An Exploratory Study Testing Environmental Wayfinding Aids as an Intervention for Children With Autism.

PURPOSE: This exploratory mixed methods experiment aimed to determine whether the application of wayfinding aids (colored doors, shapes on the floor, and signage) as an intervention could help children with autism spectrum disorder (ASD) find their way to a destination to promote independence. BACKGROUND: Several individuals with ASD have described the difficulties they experienced finding their way in the environment. This is especially relevant to complex environments like healthcare. METHODS: Participants with ASD aged 8-11 (n = 9) were randomly assigned to control or treatment groups. The test location was an empty school corridor unfamiliar to participants. Each participant was shown the way to a destination using a script pointing out existing cues (control group) or applied wayfinding aids (treatment group). Participants were taken back to the start and then asked to lead the way to the destination. Afterward, they were interviewed about their experience. Data collection included observation, behavioral mapping, and video recording. RESULTS: The variable of wayfinding scripts helped all participants find their way to the destination, but those in the treatment group found their way directly compared to 75% of the control group. Wayfinding aids made the environment more memorable to those in the treatment group. Some children were distracted by environmental stimuli, and some noticed surprising elements that helped them wayfind. CONCLUSIONS: Study results suggest that wayfinding instruction could be used as an intervention in environments with and without the application of wayfinding aids. This needs further testing in other environments. Issues included recruitment and random assignment.

Clinical physiology grand rounds.

BACKGROUND: Clinical Physiology Grand Rounds (CPGR) is an interactive, case-based conference for medical students designed to: (1) integrate preclinical and clinical learning; (2) promote inductive clinical reasoning; and (3) emphasise students as peer teachers. CPGR specifically encourages mixed learning level student interactions and emphasises the use of concept mapping. We describe the theoretical basis and logistical considerations for an interactive, integrative, mixed-learner environment such as CPGR. In addition, we report qualitative data regarding students' attitudes towards and perceptions of CPGR. CONTEXT: Medical students from first to fourth year participate in a monthly, interactive conference. PROGRAMME DESCRIPTION: The CPGR was designed to bridge gaps and reinforce linkages between basic science and clinical concepts, and to incorporate interactive vertical integration between preclinical and clinical students. Medical education and content experts use Socratic, interactive teaching methods to develop real-time concept maps to emphasise the presence and importance of linkages across curricula. PROGRAMME EVALUATION: Student focus groups were held to assess attitudes towards and perceptions of the mixed-learner environment and concept maps in CPGR. Qualitative analyses of focus group transcripts were performed to develop themes and codes describing the students' impressions of CPGR. DISCUSSION: CPGR is a case-based, interactive conference designed to help students gain an increased appreciation of linkages between basic science and clinical medicine concepts, and an increased awareness of clinical reasoning thought processes. Success is dependent upon explicit attention being given to goals for students' integrated learning.

Can naive viewers put themselves in the patients' shoes?: reliability and validity of the analogue patient methodology.

BACKGROUND: Analogue patients (APs) are untrained viewers given the task of viewing and rating their impressions of a medical interaction while taking on the patient role. This methodology is often used to assess patient perceptions when using real patient (RP) populations is unethical or impractical. OBJECTIVES: This study examines the reliability and validity of the AP methodology and its optimal implementation. RESEARCH DESIGN: Forty-six videotaped interactions of RP-physician interactions, where RP satisfaction scores existed, were viewed by 216 APs, who rated satisfaction. Interrater reliability for AP satisfaction scores was evaluated. AP and RP satisfaction scores were compared with each other and correlated with the physician's observer-coded patient-centeredness. MEASURES: RP satisfaction was measured with a 15-item scale after the whole interaction. Physicians' patient-centered behavior was coded with the Four Habits Coding Scheme. AP satisfaction was measured after viewing the entire interaction with a single satisfaction question, a 4-item satisfaction scale including that single item, and the original 15-item satisfaction scale used by the RPs. RESULTS: AP satisfaction ratings were reliable (=0.70 for 4 APs). AP satisfaction was a significant predictor of RP satisfaction (r=0.29, P=0.05), especially when the analysis was limited to the RPs who reported being less than perfectly satisfied (r=0.65, P=0.002). AP satisfaction was a better predictor than RP satisfaction of providers' patient-centered behaviors in the interaction. CONCLUSIONS: The AP methodology is a valid and reliable approach to gathering patient perception data about provider-patient interactions. Results suggest practical advice for researchers using the AP methodology.

Specific non-peroxide antibacterial effect of manuka honey on the Staphylococcus aureus proteome.

Manuka honey, derived from the New Zealand flowering plant Leptospermum scoparium, shows promise as a topical antibacterial agent and effective chronic wound dressing. The aim of this study was to determine the non-peroxide antibacterial effects of this honey on the proteome of the common wound pathogen Staphylococcus aureus. Proteomic analysis was performed on cells treated for a short time with manuka honey compared with the proteome of untreated cells as well as cells treated with a Leptospermum honey sample without antibacterial activity. Treatment with manuka honey resulted in a significant decrease in the bacterial cell growth rate as well as downregulation of ten and upregulation of two proteins. Nine of these proteins were also differentially expressed by cells treated with the inactive Leptospermum honey, but to a lesser degree, and the rate of bacterial growth was not affected. The differentially expressed proteins have roles in ribosomal function, protein synthesis, metabolic processes and transcription. Manuka honey uniquely caused downregulation of two proteins [dihydrolipoamide dehydrogenase (DLD) and elongation factor Tu (EF-Tu)] associated with two of these pathways as well as upregulation of one stress-related protein [cold shock protein C (CspC)]. The proteomic profile following treatment with manuka honey differed from the profiles of other antibacterial agents, indicating a unique mode of action and its potential value as a novel antimicrobial agent.

Perspectives on intraoperative teaching: divergence and convergence between learner and teacher.

OBJECTIVE: While current emphases on operative teaching focus on "virtual" education, residents and faculty engage most intimately in the operating room. The utilization of intraoperative teaching techniques, drawn from adult education principles, is understudied. DESIGN: A survey with both quantitative and qualitative elements was administered to surgical residents and their faculty. Thirty-eight analogous questions regarding teaching techniques, populating four general domains, were rated for frequency of application. Respondents were asked to rank best teaching practices and identify other effective educational approaches using open-ended questions. SETTING: University-based general surgical residency (5 institutions). PARTICIPANTS: General surgical residents and their faculty. RESULTS: 46 residents (77%) and 37 faculty (63%; mean 17 yrs experience) completed the survey. There was significant disagreement between residents and faculty in how frequently 32 of the 38 teaching techniques were applied (all p < 0.032). Faculty rated the technique "I set and communicate high standards" as the most frequently applied strategy, while residents rated "The faculty demonstrate technical consistency" the highest. The least employed approach, acknowledged by both groups, was "The faculty ask how they might improve their teaching." There were few differences between perceptions and preferences of junior vs. senior learners, and junior vs. senior faculty. Resident and faculty appreciation of most-effective teaching approaches was similar. Qualitative analysis of the open-ended questions yielded themes which resonate with both learners and teachers: communication processes, time pressures, optimization of the work/teaching environment, teacher engagement, patience/tolerance, autonomy, feedback, learner preparedness, and patient advocacy. CONCLUSIONS: The perceptions of residents and faculty regarding the frequency of using effective approaches for operative teaching are disparate. While faculty appear to value adult learning principles and perceive that they are employed regularly, residents have a discrepant viewpoint. However, themes that were identified by both residents and faculty through qualitative analysis provide the foundation for educational process improvements.

Electronic medical record reminders and panel management to improve primary care of elderly patients.

BACKGROUND: Most elderly patients do not receive recommended preventive care, acute care, and care for chronic conditions. METHODS: We conducted a controlled trial to assess the effectiveness of electronic medical record (EMR) reminders, with or without panel management, on health care proxy designation, osteoporosis screening, and influenza and pneumococcal vaccinations in patients older than 65 years. Physicians were assigned to 1 of the following 3 arms: EMR reminder, EMR reminder plus panel manager, or control. We assessed completion of recommended practices during a 1-year period. RESULTS: Among patients who had not already received the recommended care, health care proxy was designated in 6.5% of patients in the control arm, 8.8% of the EMR reminder arm, and 19.7% of the EMR reminder plus panel manager arm (P=.002). Bone density screening was completed in 17.7% of patients in the control arm, 19.7% of the EMR reminder arm, and 30.5% of the EMR reminder plus panel manager arm (P=.02). Pneumococcal vaccine was given to 13.1% of patients in the control arm, 19.5% of the EMR reminder arm, and 25.6% of the EMR reminder plus panel manager arm (P=.02). Influenza vaccine was given to 46.8% of patients in the control arm, 56.5% of the EMR reminder arm, and 59.7% of the EMR reminder plus panel manager arm (P=.002). Results were similar when adjusted for individual physician performance in the preceding year, patient age, patient sex, years cared for by the practice, and number of visits. CONCLUSIONS: Electronic medical record reminders alone facilitated improvement in vaccination rates and, when augmented by panel management, facilitated further improvement in vaccination rates and boosted the rates of health care proxy designation and bone density screening. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01313169.

The antibacterial activity of honey derived from Australian flora.

Chronic wound infections and antibiotic resistance are driving interest in antimicrobial treatments that have generally been considered complementary, including antimicrobially active honey. Australia has unique native flora and produces honey with a wide range of different physicochemical properties. In this study we surveyed 477 honey samples, derived from native and exotic plants from various regions of Australia, for their antibacterial activity using an established screening protocol. A level of activity considered potentially therapeutically useful was found in 274 (57%) of the honey samples, with exceptional activity seen in samples derived from marri (Corymbia calophylla), jarrah (Eucalyptus marginata) and jellybush (Leptospermum polygalifolium). In most cases the antibacterial activity was attributable to hydrogen peroxide produced by the bee-derived enzyme glucose oxidase. Non-hydrogen peroxide activity was detected in 80 (16.8%) samples, and was most consistently seen in honey produced from Leptospermum spp. Testing over time found the hydrogen peroxide-dependent activity in honey decreased, in some cases by 100%, and this activity was more stable at 4 °C than at 25 °C. In contrast, the non-hydrogen peroxide activity of Leptospermum honey samples increased, and this was greatest in samples stored at 25 °C. The stability of non-peroxide activity from other honeys was more variable, suggesting this activity may have a different cause. We conclude that many Australian honeys have clinical potential, and that further studies into the composition and stability of their active constituents are warranted.

An educational intervention for providers to promote bone health in high-risk older patients.

OBJECTIVES: To design, implement, and assess an educational intervention for providers focused on osteoporosis screening and management in older patients with chronic obstructive pulmonary disease or asthma who have been prescribed prolonged courses of oral or high-dose inhaled corticosteroids or both and are therefore at high risk for bone loss and fractures. DESIGN: One-group pretest-posttest. SETTING: Academic outpatient pulmonary practice. PARTICIPANTS: Nineteen pulmonary specialists at an academic medical center. INTERVENTION: Educational theory and a needs assessment and attitude survey guided the development of a multicomponent educational intervention. MEASUREMENTS: Change in provider behavior was assessed by auditing the electronic medical records for adherence to osteoporosis management guidelines in high-risk patients seen by participants at baseline and for 6 months after the educational intervention. Knowledge transfer and changes in attitude were assessed using pre- and posttests and surveys. RESULTS: A 19% increase in overall rate of adherence to osteoporosis management guidelines in high-risk patients was observed: 45% before intervention to 64% after intervention (n=249 patients, P=.003). Postintervention surveys and test scores also showed statistically significant gains from baseline. CONCLUSION: An educational intervention improved adherence to osteoporosis management guidelines of academic pulmonary specialists. The results of this study provide evidence for the positive effect of a multimodal educational program in altering practice behaviors.

Learner perception of oral and written examinations in an international medical training program.

BACKGROUND: There are an increasing number of training programs in emergency medicine involving different countries or cultures. Many examination types, both oral and written, have been validated as useful assessment tools around the world; but learner perception of their use in the setting of cross-cultural training programs has not been described. AIMS: The goal of this study was to evaluate learner perception of four common examination methods in an international educational curriculum in emergency medicine. METHODS: Twenty-four physicians in a cross-cultural training program were surveyed to determine learner perception of four different examination methods: structured oral case simulations, multiple-choice tests, semi-structured oral examinations, and essay tests. We also describe techniques used and barriers faced. RESULTS: There was a 100% response rate. Learners reported that all testing methods were useful in measuring knowledge and clinical ability and should be used for accreditation and future training programs. They rated oral examinations as significantly more useful than written in measuring clinical abilities (p < 0.01). Compared to the other three types of examinations, learners ranked oral case simulations as the most useful examination method for assessing learners' fund of knowledge and clinical ability (p < 0.01). CONCLUSIONS: Physician learners in a cross-cultural, international training program perceive all four written and oral examination methods as useful, but rate structured oral case simulations as the most useful method for assessing fund of knowledge and clinical ability.

Procedural competence in internal medicine residents: validity of a central venous catheter insertion assessment instrument.

PURPOSE: Despite mandates from accreditation bodies for programs to ensure procedural competence, standardized measures do not exist to assess residents' skills in performing central venous catheter (CVC) insertion. The objective of the present study was to develop an instrument to assess residents in subclavian (SC) CVC insertion, to set performance standards, and to validate the tool using performance data. METHOD: In 2007, the authors convened experts to create an assessment tool for CVC insertion using a modified Delphi method. They applied the Angoff method to a second set of experts to determine minimum passing scores (MPSs) for both the borderline trainee and the competent trainee. Two faculty evaluators then used the checklist to assess residents performing CVCs on simulators. RESULTS: The authors created and experts confirmed a 24-item checklist. Using the Angoff method, the MPS required completion of 10 major and 2 minor criteria for a trainee to show borderline proficiency with CVC insertion under supervision. This MPS was correlated with a global rating of 2 on a 5-point scale. The MPS for competence was 17 major and 5 minor criteria. None of the residents deemed competent on a global rating scale achieved the MPS for competence. CONCLUSIONS: The authors were able to create and validate a consensus-driven procedural assessment tool with data-driven standards for basic proficiency and competence that faculty can use to assess residents as they perform CVC insertion.

Honey has an antifungal effect against Candida species.

The incidence of Candida infections is escalating worldwide. The serious nature of these infections is compounded by increasing levels of drug resistance. We report that certain honeys have significant antifungal activity against clinical isolates of Candida species. Importantly, the minimum inhibitory concentration of these honeys would be achievable in a clinical setting.

The Four Habits Coding Scheme: validation of an instrument to assess clinicians' communication behavior.

OBJECTIVE: To present preliminary evidence for the reliability and validity of the Four Habits Coding Scheme (4HCS), an instrument based on a teaching model used widely throughout Kaiser Permanente to improve clinicians' communication skills. METHODS: One hundred videotaped primary care visits were coded using the 4HCS, and the data were assessed against a previously available data set for these visits, including the Roter Interaction Analysis System (RIAS), back channel responses, measures of nonverbal behavior, length of visit, and patients' post-visit assessments. RESULTS: Levels of inter-rater reliability were acceptable, and the distribution of ratings across items indicated that physicians' modal responses varied widely. Correlations between 4HCS ratings, RIAS, back channel responses, and non-verbal measures provided evidence of the instrument's construct validity. CONCLUSIONS: The Four Habits Coding Scheme, an instrument that combines both evaluative and descriptive elements of physician communication behavior and is derived from a conceptually based teaching model, has the potential to be of utility to researchers and evaluators as well as educators and clinicians. PRACTICE IMPLICATIONS: The Four Habits Coding Scheme provides a template for both guiding and measuring physician communication behaviors.

Matching patients and practitioners based on beliefs about care: results of a randomized controlled trial.

OBJECTIVE: To determine whether an intervention designed to inform and guide patients in choosing a primary care provider (PCP) could increase satisfaction and trust. DESIGN: A randomized controlled trial conducted at the Santa Clara Medical Center of the Kaiser Permanente Medical Care Program in Northern California. PATIENTS AND METHODS: Patients needing a PCP were randomly assigned to Informed Choice (provider-level information offered), Guided Choice (PCP names provided based on the similarity of patients' and practitioners' patient-centered beliefs, and patients then chose), or Usual Care. One year later, mailed questionnaires asked about patients' trust and satisfaction, perceptions of the choice process, and trust and satisfaction with Kaiser Permanente. More than 5000 adult patients were linked with a PCP as part of the project, and completed surveys were returned by 2437 patients. RESULTS: Neither intervention arm generated better matches on patient-practitioner beliefs than Usual Care; however, trust and satisfaction were higher among Guided Choice patients. Across study arms, patient-practitioner belief discrepancy showed a consistent positive association with trust, satisfaction, and attitudes toward Kaiser Permanente. CONCLUSIONS: The discrepancy between patient and practitioner beliefs about care is an important determinant of trust and satisfaction, and involving patients in the selection of their PCP can have an independent positive effect. It should be possible to build on the experience of this project to develop programs that better match patients and practitioners within managed care plans.

Primary care experiences of medicare beneficiaries, 1998 to 2000.

OBJECTIVE: To examine changes in the quality of primary care experienced and reported by Medicare beneficiaries from 1998 to 2000. DESIGN: Longitudinal observational study. SETTING: Thirteen states with large, mature Medicare HMO markets. PARTICIPANTS: Probability sample of noninstitutionalized Medicare beneficiaries aged 65 and older enrolled in traditional Medicare (FFS) or a Medicare HMO. MEASUREMENTS AND MAIN RESULTS: We examined 2-year changes in 9 measures derived from the Primary Care Assessment Survey (PCAS). The measures covered 2 broad areas of primary care performance: quality of physician-patient interactions (5 measures) and structural/organizational features of care (4 measures). For each measure, we computed the change in each beneficiary's score (1998 vs 2000) and standardized effect sizes (ES). Results revealed significant declines in 3 measures of physician-patient interaction quality (communication, interpersonal treatment, and thoroughness of physical exams; P < or = .0001). Physicians' knowledge of patients increased significantly over the 2-year period (P < or = .001). Patient trust did not change (P = .10). With regard to structural/organizational features of care, there were significant declines in financial access (P < or = .001), visit-based continuity (P < .001), and integration of care (P < or = .05), while organizational access increased (P < or = .05). With the exception of financial access, observed changes did not differ by system (FFS, HMO). CONCLUSIONS: Over a 2-year period, the quality of seniors' interactions with their primary physicians declined significantly, as did other hallmarks of primary care such as continuity, integration of care, and financial access. This decline is in sharp contrast to the marked improvements in technical quality that have been measured over this period. In an era marked by substantial national investment in quality monitoring, measures of these elements of care are notably absent from the nation's portfolio of quality indicators.

The work impact of dysthymia in a primary care population.

Physicians regard individuals with dysthymia as having relatively normal levels of functioning. This study examines in detail the work impact of dysthymia in a population of employed primary care patients. As part of an observational study conducted between 2001 and 2003 in clinics associated with three health plans in Massachusetts, we compared 69 patients diagnosed with DSM-IV dysthymia without concurrent major depressive disorder to 175 depression-free controls. Patients were employed at least 15 h per week, had no immediate plans to leave the labor market, and no major comorbid medical conditions. We assessed work absences and productivity loss due to on-the-job performance limitations ("presenteeism"). Patients with dysthymia, compared with controls, had less stable work histories and a greater frequency of significant problems at work. While absence rates were not significantly different (1.2 vs. 0.74 days, P<.09), individuals with dysthymia experienced significantly greater on-the-job productivity loss (6.3% vs. 2.8%, P<.0001). Dysthymia is an unrecognized cause of work impairment that has long-term negative consequences for individuals and their employers. The persistence of dysthymia with its serious impact on work functioning calls out for the development of new interventions.

The clinical and occupational correlates of work productivity loss among employed patients with depression.

Employers who are developing strategies to reduce health-related productivity loss may benefit from aiming their interventions at the employees who need them most. We determined whether depression's negative productivity impact varied with the type of work employees performed. Subjects (246 with depression and 143 controls) answered the Work Limitations Questionnaire and additional work questions. Occupational requirements were measured objectively. In multiple regression analyses, productivity was most influenced by depression severity (P < 0.01 in 5/5 models). However, certain occupations also significantly increased employee vulnerability to productivity loss. Losses increased when employees had occupations requiring proficiency in decision-making and communication and/or frequent customer contact (P < 0.05 in 3/5 models). The Work Limitations Questionnaire can help employers to reduce productivity loss by identifying health and productivity improvement priorities.

Cognitive transformation as a marker of resilience.

Individuals often report positive, transformative changes in response to adversity. Cognitive transformation involves a turning point in a person's life characterized by: (1) the recognition that coping with adversity resulted in new opportunities; and, (2) the reevaluation of the experience from one that was primarily traumatic or threatening to one that is growth-promoting. Cognitive transformation often signifies enhanced adaptation to adverse circumstances, and thus, is a marker of resilience. The present study examined the relationship of cognitive transformation to indicators of resilience among 35 acutely bereaved young adults and a nonbereaved comparison group. Findings strongly supported the hypothesis that transformation predicts resilience, and may reduce one's risk trajectory to enhance adaptation. Results are discussed in terms of their implications for research on resilience, and on recovery from acute or chronic adverse circumstances, including addiction.