Understanding students' feedback use in medical progress testing: A qualitative interview study.

BACKGROUND: Active engagement with feedback is crucial for feedback to be effective and improve students' learning and achievement. Medical students are provided feedback on their development in the progress test (PT), which has been implemented in various medical curricula, although its format, integration and feedback differ across institutions. Existing research on engagement with feedback in the context of PT is not sufficient to make a definitive judgement on what works and which barriers exist. Therefore, we conducted an interview study to explore students' feedback use in medical progress testing. METHODS: All Dutch medical students participate in a national, curriculum-independent PT four times a year. This mandatory test, composed of multiple-choice questions, provides students with written feedback on their scores. Furthermore, an answer key is available to review their answers. Semi-structured interviews were conducted with 21 preclinical and clinical medical students who participated in the PT. Template analysis was performed on the qualitative data using a priori themes based on previous research on feedback use. RESULTS: Template analysis revealed that students faced challenges in crucial internal psychological processes that impact feedback use, including 'awareness', 'cognizance', 'agency' and 'volition'. Factors such as stakes, available time, feedback timing and feedback presentation contributed to these difficulties, ultimately hindering feedback use. Notably, feedback engagement was higher during clinical rotations, and students were interested in the feedback when seeking insights into their performance level and career perspectives. CONCLUSION: Our study enhanced the understanding of students' feedback utilisation in medical progress testing by identifying key processes and factors that impact feedback use. By recognising and addressing barriers in feedback use, we can improve both student and teacher feedback literacy, thereby transforming the PT into a more valuable learning tool.

Does 'summative' count? The influence of the awarding of study credits on feedback use and test-taking motivation in medical progress testing.

Despite the increasing implementation of formative assessment in medical education, its' effect on learning behaviour remains questionable. This effect may depend on how students value formative, and summative assessments differently. Informed by Expectancy Value Theory, we compared test preparation, feedback use, and test-taking motivation of medical students who either took a purely formative progress test (formative PT-group) or a progress test that yielded study credits (summative PT-group). In a mixed-methods study design, we triangulated quantitative questionnaire data (n = 264), logging data of an online PT feedback system (n = 618), and qualitative interview data (n = 21) to compare feedback use, and test-taking motivation between the formative PT-group (n = 316), and the summative PT-group (n = 302). Self-reported, and actual feedback consultation was higher in the summative PT-group. Test preparation, and active feedback use were relatively low and similar in both groups. Both quantitative, and qualitative results showed that the motivation to prepare and consult feedback relates to how students value the assessment. In the interview data, a link could be made with goal orientation theory, as performance-oriented students perceived the formative PT as not important due to the lack of study credits. This led to low test-taking effort, and feedback consultation after the formative PT. In contrast, learning-oriented students valued the formative PT, and used it for self-study or self-assessment to gain feedback. Our results indicate that most students are less motivated to put effort in the test, and use feedback when there are no direct consequences. A supportive assessment environment that emphasizes recognition of the value of formative testing is required to motivate students to use feedback for learning.

Accounting for behaviour in fine-scale habitat selection: A case study highlighting methodological intricacies.

Animal habitat selection-central in both theoretical and applied ecology-may depend on behavioural motivations such as foraging, predator avoidance, and thermoregulation. Step-selection functions (SSFs) enable assessment of fine-scale habitat selection as a function of an animal's movement capacities and spatiotemporal variation in extrinsic conditions. If animal location data can be associated with behaviour, SSFs are an intuitive approach to quantify behaviour-specific habitat selection. Fitting SSFs separately for distinct behavioural states helped to uncover state-specific selection patterns. However, while the definition of the availability domain has been highlighted as the most critical aspect of SSFs, the influence of accounting for behaviour in the use-availability design has not been quantified yet. Using a predator-free population of high-arctic muskoxen Ovibos moschatus as a case study, we aimed to evaluate how (1) defining behaviour-specific availability domains, and/or (2) fitting separate behaviour-specific models impacts (a) model structure, (b) estimated selection coefficients and (c) model predictive performance as opposed to behaviour-unspecific approaches. To do so, we first applied hidden Markov models to infer different behavioural modes (resting, foraging, relocating) from hourly GPS positions (19 individuals, 153-1062 observation days/animal). Using SSFs, we then compared behaviour-specific versus behaviour-unspecific habitat selection in relation to terrain features, vegetation and snow conditions. Our results show that incorporating behaviour into the definition of the availability domain primarily impacts model structure (i.e. variable selection), whereas fitting separate behaviour-specific models mainly influences selection strength. Behaviour-specific availability domains improved predictive performance for foraging and relocating models (i.e. behaviours with medium to large spatial displacement), but decreased performance for resting models. Thus, even for a predator-free population subject to only negligible interspecific competition and human disturbance we found that accounting for behaviour in SSFs impacted model structure, selection coefficients and predictive performance. Our results indicate that for robust inference, both a behaviour-specific availability domain and behaviour-specific model fitting should be explored, especially for populations where strong spatiotemporal selection trade-offs are expected. This is particularly critical if wildlife habitat preferences are estimated to inform management and conservation initiatives.

A mixed-methods study to define Textbook Outcome for the treatment of patients with uncomplicated symptomatic gallstone disease with hospital variation analyses in Dutch trial data.

BACKGROUND: International consensus on the ideal outcome for treatment of uncomplicated symptomatic gallstone disease is absent. This mixed-method study defined a Textbook Outcome (TO) for this large group of patients. METHODS: First, expert meetings were organised with stakeholders to design the survey and identify possible outcomes. To reach consensus, results from expert meetings were converted in a survey for clinicians and for patients. During the final expert meeting, clinicians and patients discussed survey outcomes and a definitive TO was formulated. Subsequently, TO-rate and hospital variation were analysed in Dutch hospital data from patients with uncomplicated gallstone disease. RESULTS: First expert meetings returned 32 outcomes. Outcomes were distributed in a survey among 830 clinicians from 81 countries and 645 Dutch patients. Consensus-based TO was defined as no more biliary colic, no biliary and surgical complications, and the absence or reduction of abdominal pain. Analysis of individual patient data showed that TO was achieved in 64.2% (1002/1561). Adjusted-TO rates showed modest variation between hospitals (56.6-74.9%). CONCLUSION: TO for treatment of uncomplicated gallstone disease was defined as no more biliary colic, no biliary and surgical complications, and absence or reduction of abdominal pain.TO may optimise consistent outcome reporting in care and guidelines for treating uncomplicated gallstone disease.

Association of Hyperferritinemia With Distinct Host Response Aberrations in Patients With Community-Acquired Pneumonia.

BACKGROUND: Strongly elevated ferritin levels have been proposed to reflect systemic hyperinflammation in patients admitted to the intensive care unit. Knowledge of the incidence and pathophysiological implications of hyperferritinemia in patients with acute infection admitted to a non-intensive care setting is limited. METHODS: We determined the association between hyperferritinemia, defined by 2 cutoff values (500 and 250 ng/mL), and aberrations in key host response mechanisms among patients with community-acquired pneumonia (CAP) on admission to a general hospital ward (clinicaltrials.gov NCT02928367; trialregister.nl NTR6163). RESULTS: Plasma ferritin levels were higher in patients with CAP (n = 174; median [interquartile ranges], 259.5 [123.1-518.3] ng/mL) than in age- and sex-matched controls without infection (n = 50; 102.8 [53.5-185.7] ng/mL); P < .001); they were ≥500 ng/mL in 46 patients (26%) and ≥250 ng/mL in 90 (52%). Measurements of 26 biomarkers reflective of distinct pathophysiological domains showed that hyperferritinemia was associated with enhanced systemic inflammation, neutrophil activation, cytokine release, endothelial cell activation and dysfunction, and activation of the coagulation system. Results were robust across different cutoff values. CONCLUSIONS: Hyperferritinemia identifies patients with CAP with a broad deregulation of various host response mechanisms implicated in the pathogenesis of sepsis. This could inform future therapeutic strategies targeting subgroups within the CAP population.

Evaluating expert-based habitat suitability information of terrestrial mammals with GPS-tracking data.

Aim: Macroecological studies that require habitat suitability data for many species often derive this information from expert opinion. However, expert-based information is inherently subjective and thus prone to errors. The increasing availability of GPS tracking data offers opportunities to evaluate and supplement expert-based information with detailed empirical evidence. Here, we compared expert-based habitat suitability information from the International Union for Conservation of Nature (IUCN) with habitat suitability information derived from GPS-tracking data of 1,498 individuals from 49 mammal species. Location: Worldwide. Time period: 1998-2021. Major taxa studied: Forty-nine terrestrial mammal species. Methods: Using GPS data, we estimated two measures of habitat suitability for each individual animal: proportional habitat use (proportion of GPS locations within a habitat type), and selection ratio (habitat use relative to its availability). For each individual we then evaluated whether the GPS-based habitat suitability measures were in agreement with the IUCN data. To that end, we calculated the probability that the ranking of empirical habitat suitability measures was in agreement with IUCN's classification into suitable, marginal and unsuitable habitat types. Results: IUCN habitat suitability data were in accordance with the GPS data (> 95% probability of agreement) for 33 out of 49 species based on proportional habitat use estimates and for 25 out of 49 species based on selection ratios. In addition, 37 and 34 species had a > 50% probability of agreement based on proportional habitat use and selection ratios, respectively. Main conclusions: We show how GPS-tracking data can be used to evaluate IUCN habitat suitability data. Our findings indicate that for the majority of species included in this study, it is appropriate to use IUCN habitat suitability data in macroecological studies. Furthermore, we show that GPS-tracking data can be used to identify and prioritize species and habitat types for re-evaluation of IUCN habitat suitability data.

Plasma Ferritin as Marker of Macrophage Activation-Like Syndrome in Critically Ill Patients With Community-Acquired Pneumonia.

OBJECTIVES: Plasma ferritin levels above 4,420 ng/mL have been proposed as a diagnostic marker for macrophage activation-like syndrome in sepsis and used for selection of sepsis patients for anti-inflammatory therapy. We here sought to determine the frequency, presentation, outcome, and host response aberrations of macrophage activation-like syndrome, as defined by admission ferritin levels above 4,420 ng/mL, in critically ill patients with community-acquired pneumonia. DESIGN: A prospective observational cohort study. SETTING: ICUs in two tertiary hospitals in the Netherlands. PATIENTS: One hundred fifty-three patients admitted with community-acquired pneumonia. MEASUREMENTS AND MAIN RESULTS: Patients were stratified in community-acquired pneumonia-macrophage activation-like syndrome (n = 15; 9.8%) and community-acquired pneumonia-control groups (n = 138; 90.2%) based on an admission plasma ferritin level above or below 4,420 ng/mL, respectively. Community-acquired pneumonia-macrophage activation-like syndrome patients presented with a higher disease severity and had a higher ICU mortality (46.7% vs 12.3% in community-acquired pneumonia-controls; p = 0.002). Twenty-three plasma biomarkers indicative of dysregulation of key host response pathways implicated in sepsis pathogenesis (systemic inflammation, cytokine responses, endothelial cell activation, and barrier function, coagulation activation) were more disturbed in community-acquired pneumonia-macrophage activation-like syndrome patients. Hematologic malignancies were overrepresented in community-acquired pneumonia-macrophage activation-like syndrome patients (33.3% vs 5.1% in community-acquired pneumonia-controls; p = 0.001). In a subgroup analysis excluding patients with hematologic malignancies (n = 141), differences in mortality were not present anymore, but the exaggerated host response abnormalities in community-acquired pneumonia-macrophage activation-like syndrome patients remained. CONCLUSIONS: Macrophage activation-like syndrome in critically ill patients with community-acquired pneumonia occurs more often in patients with hematologic malignancies and is associated with deregulation of multiple host response pathways.

Environment and physiology shape Arctic ungulate population dynamics.

Species conservation in a rapidly changing world requires an improved understanding of how individuals and populations respond to changes in their environment across temporal scales. Increased warming in the Arctic puts this region at particular risk for rapid environmental change, with potentially devastating impacts on resident populations. Here, we make use of a parameterized full life cycle, individual-based energy budget model for wild muskoxen, coupling year-round environmental data with detailed ontogenic metabolic physiology. We show how winter food accessibility, summer food availability, and density dependence drive seasonal dynamics of energy storage and thus life history and population dynamics. Winter forage accessibility defined by snow depth, more than summer forage availability, was the primary determinant of muskox population dynamics through impacts on calf recruitment and longer term carryover effects of maternal investment. Simulations of various seasonal snow depth and plant biomass and quality profiles revealed that timing of and improved/limited winter forage accessibility had marked influence on calf recruitment (±10-80%). Impacts on recruitment were the cumulative result of condition-driven reproductive performance at multiple time points across the reproductive period (ovulation to calf weaning) as a trade-off between survival and reproduction. Seasonal and generational condition effects of snow-rich winters interacted with age structure and density to cause pronounced long-term consequences on population growth and structure, with predicted population recovery times from even moderate disturbances of 10 years or more. Our results show how alteration in winter forage accessibility, mediated by snow depth, impacts the dynamics of northern herbivore populations. Further, we present here a mechanistic and state-based model framework to assess future scenarios of environmental change, such as increased or decreased snowfall or plant biomass and quality to impact winter and summer forage availability across the Arctic.

Long-term patterns in winter habitat selection, breeding and predation in a density-fluctuating, high Arctic lemming population.

Habitat selection is expected to balance benefits and costs that maximizes fitness. Using a rare data set on collared lemming (Dicrostonyx groenlandicus) winter nest location spanning more than two decades, we show that lemmings actively select for Salix snow beds, likely due to its favorable micro-climate, and that lemming habitat selection was density-dependent. Lemmings nevertheless exhibited some flexibility in their habitat selection, which appeared to be influenced by the year-to-year variation in snow conditions. The likelihood of both lemming breeding and nest predation by stoats (Mustela erminea) was not directly linked to habitat despite a delicate interplay between habitat, nest size, breeding, and predation. Hence, the larger lemming nests were found in Salix snow beds, and these were more often used for breeding, but both larger nests and nests used for breeding were also predated more often than other nests. Our study provides a clear example of how density-dependent habitat selection acts to balance fitness in the various habitats utilized by collared lemmings.

Evaluation of a shared decision-making strategy with online decision aids in surgical and orthopaedic practice: study protocol for the E-valuAID, a multicentre study with a stepped-wedge design.

BACKGROUND: Inguinal hernia repair, gallbladder removal, and knee- and hip replacements are the most commonly performed surgical procedures, but all are subject to practice variation and variable patient-reported outcomes. Shared decision-making (SDM) has the potential to reduce surgery rates and increase patient satisfaction. This study aims to evaluate the effectiveness of an SDM strategy with online decision aids for surgical and orthopaedic practice in terms of impact on surgery rates, patient-reported outcomes, and cost-effectiveness. METHODS: The E-valuAID-study is designed as a multicentre, non-randomized stepped-wedge study in patients with an inguinal hernia, gallstones, knee or hip osteoarthritis in six surgical and six orthopaedic departments. The primary outcome is the surgery rate before and after implementation of the SDM strategy. Secondary outcomes are patient-reported outcomes and cost-effectiveness. Patients in the usual care cluster prior to implementation of the SDM strategy will be treated in accordance with the best available clinical evidence, physician's knowledge and preference and the patient's preference. The intervention consists of the implementation of the SDM strategy and provision of disease-specific online decision aids. Decision aids will be provided to the patients before the consultation in which treatment decision is made. During this consultation, treatment preferences are discussed, and the final treatment decision is confirmed. Surgery rates will be extracted from hospital files. Secondary outcomes will be evaluated using questionnaires, at baseline, 3 and 6 months. DISCUSSION: The E-valuAID-study will examine the cost-effectiveness of an SDM strategy with online decision aids in patients with an inguinal hernia, gallstones, knee or hip osteoarthritis. This study will show whether decision aids reduce operation rates while improving patient-reported outcomes. We hypothesize that the SDM strategy will lead to lower surgery rates, better patient-reported outcomes, and be cost-effective. TRIAL REGISTRATION: The Netherlands Trial Register, Trial NL8318, registered 22 January 2020. URL: https://www.trialregister.nl/trial/8318 .

Academic Success Experiences: Promoting Research Motivation andSelf-Efficacy Beliefs among Medical Students.

THEORY: Medicine is facing a physician-scientist shortage. Medical training could contribute to developing physician-scientists by stimulating student research involvement, as previous studies showed this is related to research involvement in professional practice. Motivation for research and research self-efficacy beliefs are related to student research involvement. Based on social cognitive theory, success experiences in doing research may enhance research motivation and self-efficacy beliefs. However, the role and type of success experiences in promoting research self-efficacy beliefs and motivation especially early in medical training has not yet been investigated. Therefore, we examined if academic success experiences within an undergraduate course in academic and scientific skills increased research motivation and self-efficacy beliefs among medical students. Furthermore, type of success experience was taken into account by looking at the effects of academic success experiences within standard (i.e., exam) versus authentic (i.e., research report and oral presentation) assessments. HYPOTHESES: It was hypothesized that academic success experiences increase intrinsic motivation for research and self-efficacy beliefs. Furthermore, we hypothesized that authentic assessments influence intrinsic motivation for research and self-efficacy beliefs to a larger degree than standard assessments, as the authentic assessments mirror real-world practices of researchers. METHOD: First-year undergraduate medicine students followed a course in academic and scientific skills in which they conducted research individually. Their academic success experiences were operationalized as their grades on two authentic research assessments (written report and oral presentation) and one less authentic assessment (written exam). We surveyed students before the course when entering medical school (i.e., baseline measure) and 1 year after the course in their 2nd year (i.e., postmeasure). Both the baseline and postmeasure surveys measured intrinsic motivation for research, extrinsic motivation for research, and research self-efficacy beliefs. Linear regression analyses were used to examine the relationship between academic success experiences and intrinsic motivation for research, extrinsic motivation for research, and research self-efficacy beliefs on the postmeasure. We adjusted for prior research motivation and self-efficacy beliefs at baseline. Therefore, this adjusted effect can be interpreted as an increase or decrease in motivation. In addition, we adjusted for age, gender, and grade point average (GPA) of the first 4 months, as these variables were seen as possible confounders. RESULTS: In total, 243 of 275 students participated (88.4%). Academic success experiences in writing and presenting research were related to a significant increase in intrinsic motivation for research. After adjusting for prior GPA, only the effect of presenting remained. Experiencing success in presenting enhanced research self-efficacy beliefs, also after adjusting for prior GPA. Higher grades on the exam did not affect intrinsic motivation for research or research self-efficacy significantly. Also, none of the success experiences influenced extrinsic motivation for research. CONCLUSIONS: Academic success experiences on authentic research tasks, especially presenting research, may be a good way to enhance intrinsic motivation for research and research self-efficacy beliefs. In turn, research motivation and self-efficacy beliefs promote research involvement, which is a first step in the physician-scientist pipeline. Furthermore, this study established the applicability of the social cognitive theory in a research context within the medical domain.

Development of a Clinical Teaching Unit in Internal Medicine to Promote Interprofessional and Multidisciplinary Learning: A Practical Intervention.

Problem: Effective clinical workplace learning depends on interprofessional and multidisciplinary learning. However, traditional patient wards are centered around patient care and not so much around education. Other barriers such as time constraints also contribute to suboptimal interprofessional and multidisciplinary learning. Intervention: Six formal and informal learning activities that aimed at stimulation of interprofessional and multidisciplinary learning were designed and introduced in our patient ward to enable optimal integration of clinical practice and learning. Context: The study took place in an internal medicine inpatient ward where daily patient care is performed by specialized teams consisting of different healthcare professionals from the departments of Endocrinology, Nephrology, and Infectious Diseases. In the traditional ward setting, interprofessional and multidisciplinary learning mostly takes place during shared clinical activities. In this article, we describe the development and implementation of a Clinical Teaching Unit to support learning between different healthcare professionals. Impact: The intervention was evaluated with an online questionnaire among 108 nurses, student nurses, clerks, residents, supervising clinicians, and managers. Open-ended questions (response rate 65%) were used to determine the changes in the workplace experienced by the participants since the introduction of the Clinical Teaching Unit and what influenced their learning process and motivation to learn. Closed questions (response rate 46%) aimed to measure the effect of our intervention on collaboration, learning, and the quality of care and education. The results of the open-ended questions showed that participants experienced more interprofessional collaboration and learning. This took place in a less hierarchical, safer work climate which also resulted in perceptions of a better quality of patient care and education. The closed-ended questions showed that the intervention resulted in perceptions of improved collaboration, work culture, quality of care, education, and learning conditions. Lessons Learned: The findings imply that implementation of a Clinical Teaching Unit not only facilitates the integration of patient care and education but also the integration of different professions working together. From the intervention, we also learned that a successful Clinical Teaching Unit requires investment of time and staff, clear communication between healthcare professionals, and dedication of teachers within all professions.

Variation in practice and outcomes after inguinal hernia repair: a nationwide observational study.

BACKGROUND: Inguinal hernia repair has often been used as a showcase to illustrate practice variation in surgery. This study determined the degree of hospital variation in proportion of patients with an inguinal hernia undergoing operative repair and the effect of this variation on clinical outcomes. METHODS: A nationwide, longitudinal, database study was performed in all hospitals in the Netherlands between 2013 and 2015. Patients with inguinal hernias were collected from the Diagnosis-Related-Group (DRG) database. The case-mix adjusted operation rate in patients with a new DRG determines the observed variation. Hospital variation in case-mix adjusted inguinal hernia repair-rates was calculated per year. Clinical outcomes after surgery were compared between hospitals with high and low adjusted operation-rates. RESULTS: In total, 95,637 patients were included. The overall operation rate was 71.6%. In 2013-2015, the case-mix adjusted performance of inguinal hernia repairs in hospitals with high rates was 1.6-1.9 times higher than in hospitals with low rates. Moreover, in hospitals with high adjusted rates of inguinal hernia repair the time to surgery was shorter, more laparoscopic procedures were performed, less emergency department visits were recorded post-operatively, while more emergency department visits were recorded when patients were treated conservatively compared to hospitals with low adjusted operation rates. CONCLUSION: Hospital variation in inguinal hernia repair in the Netherlands is modest, operation-rates vary by less than two-fold, and variation is stable over time. Hernia repair in hospitals with high adjusted rates of inguinal hernia repair are associated with improved outcomes.

The effect of peer modelling and discussing modelled feedback principles on medical students' feedback skills: a quasi-experimental study.

BACKGROUND: Teaching is an important professional skill for physicians and providing feedback is an important part of teaching. Medical students can practice their feedback skills by giving each other peer feedback. Therefore, we developed a peer feedback training in which students observed a peer that modelled the use of good feedback principles. Students then elaborated on the modelled feedback principles through peer discussion. This combination of peer modelling and discussing the modelled feedback principles was expected to enhance emulation of the feedback principles compared to (1) only peer modelling and (2) discussing the feedback principles without previous modelling. METHODS: In a quasi-experimental study design, 141 medical students were assigned randomly to three training conditions: peer modelling plus discussion (MD), non-peer modelled example (NM) or peer modelling without discussion (M). Before and after the training, they commented on papers written by peers. These comments served as a pre- and a post-measure of peer feedback. The comments were coded into different functions and aspects of the peer feedback. Non-parametrical Kruskall-Wallis tests were used to check for pre- and post-measure between-group differences in the functions and aspects. RESULTS: Before the training, there were no significant between-group differences in feedback functions and aspects. After the training, the MD-condition gave significantly more positive peer feedback than the NM-condition. However, no other functions or aspects were significantly different between the three conditions, mainly because the within-group interquartile ranges were large. CONCLUSIONS: The large interquartile ranges suggest that students differed substantially in the effort placed into giving peer feedback. Therefore, additional incentives may be needed to motivate students to give good feedback. Teachers could emphasise the utility value of peer feedback as an important professional skill and the importance of academic altruism and professional accountability in the peer feedback process. Such incentives may convince more students to put more effort into giving peer feedback.

Habitat suitability analysis reveals high ecological flexibility in a "strict" forest primate.

BACKGROUND: Research of many mammal species tends to focus on single habitats, reducing knowledge of ecological flexibility. The Javan lutung (Trachypithecus auratus) is considered a strict forest primate, and little is known about populations living in savannah. In 2017-2018, we investigated the density and distribution of Javan lutung in Baluran National Park, Indonesia. We conducted ad libitum follows and line transect distance sampling with habitat suitability analysis of Javan lutung. RESULTS: Estimated density was 14.91 individuals km- 2 (95% CI 7.91-28.08), and estimated population size was 3727 individuals (95% CI 1979 - 7019). Long-tailed macaque (Macaca fascicularis) habitat suitability was the main driver of lutung habitat suitability as the probability of lutung occurrence increased greatly with macaque habitat suitability. Distance to roads, and distance to secondary forest had a negative relationship with lutung occurrence. Lutung habitat suitability decreased with increasing elevation, however, Mt Baluran and the primary forest on Mt Baluran was under-sampled due to treacherous conditions. Follows of six focus groups revealed considerable use of savannah, with terrestrial travel. The follows also revealed polyspecific associations with long-tailed macaques through shared sleeping sites and inter-specific vocalisations. CONCLUSIONS: Our study provides new knowledge on the general ecology of Javan lutung, such as use of savannah habitats, underlining our need to branch out in our study sites to understand the flexibility and adaptability of our study species. Another undocumented behaviour is the polyspecific association with long-tailed macaques. We encourage more research on this subject.

Bioaccumulation of mining derived metals in blood, liver, muscle and otoliths of two Arctic predatory fish species (Gadus ogac and Myoxocephalus scorpius).

Mining activities can cause adverse and long-lasting environmental impacts and detailed monitoring is therefore essential to assess the pollution status of mining impacted areas. Here we evaluated the efficacy of two predatory fish species (Gadus ogac i.e. Greenland cod and Myoxocephalus scorpius i.e. shorthorn sculpin) as biomonitors of mining derived metals (Pb, Zn, Cd and Hg) by measuring concentrations in blood, liver, muscle and otoliths along a distance gradient near the former Black Angel Pb-Zn mine (West Greenland). We detected metals in all tissues (except Cd and Hg in otoliths) and sculpin generally displayed higher concentrations than cod. For both species, concentrations were generally highest closest to the dominant pollution source(s) and gradually decreased away from the mine. The clearest gradient was observed for Pb in blood and liver (both species), and for Pb in otoliths (sculpin only). Similar to dissolved concentrations in seawater (but in contrast to bottom sediment), no significant decrease was found for Zn, Cd and Hg in any of the tissues. This demonstrates that by including tissues of blood (representing recent accumulation) and otolith (representing more long-term exposure signals) in the sampling collection, the temporal information on contaminant exposure and accumulation can be extended. We therefore conclude that both fish species are suitable as biomonitors near Arctic mine sites and, moreover, that blood and otoliths can serve as important supplementary monitoring tissues (in addition to liver and muscle traditionally sampled) as they provide extended temporal information on recent to long-term contaminant exposure.

The association between patients' preferred treatment after the use of a patient decision aid and their choice of eventual treatment.

OBJECTIVE: To investigate the association between patients' preferred treatment and eventual treatment. Second, to compare patients with surgical treatment to watchful waiting in order to identify predictive factors for surgery. METHODS: A single-centre retrospective study was performed between December 2015 and August 2018. Patients (≥18 years) who used a patient decision aid (PDA) for gallstones or inguinal hernia were included. After their first surgical consultation, patients received access to an online PDA. The patients' preferred treatment after the PDA was compared with their choice of eventual treatment. Multivariable regression analyses were performed for predictive factors for surgery. RESULTS: In total, 567 patients with gallstones and 585 patients with an inguinal hernia were included. Of the patients with gallstones, 121 (21%) preferred watchful waiting, 367 (65%) preferred surgery, and 79 (14%) were not sure. The patients' preferred treatment was performed in 85.9%. Frequent pain attacks (OR 2.1, 95% CI 1.1-3.9, P = .020) and preference for surgery (OR 4.4, 95% CI 1.9-10.1, P = .001) independently predicted surgery. Of the patients with an inguinal hernia, 77 (13.2%) preferred watchful waiting, 452 (78.8%) preferred surgery, and 56 (9.6%) were not sure. The patients' preferred treatment was performed in 86.0%. The preference for surgery (OR 5.2, 95% CI 2.5-10.6, P < .001) independently predicted surgery and worry about complications predicted avoidance of surgery (OR 0.5, 95% CI 0.2-1.0, P = .037). CONCLUSION: This study, reflecting current clinical care, shows that patients' preferred treatment after using a PDA matches their eventual treatment choice in 86% of patients with gallstones or an inguinal hernia. In these patients, symptoms and patients' preference for surgery independently predicts eventual choice of surgery.

Twelve tips to offer a short authentic and experiential individual research opportunity to a large group of undergraduate students.

Engaging students in research during medical school could contribute to creating an academic attitude among students, which underlies practicing evidence-based medicine in future professional practice. However, attempts to involve undergraduate students in research during medical training remain inadequate. Most medical schools educate large numbers of students at the same time, especially in early phases of medical training. Large scale education on the one hand and individually providing students with authentic research experiences on the other hand is considered not that easy to achieve. Drawing on our own experiences, existing literature and theories we propose twelve tips to design and implement a course in which authentic individual research experiences can be provided to a large group of undergraduate students.

Promoting positive perceptions of and motivation for research among undergraduate medical students to stimulate future research involvement: a grounded theory study.

BACKGROUND: Research is of great value to make advancements within the medical field and, ultimately, offer the best possible patient care. Physician-scientists are key in contributing to the development of medicine, as they can bridge the gap between research and practice. However, medicine currently faces a physician-scientist shortage. A possible solution to cultivate physician-scientists is to engage medical students in research in early phases of medical school. Evidence-based strategies to stimulate positive perceptions of and motivation for research among students could help to enhance research engagement. Consequently, understanding of students' perceptions of and motivation for research is needed. Therefore, this study aimed to identify conditions under which students develop positive perceptions of and motivation for research by answering the following sub-questions: 1) how do first-year medical students perceive research? and 2) which factors contribute to motivation or demotivation for conducting research? METHODS: We conducted a qualitative study with individual interviews using a grounded theory approach, involving 13 purposively sampled first-year medical students at Leiden University Medical Center. RESULTS: Our results suggest that first-year students are already able to identify many aspects of research. Students elaborated on the relevance of research for professional practice and personal development. Furthermore, our results suggest a relationship between perceptions of and motivation for research. Some perceptions were identical to motivating or demotivating factors to conduct research, like the relevance of research for practice and performing statistics respectively. Other motivating factors were, among others, acknowledgment, autonomy, and inspiring role models. Demotivating factors were, among others, lack of autonomy and relevance, and inadequate collaboration. CONCLUSIONS: Our results contribute to the idea that perceptions of research are related to motivation for research, which offers possibilities for interventions to promote motivation for research by making use of student perceptions of research. Consequently, practical implications to stimulate research engagement in early phases of medical school are provided. Moreover, the results contribute to existing motivational theories like Theory of Planned Behavior and Self-Determination Theory within this specific domain.

Decision-Support Tools Used in the Baltic Sea Area: Performance and End-User Preferences.

Decision-support tools (DSTs) synthesize complex information to assist environmental managers in the decision-making process. Here, we review DSTs applied in the Baltic Sea area, to investigate how well the ecosystem approach is reflected in them, how different environmental problems are covered, and how well the tools meet the needs of the end users. The DSTs were evaluated based on (i) a set of performance criteria, (ii) information on end user preferences, (iii) how end users had been involved in tool development, and (iv) what experiences developers/hosts had on the use of the tools. We found that DSTs frequently addressed management needs related to eutrophication, biodiversity loss, or contaminant pollution. The majority of the DSTs addressed human activities, their pressures, or environmental status changes, but they seldom provided solutions for a complete ecosystem approach. In general, the DSTs were scientifically documented and transparent, but confidence in the outputs was poorly communicated. End user preferences were, apart from the shortcomings in communicating uncertainty, well accounted for in the DSTs. Although end users were commonly consulted during the DST development phase, they were not usually part of the development team. Answers from developers/hosts indicate that DSTs are not applied to their full potential. Deeper involvement of end users in the development phase could potentially increase the value and impact of DSTs. As a way forward, we propose streamlining the outputs of specific DSTs, so that they can be combined to a holistic insight of the consequences of management actions and serve the ecosystem approach in a better manner.