Two critical thinking models-probing questions and conceptualization-adding 4 skillsets to the teacher's armamentarium.

Critical thinking is ubiquitous in patient care. One track for critical thinking develops skillsets emulating the thought process of the master clinician using probing questions and has been offered in treatment planning, literature search, and critique, risk assessment in caries and geriatrics, technology decision-making, EBD, and IPP. This paper offers 2 additional critical thinking skillsets following this emulation model in social work and ethics. Conceptualization, another form of critical thinking, is also ubiquitous in health care, yet almost no literature exists to guide learning and assess performance on conceptualization. This paper introduces for discussion 2 examples of conceptualization-"How and how much does this situation differ from the ideal?" and "How does the student/practitioner conceptualize the outcome prior to the imminent procedure?" -used continually by the practitioner in patient care situations. The result is 4 additional critical thinking skillsets at different stages of development in the armamentarium for the teacher.

Periodontal treatment needs in the Medicaid patient population: a retrospective study in a US dental school.

OBJECTIVES: The aim of this study was to use electronic health records (EHRs) from a US dental school clinic to retrospectively investigate associations between periodontal treatment needs and insurance type in a newly insured adult Medicaid population. We hypothesized that newly insured Medicaid patients, covered by the Iowa Dental Wellness Plan (DWP), would display greater need for treatment than patients with other sources of financing. METHODS: A retrospective chart review of EHRs of patients at the University of Iowa College of Dentistry and Dental Clinics (UI COD) from 2014 to 2016 was completed. The outcome of interest whether or not a new patient was indicated for scaling and root planing (SRP) based on clinical examination. Logistic regression models analyzed associations between treatment need and source of financing, adjusting for known periodontal disease risk indicators. RESULTS: A total of 1,259 patient charts were evaluated. SRP was indicated for 56 percent of all patients. Patients with DWP coverage had significantly greater unadjusted odds of being indicated for SRP than privately insured individuals (OR = 1.47, P = 0.009). However, this association did not remain significant after adjusting for known risk indicators. CONCLUSIONS: Although individuals enrolled in DWP were not significantly more likely to need treatment than individuals with other sources of financing when adjusting for risk indicators, their demonstrated clinical need was higher than privately insured adults. Public benefit programs could anticipate greater burden of periodontal need in low-income populations due to increased prevalence of risk factors in this population.

Preventive dental care among Medicaid-enrolled senior adults: from community to nursing facility residence.

OBJECTIVE: The primary objective of this study was to determine whether the utilization rate of preventive oral health care services while senior adults were community-dwelling differed from the rate after those same senior adults were admitted to nursing facilities. A secondary objective was to evaluate other significant predictors of receipt of preventive oral health procedures after nursing facility entry. METHODS: Iowa Medicaid claims from 2007-2014 were accessed for adults who were 68+ years upon entry to a nursing facility and continuously enrolled in Medicaid for at least three years before and at least two years after admission (n = 874). Univariate, bivariate and multivariable analyses were conducted. RESULTS: During the five years that subjects were followed, 52.8% never received a dental exam and 75.9% never received a dental hygiene procedure. More Medicaid-enrolled senior adults received ≥1 preventive dental procedure in the two years while residing in a nursing facility compared to the three years before entry. In multivariable analyses, the strongest predictor of preventive oral health care utilization after entry was the receipt of preventive oral health services before entry (p < 0.01). CONCLUSIONS: The strongest predictor of receipt of dental procedures in the two years after nursing facility entry was the receipt of dental procedures in the three years before entry while community-dwelling. This underscores the importance of the senior adult establishing a source of dental care while community-dwelling.

A Randomized Controlled Trial of an Emergency Department Intervention for Patients with Chronic Noncancer Pain.

BACKGROUND: Emergency Departments (EDs) are beginning to notify their physicians of patients reporting chronic noncancer pain (CNCP) who frequent EDs, and are suggesting that the physicians not prescribe opioids to these patients. OBJECTIVES: We hypothesized that this intervention would reduce both the number of opioids prescribed to these patients by their ED physicians and the number of these patients' return visits to the ED. METHODS: We conducted a randomized controlled trial of this intervention in 13 electronically linked EDs. Patients eligible for the study were characterized by CNCP, lacked evidence of sickle cell anemia and suicide ideation, and made frequent (>10) visits to the EDs over a 12-month period. We randomly assigned 411 of these patients to either an intervention group or a control group. Our intervention comprised both an alert placed in eligible patients' medical files and letters sent to the patients and their community-based providers. The alert suggested that physicians decline requests for opioid analgesic prescriptions and instead refer these patients to community-based providers to manage their ongoing pain. RESULTS: During the 12 months after randomization, patients in the intervention and control groups averaged 11.9 and 16.6 return visits, and received prescriptions for opioids on 16% and 26% of those visits, respectively. Altogether, patients in the intervention group made 1033 fewer return visits to the EDs in the follow-up year than those in the control group. CONCLUSION: This intervention constitutes a promising practice that EDs should consider to reduce the number of visits made by frequent visitors with CNCP.

Outcomes mapping: a method for dental schools to coordinate learning and assessment based on desired characteristics of a graduate.

This project, utilizing a seldom-used approach to dental education, was designed to define the desired characteristics of a graduating dental student; convert those characteristics to educational outcomes; and use those outcomes to map a dental school's learning and assessment programs, based on outcomes rather than courses and disciplines. A detailed rubric of the outcomes expected of a graduating dental student from this school was developed, building on Commission on Dental Accreditation (CODA) standards and the school's competencies. The presence of each characteristic in the rubric was mapped within and across courses and disciplines. To assess implementation of the rubric, members of two faculty committees and all fourth-year students were asked to use it to rate 1) the importance of each characteristic, 2) the extent to which the school teaches and assesses each, and 3) the extent to which each counts toward overall assessment of competence. All thirty-three faculty members (100 percent) on the committees participated, as did forty-six of the fifty-five students (84 percent). The groups gave high scores to the importance of each characteristic, especially for knowledge and technical competence (then separate categories but merged in the final rubric) and for self-assessment, as well as the extent to which they are being taught and assessed. Respondents most commonly named critical thinking as the area that should be emphasized more. Mapping the curriculum and creating its related database allow the faculty and administration to more systematically coordinate learning and assessment than was possible with a course-based approach.

Concepts in critical thinking applied to caries risk assessment in dental education.

Much progress has been made in the science of caries risk assessment and ways to analyze caries risk, yet dental education has seen little movement toward the development of frameworks to guide learning and assess critical thinking in caries risk assessment. In the absence of previous proactive implementation of a learning framework that takes the knowledge of caries risk and critically applies it to the patient with the succinctness demanded in the clinical setting, the purpose of this study was to develop a model learning framework that combines the science of caries risk assessment with principles of critical thinking from the education literature. This article also describes the implementation of that model at one dental school and presents some preliminary assessment data.

Integrating critical thinking and evidence-based dentistry across a four-year dental curriculum: a model for independent learning.

Introducing critical thinking and evidence-based dentistry (EBD) content into an established dental curriculum can be a difficult and challenging process. Over the past three years, the University of Iowa College of Dentistry has developed and implemented a progressive four-year integrated critical thinking and EBD curriculum. The objective of this article is to describe the development and implementation process to make it available as a model for other dental schools contemplating introduction of critical thinking and EBD into their curricula. The newly designed curriculum built upon an existing problem-based learning foundation, which introduces critical thinking and the scientific literature in the D1 year, in order to expose students to the rationale and resources for practicing EBD in the D2 and D3 years and provide opportunities to practice critical thinking and apply the EBD five-step process in the D2, D3, and D4 years. All curricular content is online, and D3 and D4 EBD activities are integrated within existing clinical responsibilities. The curricular content, student resources, and student activities are described.

2013 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 31st Annual Report.

BACKGROUND: This is the 31st Annual Report of the American Association of Poison Control Centers' (AAPCC) National Poison Data System (NPDS). As of January 1, 2013, 57 of the nation's poison centers (PCs) uploaded case data automatically to NPDS. The upload interval was 8.08 [7.10, 11.63] (median [25%, 75%]) minutes, creating a near real-time national exposure and information database and surveillance system. METHODOLOGY: We analyzed the case data tabulating specific indices from NPDS. The methodology was similar to that of previous years. Where changes were introduced, the differences are identified. Poison center (PC) cases with medical outcomes of death were evaluated by a team of 38 medical and clinical toxicologist reviewers using an ordinal scale of 1-6 to assess the Relative Contribution to Fatality (RCF) of the exposure to the death. RESULTS: In 2013, 3,060,122 closed encounters were logged by NPDS: 2,188,013 human exposures, 59,496 animal exposures, 806,347 information calls, 6,116 human-confirmed nonexposures, and 150 animal-confirmed nonexposures. Total encounters showed a 9.3% decline from 2012, while health care facility human exposure calls were essentially flat, decreasing by 0.1%.All information calls decreased 21.4% and health care facility (HCF) information calls decreased 8.5%, medication identification requests (drug ID) decreased 26.8%, and human exposures reported to US PCs decreased 3.8%. Human exposures with less serious outcomes have decreased 3.7% per year since 2008 while those with more serious outcomes (moderate, major or death) have increased by 4.7% per year since 2000. The top five substance classes most frequently involved in all human exposures were analgesics (11.5%), cosmetics/personal care products (7.7%), household cleaning substances (7.6%), sedatives/hypnotics/antipsychotics (5.9%), and antidepressants (4.2%). Sedative/hypnotics/antipsychotics exposures as a class increased most rapidly (2,559 calls/year) over the last 13 years for cases showing more serious outcomes. The top five most common exposures in children of 5 years or less were cosmetics/personal care products (13.8%), household cleaning substances (10.4%), analgesics (9.8%), foreign bodies/toys/miscellaneous (6.9%), and topical preparations (6.1%). Drug identification requests comprised 50.7% of all information calls. NPDS documented 2,477 human exposures resulting in death with 2,113 human fatalities judged related (RCF of 1, undoubtedly responsible; 2, probably responsible; or 3, contributory). CONCLUSIONS: These data support the continued value of PC expertise and need for specialized medical toxicology information to manage the more severe exposures, despite a decrease in calls involving less severe exposures. Unintentional and intentional exposures continue to be a significant cause of morbidity and mortality in the United States. The near real-time, always current status of NPDS represents a national public health resource to collect and monitor US exposure cases and information calls. The continuing mission of NPDS is to provide a nationwide infrastructure for public health surveillance for all types of exposures, public health event identification, resilience response and situational awareness tracking. NPDS is a model system for the nation and global public health.

2012 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 30th Annual Report.

BACKGROUND: This is the 30(th) Annual Report of the American Association of Poison Control Centers' (AAPCC) National Poison Data System (NPDS). As of July 1, 2012, 57 of the nation's poison centers (PCs) uploaded case data automatically to NPDS. The upload interval was 7.58 [6.30, 11.22] (median [25%, 75%]) min, creating a near real-time national exposure and information database and surveillance system. METHODOLOGY: We analyzed the case data tabulating specific indices from NPDS. The methodology was similar to that of previous years. Where changes were introduced, the differences are identified. Poison center cases with medical outcomes of death were evaluated by a team of 34 medical and clinical toxicologist reviewers using an ordinal scale of 1-6 to assess the Relative Contribution to Fatality (RCF) of the exposure to the death. RESULTS: In 2012, 3,373,025 closed encounters were logged by NPDS: 2,275,141 human exposures, 66,440 animal exposures, 1,025,547 information calls, 5,679 human confirmed nonexposures, and 218 animal confirmed nonexposures. Total encounters showed a 6.9% decline from 2011, while healthcare facility (HCF) exposure calls increased by 1.2%. All information calls decreased by 14.8% and HCF information calls decreased by 1.7%, medication identification requests (Drug ID) decreased by 22.0%, and human exposures reported to US PCs decreased by 2.5%. Human exposures with less serious outcomes have decreased by 3.7% per year since 2008, while those with more serious outcomes (moderate, major, or death) have increased by 4.6% per year since 2000. The top five substance classes most frequently involved in all human exposures were analgesics (11.6%), cosmetics/personal care products (7.9%), household cleaning substances (7.2%), sedatives/hypnotics/antipsychotics (6.1%), and foreign bodies/toys/miscellaneous (4.1%). Analgesic exposures as a class increased the most rapidly (8,780 calls/year) over the last 12 years. The top five most common exposures in children aged 5 years or less were cosmetics/ personal care products (13.9%), analgesics (9.9%), household cleaning substances (9.7%), foreign bodies/toys/ miscellaneous (7.0%), and topical preparations (6.3%). Drug identification requests comprised 54.4% of all information calls. NPDS documented 2,937 human exposures resulting in death with 2,576 human fatalities judged related (RCF of 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory). CONCLUSIONS: These data support the continued value of PC expertise and need for specialized medical toxicology information to manage the more severe exposures, despite a decrease in calls involving less severe exposures. Unintentional and intentional exposures continue to be a significant cause of morbidity and mortality in the US. The near real-time, always current status of NPDS represents a national public health resource to collect and monitor US exposure cases and information calls. The continuing mission of NPDS is to provide a nationwide infrastructure for public health surveillance for all types of exposures, public health event identification, resilience response, and situational awareness tracking. NPDS is a model system for the nation and global public health.

Guiding dental student learning and assessing performance in critical thinking with analysis of emerging strategies.

Patient-centered care involves an inseparable set of knowledge, abilities, and professional traits on the part of the health care provider. For practical reasons, health professions education is segmented into disciplines or domains like knowledge, technical skills, and critical thinking, and the culture of dental education is weighted toward knowledge and technical skills. Critical thinking, however, has become a growing presence in dental curricula. To guide student learning and assess performance in critical thinking, guidelines have been developed over the past several decades in the educational literature. Prominent among these guidelines are the following: engage the student in multiple situations/exercises reflecting critical thinking; for each exercise, emulate the intended activity for validity; gain agreement of faculty members across disciplines and curriculum years on the learning construct, application, and performance assessment protocol for reliability; and use the same instrument to guide learning and assess performance. The purposes of this article are 1) to offer a set of concepts from the education literature potentially helpful to guide program design or corroborate existing programs in dental education; 2) to offer an implementation model consolidating these concepts as a guide for program design and execution; 3) to cite specific examples of exercises and programs in critical thinking in the dental education literature analyzed against these concepts; and 4) to discuss opportunities and challenges in guiding student learning and assessing performance in critical thinking for dentistry.

A controlled evaluation of case clinical effect coding by poison center specialists for detection of WMD scenarios.

BACKGROUND: Many public health entities employ computer-based syndromic surveillance to monitor for aberrations including possible exposures to weapons of mass destruction (WMD). Often, this is done by screening signs and symptoms reported for cases against syndromic definitions. Poison centers (PCs) may offer significant contributions to public health surveillance because of their detailed clinical effect data field coding and real-time data entry. Because improper clinical effect coding may impede syndromic surveillance, it is important to assess this accuracy for PCs. METHODS: An AAPCC-certified regional PC assessed the accuracy of clinical effect coding by specialists in poison information (SPIs) listening to audio recordings of standard cases. Eighteen different standardized cases were used, consisting of six cyanide, six botulism, and six control cases. Cases were scripted to simulate clinically relevant telephone conversations and converted to audio recordings. Ten SPIs were randomly selected from the center's staff to listen to and code case information from the recorded cases. Kappa scores and the percentage of correctly coding a present clinical effect were calculated for individual clinical effects summed over all test cases along with corresponding 95% confidence intervals. The rate of the case coding by the SPIs triggering the PC's automated botulism and cyanide alerts was also determined. RESULTS: The kappa scores and the percentage of correctly coding a present clinical effect varied depending on the specific clinical effect, with greater accuracy observed for the clinical effects of vomiting and agitation/irritability, and poor accuracy observed for the clinical effects of visual defect and anion gap increase. Lack of correct coding resulted in only 60 and 86% of the cases that met the botulism and cyanide surveillance definitions, respectively, triggering the corresponding alert. There was no difference observed in the percentage of coding a present clinical effect between certified (9.0 years experience) and non-certified (2.4 years experience) specialists. There were no cases of coding errors that resulted in the triggering of a false positive alert. CONCLUSION: The success of syndromic surveillance depends on accurate coding of signs and symptoms. Although PCs generally contribute high-quality data to public health surveillance, it is important to recognize this potential weak link in surveillance methods.

Development and evaluation of an interactive dental video game to teach dentin bonding.

Written and clinical tests compared the change in clinical knowledge and practical clinical skill of first-year dental students watching a clinical video recording of the three-step etch-and-rinse resin bonding system to those using an interactive dental video game teaching the same procedure. The research design was a randomized controlled trial with eighty first-year dental students enrolled in the preclinical operative dentistry course. Students' change in knowledge was measured through written examination using a pre-test and a post-test, as well as clinical tests in the form of a benchtop shear bond strength test. There was no statistically significant difference between teaching methods in regards to change in either knowledge or clinical skills, with one minor exception relating to the wetness of dentin following etching. Students expressed their preference for an interactive self-paced method of teaching.

A model for overview of student learning: a matrix of educational outcomes versus methodologies.

A concise overview of an institution's aspirations for its students becomes increasingly elusive because dental education has evolving emphases on priorities like critical thinking and adapting to new technology. The purpose of this article is to offer a learner-oriented matrix that gives a focus for discussion and an overview of an institution's educational outcomes. On one axis of the matrix, common educational outcomes are listed: knowledge, technical skills, critical thinking, ethical and professional values, patient and practice management, and social responsibility awareness. On the other axis, methodologies are listed: definition, cultivation strategies, measures (summative/formative, objective/subjective), institutional coordination, and competency determination. By completing the matrix, an overview of the process by which students reach these outcomes emerges. Each institution would likely complete the matrix differently and, ideally, with active discussion. While the matrix can first be used to establish "Where are we now?" for an institution, it can also be a starting point for more extensive matrices and further discussion. Vertical and horizontal analyses of the matrix provide a unique lens for viewing the institution's learning environment.

Unintentional poisoning in North Carolina: an emerging public health problem.

Unintentional poisoning is a fast-growing public health problem that once evoked an image of a street denizen injecting heroin or snorting cocaine. Today's victim is white, male, and middle-aged--and the drugs are prescribed. In North Carolina, unintentional poisoning is the second-leading cause of death due to unintentional injury, and injuries due to any cause are the leading cause of potential years of life lost. Comprehensive prevention measures are needed now to stem this burgeoning problem.

Classification tree methods for development of decision rules for botulism and cyanide poisoning.

INTRODUCTION: Identification of predictors of potential mass poisonings may increase the speed and accuracy with which patients are recognized, potentially reducing the number ultimately exposed and the degree to which they are affected. This analysis used a decision-tree method to sort such potential predictors. METHODS: Data from the Toxic Exposure Surveillance System were used to select cyanide and botulism cases from 1993 to 2005 for analysis. Cases of other poisonings from a single poison center were used as controls. After duplication was omitted and removal of cases from the control sample was completed, there remained 1,122 cyanide cases, 262 botulism cases, and 70,804 controls available for both analyses. Classification trees for each poisoning type were constructed, using 131 standardized clinical effects. These decision rules were compared with the current case surveillance definitions of one active poison center and the American Association of Poison Control Centers (AAPCC). RESULTS: The botulism analysis produced a 4-item decision rule with sensitivity (Se) of 68% and specificity (Sp) of 90%. Use of the single poison center and AAPCC definitions produced Se of 19.5% and 16.8%, and Sp of 99.5% and 83.2%, respectively. The cyanide analysis produced a 9-item decision rule with Se of 74% and Sp of 77%. The single poison center and AAPCC case definitions produced Se of 10.2% and 8.6%, and Sp of 99.8% and 99.8%, respectively. CONCLUSIONS: These results suggest the possibility of improved poisoning case surveillance sensitivity using classification trees. This method produced substantially higher sensitivities, but not specificities, for both cyanide and botulism. Despite limitations, these results show the potential of a classification-tree approach in the detection of poisoning events.

Severe illness in furniture makers using a new glue: 1-bromopropane toxicity confounded by arsenic.

OBJECTIVE: To describe the illnesses of four workers with high concentrations of serum bromide after exposure to glue containing 1-bromopropane (1-BP). METHODS: We reviewed all available clinical records, examined the workers, and obtained additional urinary arsenic values. We used standard autoanalyzer and other routine methods for blood and urinalysis. RESULTS: All four workers had symptoms and abnormal physical findings when hospitalized, remaining symptomatic with abnormal examinations 3 months later. Milder symptoms persisted in two workers, 8 years after their initial illnesses. Both have returned to work. Follow-up was unavailable for the other two workers. CONCLUSIONS: Severe illness occurred in four gluers after 1-BP exposures associated with elevated levels of serum bromide. All had elevated urinary arsenic concentrations, the source of which remains unknown, but which confound interpretation of the abnormal bromide levels and clinical findings present during the acute illnesses.

Effect of a prophylactic brace on wrist and ulnocarpal joint biomechanics in a cadaveric model.

BACKGROUND: Wrist pain from repetitive dorsiflexion and compression during pommel horse exercises is common among male gymnasts. PURPOSE: To determine the biomechanical effects of a prophylactic wrist brace on the wrist and ulnocarpal joints during mechanical loading in a cadaveric model. HYPOTHESIS: The lateral wedge of the palmar pad of the brace will compensate for positive ulnar variance, distributing contact forces more evenly across the radioulnar carpal joint. STUDY DESIGN: Controlled laboratory study. METHODS: Six male and six female fixed cadaveric forearm-wrist specimens were subjected to a 32.13-kg compressive load applied through the long axis of the pronated forearm with a dorsiflexed wrist in contact with a support surface. Wrist joint dorsiflexion angle and ulnocarpal joint intraarticular peak pressure were assessed under three brace conditions: Ezy ProBrace with and without palmar pad and a nonbraced control. RESULTS: Wrist joint dorsiflexion angle was significantly reduced by the Ezy ProBrace with and without the palmar pad. However, ulnocarpal joint intraarticular peak pressure was reduced only by the brace with pad. CONCLUSION: Prevention of pathologic wrist changes requires intervention in pressure attenuation, which was achieved with the Ezy ProBrace with palmar pad. CLINICAL RELEVANCE: This brace may decrease the cumulative effects of repetitive stress of pommel horse exercise training.

Formate kinetics in methanol poisoning.

OBJECTIVE: We sought to describe the kinetics, dialysis clearance, and laboratory markers of formate (FA), the toxic metabolite of methanol (meOH). METHODS: Data were obtained from a prospective, multicenter study of fomepizole +/- dialysis for methanol poisoning. Inclusion criteria confirmed methanol exposure or suspicion of exposure plus either acidemia or abnormal osmolar gap. Dialysis indications were [meOH] > 50 mg/dL, pH < 7.1, refractory acidosis, or visual toxicity. Serial plasma formate, methanol, pH, and electrolyte measurements were made. Formate was determined by gas chromatography. Endogenous and dialysis elimination half-lives were calculated as t(1/2) = 0.693/Ke, with Ke (elimination constant) derived from the slope of log (FA) vs. time. Half-lives were compared with an unpaired Student's t-test. Dialysis clearance was calculated using the Fick Principle. Pearson correlation analysis compared initial formate with initial pH, serum bicarbonate, and anion gap. RESULTS: Eleven patients were treated in the study. Eight had detectable formate with mean [FA] of 15.1 mmol/L (range 0.5-34.8). Endogenous elimination half-life was 205 +/- 90 minutes. Elimination half-life during dialysis (n = 5) was 150 +/- 37 minutes, which was not different (t = 0.22; NS). The overall dialysis formate clearance rate was 223 +/- 25 mL/min. Correlation coefficients were: pH vs. formate r2 = 0.93; bicarbonate vs. formate r2 = 0.81; and anion gap vs. formate r2 = 0.76 (all p < 0.05). CONCLUSIONS: Although dialysis clears formate, it did not significantly enhance endogenous elimination in our series of patients. Low pH, low bicarbonate, and elevated anion gap correlate independently with formate presence.