A Case of Painless Elderly-Onset Rheumatoid Arthritis.

Rheumatoid arthritis (RA) has multiple manifestations. Patients present with a variety of symptoms and varying levels of severity. Elderly-onset rheumatoid arthritis (EORA) is described as RA with onset after 60 years of age. EORA can present with different clinical and laboratory findings compared to RA in a younger patient, making awareness of the condition important. Diagnosing inflammatory arthritis can be especially challenging in an elderly population where symptoms are poorly reported and communication is often difficult. We report the case of an elderly patient whose presentation with persistent tachycardia and raised inflammatory markers led to a diagnosis of EORA. This case details an atypical presentation of EORA with convincing diagnostic features for the disease without any joint symptoms reported. Clinicians should be aware of the differences in the typical presentation of EORA versus RA, the challenges of diagnosing inflammatory arthritis in elderly, isolated patients, and the importance of early diagnosis.

Reversible strain-promoted DNA polymerization.

Molecular strain can be introduced to influence the outcome of chemical reactions. Once a thermodynamic product is formed, however, reversing the course of a strain-promoted reaction is challenging. Here, a reversible, strain-promoted polymerization in cyclic DNA is reported. The use of nonhybridizing, single-stranded spacers as short as a single nucleotide in length can promote DNA cyclization. Molecular strain is generated by duplexing the spacers, leading to ring opening and subsequent polymerization. Then, removal of the strain-generating duplexers triggers depolymerization and cyclic dimer recovery via enthalpy-driven cyclization and entropy-mediated ring contraction. This reversibility is retained even when a protein is conjugated to the DNA strands, and the architecture of the protein assemblies can be modulated between bivalent and polyvalent states. This work underscores the utility of using DNA not only as a programmable ligand for assembly but also as a route to access restorable bonds, thus providing a molecular basis for DNA-based materials with shape-memory, self-healing, and stimuli-responsive properties.

How Do Care Partners of People with Rare Dementia Use Language in Online Peer Support Groups? A Quantitative Text Analysis Study.

We used quantitative text analysis to examine conversations in a series of online support groups attended by care partners of people living with rare dementias (PLWRD). We used transcripts of 14 sessions (>100,000 words) to explore patterns of communication in trained facilitators' (n = 2) and participants' (n = 11) speech and to investigate the impact of session agenda on language use. We investigated the features of their communication via Poisson regression and a clustering algorithm. We also compared their speech with a natural speech corpus. We found that differences to natural speech emerged, notably in emotional tone (d = -3.2, p < 0.001) and cognitive processes (d = 2.8, p < 0.001). We observed further differences between facilitators and participants and between sessions based on agenda. The clustering algorithm categorised participants' contributions into three groups: sharing experience, self-reflection, and group processes. We discuss the findings in the context of Social Comparison Theory. We argue that dedicated online spaces have a positive impact on care partners in combatting isolation and stress via affiliation with peers. We then discuss the linguistic mechanisms by which social support was experienced in the group. The present paper has implications for any services seeking insight into how peer support is designed, delivered, and experienced by participants.

International Standards for Dementia Workforce Education and Training: A Scoping Review.

BACKGROUND AND OBJECTIVES: The increasing number of people with dementia requires transparency and quality dementia education, training, and care. This scoping review aimed to determine the key elements of national or state-wide standards on dementia education and training that could underpin the development of international standards for dementia workforce training and education. RESEARCH DESIGN AND METHODS: The English-language peer-reviewed and gray literature were searched (2010-20). Key search domains were training, workforce, standards/frameworks, and dementia. RESULTS: Thirteen standards were identified from the United Kingdom (n = 5), the United States (n = 4), Australia (n = 3), and Ireland (n = 1). Most standards focused on training health care professionals with some including people in customer-centric settings, people living with dementia, and informal carers or the general community. Seventeen training topics were identified in 10 or more of the 13 standards. Cultural safety, rural issues, health care professional self-care, digital literacy, and health promotion topics were less commonly reported. The barriers to standards implementation were lack of organizational support, lack of access to relevant training, low staff literacy, lack of funding, high staff turnover, ineffective past program cycles, and inconsistent service delivery. Enablers included a strong implementation plan, funding, strength of partnerships, and building on previous work. DISCUSSION AND IMPLICATIONS: The U.K. Dementia Skills and Core Training Standard, the Irish Department of Health Dementia Together, and the National Health Services Scotland Standard are the recommended strongest standards for underpinning the development of international standards. It is essential that training standards are tailored to the needs of the consumer, worker, and regions.

Effects of vildagliptin on wound healing and markers of inflammation in patients with type 2 diabetic foot ulcer: a prospective, randomized, double-blind, placebo-controlled, single-center study.

INTRODUCTION: Diabetic foot ulcers (DFU) are one of the leading long-term complications experienced by patients with diabetes. Dipeptidyl Peptidase 4 inhibitors (DPP4is) are a class of antihyperglycemic medications prescribed to patients with diabetes to manage glycaemic control. DPP4is may also have a beneficial effect on DFU healing. This study aimed to determine vildagliptin's effect on inflammatory markers and wound healing. TRIAL DESIGN: Prospective, randomized, double-blind, placebo-controlled, single-center study. METHODS: Equal number of participants were randomized into the treatment and placebo groups. The treatment was for 12 weeks, during which the participants had regular visits to the podiatrist, who monitored their DFU sizes using 3D camera, and blood samples were taken at baseline, six weeks, and 12 weeks during the study for measurement of inflammatory markers. In addition, demographic characteristics, co-morbidities, DFU risk factors, and DFU wound parameters were recorded. RESULTS: 50 participants were recruited for the study, with 25 assigned to placebo and 25 to treatment group. Vildagliptin treatment resulted in a statistically significant reduction of HBA1c (p < 0.02) and hematocrit (p < 0.04), total cholesterol (p < 0.02), LDL cholesterol (p < 0.04), and total/HDL cholesterol ratio (P < 0.03) compared to the placebo group. Also, vildagliptin had a protective effect on DFU wound healing, evidenced by the odds ratio (OR) favoring the intervention of 11.2 (95% CI 1.1-113.5; p < 0.04) and the average treatment effect on the treated (ATET) for vildagliptin treatment group showed increased healing by 35% (95%CI; 10-60, p = 0.01) compared to placebo with the model adjusted for microvascular complications, smoking, amputation, dyslipidemia, peripheral vascular disease (PVD) and duration of diabetes. CONCLUSIONS: Vildagliptin treatment was effective in healing DFU in addition to controlling the diabetes. Our findings support the use of DPP4is as a preferred option for treating ulcers in patients with diabetes. Further studies on a larger population are warranted to confirm our findings and understand how DPP4is could affect inflammation and DFU healing.

Persuasive Design Solutions for a Sustainable Workforce: Review of Persuasive Apps for Real-Time Capability Support for Rural Health Care Professionals.

BACKGROUND: There is a need to further investigate how persuasive design principles can change rural health professionals' behaviors to look after their own health workforce capability. Several theories are used when developing apps to persuade people to change behavior, including the Persuasive System Design Model, consisting of primary task, dialogue, system credibility, and social support categories, and Cialdini's principles of persuasion. These have not been analyzed yet in the field of health workforce capability. OBJECTIVE: This study aims to determine the persuasive design techniques used in capability building-related apps and to provide recommendations for designing a health workforce app to increase their persuasiveness. METHODS: A Python script was used to extract a total of 3060 apps from Google Play. Keywords centered around health workforce capability elements. App inclusion criteria were as follows: been updated since 2019, rated by users on average 4 and above, and more than 100,000 downloads. Next, 2 experts reviewed whether 32 persuasive strategies were used in the selected apps, and these were further analyzed by capability categories: competencies and skills, health and personal qualities, values and attitudes, and work organization. RESULTS: In all, 53 mobile apps were systematically reviewed to identify the persuasive design techniques. The most common were surface credibility (n=48, 90.6%) and liking (n=48), followed by trustworthiness (n=43, 81.1%), reminders (n=38, 71.7%), and suggestion (n=30, 56.6%). The techniques in the social support domain were the least used across the different apps analyzed for health workforce capability, whereas those in the primary task support domain were used most frequently. The recommendations reflect learnings from our analysis. These findings provided insight into mobile app design principles relevant to apps used in improving health workforce capability. CONCLUSIONS: Our review showed that there are many persuasive design techniques that can assist in building health workforce capability. Additionally, several apps are available in the market that can assist in improving health workforce capability. There is, however, a specific lack of digital, real-time support to improve health workforce capability. Social support strategies through using social support persuasive design techniques will need to be integrated more prominently into a health workforce capability app. An app to measure and monitor health workforce capability scores can be used in conjunction with direct real-world person and real-time support to discuss and identify solutions to improve health workforce capability for rural and remote health professionals who are at high risk of burnout or leaving the rural health workforce.

Encoding hierarchical assembly pathways of proteins with DNA.

The structural and functional diversity of materials in nature depends on the controlled assembly of discrete building blocks into complex architectures via specific, multistep, hierarchical assembly pathways. Achieving similar complexity in synthetic materials through hierarchical assembly is challenging due to difficulties with defining multiple recognition areas on synthetic building blocks and controlling the sequence through which those recognition sites direct assembly. Here, we show that we can exploit the chemical anisotropy of proteins and the programmability of DNA ligands to deliberately control the hierarchical assembly of protein-DNA materials. Through DNA sequence design, we introduce orthogonal DNA interactions with disparate interaction strengths ("strong" and "weak") onto specific geometric regions of a model protein, stable protein 1 (Sp1). We show that the spatial encoding of DNA ligands leads to highly directional assembly via strong interactions and that, by design, the first stage of assembly increases the multivalency of weak DNA-DNA interactions that give rise to an emergent second stage of assembly. Furthermore, we demonstrate that judicious DNA design not only directs assembly along a given pathway but can also direct distinct structural outcomes from a single pathway. This combination of protein surface and DNA sequence design allows us to encode the structural and chemical information necessary into building blocks to program their multistep hierarchical assembly. Our findings represent a strategy for controlling the hierarchical assembly of proteins to realize a diverse set of protein-DNA materials by design.

Controlling the DNA Hybridization Chain Reaction.

A novel method for controlling the oligomerization of metastable DNA hairpins using the hybridization chain reaction (HCR) is reported. Control was achieved through the introduction of a base-pair mismatch in the duplex of the hairpins. The mismatch modification allows one to kinetically differentiate initiation versus propagation events, leading to DNA oligomers up to 10 monomers long and improving dispersities from 2.5 to 1.3-1.6. Importantly, even after two consecutive chain extensions, dispersity remained unaffected, showing that well-defined block co-oligomers can be achieved. As a proof-of-concept, this technique was then applied to hairpin monomers functionalized with a mutant green fluorescent protein to prepare protein oligomers. Taken together, this work introduces an effective method for controlling living macromolecular HCR oligomerization in a manner analogous to the controlled polymerization of small molecules.

Influence of Ethnicity on Outcomes of Diabetes Inpatient Hypoglycemia: an Australian Perspective.

AIMS: To evaluate outcomes of diabetic inpatient hypoglycemia among Aboriginal and Torres Strait Islander (ATSI) compared with Australian Caucasian patients. METHODS: A retrospective audit of diabetic patients aged > 18 years admitted at a regional hospital general ward between April 1, 2015, and March 31, 2016, was analyzed. The database contains clinical information at the time of admission and initial discharge and readmission within 4 weeks thereafter. RESULTS: A total of 1618 (of 6027) patients were admitted with diabetes representing 23.7% of the total ward admissions, of which 484 (29.9%) had inpatient hypoglycemia. Of the 91 patients with available data analyzed, ATSI origin with inpatient hypoglycemia was associated with longer length of stay (LOS) (hazard ratio [HR], 2.1, 95% confidence interval [CI], 1.2-3.5), whereas severe hypoglycemia (≤ 2.2 mmol/L) in both ATSI and non-ATSI was significantly associated with longer LOS (HR, 2.3; 95% CI, 1.2-4.2). No significant differences in LOS were found for gender, age, and Carlson comorbidity index (CCI). The adjusted model for likelihood of readmission, gender, indigenous status, and CCI were not significant risk factors for readmission to the hospital. Readmitted patients were older (50-59 years vs < 50 years, P = 0.001; 60-69 years vs < 50 years, P = 0.032; 70+ years vs < 50 years, P = 0.031). CONCLUSION: We reported high rate of inpatient hypoglycemia in our study population. Indigenous Australian diabetic patients with inpatient hypoglycemia had significantly longer LOS compared with non-Indigenous Caucasian counterparts. Further prospective studies on a larger population are needed to confirm our findings.

DNA-Directed Protein Packing within Single Crystals.

Designed DNA-DNA interactions are investigated for their ability to modulate protein packing within single crystals of mutant green fluorescent proteins (mGFPs) functionalized with a single DNA strand (mGFP-DNA). We probe the effects of DNA sequence, length, and protein-attachment position on the formation and protein packing of mGFP-DNA crystals. Notably, when complementary mGFP-DNA conjugates are introduced to one another, crystals form with nearly identical packing parameters, regardless of sequence if the number of bases is equivalent. DNA complementarity is essential, because experiments with non-complementary sequences produce crystals with different protein arrangements. Importantly, the DNA length and its position of attachment on the protein markedly influence the formation of and protein packing within single crystals. This work shows how designed DNA interactions can be used to influence the growth and packing in X-ray diffraction quality protein single crystals and is thus an important step forward in protein crystal engineering.

Protein Materials Engineering with DNA.

Proteins are a class of nanoscale building block with remarkable chemical complexity and sophistication: their diverse functions, shapes, and symmetry as well as atomically monodisperse structures far surpass the range of conventional nanoparticles that can be accessed synthetically. The chemical topologies of proteins that drive their assembly into materials are central to their functions in nature. However, despite the importance of protein materials in biology, efforts to harness these building blocks synthetically to engineer new materials have been impeded by the chemical complexity of protein surfaces, making it difficult to reliably design protein building blocks that can be robustly transformed into targeted materials. Here we describe our work aimed at exploiting a simple but important concept: if one could exchange complex protein-protein interactions with well-defined and programmable DNA-DNA interactions, one could control the assembly of proteins into structurally well-defined oligomeric and polymeric materials and three-dimensional crystals. As a class of nanoscale building block, proteins with surface DNA modifications have a vast design space that exceeds what is practically and conceptually possible with their inorganic counterparts: the sequences of the DNA and protein and the chemical nature and position of DNA attachment all play roles in dictating the assembly behavior of protein-DNA conjugates. We summarize how each of these design parameters can influence structural outcome, beginning with proteins with a single surface DNA modification, where energy barriers between protein monomers can be tuned through the sequence and secondary structure of the oligonucleotide. We then explore challenges and progress in designing directional interactions and valency on protein surfaces. The directional binding properties of protein-DNA conjugates are ultimately imposed by the amino acid sequence of the protein, which defines the spatial distribution of DNA modification sites on the protein. Through careful design and mutagenesis, bivalent building blocks that bind directionally to form one-dimensional assemblies can be realized. Finally, we discuss the assembly of proteins densely modified with DNA into crystalline superlattices. At first glance, these protein building blocks display crystallization behavior remarkably similar to that of their DNA-functionalized inorganic nanoparticle counterparts, which allows design principles elucidated for DNA-guided nanoparticle crystallization to be used as predictive tools in determining structural outcomes in protein systems. Proteins additionally offer design handles that nanoparticles do not: unlike nanoparticles, the number and spatial distribution of DNA can be controlled through the protein sequence and DNA modification chemistry. Changing the spatial distributions of DNA can drive otherwise identical proteins down distinct crystallization pathways and yield building blocks with exotic distributions of DNA that crystallize into structures that are not yet attainable using isotropically functionalized particles. We highlight challenges in accessing other classes of architectures and establishing general design rules for DNA-mediated protein assembly. Harnessing surface DNA modifications to build protein materials creates many opportunities to realize new architectures and answer fundamental questions about DNA-modified nanostructures in both materials and biological contexts. Proteins with surface DNA modifications are a powerful class of nanomaterial building blocks for which the DNA and protein sequences and the nature of their conjugation dictate the material structure.

Programming Protein Polymerization with DNA.

A strategy that utilizes DNA for controlling the association pathway of proteins is described. This strategy uses sequence-specific DNA interactions to program energy barriers for polymerization, allowing for either step-growth or chain-growth pathways to be accessed. Two sets of mutant green fluorescent protein (mGFP)-DNA monomers with single DNA modifications have been synthesized and characterized. Depending on the deliberately controlled sequence and conformation of the appended DNA, these monomers can be polymerized through either a step-growth or chain-growth pathway. Cryo-electron microscopy with Volta phase plate technology enables the visualization of the distribution of the oligomer and polymer products, and even the small mGFP-DNA monomers. Whereas cyclic and linear polymer distributions were observed for the step-growth DNA design, in the case of the chain-growth system linear chains exclusively were observed, and a dependence of the chain length on the concentration of the initiator strand was noted. Importantly, the chain-growth system possesses a living character whereby chains can be extended with the addition of fresh monomer. This work represents an important and early example of mechanistic control over protein assembly, thereby establishing a robust methodology for synthesizing oligomeric and polymeric protein-based materials with exceptional control over architecture.

DNA-Encoded Protein Janus Nanoparticles.

Asymmetric functionality and directional interactions, which are characteristic of noncentrosymmetric particles, such as Janus particles, present an opportunity to encode particles with properties, but also a great synthetic challenge. Here, we exploit the chemical anisotropy of proteins, and the versatile chemistry of DNA to synthesize a protein-based Janus nanoparticle comprised of two proteins encoded with sequence-specific nucleic acid domains, tethered together by an interprotein "DNA bond". We use these novel nanoparticles to realize a new class of three-dimensional superlattice, only possible when two sides of the particle are modified with orthogonal oligonucleotide sequences. The low symmetry, intrinsic to Janus particles, enables the realization of unprecedented multicomponent nanoparticle superlattices with unique, hexagonal layered architectures. In addition, the interprotein "DNA bond" can be modulated to selectively expand the lattice in a single direction. The results presented herein not only emphasize the power of rationally designing nanoscale building blocks to create highly engineered colloidal crystals, but also establish a precedent for applications of multidomain DNA-encoded nanoparticles, especially in the field of colloidal crystallization.

Serum procollagen type 1 N propeptide: A novel diagnostic test for diabetic foot osteomyelitis - A case-control study.

BACKGROUND: The objective of the study was to determine whether serum levels of procollagen type 1 N propeptide (P1NP), a bone formation turnover marker, differs between diabetic foot ulcer with osteomyelitis (DFO) and diabetic foot ulcers without osteomyelitis serving as controls. It was also aimed to assess the usefulness of P1NP in diagnosing DFO compared to other common inflammatory markers. MATERIALS AND METHODS: A case-control study was designed comparing the aforementioned groups. Patients were classified as osteomyelitis and controls based on the International Working Group diagnostic criteria. Serum P1NP and three other inflammatory markers, namely, C-reactive protein (CRP), white blood cells (WBC), and platelets were analyzed on patients with DFO and controls. RESULTS: The mean serum P1NP levels were significantly higher in the DFO group (n: 16), 10.5 ± 5.2 (ng/ml), than the control group (n: 11) 3.1 ± 2.8 (ng/ml), P = 0.001. P1NP showed the highest sensitivity/specificity 86.7%/80% compared to 70.6%/80%, 56.2%/45.4%, and 50%/37% for CRP, WBC and platelets, respectively. Receiver operator characteristic curves showed the best value of area under the curve of 0.9 for P1NP compared to 0.85, 0.54, and 0.46 for CRP, WBC, and platelets. CONCLUSION: We found marked elevation of serum P1NP in diabetic foot ulcer with bone infection with potential value in using it to diagnose DFO.

Successful implementation of new osteopathic graduate medical education programs in a community hospital: challenges and lessons learned.

Development of new osteopathic graduate medical education (OGME) programs has emerged as a priority for the osteopathic medical profession. As colleges of osteopathic medicine (COMs) expand class sizes and branch campuses, and as new COMs are launched, availability of sufficient internship, residency, and fellowship positions for future COM graduates will become a challenge. Because of constraints in graduate medical education reimbursement, growth of existing training programs is limited. For hospitals that did not sponsor internship and residency programs before January 1, 1995, the Centers for Medicare and Medicaid Services offers an exception to funding restraints on expansion of training programs. However, successful development and implementation of new OGME programs remains a formidable undertaking. Moreover, because of idiosyncrasies of medical education reimbursement, successful recruitment of COM graduates into new training positions is paramount to ensure program viability. The authors describe lessons learned from the successful implementation of new OGME programs in a community hospital, and they offer recommendations for other hospitals considering such an endeavor.

Quantitative validation of a general competency composite assessment evaluation.

OBJECTIVES: The authors sought to modify and validate a composite assessment evaluation process that assesses resident acquisition of the Accreditation Council for Graduate Medical Education (ACGME) general competencies (GCs). METHODS: This study critically analyzed the evaluation process used in a multicenter study (150 emergency medicine resident evaluations) to determine whether the procedure was psychometrically valid. For each GC, principal component analysis (PCA) was used to determine whether certain evaluation items could be eliminated, as well as to determine the magnitude of variability explained by up to three linear combinations or "principal components." The factor proportions (factor loadings) of various eigenvectors were measured to determine the degree of variability (determined by the square of the factor proportion) within a data or item set. The factor proportions essentially measure the length of the eigenvector as determined from a correlation matrix. RESULTS: The first three principal components are reported as factor proportion sum (% of total variability) as follows: patient care 0.91 (83%), medical knowledge 0.87 (76%), practice-based learning and improvement 0.90 (81%), interpersonal and communication skills 0.84 (71%), professionalism 0.74 (55%), and systems-based practice 0.80 (64%). PCA showed that evaluating certain traditional categories such as medical knowledge seemed to capture a single element, whereas professionalism appeared to measure a more complex, multidimensional phenomenon. CONCLUSIONS: By using a structured development process, the authors were able to create valid evaluation items for determining resident acquisition of the ACGME GCs.

AOA membership and board certification of residency graduates: comparison of three programs accepting osteopathic physicians--implications for graduate medical education.

The purpose of this study was to determine membership status in the American Osteopathic Association (AOA) and osteopathic board certification status for osteopathic physicians completing osteopathic, allopathic, and dually accredited residency programs. Rates of AOA membership and osteopathic board certification of osteopathic graduates from a dually accredited residency were compared to rates of osteopathic graduates of an allopathic residency in the same training facility. These same two parameters were compared between the dually accredited residency and an osteopathic residency. Osteopathic graduates from the dually accredited residency had significantly higher rates of AOA membership and osteopathic board certification when compared with the osteopathic graduates of an allopathic residency. Moreover, no significant difference existed between the rates of these two measures for osteopathic resident graduates from the dually accredited residency when compared with graduates of an osteopathic residency. Implications of the results are discussed.

General competencies are intrinsic to emergency medicine training: a multicenter study.

OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) has promulgated six areas called General Competencies (GCs) that residency programs are required to evaluate. The authors sought to determine if these domains were an intrinsic part of emergency medicine (EM) residency training by using a global assessment evaluation device. METHODS: This was an observational, multicenter, cross-sectional study that compared GC acquisition between first-, second-, and third-year (EM1, EM2, and EM3) residents. Five postgraduate year (PGY) 1 to PGY 3 allopathic EM programs in Michigan participated. A global assessment form using a 1 through 9 ordinal scale with 86 scoring items was given to program directors for each resident in their programs. Analysis of variance (ANOVA) was used to compare the means between EM1, EM2, and EM3 scores. RESULTS: Five EM programs evaluated 150 residents. The GC scores were as follows: Patient Care: EM1 4.92, EM2 5.79, and EM3 6.40; Medical Knowledge: EM1 4.90, EM2 5.80, and EM3 6.46; Practice-based Learning and Improvement: EM1 4.60, EM2 5.48, and EM3 6.16; Interpersonal and Communication Skills: EM1 4.99, EM2 5.39, and EM3 6.01; Professionalism: EM1 5.43, EM2 5.68, and EM3 6.27; Systems-based Practice: EM1 4.80, EM2 5.48, and EM3 6.21. ANOVA showed statistically significant differences (p < 0.001) for all GCs. CONCLUSIONS: EM residents from several residency programs showed statistically significant progressive acquisition of the ACGME GCs using a global assessment device. This suggests that the GCs may be an intrinsic component in the training of EM residents.

Using standardized oral examinations to evaluate general competencies.

Emergency medicine residency programs are required by the Accreditation Council for Graduate Medical Education (ACGME) to formally evaluate each resident with oral and written examinations. The Michigan State University Emergency Medicine Residency Program in Lansing conducts monthly standardized oral examinations (SOEs) as part of each resident's evaluation. Recently, the ACGME has advanced six areas, termed "general competencies," that should be acquired during graduate medical education. According to the ACGME, these competencies should be included in the educational process of all residency programs. In promulgating these competencies, the ACGME did not provide examples of core content, strategies for implementation, or methods of evaluation; rather, individual residency programs are required to develop their own methods. The authors describe a modification of an existing SOE strategy that assesses residents' knowledge, skills, experiences, and attitudes as reflected in the general competencies.