The relationship between neutrophil-to-lymphocyte ratio and albuminuria in type 2 diabetic patients: a pilot study.

INTRODUCTION: Diabetes mellitus (DM) has become a global economic burden due to treatment costs and attendant complications. Albuminuria is the precursor of end stage renal failure and is an inflammatory process. In the recent past, it has been reported that the neutrophil/lymphocyte ratio (NLR), which is a cost-effective and accessible marker, may be a favorable indicator of the inflammatory status. The aim of this study was to investigate the relationship between the neutrophil/lymphocyte ratio and the presence and level of diabetic nephropathy (DN). MATERIAL AND METHODS: A total of 112 patients with type-2 DM who were followed by our internal medicine and nephrology clinics between February 2013 and June 2014 were included in this pilot study and were retrospectively evaluated. All participants had a 24-hour urinary albumin excretion (UAE) record. Demographic parameters, biochemical parameters and albuminuria levels were recorded. Patients were divided into three groups according to their level of albuminuria. RESULTS: Significant differences were detected between the groups in terms of NLR (p < 0.001). There was a linear increase in NLR in parallel to the increase in 24-hour UAE mean values (p < 0.001). A positive correlation was detected between NLR and C-reactive protein, urea, creatinine, and red cell distribution width. However, 24-hour UAE was negatively correlated with lymphocyte count (p < 0.001). CONCLUSIONS: A high degree of correlation was determined among albuminuria, glomerular filtration rate and NLR levels. These results may suggest the notion that diabetic nephropathy involves an inflammatory process.

Neutrophil-to-lymphocyte ratio in patients with peripheral vertigo: a prospective controlled clinical study.

We aimed to investigate the relationship between peripheral vertigo and inflammation by using the neutrophil-to-lymphocyte ratio (NLR) as an inflammatory marker. We recruited 103 patients with peripheral vertigo (71 women, 32 men; mean age, 39.8 ± 14.7 years) who presented to the Otolaryngology Department of Dumlupinar University Hospital. Vertigo patients with systemic diseases, neurological disorders, malignancy or any inflammatory disease that could alter the NLR were excluded from the study. We also enrolled 103 age- and sex-matched healthy subjects (controls; 82 women, 21 men; mean age, 36.7 ± 13.5 years) who underwent routine checkups in our hospital. The vertigo patients underwent full otolaryngologic and neurologic examinations and audiometric tests to rule out any other pathology causing the peripheral vertigo. NLR was calculated in all subjects and was compared between the patient and control groups. There were no significant differences between the study and control groups in terms of lipid profiles, liver-function tests, white blood cell (WBC) count, hemoglobin level, mean platelet volume, and vitamin B12 and folate levels. The mean NLR was significantly higher in the patients than in the controls (P<0.05). In conclusion, this study, which was the first to investigate the relationship between the NLR and peripheral vertigo, found that the NLR is significantly higher among peripheral vertigo patients than among healthy controls. This result suggests that the NLR is a novel potential marker of stress in peripheral vertigo patients.

Exploring psychometric models to enhance standardized patient quality assurance: evaluating standardized patient performance over time.

PURPOSE: To explore methods to assess standardized patient (SP) performance over time so as to sustain objective performance in a high-stakes clinical skills examination and to inform quality assurance. METHOD: The authors selected data from the United States Medical Licensing Examination-Step 2 Clinical Skills to assess the relative usefulness of the classical measurement and common factor models in determining the difficulty and discrimination of SP-medical case pairs (SP-cases) on communication scores over time. The common factor model is an alternative to the classical measurement model and can be used to calibrate SP-case parameters. The sample comprised 88 SP-case combinations in test administrations throughout the year 2010. The authors constructed four time segments from scoring cohorts; computed, for each method, difficulty and discrimination parameters for each SP-case within each time segment; and then compared the efficacy of each. They also compared qualitative SP-case performance standards established through video monitoring to the common factor model for relative usefulness in identifying SP-case outliers. RESULTS: SP-case difficulty parameters produced by the classical measurement and common factor models were similarly useful for SP performance evaluation over time. The SP-case discrimination parameters produced by the common factor model appeared to capture more variation in performance. CONCLUSIONS: Although either method is equally useful for assessing SP-case difficulty, the common factor model is more sensitive to fluctuations in SP-case discrimination and could be an additionally useful source of information to identify outliers and to direct quality assurance resources for routine SP evaluation.

Measurement precision for repeat examinees on a standardized patient examination.

Examinees who initially fail and later repeat an SP-based clinical skills exam typically exhibit large score gains on their second attempt, suggesting the possibility that examinees were not well measured on one of those attempts. This study evaluates score precision for examinees who repeated an SP-based clinical skills test administered as part of the US Medical Licensing Examination sequence. Generalizability theory was used as the basis for computing conditional standard errors of measurement (SEM) for individual examinees. Conditional SEMs were computed for approximately 60,000 single-take examinees and 5,000 repeat examinees who completed the Step 2 Clinical Skills Examination(®) between 2007 and 2009. The study focused exclusively on ratings of communication and interpersonal skills. Conditional SEMs for single-take and repeat examinees were nearly indistinguishable across most of the score scale. US graduates and IMGs were measured with equal levels of precision at all score levels, as were examinees with differing levels of skill speaking English. There was no evidence that examinees with the largest score changes were measured poorly on either their first or second attempt. The large score increases for repeat examinees on this SP-based exam probably cannot be attributed to unexpectedly large errors of measurement.

Evaluating construct equivalence and criterion-related validity for repeat examinees on a standardized patient examination.

PURPOSE: Prior studies report large score gains for examinees who fail and later repeat standardized patient (SP) assessments. Although research indicates that score gains on SP exams cannot be attributed to memorizing previous cases, no studies have investigated the empirical validity of scores for repeat examinees. This report compares single-take and repeat examinees in terms of both internal (construct) validity and external (criterion-related) validity. METHOD: Data consisted of test scores for examinees who took the United States Medical Licensing Examination Step 2 Clinical Skills (CS) exam between July 16, 2007, and September 12, 2009. The sample included 12,090 examinees who completed Step 2 CS on one occasion and another 4,030 examinees who completed the exam on two occasions. The internal measures included four separately scored performance domains of the Step 2 CS examination, whereas the external measures consisted of scores on three written assessments of medical knowledge (Step 1, Step 2 clinical knowledge, and Step 3). The authors subjected the four Step 2 CS domains to confirmatory factor analysis and evaluated correlations between Step 2 CS scores and the three written assessments for single-take and repeat examinees. RESULTS: The factor structure for repeat examinees on their first attempt was markedly different from the factor structure for single-take examinees, but it became more similar to that for single-take examinees by their second attempt. Scores on the second attempt correlated more highly with all three external measures. CONCLUSIONS: The findings support the validity of scores for repeat examinees on their second attempt.

A multivariate generalizability analysis of history-taking and physical examination scores from the USMLE step 2 clinical skills examination.

BACKGROUND: In clinical skills, closely related skills are often combined to form a composite score. For example, history-taking and physical examination scores are typically combined. Interestingly, there is relatively little research to support this practice. METHOD: Multivariate generalizability theory was employed to examine the relationship between history-taking and physical examination scores from the United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills examination. These two proficiencies are currently combined into a data-gathering score. RESULTS: The physical examination score is less generalizable than the score for history taking, and there is only a modest to moderate relationship between these two proficiencies. CONCLUSIONS: A decision about combining physical examination and history-taking proficiencies into one composite score, as well as the weighting of these components, should be driven by the intended use of the score. The choice of weights in combining physical examination and history taking makes a substantial difference in the precision of the resulting score.

A comparison of alternative item weighting strategies on the data gathering component of a clinical skills performance assessment.

BACKGROUND: Checklist scores used to produce the data gathering score on the Step 2 CS examination are currently weighted using an algorithm based on expert judgment about the importance of the item. The present research was designed to compare this approach with alternative weighting strategies. METHOD: Scores from 21,140 examinees who took the United States Medical Licensing Examination Step 2 between May 2006 and February 2007 were subjected to five weighting models: (1) a regression weights model, (2) a factor loading weights model, (3) a standardized response model, (4) an equal weights model, and (5) the operational expert-judgment weights model. RESULTS: Alternative weighting procedures may have a significant impact on the reliability and validity of checklist scores. CONCLUSIONS: The results suggest that the current weighting procedure is useful, and the regression-based model holds promise for practical application. The regression-based model produces scores that are more reliable than those produced by the current procedure and more strongly related to the external criteria.