case of a 39-year-old male who initially presented with pain in his right upper extremity, fevers and chills of three week duration. He admitted to regularly injecting heroin in his distal right upper extremity with visible erythema, tenderness and streaking along the path of vein along the injection site. Radiographic studies including X-ray of the right arm, ultrasound and a subsequent MRI of the right arm were not significant for any osteomyelitis, deep venous thrombus, abscess, cellulitis, osteomyelitis, or pyomyositis. Blood culture grew Sphingomonas paucimobilis. Patient was initially started on vancomycin and piperacillin/tazobactam and subsequently switched to levofloxacin to complete a 14 day course. Patient admitted to using toilet water to mix his heroin which we suspect may have been the source of his bacteremia. Since it was first reported in 1979, a wide variety of community-acquired and hospital-acquired infections have been attributed to this Sphingomonas. It is ubiquitous to natural environment. We believe that due to its widespread habitat and ability to survive in stress conditions it could be a potential future threat in the era of increasing antimicrobial resistance globally. More research needs to be done on early identification, pathogenesis, treatment and eradication of the organism.

An unexpected deterrent in diagnosing refractory celiac disease and enteropathy-associated T-cell lymphoma: a gluten-free diet.

Enteropathy-associated T-cell lymphoma (EATL) is a rare disease found in the small bowel and is seen most commonly in patients with refractory celiac disease (RCD). We present a case of an elderly male with celiac disease (CD) diagnosed in childhood with months of abdominal pain and diarrhea despite attempting to avoid gluten in his diet. After persistent symptoms for months, the patient was admitted for an acute abdomen and was found to have small bowel perforation due to a jejunal mass that was diagnosed as an EATL. In 2-5% of adult onset CD, serious complications such as RCD or malignancy develop. The clinical course for EATL is aggressive and generally has a poor prognosis. This case highlights the importance of early clinical suspicion for a small bowel malignancy in patients with a long-standing history of CD and acute worsening of symptoms. Early workup and diagnosis is vital in improving morbidity and mortality in patients with EATL.

Invasive meningococcal disease without meningitis: a forgotten diagnosis.

Neisseria meningitidis, a Gram-negative diplococcus, is an uncommon cause of pneumonia. There have been only about 344 cases reported worldwide from 1906 to 2015. To our knowledge, there have been only 3 cases reported in the USA in the past 2 decades. We present a case of a 72-year-old male with a past medical history of severe COPD, obstructive sleep apnea, and stage I lung cancer status post-stereotactic body radiation therapy 1 year ago, who was admitted with a 6-day history of productive cough with yellowish sputum, shortness of breath, extreme myalgias, and fatigue. Chest X-ray revealed an infiltrative process in the left lower lung field and left-sided pleural effusion. Blood cultures grew beta-lactamase-negative N. meningitidis after 24 hours. Our patient was initially treated with broad-spectrum antibiotics, which were later switched to amoxicillin to complete a total of 14 days of antibiotics. Diagnosing meningococcal pneumonia requires a high level of suspicion, as sputum cultures may be falsely positive due to asymptomatic carriage of the organism in the upper respiratory tract in up to 10% of outpatient population. We highlight this case as early recognition and treatment is critical. The case fatality rate for N. meningitidis pneumonia has been reported to be higher compared with meningococcal meningitis.

Abdominal pain with a twist: a rare presentation of acute gastric volvulus.

Acute gastric volvulus is a life threatening condition requiring early diagnosis and aggressive management. Diagnosis of gastric volvulus remains a challenge for clinicians due to variable, non-specific clinical presentation, which requires a high level of suspicion. It should be considered in patients presenting with chest pain and/or epigastric pain, especially in the elderly population. Endoscopic de-rotation could be initially attempted as a therapeutic modality especially in patients who cannot undergo surgery. However, surgery remains the main stay of treatment. Delay in diagnosis can lead to complications like mucosal ischemia, necrosis or perforation, shock, which substantially increase the morbidity and mortality.

May-Thurner syndrome: High output cardiac failure as a result of iatrogenic iliac fistula.

May-Thurner syndrome (MTS) also termed iliocaval compression or Cockett-Thomas syndrome is a common, although rarely diagnosed, condition in which the patient has an anatomical variant wherein the right common iliac artery overlies and compresses the left common iliac vein against the fifth lumbar spine resulting in increased risk of iliofemoral deep venous thrombosis. This variant has been shown to be present in over 23% of the population but most go undetected. We present a patient with MTS who developed high output cardiac failure due to an iatrogenic iliac fistula. The patient underwent an extensive workup for a left to right shunt including MRI and arterial duplex in the vascular lab. He was ultimately found to have a 2.1 cm left common iliac artery aneurysm and history of common iliac stent. We took the patient to the operating room for aortogram with placement of an endovascular plug of the left internal iliac artery and aorto-bi-iliac stent graft placement with CO2 and IV contrast. Subsequently the patient underwent successful stent placement in the area that was compressed followed by 6 mo of anticoagulation with warfarin. The flow from the fistula decreased significantly.

Association of clinical signs and symptoms of Ebola viral disease with case fatality: a systematic review and meta-analysis.

BACKGROUND: Ebola virus disease (EVD) is a public health emergency of international concern. There is limited laboratory and clinical data available on patients with EVD. This is a meta-analysis to assess the utility of clinical signs, symptoms, and laboratory data in predicting mortality in EVD. AIM: To assess the utility of clinical signs, symptoms, and laboratory data in predicting mortality in EVD. METHOD: Study selection criterion: EVD articles with more than 35 EVD cases that described the clinical features were included. Data collection and extraction: Articles were searched in Medline, PubMed, Ovid journals, and CDC and WHO official websites. STATISTICAL METHODS: Pooled proportions were calculated using DerSimonian Laird method (random effects model). RESULTS: Initial search identified 634 reference articles, of which 67 were selected and reviewed. Data were extracted from 10 articles (N=5,792) of EVD which met the inclusion criteria. Bleeding events (64.5% vs. 25.1%), abdominal pain (58.3% vs. 37.5%), vomiting (60.8% vs. 31.7%), diarrhea (69.9% vs. 37.8%), cough (31.6% vs. 22.3%), sore throat (47.7% vs. 19.8%), and conjunctivitis (39.3% vs. 20.3%) were more often present in pooled proportion of fatal cases as compared to EVD survivors. CONCLUSIONS: Clinical features of EVD that may be associated with higher mortality include bleeding events, vomiting, diarrhea, abdominal pain, cough, sore throat, and conjunctivitis. These patients should be identified promptly, and appropriate management should be instituted immediately.

Students' use of mass media for ideas about romantic relationships was influenced by perceived realism of presentations and parental happiness.

52 undergraduates between 18 and 24 years of age (34 women) answered a questionnaire about their use of mass media for ideas about romantic relationships and indicated how happy their parents' relationship seemed during the students' formative years. If sitcoms, dramas, magazine articles, or books were seen as realistic or presenting an ideal for which to strive in real life, students used ideas about romantic relationships presented more frequently, and they also more frequently explored sitcoms and dramas for ideas, but not magazines or books. If the parental relationship was seen as happy, students were more likely to use TV and magazines but not books for ideas; they evaluated sitcoms as more and books as less realistic.

Summary of guidance for the management of early bowel cancer.

Colorectal cancer is an important public health problem and one of the most common cancers registered in New Zealand. In 2009 the New Zealand Guidelines Group were commissioned to produce and evidence-based summary of current New Zealand and international data to inform best practice in the management of people with early bowel cancer. A guideline development team was convened, representing a range of stakeholder groups who met to discuss and agree on the recommendations for a clinical practice guideline. This article summarises the guideline methods and reports the recommendations from the Management of Early Bowel Cancer guideline, published in 2011.

Extending monetary values to broader performance and impact measures: Transportation applications and lessons for other fields.

This article examines recent progress at assigning monetary values to what are normally considered "hard to quantify" benefits of transportation projects. It focuses on three types of impacts - environmental quality, health and wider economic impacts - to examine how transportation project evaluation methods have evolved in recent years and how they compare to methods used for evaluation of non-transportation programs. Examples of recent practice are provided to show how transport agencies are continuing to refine performance measures to include broader impacts in project evaluation. A classification is provided to distinguish direct traveler effects from indirect effects on non-travelers, a step important to maximize coverage and minimize double-counting of impacts. For each type of impact, the paper discusses the range of variation in monetized values and shows that the variation is due less to imprecision in measurement than to fundamental issues about whether to use damage compensation, impact avoidance costs, stated preferences or behavioral valuation perspectives to define those values. Case studies as diverse as Australian roads, Wisconsin energy programs and Appalachian economic development programs are used to show how common methods are evolving among transport and non-transport agencies to improve impact measurement and its use in project evaluation.