Reactive airways dysfunction syndrome (RADS): fact or fantasy?

Most evidence suggests that RADS is a distinct syndrome and not simply an exacerbation of pre-existing hyperresponsiveness. There is no doubt that much remains to be explained regarding pathogenesis. On the other hand, I urge caution about the claims of "low-level RADS" (15). Here the data are much more anecdotal and leave much to be desired.     

Reactive airways dysfunction syndrome (RADS): fact or fantasy?

Most evidence suggests that RADS is a distinct syndrome and not simply an exacerbation of pre-existing hyperresponsiveness. There is no doubt that much remains to be explained regarding pathogenesis. On the other hand, I urge caution about the claims of "low-level RADS" (15). Here the data are much more anecdotal and leave much to be desired.     

Exploring the Transition to Practice for the Newly Credentialed Athletic Trainer: A Programmatic View

Context Some newly credentialed athletic trainers (ATs) pursue a postprofessional degree with a curriculum that specifically advances their athletic training practice. It is unknown how those postprofessional programs assist in their transition to practice.Objective To gain an understanding of initiatives used by postprofessional athletic training programs to facilitate role transition from student to professional during their graduate degree programs.Design Qualitative study.Setting Semistructured telephone interviews.Results Three facilitators of transition to practice emerged: orientation sessions, mentoring, and assistantship. Participants used orientation sessions ranging from a few hours to more than 1 week to provide and discuss program polices and expectations and to outline roles and responsibilities. Faculty, preceptors, and mentors were integrated into the orientation for the academic and clinical portions of the program. All participants described a mentoring process in which students were assigned by the program or informally developed. Mentors included the assigned preceptor, a staff AT, or peer students in the program. The clinical assistantship provided exposure to the daily aspects of being an AT. Barriers to transition to practice included previous educational experiences and time management. Participants reported that students with more diverse didactic and clinical education experiences had easier transitions. The ability to manage time also emerged as a challenge.Conclusions Postprofessional athletic training programs used a formal orientation session as an initial means to help the newly credentialed AT transition into the role. Mentoring provided both more informal and ongoing support during the transition.Key Words: mentoring, orientation, time management

Key Points

• Program directors used orientation sessions and mentoring to help support the transition from student to credentialed athletic trainer.
• The clinical assistantship provided the foundations for transition, as it conveyed role engagement.
• Mentoring was mostly informal but provided the ongoing support needed during the transition from student to credentialed athletic trainer.

Recent debate and anecdotal evidence have suggested that newly credentialed athletic trainers (ATs) are not as prepared for the demands of professional practice as they once were.^1–6 However, these ATs still are expected to be completely autonomous practitioners and provide safe patient care. Most of these newly credentialed ATs are employed in graduate assistantship positions and are navigating workloads comparable with those of full-time staff members and associated expectations of patient care.⁷Whereas new ATs have met all credentialing requirements and are viewed as being able to function as ATs, having complete autonomy and ultimate decision-making power is a new experience. In fact, many recent graduates who gain certification seek positions that will provide support while they build confidence with decision making.^8–11 Many of these positions are as graduate assistants, which allow for continued clinical experience coupled with didactic learning. Clinical independence combined with mentoring has emerged as not only an attractor to the graduate-student role¹¹ but also an expectation for socializing them into their roles as graduate students.^9,10 Athletic trainers who become graduate assistants are placed in a unique situation, as they are expected to juggle roles as students; health care providers; and in some cases, preceptors or classroom instructors. Role strain and burnout are likely to manifest, especially due to the demands placed on them at such an early stage in their careers as they attempt to gain role inductance and experience as ATs.^7,12The ability to provide safe patient care is a concern for many health care providers but is of great concern for newly credentialed ATs. During this period, they are attempting for the first time to make decisions regarding patient care without clinical supervision and feedback. A high rate of medical errors and burnout occurs among newly credentialed health care providers.¹³ Graduate assistants, who are often newly credentialed ATs, do experience burnout,⁷ and if medical errors result because of burnout, they are likely to affect the ATs'' professional development and clinical competence. The National Council of State Boards of Nursing issued an initiative to begin exploring transition-to-practice techniques to formalize the transition to practice for new nurses.¹⁴ This initiative aims to reduce medial errors, reduce turnover, and enhance patient safety and care. Recently, the National Athletic Trainers'' Association (NATA) Executive Committee for Education recommended exploring the employer''s responsibility to provide development and supervision for newly credentialed ATs to create effective support models for their transition to practice.¹⁵ Attending a postprofessional athletic training program is one model that can help newly credentialed ATs transition to practice. Currently, 16 postprofessional athletic training programs are accredited by the Commission on Accreditation of Athletic Training Education (CAATE),¹⁶ and a host of other programs offer comparable curriculums but are not accredited to date. These programs lead to a master''s or doctorate degree for learners who are already credentialed as ATs and expand the depth and breadth of the applied, experiential, and propositional knowledge and skills of ATs through didactic, clinical, and research experiences. Most often, students in these postprofessional programs have recently completed their undergraduate athletic training education, have no work experience, and are transitioning from student to newly credentialed AT. Furthermore, individuals enrolled in these postprofessional programs are looking for experiences that will nurture their growth as ATs from both clinical and didactic standpoints.¹¹ The graduate-assistant role is recognized as a “rite of passage” used to acclimate the AT and allow for improved decision making¹⁷; however, the initiatives that postprofessional programs use to assist the student transitioning into this role are unknown. By identifying these initiatives, educational models that support transition to practice can be identified. Therefore, the purpose of our study was to gain an understanding of initiatives used by postprofessional athletic training programs to facilitate role transition from student to professional during their graduate degree programs. Little information exists from the program viewpoint; thus, we need to gain a comprehensive understanding of the role-transition process for the AT, which includes facilitators and barriers that may exist in the transition. Facilitators¹⁸ are likely those factors that are supportive, ongoing, and viewed as a positive aspect of role transition. Conversely, barriers¹⁸ are factors that may hinder transition or cause a delay in transition; these likely include lack of confidence and unawareness of their new role.     

Epistemology and Psychotherapy Data: The Unspeakable, Unbearable, Horrible Truth

Recent discussions of the scientist/practitioner schism in clinical psychology have begun to take note of the epistemology of practice. This article focuses on the far-reaching implications of a very specific aspect of psychotherapy practice—the uncovering of concealed clinical phenomena. These phenomena are both ubiquitous and inaccessible to conventional research methods, leaving the profession in an epistemological dilemma. Using the extensive philosophical analysis of the nature of testimony by the Australian philosopher C. A. J. Coady, It is shown that such anecdotal data are not necessarily invalid (as is often asserted) and may be legitimately used in constructing the knowledge base for the profession of clinical psychology. At the same time, this analysis points the way to new forms of research collaboration between researchers and clinicians in psychology.     

Delta-9-tetrahydrocannabinol and cannabidiol, but not ondansetron, interfere with conditioned retching reactions elicited by a lithium-paired context in Suncus murinus: An animal model of anticipatory nausea and vomiting

Chemotherapy patients report not only acute nausea and vomiting during the treatment itself, but also report anticipatory nausea and vomiting upon re-exposure to the cues associated with the treatment. We present a model of anticipatory nausea based on the emetic reactions of the Suncus murinus (musk shrew). Following three pairings of a novel distinctive contextual cue with the emetic effects of an injection of lithium chloride, the context acquired the potential to elicit conditioned retching in the absence of the toxin. The expression of this conditioned retching reaction was completely suppressed by pretreatment with each of the principal cannabinoids found in marijuana, Delta(9)-tetrahydrocannabinol or cannabidiol, at a dose that did not suppress general activity. On the other hand, pretreatment with a dose of ondansetron (a 5-HT(3) antagonist) that interferes with acute vomiting in this species, did not suppress the expression of conditioned retching during re-exposure to the lithium-paired context. These results support anecdotal claims that marijuana, but not ondansetron, may suppress the expression of anticipatory nausea.     

粗糙集在构建骨肿瘤辅助诊断知识库的应用研究

在骨肿瘤辅助诊断专家系统研究中，知识库的建立是一直困扰系统建立的瓶颈问题，知识库的好坏不仅影响到后续推理过程，而且还对诊断的精度有着很大的影响。本文使用基于粗糙集理论的数据挖掘技术，对已确诊病例资料数据库进行数据分析，建立骨肿瘤与患者临床表现之间的推理关系，并结合医生的临床实践，最终形成一个比较完备的辅助诊断知识数据库，为后续的推理、解释程序打下良好的基础。     

Updating the East Asian mtDNA phylogeny: a prerequisite for the identification of pathogenic mutations

Knowledge about the world phylogeny of human mitochondrial DNA (mtDNA) is essential not only for evaluating the pathogenic role of specific mtDNA mutations but also for performing reliable association studies between mtDNA haplogroups and complex disorders. In the past few years, the main features of the East Asian portion of the mtDNA phylogeny have been determined on the basis of complete sequencing efforts, but representatives of several basal lineages were still lacking. Moreover, some recently published complete mtDNA sequences did apparently not fit into the known phylogenetic tree and conflicted with the established nomenclature. To refine the East Asian mtDNA tree and resolve data conflicts, we first completely sequenced 20 carefully selected mtDNAs--likely representatives of novel sub-haplogroups--and then, in order to distinguish diagnostic mutations of novel haplogroups from private variants, we applied a 'motif-search' procedure to a large sample collection. The novel information was incorporated into an updated East Asian mtDNA tree encompassing more than 1000 (near-) complete mtDNA sequences. A reassessment of the mtDNA data from a series of disease studies testified to the usefulness of such a refined mtDNA tree in evaluating the pathogenicity of mtDNA mutations. In particular, the claimed pathogenic role of mutations G3316A, T3394C, A4833G and G15497A appears to be most questionable as those initial claims were derived from anecdotal findings rather than e.g. appropriate association studies. Following a guideline based on the phylogenetic knowledge as proposed here could help avoiding similar problems in the future.     

Intradermal, epidermal and transcutaneous vaccination: from immunology to clinical practice

The dermis and epidermis are alternative sites for prophylactic vaccination that have received renewed interest in recent years, not only because of the ease of access to the skin, but also its unique immunological properties. This review discusses the characteristics of the skin, current knowledge on skin immunity and clinical experience with cutaneous immunization against infectious diseases, with a special focus on intradermal immunization. The most widely accepted paradigm explaining the efficacy of cutaneous immunization is reviewed and recent research suggesting where this paradigm may need some refinement is highlighted. Clinical investigations that have concentrated on the intradermal route to vaccinate against influenza, rabies or hepatitis B support the current knowledge on skin immunity and, when combined with recent progress made in the development of user-friendly injection systems, have stimulated the ongoing clinical development of novel vaccines.     

Medication adherence as a learning process: insights from cognitive psychology

Non-adherence to medications is one of the largest contributors to sub-optimal health outcomes. Many theories of adherence include a ‘value–expectancy’ component in which a patient decides to take a medication partly based on expectations about whether it is effective, necessary, and tolerable. We propose reconceptualising this common theme as a kind of ‘causal learning’ – the patient learns whether a medication is effective, necessary, and tolerable, from experience with the medication. We apply cognitive psychology theories of how people learn cause–effect relations to elaborate this causal-learning challenge. First, expectations and impressions about a medication and beliefs about how a medication works, such as delay of onset, can shape a patient’s perceived experience with the medication. Second, beliefs about medications propagate both ‘top-down’ and ‘bottom-up’, from experiences with specific medications to general beliefs about medications and vice versa. Third, non-adherence can interfere with learning about a medication, because beliefs, adherence, and experience with a medication are connected in a cyclic learning problem. We propose that by conceptualising non-adherence as a causal-learning process, clinicians can more effectively address a patient’s misconceptions and biases, helping the patient develop more accurate impressions of the medication.     

Effectiveness of problem-based learning curricula: research and theory.

PURPOSE: This article provides a critical overview of problem-based learning (PBL), its effectiveness for knowledge acquisition and clinical performance, and the underlying educational theory. The focus of the paper is on (1) the credibility of claims (both empirical and theoretical) about the ties between PBL and educational outcomes and (2) the magnitude of the effects. METHOD: The author reviewed the medical education literature, starting with three reviews published in 1993 and moving on to research published from 1992 through 1998 in the primary sources for research in medical education. For each study the author wrote a summary, which included study design, outcome measures, effect sizes, and any other information relevant to the research conclusion. RESULTS AND CONCLUSION: The review of the literature revealed no convincing evidence that PBL improves knowledge base and clinical performance, at least not of the magnitude that would be expected given the resources required for a PBL curriculum. The results were considered in light of the educational theory that underlies PBL and its basic research. The author concludes that the ties between educational theory and research (both basic and applied) are loose at best.     

A life with prosopagnosia

The author gives an anecdotal account of his life with developmental prosopagnosia (DP). He was not formally diagnosed until the age of 53 and has evolved a complicated strategy for recognizing people based on non-facial physical features and context. He describes his experiences through infancy, school, university life and courtship, work and family life. He believes that he has lived a full and successful life despite DP but that some aspects of his social and work life were impaired by face-blindness. In his experience people react positively and helpfully if the consequences of DP are explained to them, and this improves social interactions and communications.     

Evidence-guided education: patients' outcome data should influence our teaching priorities.

How should medical educators choose learning objectives and teaching content in clinical education? Given the information chain reaction, coverage of all significant topics in sufficient depth is not possible. Choosing subjects of high priority is essential if education is to have maximum impact on quality of care. These priorities should not derive from tradition and opinion, but should be informed by patient outcomes, the ultimate standard for assessing educational effectiveness. Building upon prior initiatives linking education to practice, the author uses the term "evidence-guided education" to express the process of influencing curricular choices with evidence from health outcomes. Sources of outcome evidence include incident reports, morbidity and mortality conferences, surveillance of quality of care in particular venues, case series, surveys of adverse events and "near-misses," and malpractice claims. Starting with anecdotal occurrences, additional case-finding may establish patterns of poor outcomes, some of which may be preventable. Credible research data on outcomes can inform prioritization for objectives and content at successive institutional levels, which should improve practices and outcomes, completing the loop of feedback, implementation, and improved health. The closer the educational intervention is to practice, the more accountable it becomes. Thus, EGE is more amenable to evaluation at residents' and practitioners' levels and more difficult at the undergraduate level. However, outcome evidence should still inform undergraduate teaching, since this constitutes the platform for future learning. Severe constraints on learning time mandate prioritization of content and suggest the need for the judicious application of outcome evidence in place of mere opinion.     

Expectations and essentials for the community practice of pathology

In 3 surveys during the past 10 years, community hospital pathologists were asked what they want, need, or look for when employing a pathologist and, more specifically, what skills and knowledge a newly minted pathologist should have to be successful in the community practice of pathology. The most recent survey, done in spring of 2005, cited surgical pathology diagnosis, frozen section diagnosis, gross dissection, cytology, and fine-needle aspiration as essentials in anatomic pathology. For clinical pathology, knowledge of clinical medicine and test strategies that use the laboratory for clinical problem solving was paramount. New expectations in the latest survey were knowledge of molecular pathology and experience in quality assurance procedures. New pathologists generally meet the expectations of the community hospital workplace; however, there were some deficiencies: they were not proficient in gross pathology or autopsy pathology, they were slow, and many lack the clinical knowledge and experience to be effective consultants. The principal attribute that determines success in the practice of pathology, however, is skill in communication and interpersonal relations, and this remains the major deficiency of the fledgling pathologist.     

Social Construction: Vistas in Clinical Child and Adolescent Psychology

We explore here the potentials of a social constructionist orientation to knowledge for research and clinical practice. Dialogues on social construction emphasize the communal origins of knowledge. They stress the cultural basis of knowledge claims, the significance of language, the value saturation of all knowledge, and the significance of relationships as opposed to individuals. An initial illustration of constructionism in action centers on adolescent risk behavior. Such behavior is often constructed negatively within popular writings and the social science and thus ignores the meaning of such actions to the adolescents themselves. Discourse analysis indicates that for adolescents risky behavior serves important functions of enhancing group solidarity and establishing positive identity. A second illustration, exploring the implications of constructionism for therapy, places a strong emphasis on the therapist as a collaborator in the building of meaning. Traditional investments in diagnosis and treatment are replaced with the collaborative creation of new possibilities for action.     

Systematic instruction in laboratory medicine: Effects on the clinical problem solving performance of medical students

Modified patient management problems were administered to senior medical students in pre- and postexamination formats to evaluate the effects of systematic instruction in laboratory medicine on clinical problem solving performance. Significant improvements were noted on several of the derived performance measures studied. Most improvements could be attributed to the course of instruction, some were problem dependent, and students with some prior clinical experience exhibited more improvement than did their less experienced colleagues. Evidence is presented to suggest that poor problem solving performance, as evident from pre-examination results, reflects not any inherent problem solving deficiency, but a specific lack of knowledge. The greater degree of improvement exhibited by inexperienced students toward greater hypothesis specificity and higher diagnostic goal indices leads us to speculate that inexperienced students structure knowledge differently from their experienced counterparts. It is concluded that systematic instruction aimed at improving laboratory utilization is capable of evaluation and, at least in simulated format, leads to improved clinical problem solving. The implications are discussed.     

Social construction: vistas in clinical child and adolescent psychology.

We explore here the potentials of a social constructionist orientation to knowledge for research and clinical practice. Dialogues on social construction emphasize the communal origins of knowledge. They stress the cultural basis of knowledge claims, the significance of language, the value saturation of all knowledge, and the significance of relationships as opposed to individuals. An initial illustration of constructionism in action centers on adolescent risk behavior. Such behavior is often constructed negatively within popular writings and the social science and thus ignores the meaning of such actions to the adolescents themselves. Discourse analysis indicates that for adolescents risky behavior serves important functions of enhancing group solidarity and establishing positive identity. A second illustration, exploring the implications of constructionism for therapy, places a strong emphasis on the therapist as a collaborator in the building of meaning. Traditional investments in diagnosis and treatment are replaced with the collaborative creation of new possibilities for action.     

Are our impressions of allergy test performances correct?

BACKGROUND: The clinical diagnosis is often subjective and susceptible to bias, yet it is the primary standard by which diagnostic tests are judged. Consequently, our opinions regarding various diagnostic tests may not be entirely accurate. OBJECTIVE: To investigate the accuracy of the clinical history compared with concordant skin and quantitative specific IgE (s-IgE) measurements. METHODS: Consecutive, consenting patients (N = 152) at 2 different allergy centers were examined by history and physical examination (HPE) alone to determine their sensitivity to 7 common allergens. Results were classified as positive, negative, or indeterminate. The HPE results were then compared to concordant skin prick testing (SPT) and s-IgE measurements and to quantitative IgE antibody measurements with and without knowledge of the SPT results. RESULTS: Diagnosis by HPE deviated considerably from concordant SPT and s-IgE results. This deviation differed between allergists and allergens, reflecting a positive HPE bias that averaged 22%. Seventy-six percent of the HPE results judged indeterminate were resolved as negative. Using additional information from the quantification of s-IgE antibodies, considerable differences between the sites in the level of s-IgE associated with a positive HPE result with and without SPT results were observed. CONCLUSIONS: Relative to the SPT and quantification of s-IgE antibodies, the diagnosis by HPE alone to common allergens is not consistent. Discrepancies were dependent on both allergen and allergist. The quantitative s-IgE data revealed that allergists use available information from the HPE and SPT differently. Since the HPE is the primary standard used in judging test efficacy (sensitivity and specificity), our current impressions of test performances are not likely to be accurate.