Home Auditory Environments of Children With Cochlear Implants and Children With Normal Hearing.

OBJECTIVES: Early home auditory environment plays an important role in children's spoken language development and overall well-being. This study explored differences in the home auditory environment experienced by children with cochlear implants (CIs) relative to children with normal hearing (NH). DESIGN: Measures of the child's home auditory environment, including adult word count (AWC), conversational turns (CTs), child vocalizations (CVs), television and media (TVN), overlapping sound (OLN), and noise (NON), were gathered using the Language Environment Analysis System. The study included 16 children with CIs (M = 22.06 mo) and 25 children with NH (M = 18.71 mo). Families contributed 1 to 3 daylong recordings quarterly over the course of approximately 1 year. Additional parent and infant characteristics including maternal education, amount of residual hearing, and age at activation were also collected. RESULTS: The results showed that whereas CTs and CVs increased with child age for children with NH, they did not change as a function of age for children with CIs; NON was significantly higher for the NH group. No significant group differences were found for the measures of AWC, TVN, or OLN. Moreover, measures of CTs, CVs, TVN, and NON from children with CIs were associated with demographic and child factors, including maternal education, age at CI activation, and amount of residual hearing. CONCLUSIONS: These findings suggest that there are similarities and differences in the home auditory environment experienced by children with CIs and children with NH. These findings have implications for early intervention programs to promote spoken language development for children with CIs.

Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update From the American College of Physicians.

Description: This guideline updates the 2008 American College of Physicians (ACP) recommendations on treatment of low bone density and osteoporosis to prevent fractures in men and women. This guideline is endorsed by the American Academy of Family Physicians. Methods: The ACP Clinical Guidelines Committee based these recommendations on a systematic review of randomized controlled trials; systematic reviews; large observational studies (for adverse events); and case reports (for rare events) that were published between 2 January 2005 and 3 June 2011. The review was updated to July 2016 by using a machine-learning method, and a limited update to October 2016 was done. Clinical outcomes evaluated were fractures and adverse events. This guideline focuses on the comparative benefits and risks of short- and long-term pharmacologic treatments for low bone density, including pharmaceutical prescriptions, calcium, vitamin D, and estrogen. Evidence was graded according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Target Audience and Patient Population: The target audience for this guideline includes all clinicians. The target patient population includes men and women with low bone density and osteoporosis. Recommendation 1: ACP recommends that clinicians offer pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women who have known osteoporosis. (Grade: strong recommendation; high-quality evidence). Recommendation 2: ACP recommends that clinicians treat osteoporotic women with pharmacologic therapy for 5 years. (Grade: weak recommendation; low-quality evidence). Recommendation 3: ACP recommends that clinicians offer pharmacologic treatment with bisphosphonates to reduce the risk for vertebral fracture in men who have clinically recognized osteoporosis. (Grade: weak recommendation; low-quality evidence). Recommendation 4: ACP recommends against bone density monitoring during the 5-year pharmacologic treatment period for osteoporosis in women. (Grade: weak recommendation; low-quality evidence). Recommendation 5: ACP recommends against using menopausal estrogen therapy or menopausal estrogen plus progestogen therapy or raloxifene for the treatment of osteoporosis in women. (Grade: strong recommendation; moderate-quality evidence). Recommendation 6: ACP recommends that clinicians should make the decision whether to treat osteopenic women 65 years of age or older who are at a high risk for fracture based on a discussion of patient preferences, fracture risk profile, and benefits, harms, and costs of medications. (Grade: weak recommendation; low-quality evidence).

Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians.

DESCRIPTION: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the management of chronic insomnia disorder in adults. METHODS: This guideline is based on a systematic review of randomized, controlled trials published in English from 2004 through September 2015. Evaluated outcomes included global outcomes assessed by questionnaires, patient-reported sleep outcomes, and harms. The target audience for this guideline includes all clinicians, and the target patient population includes adults with chronic insomnia disorder. This guideline grades the evidence and recommendations by using the ACP grading system, which is based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. RECOMMENDATION 1: ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder. (Grade: strong recommendation, moderate-quality evidence). RECOMMENDATION 2: ACP recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful. (Grade: weak recommendation, low-quality evidence).

Health impact of human rights testimony: harming the most vulnerable?

BACKGROUND: Current legal efforts to document human rights violations typically include interviews in which survivors are asked to provide detailed descriptions of their traumatic experiences during a single meeting. Research on similar interview techniques used as part of a mental health treatment (eg, debriefing) has raised concerns that they might worsen mental health-more than doubling the risk of post-traumatic stress disorder in some studies. While controversy over the mental health impact of debriefing continues, debriefing treatments have been discontinued in most clinics nearly 2 decades ago. The purpose of this article is to promote the development and integration of preventative measures to limit potential mental health damage associated with legal endeavours to address human rights violations and international crimes. METHODS AND FINDINGS: Given the recent growth of the field of global mental health and its current capacity to provide feasible, acceptable, effective care in low-resource settings, we propose a research agenda to identify the mental health impact of current human rights legal practices and test a model of scalable medicolegal care that minimises risk by integrating mental health monitoring and applying up-to-date models of trauma treatment, including multiple meeting sessions, as indicated. CONCLUSIONS: As the fields of global health, human rights law, international criminal law and transitional justice increasingly overlap in their efforts to assist communities affected by grave violence, we propose that synchronising efforts may offer important opportunities to improve mental health for survivors.

The impact of intramural grants on educators' careers and on medical education innovation.

PURPOSE: The University of California, San Francisco (UCSF), Haile T. Debas Academy of Medical Educators Innovations Funding program awards competitive grants to create novel curricula and faculty development programs, compare pedagogical approaches, and design learner assessment methods. The authors examined the principal investigators' (PIs') perceptions of the impact of these intramural grants on their careers and on medical education innovation. METHOD: At 12 months (project completion) and 24 months (follow-up), PIs submit a progress report describing the impact of their grant on their careers, work with collaborators, subsequent funding, project dissemination, and the UCSF curriculum. The authors analyzed these reports using qualitative thematic analysis and achieved consensus in coding and interpretation through discussion. RESULTS: From 2001 to 2012, the program funded 77 PIs to lead 103 projects, awarding over $2.2 million. The authors analyzed reports from 88 grants (85.4%) awarded to 68 PIs (88.3%). PIs noted that the funding led to accelerated promotion, expanded networking opportunities, enhanced knowledge and skills, more scholarly publications and presentations, extramural funding, and local and national recognition. They also reported that the funding improved their status in their departments, enhanced their careers as medical educators, laid the foundation for subsequent projects, and engaged an array of stakeholders, including trainees and junior faculty. CONCLUSIONS: These modest intramural education grants not only created innovative, enduring programs but also promoted educators' professional identity formation, fostered collaborations, supported junior faculty in finding their desired career paths, provided advancement opportunities, and raised the local and national profiles of recipients.

The paucity of evidence supporting screening for stages 1-3 CKD in asymptomatic patients with or without risk factors.

The American College of Physicians recently published a guideline on screening for CKD that recommends against screening for CKD in asymptomatic adults without risk factors. The generally accepted criteria for population-based screening for disease state that screening should improve important clinical outcomes while limiting harms for those individuals screened. However, CKD screening does not meet these criteria. There is currently no evidence evaluating or demonstrating benefits for providing early treatment for patients identified via screening who do not have risk factors. On the other hand, harms are associated with the screening and include false-positive results, unnecessary testing and treatment, and disease labeling.

Advances in clinical education: a model for infectious disease training for mid-level practitioners in Uganda.

Advances in health professional education have been slow to materialize in many developing countries over the past half-century, contributing to a widening gap in quality of care compared to developed countries. Recent calls for reform in global health professional education have stressed, among other priorities, the need for approaches that strengthen clinical reasoning skills. While the development of these skills is critical to enhance health systems, little research has been carried out on the effectiveness of applying these strategies in the context of severe human resource shortages and complex disease presentations. Integrated Infectious Disease Capacity Building Evaluation (IDCAP) based at the Infectious Diseases Institute at Makerere University created a training program using current best practices in clinical education to support the development of complex reasoning skills among clinicians in rural Uganda. Over a period of 9 months, the program integrated classroom and clinic-based training approaches and measured indicators of success with particular reference to common infectious diseases. This article describes in detail the IDCAP approach to integrating advances in health professional education theory in the context of an overburdened, inadequately resourced primary health care system; results from the evaluation are expected in 2012.

Tips for teaching in longitudinal clerkships.

BACKGROUND: Longitudinal clinics (LCs) are increasingly common learning settings for North American medical students. However, the structure of an LC is distinct from a traditional block rotation, and requires different teaching strategies to maximise opportunities for learning. CONTEXT: The length of the relationship between student and teacher in an LC allows the teacher to focus on the basics of orientation early in the year, and to gradually entrust the student with more responsibility. The trajectory of learning can be anticipated by a teacher and used to guide the student's development over time. INNOVATION AND IMPLICATIONS: We gathered feedback from students and teachers who participated in a year-long LC, and offer four tips for effective workplace learning. By using these tips, teachers can ease the transition into a complex work environment and maximise learning from clinical encounters.

Expert patients: learning from HIV.

The outbreak of HIV in the early 1980s saw widespread activism among patients and community supporters. The author, a young physician in San Francisco at the time, describes how coming of age as a clinician in the midst of this activism affected her concept of the patient-physician relationship. The insistence of a particular patient, Robert, on specifying his treatment goals illustrates that even people with substantial cognitive challenges can participate in their own care in an egalitarian and active manner.

Mainstreaming quality and safety: a reformulation of quality and safety education for health professions students.

The urgent need to expand the ability of health professionals to improve the quality and safety of patient care in the USA has been well documented. Yet the current methods of teaching quality and safety to health professionals are inadequate for the task. To the extent that quality and safety are addressed at all, they are taught using pedagogies with a narrow focus on content transmission, didactic sessions that are spatially and temporally distant from clinical work, and quality and safety projects segregated from the provision of actual patient care. In this article an argument for a transformative reorientation in quality and safety education for health professions is made. This transformation will require new pedagogies in which a) quality improvement is an integral part of all clinical encounters, b) health professions students and their clinical teachers become co-learners working together to improve patient outcomes and systems of care, c) improvement work is envisioned as the interdependent collaboration of a set of professionals with different backgrounds and perspectives skillfully optimising their work processes for the benefit of patients, and d) assessment in health professions education focuses on not just individual performance but also how the care team's patients fared and how the systems of care were improved.

Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010.

The Carnegie Foundation for the Advancement of Teaching, which in 1910 helped stimulate the transformation of North American medical education with the publication of the Flexner Report, has a venerated place in the history of American medical education. Within a decade following Flexner's report, a strong scientifically oriented and rigorous form of medical education became well established; its structures and processes have changed relatively little since. However, the forces of change are again challenging medical education, and new calls for reform are emerging. In 2010, the Carnegie Foundation will issue another report, Educating Physicians: A Call for Reform of Medical School and Residency, that calls for (1) standardizing learning outcomes and individualizing the learning process, (2) promoting multiple forms of integration, (3) incorporating habits of inquiry and improvement, and (4) focusing on the progressive formation of the physician's professional identity. The authors, who wrote the 2010 Carnegie report, trace the seeds of these themes in Flexner's work and describe their own conceptions of them, addressing the prior and current challenges to medical education as well as recommendations for achieving excellence. The authors hope that the new report will generate the same excitement about educational innovation and reform of undergraduate and graduate medical education as the Flexner Report did a century ago.