The reliability of the College of Intensive Care Medicine of Australia and New Zealand "Hot Case" examination.

BACKGROUND: High stakes examinations used to credential trainees for independent specialist practice should be evaluated periodically to ensure defensible decisions are made. This study aims to quantify the College of Intensive Care Medicine of Australia and New Zealand (CICM) Hot Case reliability coefficient and evaluate contributions to variance from candidates, cases and examiners. METHODS: This retrospective, de-identified analysis of CICM examination data used descriptive statistics and generalisability theory to evaluate the reliability of the Hot Case examination component. Decision studies were used to project generalisability coefficients for alternate examination designs. RESULTS: Examination results from 2019 to 2022 included 592 Hot Cases, totalling 1184 individual examiner scores. The mean examiner Hot Case score was 5.17 (standard deviation 1.65). The correlation between candidates' two Hot Case scores was low (0.30). The overall reliability coefficient for the Hot Case component consisting of two cases observed by two separate pairs of examiners was 0.42. Sources of variance included candidate proficiency (25%), case difficulty and case specificity (63.4%), examiner stringency (3.5%) and other error (8.2%). To achieve a reliability coefficient of > 0.8 a candidate would need to perform 11 Hot Cases observed by two examiners. CONCLUSION: The reliability coefficient for the Hot Case component of the CICM second part examination is below the generally accepted value for a high stakes examination. Modifications to case selection and introduction of a clear scoring rubric to mitigate the effects of variation in case difficulty may be helpful. Increasing the number of cases and overall assessment time appears to be the best way to increase the overall reliability. Further research is required to assess the combined reliability of the Hot Case and viva components.

The Hematological Effects of Extracorporeal Membrane Oxygenator Exchange.

Membrane oxygenator failure during venovenous (V-V) extracorporeal membrane oxygenation (ECMO) can lead to life-threatening hypoxia, high replacement costs, and may be associated with a hyperfibrinolytic state and bleeding. The current understanding of the underlying mechanisms that drive this is limited. The primary aim of this study therefore is to investigate the hematological changes that occur before and after membrane oxygenator and circuit exchanges (ECMO circuit exchange) in patients with severe respiratory failure managed on V-V ECMO. We analyzed 100 consecutive V-V ECMO patients using linear mixed-effects modeling to evaluate hematological markers in the 72 hours before and 72 hours after ECMO circuit exchange. A total of 44 ECMO circuit exchanges occurred in 31 of 100 patients. The greatest change from baseline to peak were seen in plasma-free hemoglobin (42-fold increase p < 0.01) and the D-dimer:fibrinogen ratio (1.6-fold increase p = 0.03). Bilirubin, carboxyhemoglobin, D-dimer, fibrinogen, and platelets also showed statistically significant changes ( p < 0.01), whereas lactate dehydrogenase did not ( p = 0.93). Progressively deranged hematological markers normalize more than 72 hours after ECMO circuit exchange, with an associated reduction in membrane oxygenator resistance. This supports the biologic plausibility that ECMO circuit exchange may prevent further complications such as hyperfibrinolysis, membrane failure, and clinical bleeding.

Too hot to handle? Assessing the validity and reliability of the College of Intensive Care Medicine "Hot Case" examination.

The College of Intensive Care Medicine of Australia and New Zealand is responsible for credentialling trainees for specialist practice in intensive care medicine for the safety of patients and the community. This involves defining trainees' performance standards and testing trainees against those standards to ensure safe practice. The second part examination performed towards the end of the training program is a high-stakes assessment. The two clinical "Hot Cases" performed in the examination have a low pass rate, with most candidates failing at least one of the cases. There is increasing expectation for medical specialist training colleges to provide fair and transparent assessment processes to enable defensible decisions regarding trainee progression. Examinations are a surrogate marker of clinical performance with advantages, disadvantages and inevitable compromises. This article evaluates the Hot Case examination using Kane's validity framework and van der Vleuten's utility equation, and identifies issues with validity and reliability which could be managed through an ongoing improvement process.

Nurses' Responses and Reactions to an Emergent Pediatric Simulation Exercise.

Pediatric nurses' responses and reactions in emergent simulations are understudied. Using authority gradient theory as a guide, the purpose of this study was to examine nurses' reactions during an emergency simulation exercise when directed to give an incorrect medication dose. Ten groups of noncritical care nurses were videotaped from the beginning of the simulation through debriefing. Although errors were made during the simulation event, all groups responded correctly during debriefing, indicating that authority gradient may play a role in clinical decision-making.

Very old patients urgently referred to the intensive care unit: long-term outcomes for admitted and declined patients.

BACKGROUND: Outcomes for very old patients (≥ 80 years) referred but not admitted to an intensive care unit have not been described in Australia and New Zealand. OBJECTIVE: To ascertain long-term (12-month) outcomes for very old patients urgently referred for ICU support at a tertiary referral hospital. DESIGN, SETTING AND PATIENTS: A retrospective, medical record review of 1240 very old patients (≥ 80 years) who were urgently referred to an Australian, 31-bed ICU over a 40-month period from March 2011 to August 2014. Referrals were divided into those who were "too well" for the ICU, admitted to the ICU, and "too sick" for the ICU. Data and main outcome measures: Data were extracted from hospital records, the ICU patient database and the Australian Institute of Health and Welfare National Death Index, and our main outcome measures were health status and destination at hospital discharge, and 12-month mortality rates. RESULTS: Urgent admissions of very old patients accounted for 6.9% of total ICU admissions (443/6415). The hospital mortality rate was 16.0% (93/583) for patients who were too well, 32.1% (142/443) for those admitted to the ICU, and 69.2% (148/214) for those too sick (P ≥ 0.001). Mortality rates 12 months after referral were 40.8% (238/583), 46.0% (204/443) and 88.3% (189/214), respectively (P ≥ 0.001). CONCLUSION: Very old patients considered too well for the ICU have a significantly lower hospital mortality rate than those admitted to the ICU after urgent referral. However, 12 months after referral, patients considered too well for ICU admission have a mortality rate approaching that of very old patients admitted to the ICU. Over half of very old patients urgently referred to the ICU die within 12 months.

Management of Cerebellar Tonsillar Herniation following Lumbar Puncture in Idiopathic Intracranial Hypertension.

Lumbar puncture is performed routinely for diagnostic and therapeutic purposes in idiopathic intracranial hypertension, despite lumbar puncture being classically contraindicated in the setting of raised intracranial pressure. We report the case of a 30-year-old female with known idiopathic intracranial hypertension who had cerebellar tonsillar herniation following therapeutic lumbar puncture. Management followed guidelines regarding treatment of traumatic intracranial hypertension, including rescue decompressive craniectomy. We hypothesize that the changes in brain compliance that are thought to occur in the setting of idiopathic intracranial hypertension are protective against further neuronal injury due to axonal stretch following decompressive craniectomy.

The use of electronic pharmacy data to investigate prescribed medications and fatal motor vehicle crashes in a military population, 2002-2006.

The authors examined the association between prescribed medications and fatal motor vehicle crashes (MVCs) in an active duty military population between 2002 and 2006. Using a case-control design, MVC deaths were ascertained using a military mortality registry, and an integrated health system database provided information on health system eligibility, pharmacy transactions, and medical encounters. Cases and controls were matched on comparable observation time outside periods of deployment. Among selected categories, only one, antidepressant medications, was an independent predictor of fatal MVC (odds ratio, 3.19; 95% confidence interval, 1.01-10.07). Male gender, Black race, enlisted rank, service branch (Navy and Marine Corps), and selected co-morbidities were also independent predictors. Unexpectedly, the odds of younger age quartiles (< 27 years) and history of deployment were reduced for MVC cases. Although results need to be considered in the context of data limitations, the association between prescribed antidepressants and fatal MVC may reflect unmeasured co-morbidities, such as combined effects of prescribed and over-the-counter medications and/or alcohol or other substance abuse. Younger individuals, representing new military accessions in training or returning from deployment with serious injuries, may have fewer opportunities to operate vehicles, or targeted efforts to reduce MVC following deployment may be showing a positive effect.

Magnetic source separation in Earth's outer core.

We present evidence that the source of Earth's axial dipole field is largely independent from the sources responsible for the rest of the geomagnetic field, the so-called nonaxial dipole (NAD) field. Support for this claim comes from correlations between the structure of the historic field and the behavior of the paleomagnetic field recorded in precisely dated lavas at those times when the axial dipole was especially weak or nearly absent. It is argued that a "stratification" of magnetic sources exists in the fluid core such that the axial dipole is the only observed field component that is nearly immune from the influence exerted by the lowermost mantle. It follows that subsequent work on spherical harmonic-based field descriptions may now incorporate an understanding of a dichotomy of spatial-temporal dynamo processes.

Hepatitis infection in the treatment of opioid dependence and abuse.

Many new and existing cases of viral hepatitis infections are related to injection drug use. Transmission of these infections can result directly from the use of injection equipment that is contaminated with blood containing the hepatitis B or C virus or through sexual contact with an infected individual. In the latter case, drug use can indirectly contribute to hepatitis transmission through the dis-inhibited at-risk behavior, that is, unprotected sex with an infected partner. Individuals who inject drugs are at-risk for infection from different hepatitis viruses, hepatitis A, B, or C. Those with chronic hepatitis B virus infection also face additional risk should they become co-infected with hepatitis D virus. Protection from the transmission of hepatitis viruses A and B is best achieved by vaccination. For those with a history of or who currently inject drugs, the medical management of viral hepatitis infection comprising screening, testing, counseling and providing care and treatment is evolving. Components of the medical management of hepatitis infection, for persons considering, initiating, or receiving pharmacologic therapy for opioid addiction include: testing for hepatitis B and C infections; education and counseling regarding at-risk behavior and hepatitis transmission, acute and chronic hepatitis infection, liver disease and its care and treatment; vaccination against hepatitis A and B infection; and integrative primary care as part of the comprehensive treatment approach for recovery from opioid abuse and dependence. In addition, participation in a peer support group as part of integrated medical care enhances treatment outcomes. Liver disease is highly prevalent in patient populations seeking recovery from opioid addiction or who are currently receiving pharmacotherapy for opioid addiction. Pharmacotherapy for opioid addiction is not a contraindication to evaluation, care, or treatment of liver disease due to hepatitis virus infection. Successful pharmacotherapy for opioid addiction stabilizes patients and improves patient compliance to care and treatment regimens as well as promotes good patient outcomes. Implementation and integration of effective hepatitis prevention programs, care programs, and treatment regimens in concert with the pharmacological therapy of opioid addiction can reduce the public health burdens of hepatitis and injection drug use.

Comparison of asymmetry in cerebral blood flow between brain hemispheres using digital subtraction angiography.

BACKGROUND AND PURPOSE: Recently, endovascular techniques have gained significant therapeutic potential for both treatment and prevention of stroke. Cerebral angiography, which is an essential component of these procedures, has been used to provide morphological information regarding condition of blood vessels. In this study, we propose to determine the possibility of acquiring information regarding cerebral blood flow (CBF) in addition to morphologic information from data routinely available during angiography. METHODS: Digital subtraction angiography sequences were obtained for eight patients having occlusive disease in internal carotid artery (ICA) territories. Two regions-of-interest (ROIs) corresponding to the two brain hemispheres on AP view were delineated. For each image, the average pixel value within each ROI was calculated and used to generate time-density curves. Indices obtained from each curve were compared with each other and with the results obtained from the single photon emission computed tomography (SPECT) studies performed a pre- or postangiography procedure. RESULTS: Comparison between ICA stenosis and cerebral perfusion measurements revealed that cerebral perfusion deficit can be independent of arterial occlusive disease. The indices obtained from the time-density curves exhibit a correlating trend with the results from SPECT studies. However, lack of sufficient sample data prevented any meaningful statistical analysis to be conducted. CONCLUSIONS: We have developed a technique for utilizing the angiographic data for the important task of routinely and easily measuring CBF. Availability of CBF measurements during cerebral angiography may favorably impact upon the appropriate use of endovascular procedures and potentially contribute to the reduction of morbidity and mortality associated with stroke.

Structural and temporal requirements for geomagnetic field reversal deduced from lava flows.

Reversals of the Earth's magnetic field reflect changes in the geodynamo--flow within the outer core--that generates the field. Constraining core processes or mantle properties that induce or modulate reversals requires knowing the timing and morphology of field changes that precede and accompany these reversals. But the short duration of transitional field states and fragmentary nature of even the best palaeomagnetic records make it difficult to provide a timeline for the reversal process. 40Ar/39Ar dating of lavas on Tahiti, long thought to record the primary part of the most recent 'Matuyama-Brunhes' reversal, gives an age of 795 +/- 7 kyr, indistinguishable from that of lavas in Chile and La Palma that record a transition in the Earth's magnetic field, but older than the accepted age for the reversal. Only the 'transitional' lavas on Maui and one from La Palma (dated at 776 +/- 2 kyr), agree with the astronomical age for the reversal. Here we propose that the older lavas record the onset of a geodynamo process, which only on occasion would result in polarity change. This initial instability, associated with the first of two decreases in field intensity, began approximately 18 kyr before the actual polarity switch. These data support the claim that complete reversals require a significant period for magnetic flux to escape from the solid inner core and sufficiently weaken its stabilizing effect.

Using a structured medical note for determining the safety profile of anthrax vaccine for US soldiers in Korea.

Selected military personnel are immunized with an FDA-licensed anthrax vaccine unless there are clinical contraindications. The objective of this analysis is to capture the experience of soldiers receiving anthrax vaccine to assist in better patient-provider communication and clarify the safety profile of the vaccine in this population as a quality-assurance initiative. Between August 1998 and July 1999, 2824 soldiers immunized against anthrax at one military clinic completed a structured medical note that was reviewed by a clinician. Female gender, prior vaccine-associated adverse events, and medication use were significantly related to higher reports of adverse events. All reported immediate consequences resolved.

Initial report of a hepatitis investigation in rural Belize

In spring 1991, Belizian health officials expressed concern about a possible hepatitis outbreak in a banana farming district. A study was designed to identify cases and to address the serological prevalence of hepatitis virus markers. Three populations were studied: (i) persons meeting a clinical case definition for hepatitis; (ii) designated banana workers; and (iii) people in a random sample of households in the community. Information was collected using questionnaires and sera were collected for laboratory testing. This report presents the preliminary results of a study conducted in June 1991. Among people who met the clinical case definition, 24 percent of 42 tested had immunoglobulin M antibody to hepatitis B virus (HBV) core antigen (anti-HBc IgM). In the worker and household survey populations, 248 and 280 people, respectively, were tested for anti-HBc IgM. In each group, 4 percent were positive. HBV surface antigen was found in 37 percent of 43 clinical cases, 18 percent of workers, and 13 percent of people in the household survey. Among the 3 study populations, the prevalence of HBV core antibody (anti-HBc) ranged from 73 percent to 81 percent. Almost all tested persons had evidence of prior infection with hepatitis viruses A and B was widespread, but an aetiology could not be established for most of the clinical cases. However, the prevalence of hepatitis B markers in this population was very high compared to other reports from the Caribbean (AU)

The prevalence of hepatitis A and B infection among different ethnic groups in Belize - abstract

Little is known about the prevalence of infection with hepatitis viruses in Belize, Central America. We conducted a serological survey among members of the Belize Defence Force (BDF), which comprises the five major ethnic groups in Belize, in order to estimate the prevalence of hepatitis A and B among men and women of military age in Belize. Of approximately 600 men and women in the BDF, 394 (66 per cent) volunteered to participate. Antibody to hepatitis A was found in 95 per cent with similar rates by age, rank and ethnicity. Antibody to hepatitis B core antigen (anti-HBc) was found in 31 per cent. The prevalence of anti-HBc varied significantly among the ethnic groups, with the lowest rates in Mayan Indians (5 per cent) and Mestizo (7 per cent), with significantly higher rates among Creoles (30 per cent) and Garifuna (54 per cent). Rates increased with increasing age from 25 per cent in those 18 - 24 years to 35 per cent in those over 35 years of age (p = 0.6, chi-square for trend). Hepatitis B surface antigen was found in 15 (4 per cent) overall. Rates of hepatitis A and B antibodies among 70 military recruits (mean age 20 years) were similar to those among regular forces; anti-HAV was found in 91 per cent, anti-HBc in 34 per cent, and HBsAg in 6 per cent. In this young healthy population, exposure to hepatitis A before the age of 18 years is almost universal, while exposure to hepatitis B is related to age and ethnicity (AU)

Initial report of a viral hepatitis investigation in rural Belize - abstract

In spring 1991, concern was expressed in Belize about a hepatitis outbreak. A cross-sectional study was designed to address hepatitis prevalence in a farming district. Three populations were identified: anyone meeting a case definition for hepatitis, any designated worker, and a random sample of the community by household. Survey information was collected on the farm, household, and individual. Sera were collected for laboratory study. This study reports on the current findings from 509 sera collected in June 1991. There had been widespread exposure to hepatitis A(98 percent). New hepatitis was primarily due to hepatitis B(24 percent of clinical cases, 4 percent of people in the random household sample, and 5 percent of workers). In our total, 16 percent had hepatitis B surface antigen and were potential carriers, while 73 percent had evidence of past hepatitis C by our detection method, and delta particle was not present in any of the tested cases. Hepatitis E antibody was detected in two cases. One risk revolved around perceptions of good medical care, using injectable medications. (AU)