The student is key: A realist review of educational interventions to develop analytical and non-analytical clinical reasoning ability.

OBJECTIVES: Clinical reasoning refers to the cognitive processes used by individuals as they formulate a diagnosis or treatment plan. Clinical reasoning is dependent on formal and experiential knowledge. Developing the ability to acquire and recall knowledge effectively for both analytical and non-analytical cognitive processing has patient safety implications. This realist review examines the way educational interventions develop analytical and non-analytical reasoning ability in undergraduate education. A realist review is theory-driven, seeking not only to identify if an intervention works, but also understand the reasons why, for whom, and in what circumstances. The aim of this study is to develop understanding about the way educational interventions develop effective analytical and non-analytical clinical reasoning ability, when they do, for whom and in what circumstances. METHODS: Literature from a scoping search, combined with expert opinion and researcher experience was synthesised to generate an initial programme theory (IPT). Four databases were searched and articles relevant to the developing theory were selected as appropriate. Factors affecting educational outcomes at the individual student, teacher and wider organisational levels were investigated in order to further refine the IPT. RESULTS: A total of 28 papers contributed to the overall programme theory. The review predominantly identified evidence of mechanisms for interventions at the individual student level. Key student level factors influencing the effectiveness of interventions included an individual's self-confidence, self-efficacy and pre-existing level of knowledge. These contexts influenced a variety of educational interventions, impacting both positively and negatively on educational outcomes. CONCLUSIONS: Development of analytical and non-analytical clinical reasoning ability requires activities that enhance knowledge acquisition and recall alongside the accumulation of clinical experience and opportunities to practise reasoning in real or simulated clinical environments. However, factors such as pre-existing knowledge and self-confidence influence their effectiveness, especially amongst individuals with 'low knowledge.' Promoting non-analytical reasoning once novices acquire more clinical knowledge is important for the development of clinical reasoning in undergraduate education.

Renal anomalies and lymphedema distichiasis syndrome. A rare association?

Lymphedema distichiasis syndrome (LDS) is a rare, autosomal dominant genetic condition, characterized by lower limb lymphedema and distichiasis. Other associated features that have been reported include varicose veins, cleft palate, congenital heart defects, and ptosis. We update a previously reported family with a pathogenic variant in FOXC2 (c.412-413insT) where five affected individuals from the youngest generation had congenital renal anomalies detected on prenatal ultrasound scan. These included four fetuses with hydronephrosis and one with bilateral renal agenesis. A further child with LDS had prominence of the left renal pelvis on postnatal renal ultrasound. We also describe a second family in whom the proband and his affected son had congenital renal anomalies; left ectopic kidney, right duplex kidney, and bilateral duplex collecting systems with partial duplex kidney with mild degree of malrotation, respectively. Foxc2 is expressed in the developing kidney and therefore congenital renal anomalies may well be associated, potentially as a low penetrance feature. We propose that all individuals diagnosed with LDS should have a baseline renal ultrasound scan at diagnosis. It would also be important to consider the possibility of renal anomalies during prenatal ultrasound of at risk pregnancies, and that the presence of hydronephrosis may be an indication that the baby is affected with LDS.

Multi-layered genome defences in bacteria.

Bacteria have evolved a variety of defence mechanisms to protect against mobile genetic elements, including restriction-modification systems and CRISPR-Cas. In recent years, dozens of previously unknown defence systems (DSs) have been discovered. Notably, diverse DSs often coexist within the same genome, and some co-occur at frequencies significantly higher than would be expected by chance, implying potential synergistic interactions. Recent studies have provided evidence of defence mechanisms that enhance or complement one another. Here, we review the interactions between DSs at the mechanistic, regulatory, ecological and evolutionary levels.

Update on Guidelines for Sexually Transmitted Infection Treatment and Management in the Adult and Adolescent Population.

Sexually transmitted infections (STIs) are a prevalent global health care problem. Incidence rates are rising yearly. STI incidence is highest for adolescents and young adults ages 15 to 24, who are diagnosed with half of all new STIs. Chlamydia trachomatis and Neisseria gonorrhea are common STIs caused by bacteria. Treatment guidelines change frequently as a result of antimicrobial resistance and public health trends. It is important for primary care providers to remain up to date with new guidelines. This article provides updates on pharmacologic treatment as well as patient education and follow-up specific to the primary care setting.

Exploring the Utility of Entrustable Professional Activities as a Framework to Enhance Nurse Practitioner Education.

BACKGROUND: Entrustable professional activities (EPAs) are used in medical education in the assessment of clinical competence, but consideration of EPAs in nurse practitioner (NP) education is emerging. PROBLEM: There are critical points in the NP educational trajectory when a student should demonstrate requisite knowledge and abilities. It can be challenging to assess and measure clinical proficiency in a way that can be clearly interpreted by students, faculty, and preceptors. APPROACH: NP faculty reviewed a set of medical EPAs that were linked with physician competencies to determine if they related to national NP competency areas and learning activities in their curriculum. CONCLUSIONS: Several NP competency areas (8 of 9) related to these EPAs, and the learning activities also related to multiple EPAs. Although further work would be needed to tailor EPAs to the NP role and link them specifically with NP competencies, EPAs may offer another valuable method for clinical evaluation of NP students.

Discharging Mrs. Fox: A Team-Based Interprofessional Collaborative Standardized Patient Encounter.

INTRODUCTION: In 2003, the Institute of Medicine recommended that interprofessional education be incorporated into the training programs of health care professionals. However, many logistical challenges hinder formal interprofessional learning in health care profession programs. METHODS: This resource is a 3-hour interprofessional small-group session designed for health professions student teams to engage in a standardized patient encounter, each team member contributing a profession-specific perspective to create a collaborative care plan across five discharge decisions. The activity includes a simulated standardized patient encounter and debrief session wherein students discuss the role of bias and communication and create a collaborative care plan. RESULTS: Following the activity, participants were surveyed about the value of the educational experience. Over 12 months, 106 students (81 medicine, nine nursing, 16 pharmacy) participated in the interprofessional activity. Eighty-four students responded to the postevent survey (79% response rate). Students were confident that the experience helped them integrate profession-specific knowledge, create a shared care plan, and understand how interprofessional collaboration contributes to quality care. The debriefing session and interprofessional interaction were an integral component of the experience. DISCUSSION: This resource is a feasible interprofessional small-group activity that has been implemented without excessive faculty time or institutional resources. It is adaptable to institutional needs, local resources, level of trainee, and professions. The session provides interprofessional students the opportunity to engage with one another and with the patient in a collaborative decision-making activity focused around a critical transition of care.

Pediatric and Adolescent Gynecology in Europe: Clinical Services, Standards of Care, and Training.

STUDY OBJECTIVE: To identify current clinical services and training available across Europe within pediatric and adolescent gynecology (PAG) and establish the extent to which PAG services meet current European Board and College of Obstetrics and Gynecology (EBCOG) standards. DESIGN: Quantitative and qualitative questionnaire. SETTING: European countries that are members of the EBCOG and the European Association of Pediatric and Adolescent Gynecology. PARTICIPANTS: Thirty-six countries that were approached beginning in September 2013; data were obtained from 27 countries. INTERVENTIONS: Questionnaires with 28 stems were sent to clinical leaders in 36 European countries. MAIN OUTCOME MEASURES: National society, national standards, legislation for female genital mutilation, protocols for transition to adult services, human papilloma virus vaccination programs, sex and contraception education, safeguarding, clinical leads for PAG, delivery of PAG services, and training available for PAG. RESULTS: Of 36 countries, 27 responded. Seventy-seven percent had a national PAG society but only 44% had national standards in PAG. There was agreement that PAG cases should be multidisciplinary but not all have clinical networks in place to facilitate this. Human papilloma virus programs are available in some European countries and not all have legislation against female genital mutilation. A significant proportion of cases continue to be seen in adult gynecology clinics as opposed to designated PAG clinics with only 41% with processes to transfer patients into adult care. CONCLUSION: In this article we provide a framework to explore areas for improvement within PAG services and training across Europe. The EBCOG standards of care are not being adhered to in many countries because processes and clinical networks are not in place to facilitate them.