A Quality Improvement Approach to Modification of a Point-of-Care Ultrasound Curriculum.

Background: There is increasing emphasis on resident involvement in quality improvement (QI) efforts, yet resident engagement in QI has remained low for many reasons. Although QI methods are classically applied to clinical processes, there are many opportunities to incorporate QI principles into curricular design and implementation. Objective: Demonstrate the utility of QI methods when applied to curricular design and the implementation of a novel point-of-care ultrasound portfolio development and quality assurance program at a large internal medicine residency program. Methods: We applied foundational QI methods, including process mapping, plan-do-study-act (PDSA) cycles, time-trap identification, run-chart analysis, and qualitative interviews throughout the curricular design and implementation phases to rapidly identify areas for improvement and perform timely tests of change. Results: Fifty-one interns participated in the curriculum, submitting 731 images in the first trimester. Process mapping and submission review revealed that 29% of images were saved to the incorrect digital archive. Resident-reviewer interpretation concordance was present in 80.7% of submissions. In 95.2% of completed quality assurance cards, the same information was provided in the commentary feedback and the evaluator's checklists, representing a time trap. Interventions included restricting access to image archives and removing redundant fields from quality assurance cards. The time to feedback fell from 69.5 to 6.5 days, demonstrating nonrandom variation via run-chart analysis. Conclusion: This pilot study demonstrates the successful application of QI methods to a novel point-of-care ultrasound curriculum. The systematic use of these methodologies in curricular design and implementation allows expeditious curricular improvement. Emphasizing the relevance of QI methods to subject matter beyond clinical processes may increase resident engagement in QI efforts.

Preliminary evidence from planarians that cotinine establishes a conditioned place preference.

While the psychoactive stimulant nicotine has been the subject of extensive research, considerably less attention has focused on other compounds found in either tobacco smoke or that are nicotine metabolites. Recent papers have suggested that some of the compounds in question may either alter nicotine's effects or have reinforcing properties themselves, although they would only be experienced after consumption of tobacco. The potential for these compounds to function as reinforcers or to potentiate the reinforcing properties of nicotine merits investigation. To pursue this line of inquiry, we examined cotinine in a planarian model of environmental place preference. In the present study, planarians demonstrated that the compound cotinine, which is present in tobacco smoke, and is also the principal nicotine metabolite, establishes a conditioned place preference. These data represent the first ever demonstration that cotinine will establish a conditioned place preference in planarians and possibly contribute to the addictive properties of nicotine.

Metacognition in the classroom: The association between students' exam predictions and their desired grades.

Students are overconfident when making grade predictions, and worse, the lowest-performing students are generally the most overconfident. Because metacognitive accuracy is associated with academic performance, multiple studies have attempted to improve metacognitive accuracy with mixed results. However, these studies may be of limited use because we do not understand the types of information university students use to make performance predictions. The current studies examined the possibility that university students' predictions are associated with their desires-the grade they want to receive. Studies 1-4 demonstrated that students' desired grades were strongly associated with their grade predictions across different courses, universities, and measurement strategies. Study 4 also showed that, if warned about the previous results, students could reduce their reliance on their desired grades and improve the accuracy of their predictions relative to control. Together, results demonstrated that students' exam predictions are associated with their desired grades.

The Effect of Prior Task Success on Older Adults' Memory Performance: Examining the Influence of Different Types of Task Success.

BACKGROUND/STUDY CONTEXT: Negative aging stereotypes can lead older adults to perform poorly on memory tests. Yet, memory performance can be improved if older adults have a single successful experience on a cognitive test prior to participating in a memory experiment (Geraci & Miller, 2013, Psychology and Aging, 28, 340-345). The current study examined the effects of different types of prior task experience on subsequent memory performance. METHODS: Before participating in a verbal free recall experiment, older adults in Experiment 1 successfully completed either a verbal or a visual cognitive task or no task. In Experiment 2, they successfully completed either a motor task or no task before participating in the free recall experiment. RESULTS: Results from Experiment 1 showed that relative to control (no prior task), participants who had prior success, either on a verbal or a visual task, had better subsequent recall performance. Experiment 2 showed that prior success on a motor task, however, did not lead to a later memory advantage relative to control. CONCLUSION: These findings demonstrate that older adults' memory can be improved by a successful prior task experience so long as that experience is in a cognitive domain.

The influence of retrieval practice on metacognition: The contribution of analytic and non-analytic processes.

People may change their memory predictions after retrieval practice using naïve theories of memory and/or by using subjective experience - analytic and non-analytic processes respectively. The current studies disentangled contributions of each process. In one condition, learners studied paired-associates, made a memory prediction, completed a short-run of retrieval practice and made a second prediction. In another condition, judges read about a yoked learners' retrieval practice performance but did not participate in retrieval practice and therefore, could not use non-analytic processes for the second prediction. In Study 1, learners reduced their predictions following moderately difficult retrieval practice whereas judges increased their predictions. In Study 2, learners made lower adjusted predictions than judges following both easy and difficult retrieval practice. In Study 3, judge-like participants used analytic processes to report adjusted predictions. Overall, the results suggested non-analytic processes play a key role for participants to reduce their predictions after retrieval practice.

Improving metacognitive accuracy: how failing to retrieve practice items reduces overconfidence.

People often exhibit inaccurate metacognitive monitoring. For example, overconfidence occurs when people judge that they will remember more information on a future test then they actually do. The present experiments examined whether a small number of retrieval practice opportunities would improve participants' metacognitive accuracy by reducing overconfidence. Participants studied Lithuanian-English paired associates and predicted their performance on an upcoming memory test. Then they attempted to retrieve one or more practice items (or none in the control condition) and made a second prediction. Experiment 1 showed that failing to retrieve a single practice item lead to improved subsequent performance predictions - participants became less overconfident. Experiment 2 directly manipulated retrieval failure and showed that again failure to retrieve a single practice item significantly improved subsequent predictions, relative to when participants successfully retrieved the practice item. Finally, Experiment 3 showed that additional retrieval practice opportunities reduced overconfidence and improved prediction accuracy.

The bizarreness effect: evidence for the critical influence of retrieval processes.

People show better memory for bizarre sentences relative to common sentences, a finding referred to as the bizarrness effect. Interestingly, this effect is typically only obtained using a mixed-list design, in which participants study common and bizarre sentences in the same list. This bizarreness effect in mixed-list designs has been explained as the result of both enhanced encoding processes and efficient retrieval processes. The present experiment was designed to isolate the unique contributions of the retrieval context to the bizarreness effect. Participants studied common sentences in one room under one set of instructions, and bizarre sentences in another room under another set of instructions. At test, participants recalled the common and bizarre sentences either together or separately. The results showed that the bizarreness effect was only obtained when participants recalled the common and bizarre items together; no bizarreness advantage emerged when participants were required to recall the common and bizarre items separately. These results suggest that differential encoding processes are not necessary for explaining the bizarreness effect in memory. Rather, retrieval of the mixed-list context appears to be critical for obtaining the effect.

Improving older adults' memory performance using prior task success.

Holding negative aging stereotypes can lead older adults to perform poorly on memory tests. We attempted to improve older adults' memory performance by giving them task experience that would counter their negative performance expectations. Before participating in a memory experiment, younger and older adults were given a cognitive task that they could either successfully complete, not successfully complete, or they were given no prior task. For older adults, recall was significantly higher and self-reported anxiety was significantly lower for the prior task success group relative to the other groups. There was no effect of prior task experience on younger adults' memory performance. Results suggest that older adults' memory can be improved with a single successful prior task experience.

Greater precision when measuring dementia severity: establishing item parameters for the Clinical Dementia Rating Scale.

BACKGROUND/AIMS: An item response theory (IRT)-based scoring approach to the Clinical Dementia Rating Scale (CDR) can account for the pattern of scores across the CDR items (domains) and their differential abilities to indicate dementia severity. In doing so, an IRT-based approach can provide greater precision than other CDR scoring algorithms. However, neither a good set of item parameters nor an easily digestible set of instructions needed to implement this approach is readily available. METHODS: Participants were 1,326 patients at the Baylor College of Medicine Alzheimer's Disease and Memory Disorders Clinic. RESULTS: The item parameters necessary for an IRT-based scoring approach were identified (a parameters ranged from 3.01 to 6.22; b parameters ranged from -2.46 to 2.07). CONCLUSION: This study provides, and demonstrates how to easily apply, IRT-based item parameters for the CDR

In vivo biodistribution and small animal PET of (64)Cu-labeled antimicrobial peptoids.

Peptoids are a rapidly developing class of biomimetic polymers based on oligo-N-substituted glycine backbones, designed to mimic peptides and proteins. Inspired by natural antimicrobial peptides, a group of cationic amphipathic peptoids has been successfully discovered with potent, broad-spectrum activity against pathogenic bacteria; however, there are limited studies to address the in vivo pharmacokinetics of the peptoids. Herein, (64)Cu-labeled DOTA conjugates of three different peptoids and two control peptides were synthesized and assayed in vivo by both biodistribution studies and small animal positron emission tomography (PET). The study was designed in a way to assess how structural differences of the peptidomimetics affect in vivo pharmacokinetics. As amphipathic molecules, major uptake of the peptoids occurred in the liver. Increased kidney uptake was observed by deleting one hydrophobic residue in the peptoid, and (64)Cu-3 achieved the highest kidney uptake of all the conjugates tested in this study. In comparison to peptides, our data indicated that peptoids had general in vivo properties of higher tissue accumulation, slower elimination, and higher in vivo stability. Different administration routes (intravenous, intraperitoneal, and oral) were investigated with peptoids. When administered orally, the peptoids showed poor bioavailability, reminiscent of that of peptide. However, remarkably longer passage through the gastrointestinal (GI) tract without rapid digestion was observed for peptoids. These unique in vivo properties of peptoids were rationalized by efficient cellular membrane permeability and protease resistance of peptoids. The results observed in the biodistribution studies could be confirmed by PET imaging, which provides a reliable way to evaluate in vivo pharmacokinetic properties of peptoids noninvasively and in real time. The pharmacokinetic data presented here can provide insight for further development of the antimicrobial peptoids as pharmaceuticals.

Sex differences in cardiovascular disease risk and exercise in type 2 diabetes.

Diabetes currently affects approximately 14% of the US population, and cardiovascular disease (CVD) is a leading cause of morbidity and mortality in those with diabetes. Although in the general population women are at lower risk than men for CVD, women have a disproportionately greater increase in risk for CVD than do men in the context of diabetes. Physical activity is considered a cornerstone in the prevention and treatment of CVD and its risk factors, but greater barriers to physical activity may exist for women with diabetes compared to their male counterparts. In this article, we review sex differences in CVD incidence and risk among diabetics, sex differences in physical activity behaviors, cardiovascular abnormalities and impaired exercise capacity in women living with diabetes, and the effects of exercise on prevention and treatment of CVD in diabetic women. Finally, we discuss future research needed to clarify potential sex differences in the cardiovascular effects of diabetes and to establish ways to reduce the barriers to exercise in women with diabetes.

Dementia staging across three different methods.

BACKGROUND/AIMS: To investigate the effectiveness of an item response theory (IRT)-based approach to staging dementia. METHODS: IRT estimates of dementia severity in 1,485 patients were used to stage dementia and then compared to dementia staging using the classic Clinical Dementia Rating Scale (CDR) algorithm and the Sum of the Boxes (SOB) approach. RESULTS: Measurement imprecision was highest when dementia stages were determined based on the classic algorithm (48% of sample), lower when they were determined based on the SOB approach (12%), and lowest when determined using IRT-based staging (0%). CONCLUSION: The classic CDR algorithm weights boxes largely according to clinical experience. The SOB approach weights all boxes equally. The IRT approach weights boxes according to their actual ability to identify dementia severity and therefore provides the most precise information for staging dementia.

Unskilled but aware: reinterpreting overconfidence in low-performing students.

People are generally overconfident in their self-assessments and this overconfidence effect is greatest for people of poorer abilities. For example, poor students predict that they will perform much better on exams than they do. One explanation for this result is that poor performers in general are doubly cursed: They lack knowledge of the material, and they lack awareness of the knowledge that they do and do not possess. The current studies examined whether poor performers in the classroom are truly unaware of their deficits by examining the relationship between students' exam predictions and their confidence in these predictions. Relative to high-performing students, the poorer students showed a greater overconfidence effect (i.e., their predictions were greater than their performance), but they also reported lower confidence in these predictions. Together, these results suggest that poor students are indeed unskilled but that they may have some awareness of their lack of metacognitive knowledge.

Short alkylated peptoid mimics of antimicrobial lipopeptides.

We report the creation of alkylated poly-N-substituted glycine (peptoid) mimics of antimicrobial lipopeptides with alkyl tails ranging from 5 to 13 carbons. In several cases, alkylation significantly improved the selectivity of the peptoids with no loss in antimicrobial potency. Using this technique, we synthesized an antimicrobial peptoid only 5 monomers in length with selective, broad-spectrum antimicrobial activity as potent as previously reported dodecameric peptoids and the antimicrobial peptide pexiganan.

Item response theory reveals variability of functional impairment within clinical dementia rating scale stages.

BACKGROUND/AIMS: To investigate whether an item response theory (IRT) approach to measuring variations of dementia severity within Clinical Dementia Rating (CDR) stages is associated with activities of daily living (ADLs). METHODS: IRT estimates of dementia severity within CDR stages in 1,181 patients were correlated with ADLs and analyzed. RESULTS: IRT-determined dementia severity was significantly correlated with ADLs in three of four impaired dementia stages. CONCLUSION: An IRT approach shows considerable advantages over traditional scoring practices of the CDR not only because it increases precision in dementia measurement, but also because it enables one to discover more precise associations with functional outcomes such as ADLs.

Cardiac dysfunction during exercise in uncomplicated type 2 diabetes.

PURPOSE: Type 2 diabetes mellitus (T2DM) has been associated with reduced peak exercise capacity (VO(2peak)). The causes of this impairment are not clearly established, but evidence suggests that abnormalities in cardiac function play a significant role. We hypothesized that exercise would be associated with impaired cardiac function and hemodynamics in recently diagnosed T2DM, even in the absence of clinically evident cardiovascular complications. METHODS: After baseline normal echocardiography screening, 10 premenopausal women with uncomplicated T2DM (average duration of diagnosed T2DM, 3.6 yr) and 10 healthy nondiabetic women of similar age, weight, and activity levels performed a peak cardiopulmonary exercise test while instrumented with an indwelling pulmonary artery catheter for assessing cardiac function. On separate days, technetium-99m sestamibi (cardolite) imaging was performed to assess myocardial perfusion at rest and peak exercise in seven T2DM and seven control patients. RESULTS: Resting measures of cardiac hemodynamics were similar in T2DM and control subjects. Absolute VO(2peak) (mL x min(-1)) and peak cardiac output (L x min(-1)) tended to be lower in T2DM than in control subjects but did not reach statistical significance. However, pulmonary capillary wedge pressure (PCWP) rose significantly more during exercise in T2DM than in controls (148% vs 109% increase at peak exercise, P < 0.01). Normalized myocardial perfusion index was lower in persons with diabetes than in controls (11.0 +/- 3.5 x e(-9) vs 17.5 +/- 8.1 x e(-9), respectively, P < 0.05) and inversely related to peak exercise PCWP (R = -0.56, P < 0.05). CONCLUSIONS: Cardiac hemodynamics during graded exercise are altered in women with recently diagnosed T2DM as demonstrated by the disproportionate increase in PCWP at peak exercise compared with controls subjects. Cardiac abnormalities observed are potentially early signs of subclinical cardiac dysfunction associated with T2DM, which may precede the more greatly impaired cardiac function at rest and with exercise observed in longer established T2DM.