How Do Learners Receive Feedback on Note-Writing? A Scoping Review.

PURPOSE: The literature assessing the process of note-writing based on gathered information is scant. This scoping review investigates methods of providing feedback on learners' note-writing abilities. METHOD: Scopus and Web of Science were searched for studies that investigated feedback on student notes or reviewed notes written on an information or data-gathering activity in health care and other fields in August 2022. Of 426 articles screened, 23 met the inclusion criteria. Data were extracted on the article title, publication year, study location, study aim, study design, number of participants, participant demographics, level of education, type of note written, field of study, form of feedback given, source of the feedback, and student or participant rating of feedback method from the included articles. Then possible themes were identified and a final consensus-based thematic analysis performed. RESULTS: Themes identified in the 23 included articles were as follows: (1) Learners found faculty and peer feedback beneficial; (2) Direct written comments and evaluation tools, such as rubrics or checklists, were the most common feedback methods; (3) Reports on notes in real clinical settings were limited (simulated clinical scenarios in preclinical curriculum were the most studied); (4) Feedback providers and recipients benefit from having prior training on providing and receiving feedback; (5) Sequential or iterative feedback was beneficial for learners but can be time intensive for faculty and confounded by maturation effects; and (6) Use of technology and validated assessment tools facilitate the feedback process through ease of communication and improved organization. CONCLUSIONS: The various factors influencing impact and perception of feedback include the source, structure, setting, use of technology, and amount of feedback provided. As the utility of note-writing in health care expands, studies are needed to clarify the value of note feedback in learning and the role of innovative technologies in facilitating note feedback.

A trillion trees: carbon capture or fuelling fires?

Afforesting grassy systems for carbon gain using flammable plantation trees could shift the fire regime from lower intensity grass-fuelled fires to high-intensity crown fires. Future changes in climate will worsen this. We highlight the fire risk of trees planted for carbon and costs of fire protection using African examples.

Trees, carbon, and the psychology of landscapes.

Mitigating climate change while safeguarding biodiversity and livelihoods is a major challenge. However, rampant afforestation threatens biodiversity and livelihoods, with questionable benefits to carbon storage. The narrative of landscape degradation is often applied without considering the history of the landscape. While some landscapes are undoubtedly deforested, others existed in open or mosaic states before human intervention, or have been deliberately maintained as such. In psychology, a 'fundamental attribution error' is made when characteristics are attributed without consideration of context or circumstances. We apply this concept to landscapes, and then propose a process that avoids attribution errors by testing a null hypothesis regarding past forest extent, using palaeoecology and other long-term data, alongside ecological and stakeholder knowledge.

Automated Patient Note Grading: Examining Scoring Reliability and Feasibility.

PURPOSE: Scoring postencounter patient notes (PNs) yields significant insights into student performance, but the resource intensity of scoring limits its use. Recent advances in natural language processing (NLP) and machine learning allow application of automated short answer grading (ASAG) for this task. This retrospective study evaluated psychometric characteristics and reliability of an ASAG system for PNs and factors contributing to implementation, including feasibility and case-specific phrase annotation required to tune the system for a new case. METHOD: PNs from standardized patient (SP) cases within a graduation competency exam were used to train the ASAG system, applying a feed-forward neural networks algorithm for scoring. Using faculty phrase-level annotation, 10 PNs per case were required to tune the ASAG system. After tuning, ASAG item-level ratings for 20 notes were compared across ASAG-faculty (4 cases, 80 pairings) and ASAG-nonfaculty (2 cases, 40 pairings). Psychometric characteristics were examined using item analysis and Cronbach's alpha. Inter-rater reliability (IRR) was examined using kappa. RESULTS: ASAG scores demonstrated sufficient variability in differentiating learner PN performance and high IRR between machine and human ratings. Across all items the ASAG-faculty scoring mean kappa was .83 (SE ± .02). The ASAG-nonfaculty pairings kappa was .83 (SE ± .02). The ASAG scoring demonstrated high item discrimination. Internal consistency reliability values at the case level ranged from a Cronbach's alpha of .65 to .77. Faculty time cost to train and supervise nonfaculty raters for 4 cases was approximately $1,856. Faculty cost to tune the ASAG system was approximately $928. CONCLUSIONS: NLP-based automated scoring of PNs demonstrated a high degree of reliability and psychometric confidence for use as learner feedback. The small number of phrase-level annotations required to tune the system to a new case enhances feasibility. ASAG-enabled PN scoring has broad implications for improving feedback in case-based learning contexts in medical education.

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.

The global spectrum of plant form and function: enhanced species-level trait dataset.

Here we provide the 'Global Spectrum of Plant Form and Function Dataset', containing species mean values for six vascular plant traits. Together, these traits -plant height, stem specific density, leaf area, leaf mass per area, leaf nitrogen content per dry mass, and diaspore (seed or spore) mass - define the primary axes of variation in plant form and function. The dataset is based on ca. 1 million trait records received via the TRY database (representing ca. 2,500 original publications) and additional unpublished data. It provides 92,159 species mean values for the six traits, covering 46,047 species. The data are complemented by higher-level taxonomic classification and six categorical traits (woodiness, growth form, succulence, adaptation to terrestrial or aquatic habitats, nutrition type and leaf type). Data quality management is based on a probabilistic approach combined with comprehensive validation against expert knowledge and external information. Intense data acquisition and thorough quality control produced the largest and, to our knowledge, most accurate compilation of empirically observed vascular plant species mean traits to date.

Quantifying the environmental limits to fire spread in grassy ecosystems.

Modeling fire spread as an infection process is intuitive: An ignition lights a patch of fuel, which infects its neighbor, and so on. Infection models produce nonlinear thresholds, whereby fire spreads only when fuel connectivity and infection probability are sufficiently high. These thresholds are fundamental both to managing fire and to theoretical models of fire spread, whereas applied fire models more often apply quasi-empirical approaches. Here, we resolve this tension by quantifying thresholds in fire spread locally, using field data from individual fires (n = 1,131) in grassy ecosystems across a precipitation gradient (496 to 1,442 mm mean annual precipitation) and evaluating how these scaled regionally (across 533 sites) and across time (1989 to 2012 and 2016 to 2018) using data from Kruger National Park in South Africa. An infection model captured observed patterns in individual fire spread better than competing models. The proportion of the landscape that burned was well described by measurements of grass biomass, fuel moisture, and vapor pressure deficit. Regionally, averaging across variability resulted in quasi-linear patterns. Altogether, results suggest that models aiming to capture fire responses to global change should incorporate nonlinear fire spread thresholds but that linear approximations may sufficiently capture medium-term trends under a stationary climate.

Feedbacks in ecology and evolution.

Ecology and evolutionary biology have focused on how organisms fit the environment. Less attention has been given to the idea that organisms can also modify their environment, and that these modifications can feed back to the organism, thus providing a key factor for their persistence and evolution. There are at least three independent lines of evidence emphasizing these biological feedback processes at different scales: niche construction (population scale); alternative biome states (community scale); and the Gaia hypothesis (planetary scale). These feedback processes make us rethink traditional concepts like niche and adaptation. We argue that organism-environment feedbacks must become a regular part of ecological thinking, especially now that the Earth is quickly changing.

Biome boundary maintained by intense belowground resource competition in world's thinnest-rooted plant community.

Recent findings point to plant root traits as potentially important for shaping the boundaries of biomes and for maintaining the plant communities within. We examined two hypotheses: 1) Thin-rooted plant strategies might be favored in biomes with low soil resources; and 2) these strategies may act, along with fire, to maintain the sharp boundary between the Fynbos and Afrotemperate Forest biomes in South Africa. These biomes differ in biodiversity, plant traits, and physiognomy, yet exist as alternative stable states on the same geological substrate and in the same climate conditions. We conducted a 4-y field experiment to examine the ability of Forest species to invade the Fynbos as a function of growth-limiting nutrients and belowground plant-plant competition. Our results support both hypotheses: First, we found marked biome differences in root traits, with Fynbos species exhibiting the thinnest roots reported from any biome worldwide. Second, our field manipulation demonstrated that intense belowground competition inhibits the ability of Forest species to invade Fynbos. Nitrogen was unexpectedly the resource that determined competitive outcome, despite the long-standing expectation that Fynbos is severely phosphorus constrained. These findings identify a trait-by-resource feedback mechanism, in which most species possess adaptive traits that modify soil resources in favor of their own survival while deterring invading species. Our findings challenge the long-held notion that biome boundaries depend primarily on external abiotic constraints and, instead, identify an internal biotic mechanism-a selective feedback among traits, plant-plant competition, and ecosystem conditions-that, along with contrasting fire regime, can act to maintain biome boundaries.

In Situ Simulation for Adoption of New Technology to Improve Sepsis Care in Rural Emergency Departments.

OBJECTIVES: The aims of the study were to evaluate whether in situ (on-site) simulation training is associated with increased telemedicine use for patients presenting to rural emergency departments (EDs) with severe sepsis and septic shock and to evaluate the association between simulation training and telehealth with acute sepsis bundle (SEP-1) compliance and mortality. METHODS: This was a quasi-experimental study of patients presenting to 2 rural EDs with severe sepsis and/or septic shock before and after rollout of in situ simulation training that included education on sepsis management and the use of telehealth. Unadjusted and adjusted analyses were conducted to describe the association of simulation training with sepsis process of care markers and with mortality. RESULTS: The study included 1753 patients, from 2 rural EDs, 629 presented before training and 1124 presented after training. There were no differences in patient characteristics between the 2 groups. Compliance with several SEP-1 bundle components improved after training: antibiotics within 3 hours, intravenous fluid administration, repeat lactic acid assessment, and vasopressor administration. The use of telemedicine increased from 2% to 5% after training. Use of telemedicine was associated with increases in repeat lactic acid assessment and reassessment for septic shock. We did not demonstrate an improvement in mortality across either of the 2 group comparisons. CONCLUSIONS: We demonstrate an association between simulation and improved care delivery. Implementing an in situ simulation curriculum in rural EDs was associated with a small increase in the use of telemedicine and improvements in sepsis process of care markers but did not demonstrate improvement in mortality. The small increase in telemedicine limited conclusions on its impact.

A novel in situ simulation framework for introduction of a new technology: the 3-Act-3-Debrief model.

BACKGROUND: New technologies for clinical staff are typically introduced via an "in-service" that focuses on knowledge and technical skill. Successful adoption of new healthcare technologies is influenced by multiple other factors as described by the Consolidated Framework in Implementation Research (CFIR). A simulation-based introduction to new technologies provides opportunity to intentionally address specific factors that influence adoption. METHODS: The new technology proposed for adoption was a telehealth cart that provided direct video communication with electronic intensive care unit (eICU) staff for a rural Emergency Department (ED). A novel 3-Act-3-Debrief in situ simulation structure was created to target predictive constructs from the CFIR and connect debriefing to specific workflows. The structure and content of the simulation in relation to the framework is described. Participants completed surveys pre-simulation/post-simulation to measure change in their readiness to adopt the new technology. RESULTS: The scenario was designed and pilot tested before implementation at two rural EDs. There were 60 interprofessional participants across the 2 sites, with 58 pre-simulation and 59 post-simulation surveys completed. The post-simulation mean ratings for each readiness measure (feasibility, quality, resource availability, role clarity, staff receptiveness, and tech usability) increased significantly as a result of the simulation experience. CONCLUSIONS: A novel 3-stage simulation-debriefing structure positively targets factors influencing the adoption of new healthcare technologies.

Sepsis Alerts in Emergency Departments: A Systematic Review of Accuracy and Quality Measure Impact.

INTRODUCTION: For early detection of sepsis, automated systems within the electronic health record have evolved to alert emergency department (ED) personnel to the possibility of sepsis, and in some cases link them to suggested care pathways. We conducted a systematic review of automated sepsis-alert detection systems in the ED. METHODS: We searched multiple health literature databases from the earliest available dates to August 2018. Articles were screened based on abstract, again via manuscript, and further narrowed with set inclusion criteria: 1) adult patients in the ED diagnosed with sepsis, severe sepsis, or septic shock; 2) an electronic system that alerts a healthcare provider of sepsis in real or near-real time; and 3) measures of diagnostic accuracy or quality of sepsis alerts. The final, detailed review was guided by QUADAS-2 and GRADE criteria. We tracked all articles using an online tool (Covidence), and the review was registered with PROSPERO registry of reviews. A two-author consensus was reached at the article choice stage and final review stage. Due to the variation in alert criteria and methods of sepsis diagnosis confirmation, the data were not combined for meta-analysis. RESULTS: We screened 693 articles by title and abstract and 20 by full text; we then selected 10 for the study. The articles were published between 2009-2018. Two studies had algorithm-based alert systems, while eight had rule-based alert systems. All systems used different criteria based on systemic inflammatory response syndrome (SIRS) to define sepsis. Sensitivities ranged from 10-100%, specificities from 78-99%, and positive predictive value from 5.8-54%. Negative predictive value was consistently high at 99-100%. Studies showed some evidence for improved process-of-care markers, including improved time to antibiotics. Length of stay improved in two studies. One low quality study showed improved mortality. CONCLUSION: The limited evidence available suggests that sepsis alerts in the ED setting can be set to high sensitivity. No high-quality studies showed a difference in mortality, but evidence exists for improvements in process of care. Significant further work is needed to understand the consequences of alert fatigue and sensitivity set points.

Savanna tree evolutionary ages inform the reconstruction of the paleoenvironment of our hominin ancestors.

Ideas on hominin evolution have long invoked the emergence from forests into open habitats as generating selection for traits such as bipedalism and dietary shifts. Though controversial, the savanna hypothesis continues to motivate research into the palaeo-environments of Africa. Reconstruction of these ancient environments has depended heavily on carbon isotopic analysis of fossil bones and palaeosols. The sparsity of the fossil record, however, imposes a limit to the strength of inference that can be drawn from such data. Time-calibrated phylogenies offer an additional tool for dating the spread of savanna habitat. Here, using the evolutionary ages of African savanna trees, we suggest an initial tropical or subtropical expansion of savanna between 10 and 15 Ma, which then extended to higher latitudes, reaching southern Africa ca. 3 Ma. Our phylogenetic estimates of the origin and latitudinal spread of savannas broadly correspond with isotopic age estimates and encompass the entire hominin fossil record. Our results are consistent with the savanna hypothesis of early hominin evolution and reignite the debate on the drivers of savanna expansion. Our analysis demonstrates the utility of phylogenetic proxies for dating major ecological transitions in geological time, especially in regions where fossils are rare or absent or occur in discontinuous sediments.

On the Three Major Recycling Pathways in Terrestrial Ecosystems.

Plants are the largest biomass component of most terrestrial ecosystems, and litter decomposition is considered the dominant process by which nutrients return to plants. We show that in terrestrial ecosystems, there are three major pathways by which plant biomass is degraded into forms that release nutrients again available to plants: microbial decomposition; vertebrate herbivory; and wildfires. These processes act at different spatial and temporal scales, have different niches, and generates different ecological and evolutionary feedbacks. This holistic view in which microbes, herbivores, and wildfires play a joint role in the functioning of ecosystems contributes to a better understanding of the diversity of mechanisms regulating the biosphere.

A Rare De Novo Myoepithelial Carcinoma Ex Pleomorphic Adenoma in a Young Woman.

Carcinoma ex pleomorphic adenoma, an uncommon neoplasm of the parotid gland, accounts for less than 4% of salivary gland tumors. It arises from a benign pleomorphic adenoma presenting in the sixth to eighth decades of life. We present this as a unique account of a primary parotid gland carcinoma, arising from myoepithelial cells, without a known precursor lesion, in a 28-year-old woman. This presentation seeks to provide familiarity of an unusual presentation of an unexpected rare pathology in a young female patient and the tools utilized for an accurate diagnosis.

Mismatches between demographic niches and geographic distributions are strongest in poorly dispersed and highly persistent plant species.

The ecological niche of a species describes the variation in population growth rates along environmental gradients that drives geographic range dynamics. Niches are thus central for understanding and forecasting species' geographic distributions. However, theory predicts that migration limitation, source-sink dynamics, and time-lagged local extinction can cause mismatches between niches and geographic distributions. It is still unclear how relevant these niche-distribution mismatches are for biodiversity dynamics and how they depend on species life-history traits. This is mainly due to a lack of the comprehensive, range-wide demographic data needed to directly infer ecological niches for multiple species. Here we quantify niches from extensive demographic measurements along environmental gradients across the geographic ranges of 26 plant species (Proteaceae; South Africa). We then test whether life history explains variation in species' niches and niche-distribution mismatches. Niches are generally wider for species with high seed dispersal or persistence abilities. Life-history traits also explain the considerable interspecific variation in niche-distribution mismatches: poorer dispersers are absent from larger parts of their potential geographic ranges, whereas species with higher persistence ability more frequently occupy environments outside their ecological niche. Our study thus identifies major demographic and functional determinants of species' niches and geographic distributions. It highlights that the inference of ecological niches from geographical distributions is most problematic for poorly dispersed and highly persistent species. We conclude that the direct quantification of ecological niches from demographic responses to environmental variation is a crucial step toward a better predictive understanding of biodiversity dynamics under environmental change.