The Use of Standardized Patients within a Procedural Competency Model to Teach Death Disclosure

OBJECTIVE: To design, implement, and evaluate a multi-dimensional, interdisciplinary, educational training module that enables residents to deliver an effective and empathic death disclosure in the emergency setting. The Accreditation Council for Graduate Medical Education (ACGME) "Toolbox of Assessment Methods" to assess competency was adopted as the foundation of this project. METHODS: Sixteen emergency medicine residents, eight postgraduate year 1 (PGY-1) and eight PGY-2, underwent a one-day training and evaluation exercise. The exercise consisted of: 1) a large-group didactic session, 2) a small-group didactic session, and 3) two standardized patient (SP) examinations. Changes in comfort levels, training helpfulness, and competency were measured. Inter-rater agreement between evaluators was examined. RESULTS: Trainees reported improvement in comfort levels and high levels of satisfaction regarding the helpfulness of the training. Good interrater agreement was obtained regarding resident competency to perform a death disclosure between the faculty and SP evaluators [kappa 0.61; 95% confidence interval (95% CI) = 0.33 to 0.88]. However, overall agreement among raters was poor (kappa 0.16; standard error = 0.26). This poor agreement reflected a lack of agreement between resident and SP evaluators (kappa 0.08; 95% CI = 0.16 to 0.33) and resident and faculty evaluators (kappa -0.02; 95% CI = 0.30 to 0.26). CONCLUSIONS: This project used the ACGME "Toolbox of Assessment Methods" to evaluate the competency of emergency medicine trainees to perform an effective and empathic death disclosure. The finding of inconsistent competency assessments by resident self-evaluators compared with those assessments made by faculty and standardized patients have important implications in future curricular design.     

Evaluation of the potential impact of age- and gender-specific lung morphology and ventilation rate on the dosimetry of vapors

In recent years, there have been growing concerns that due to differences, both pharmacokinetic and pharmacodynamic, between children and adults, children could be at greater risk of adverse effects following chemical exposure. The specific goal of this study was to demonstrate an approach for using physiologically based pharmacokinetic (PBPK) modeling to compare inhalation dosimetry in the adult and the child of both males and females. Three categories of gases were considered: rapidly and irreversibly reactive in the respiratory tract (ozone), relatively water-soluble and nonreactive (isopropanol), and relatively water-insoluble and nonreactive (styrene, vinyl chloride, and perchloroethylene). The nonreactive chemicals were also selected because they are metabolized in the respiratory tract. The age-related changes observed for the estimated dose metrics were a function of the physiochemical properties of the inhaled vapor and their interactions in the body. Blood concentrations estimated for all vapors, either poorly metabolized (e.g., PERC), moderately metabolized (e.g., ST), or highly metabolized vapors (e.g., IPA and VC), varied less than a factor of two between infants and adults. These changes, moreover, were confined to the first year after birth, a relatively short window compared to the total lifespan of the individual. In contrast, circulating metabolite concentrations estimated in the blood, as well as amounts metabolized in the liver and lung, appeared to be a strong function of age, due to their dependence on the maturity of the pertinent metabolic enzyme systems.     

Heterogeneous Optimization Framework: Reproducible Preprocessing of Multi-Spectral Clinical MRI for Neuro-Oncology Imaging Research

Neuroimaging research often relies on clinically acquired magnetic resonance imaging (MRI) datasets that can originate from multiple institutions. Such datasets are characterized by high heterogeneity of modalities and variability of sequence parameters. This heterogeneity complicates the automation of image processing tasks such as spatial co-registration and physiological or functional image analysis. Given this heterogeneity, conventional processing workflows developed for research purposes are not optimal for clinical data. In this work, we describe an approach called Heterogeneous Optimization Framework (HOF) for developing image analysis pipelines that can handle the high degree of clinical data non-uniformity. HOF provides a set of guidelines for configuration, algorithm development, deployment, interpretation of results and quality control for such pipelines. At each step, we illustrate the HOF approach using the implementation of an automated pipeline for Multimodal Glioma Analysis (MGA) as an example. The MGA pipeline computes tissue diffusion characteristics of diffusion tensor imaging (DTI) acquisitions, hemodynamic characteristics using a perfusion model of susceptibility contrast (DSC) MRI, and spatial cross-modal co-registration of available anatomical, physiological and derived patient images. Developing MGA within HOF enabled the processing of neuro-oncology MR imaging studies to be fully automated. MGA has been successfully used to analyze over 160 clinical tumor studies to date within several research projects. Introduction of the MGA pipeline improved image processing throughput and, most importantly, effectively produced co-registered datasets that were suitable for advanced analysis despite high heterogeneity in acquisition protocols.     

A role for dopamine D1-like receptors in acute food deprivation-induced reinstatement of heroin seeking in rats

Dopamine has a critical role in drug reinforcement and the reinstatement of drug seeking due to priming or exposure to drug-associated cues. In contrast, the role of dopamine in stress-induced reinstatement is not clear. We have previously demonstrated that acute food deprivation, a clinically relevant stressor, reinstates heroin seeking in rats via a leptin-dependent mechanism. Recent reports have suggested a modulating role for leptin on dopamine transmission and drug-related behaviours. Thus, here we investigated the role of dopamine in acute food deprivation-induced reinstatement of heroin seeking. Rats were trained to self-administer heroin (0.05 mg/kg per infusion) for 10 d. Following training, heroin seeking was extinguished and rats were tested for 48-h food deprivation-induced reinstatement while pretreated with the dopamine D1-, D2-, or D3-like receptor antagonists: SCH 23390 (0.0, 5.0 or 10.0 microg/kg), raclopride (0.0, 50.0 or 100.0 microg/kg) or NGB 2904 (0.0, 0.1 or 5.0 mg/kg), respectively. The dopamine D1-like receptor antagonist, SCH 23390, but neither of the other antagonists, showed a dose-dependent attenuation of food deprivation-induced reinstatement. Our results suggest that acute food deprivation-induced reinstatement may be mediated, at least in part, by activation of the dopamine D1-like receptor.     

Merkel cell carcinoma in situ

BACKGROUND: Merkel cell carcinoma (MCC) is a dermal small blue-cell tumor that occurs in the elderly on the sun damaged head and neck. Epidermal involvement is unusual and MCC limited to the epidermis is very rare. CASE REPORT: A slightly tender pink hyperkeratotic papule was noted on the dorsal right hand of a 76-year-old man with a history of multiple skin cancers. An intraepidermal proliferation of small blue cells distributed in nests and single units at all levels of the epidermis was found within a solar keratosis and adjacent to an area of squamous cell carcinoma in situ. Cytokeratin 20 and neuron specific enolase highlighted these cells and failed to reveal dermal involvement. There was no residue on re-excision. CONCLUSION: We report the third case of MCC in situ. These lesions have only been reported in association with squamous neoplasms on the extremities.     

A workshop to teach medical students communication skills and clinical knowledge about end-of-life care

We describe a half-day workshop to teach third-year medical students three focused end-of-life care skills: breaking bad news, discussing advance directives, and assessing and managing pain. Our workshop included a readers’ theater exercise and three role-play exercises. In two of the workshops, faculty members played the role of patients. We used readers’ theater to engage the students on an emotional level and set a reflective tone for the workshop. Evaluations reflected that most respondents felt that the workshop enhanced their understanding and ability to address these skills with patients. By 6 months, many students reported applying these skills to patient care in a way they thought was effective. This project was supported by a grant from the Courts Foundation, Atlanta, Ga. We wish to thank Tanisha J. Sullivan, BA for coordinating the workshop.     

Counting physicians: inconsistencies in a commonly used source for workforce analysis.

PURPOSE: To assess the accuracy of the AMA Masterfile. METHOD: In 2002, the authors compared the listing in the Masterfile for pediatric cardiologists with a roster of all such physicians documented by the American Board of Pediatrics (ABP) to have completed pediatric cardiology training. Physicians listed on the Masterfile but without ABP records of training completion received a mail survey. For main outcome measures, the differences in state-level distribution of pediatric cardiologists were used, depending on whether data were from the ABP or the AMA Masterfile. Survey items included nature and duration of medical training, the amount of time caring for pediatric or adult cardiology patients, and whether the respondent conducted echocardiograms and/or cardiac catheterizations on children and/or adults. RESULTS: Of the 2,675 unique, individual physicians obtained from the queries of both lists, 58% (1,558) were listed by both the Masterfile and the ABP. Another 28% (738) were listed by the AMA Masterfile only, and 4% (108) were listed by the ABP only.Of those listed by the Masterfile only, 40% reported they provide no pediatric cardiology care. The amount of pediatric cardiology training was highly variable among the remainder of the respondents. CONCLUSIONS: There are large differences in the number and distribution of physicians identified as pediatric cardiologists between these two datasets. Also, many are potentially providing care for which they have little or no training. Use of such data has the potential to lead to policy options at odds with the actual needs of our nation as a whole or of specific geographic areas.     

Sustained selective attention skills of preschool children with specific language impairment: evidence for separate attentional capacities.

PURPOSE: The present study was designed to investigate the performance of preschool children with specific language impairment (SLI) and their typically developing (TD) peers on sustained selective attention tasks. METHOD: This study included 23 children diagnosed with SLI and 23 TD children matched for age, gender, and maternal education level. The children's sustained selective attention skills were assessed with different types of stimuli (visual, nonverbal-auditory, linguistic) under 2 attentional load conditions (high, low) using computerized tasks. A mixed design was used to compare children across groups and performance across tasks. RESULTS: The SLI participants exhibited poorer performance than their peers on the sustained selective attention tasks presented in the auditory modality (linguistic and nonverbal-auditory) under the high attentional load conditions. Performance was comparable with their peers under the low attentional load conditions. The SLI group exhibited similar performance to their peers on the visual tasks regardless of attentional load. CONCLUSION: These results support the notion of attention difficulties in preschool children with SLI and suggest separate attentional capacities for different stimulus modalities.