Introducing Summative Progress Testing in Radiology Residency: Little Change in Residents' Test Results After Transitioning from Formative Progress Testing.

INTRODUCTION: Educational effects of transitioning from formative to summative progress testing are unclear. Our purpose was to investigate whether such transitioning in radiology residency is associated with a change in progress test results. METHODS: We investigated a national cohort of radiology residents (N > 300) who were semi-annually assessed through a mandatory progress test. Until 2014, this test was purely formative for all residents, but in 2014/2015, it was transitioned (as part of a national radiology residency program revision) to include a summative pass requirement for new residents. In 7 posttransitioning tests in 2015-2019, including summatively and formatively tested residents who followed the revised and pre-transitioning residency program, respectively, we assessed residents' relative test scores and percentage of residents that reached pass standards. RESULTS: Due to our educational setting, most posttransitioning tests had no residents in the summative condition in postgraduate year 4-5, nor residents in the formative condition in year 0.5-2. Across the 7 tests, relative test scores in postgraduate year 1-3 of the summative resident group and year 3.5-4.5 of the formative group differed significantly (p < 0.01 and p < 0.05, respectively, Kruskal-Wallis test). However, scores fluctuated without consistent time trends and without consistent differences between both resident groups. Percentage of residents reaching the pass standard did not differ significantly across tests or between groups. DISCUSSION: Transitioning from formative to summative progress testing was associated with overall steady test results of the whole resident group in 4 post-transitioning years. We do not exclude that transitioning may have positive educational effects for resident subgroups.

Methodology of method comparison studies evaluating the validity of cardiac output monitors: a stepwise approach and checklist.

The validity of each new cardiac output (CO) monitor should be established before implementation in clinical practice. For this purpose, method comparison studies investigate the accuracy and precision against a reference technique. With the emergence of continuous CO monitors, the ability to detect changes in CO, in addition to its absolute value, has gained interest. Therefore, method comparison studies increasingly include assessment of trending ability in the data analysis. A number of methodological challenges arise in method comparison research with respect to the application of Bland-Altman and trending analysis. Failure to face these methodological challenges will lead to misinterpretation and erroneous conclusions. We therefore review the basic principles and pitfalls of Bland-Altman analysis in method comparison studies concerning new CO monitors. In addition, the concept of clinical concordance is introduced to evaluate trending ability from a clinical perspective. The primary scope of this review is to provide a complete overview of the pitfalls in CO method comparison research, whereas other publications focused on a single aspect of the study design or data analysis. This leads to a stepwise approach and checklist for a complete data analysis and data representation.

The don't know option in progress testing.

Formula scoring (FS) is the use of a don't know option (DKO) with subtraction of points for wrong answers. Its effect on construct validity and reliability of progress test scores, is subject of discussion. Choosing a DKO may not only be affected by knowledge level, but also by risk taking tendency, and may thus introduce construct-irrelevant variance into the knowledge measurement. On the other hand, FS may result in more reliable test scores. To evaluate the impact of FS on construct validity and reliability of progress test scores, a progress test for radiology residents was divided into two tests of 100 parallel items (A and B). Each test had a FS and a number-right (NR) version, A-FS, B-FS, A-NR, and B-NR. Participants (337) were randomly divided into two groups. One group took test A-FS followed by B-NR, and the second group test B-FS followed by A-NR. Evidence for impaired construct validity was sought in a hierarchical regression analysis by investigating how much of the participants' FS-score variance was explained by the DKO-score, compared to the contribution of the knowledge level (NR-score), while controlling for Group, Gender, and Training length. Cronbach's alpha was used to estimate NR and FS-score reliability per year group. NR score was found to explain 27 % of the variance of FS [F(1,332) = 219.2, p < 0.0005], DKO-score, and the interaction of DKO and Gender were found to explain 8 % [F(2,330) = 41.5, p < 0.0005], and the interaction of DKO and NR 1.6 % [F(1,329) = 16.6, p < 0.0005], supporting our hypothesis that FS introduces construct-irrelevant variance into the knowledge measurement. However, NR-scores showed considerably lower reliabilities than FS-scores (mean year-test group Cronbach's alphas were 0.62 and 0.74, respectively). Decisions about FS with progress tests should be a careful trade-off between systematic and random measurement error.

Chronic infection and inflammation affect exercise capacity in cystic fibrosis.

Pulmonary function and nutritional status are important determinants of exercise capacity in patients with cystic fibrosis (CF). Studies investigating the effects of determinants, such as genotype or infection and inflammation, are scarce and have never been analysed in a multivariate longitudinal model. A prospective longitudinal cohort study was performed to evaluate whether genotype, chronic inflammation and infection were associated with changes in exercise capacity. Furthermore, we investigated whether exercise capacity can predict clinical outcome. 504 exercise tests of 149 adolescents with CF were evaluated. Maximal oxygen uptake corrected for body mass % predicted declined 20% during adolescence, and was associated with immunoglobulin (Ig)G levels and chronic Pseudomonas aeruginosa infection. A lower exercise capacity was associated with a higher mortality, steeper decline in pulmonary function and greater increase in IgG levels. Since a decline in exercise capacity during adolescence was negatively associated with IgG levels and chronic P. aeruginosa infection, these data emphasise the importance of prevention and treatment of chronic inflammation and infections in patients with CF. Furthermore, a lower exercise capacity was associated with a higher mortality rate, steeper decline in pulmonary function and higher increase in IgG levels with increasing age in adolescents with CF. This stresses the value of regular exercise testing for assessing prognosis in adolescents with CF.

Screening for emphysema via exhaled volatile organic compounds.

Chronic obstructive pulmonary disease (COPD)/emphysema risk groups are well defined and screening allows for early identification of disease. The capability of exhaled volatile organic compounds (VOCs) to detect emphysema, as found by computed tomography (CT) in current and former heavy smokers participating in a lung cancer screening trial, was investigated. CT scans, pulmonary function tests and breath sample collections were obtained from 204 subjects. Breath samples were analyzed with a proton-transfer reaction mass spectrometer (PTR-MS) to obtain VOC profiles listed as ions at various mass-to-charge ratios (m/z). Using bootstrapped stepwise forward logistic regression, we identified specific breath profiles as a potential tool for the diagnosis of emphysema, of airflow limitation or gas-exchange impairment. A marker for emphysema was found at m/z 87 (tentatively attributed to 2-methylbutanal). The area under the receiver operating characteristic curve (ROC) of this marker to diagnose emphysema was 0.588 (95% CI 0.453-0.662). Mass-to-charge ratios m/z 52 (most likely chloramine) and m/z 135 (alkyl benzene) were linked to obstructive disease and m/z 122 (most probably alkyl homologs) to an impaired diffusion capacity. ROC areas were 0.646 (95% CI 0.562-0.730) and 0.671 (95% CI 0.524-0.710), respectively. In the screening setting, exhaled VOCs measured by PTR-MS constitute weak markers for emphysema, pulmonary obstruction and impaired diffusion capacity.

Size of third and fourth ventricle in obstructive and communicating acute hydrocephalus after aneurysmal subarachnoid hemorrhage.

In patients with acute hydrocephalus after aneurysmal subarachnoid haemorrhage (SAH), lumbar drainage is possible if the obstruction is in the subarachnoid space (communicating hydrocephalus). In case of intraventricular obstruction (obstructive hydrocephalus), ventricular drainage is the only option. A small fourth ventricle is often considered a sign of obstructive hydrocephalus. We investigated whether the absolute or relative size of the fourth ventricle can indeed distinguish between these two types of hydrocephalus. On CT-scans of 76 consecutive patients with acute headache but normal CT and CSF, we measured the cross-sectional surface of the third and fourth ventricle to obtain normal planimetric values. Subsequently we performed the same measurements on 117 consecutive SAH patients with acute hydrocephalus. These patients were divided according to the distribution of blood on CT-scan into three groups: mainly intraventricular blood (n=15), mainly subarachnoid blood (n=54) and both intraventricular and subarachnoid blood (n=48). The size of the fourth ventricle exceeded the upper limit of normal in 2 of the 6 (33%) patients with intraventricular blood but without haematocephalus, and in 15 of the 54 (28%) patients with mainly subarachnoid blood. The mean ratio between the third and fourth ventricle was 1.45 (SD 0.66) in patients with intraventricular blood and 1.42 (SD 0.91) in those with mainly subarachnoid blood. Neither fourth ventricular size nor the ratio between the third and fourth ventricles discriminates between the two groups. A small fourth ventricle does not necessarily accompany obstructive hydrocephalus and is therefore not a contraindication for lumbar drainage.

Impact of integration of clinical and outpatient units on cancer patient satisfaction.

OBJECTIVE: There is an ongoing drive to measure and improve quality of care. Donabedians' quality framework with structure, process and outcome domains provides a useful hold to examine quality of care. The aim of this study was to address the effect of an intervention in hospital structure (integration of three units into one) with the purpose of improving processes (increase meeting, cooperation and communication between professionals and patients) and its effect on the outcome (cancer patient satisfaction). DESIGN: Pre-test-post-test. SETTING: University Medical Center Utrecht, The Netherlands, Department of Medical Oncology. PARTICIPANTS: Cancer patients (n = 174, n = 97). INTERVENTIONS: Physical integration by bringing separately located units (outpatient clinic, day-care clinic, clinical ward) together in one wing of the hospital and adjustments in communication and coordination structures. MAIN OUTCOME MEASURE: Patient satisfaction questionnaire. RESULTS: Satisfaction with care improved for six scales (27%) after integration. Effect sizes (ESs) ranged from 0.36 to 0.80, indicating a small to moderate effect. The most important improvement was found at the day-care clinic on aspects like 'the degree in which the nurses were informed about a patients situation', 'privacy', 'interior design', 'quality of hospital equipment', 'sanitary supplies' and 'waiting periods'. With regard to continuity and coordination of care, satisfaction increased for five items (28% of items concerning continuity and coordination of care). ESs ranged from 0.42 to 0.75. CONCLUSIONS: Integration of three oncology units into one unit had a positive impact on care delivery processes and resulted in improved patient satisfaction concerning care and treatment.

Use of a gonadotropin releasing hormone agonist implant as an alternative for surgical castration in male ferrets (Mustela putorius furo).

Surgical castration in ferrets has been implicated as an etiological factor in the development of hyperadrenocorticism in this species due to a castration-related increase in plasma gonadotropins. In search for a suitable alternative, the effect of treatment with the depot GnRH-agonist implant, deslorelin, on plasma testosterone concentrations and concurrent testes size, spermatogenesis, and the typical musky odor of intact male ferrets was investigated. Twenty-one male ferrets, equally divided into three groups, were either surgically castrated, received a slow release deslorelin implant or received a placebo implant. Plasma FSH and testosterone concentrations, testis size and spermatogenesis were all suppressed after the use of the deslorelin implant. The musky odor in the ferrets which had received a deslorelin implant was less compared to the ferrets which were either surgically castrated or had received a placebo implant. These results indicate that the deslorelin implant effectively prevents reproduction and the musky odor of intact male ferrets and is therefore considered a suitable alternative for surgical castration in these animals.

Long-term effects of husbandry procedures on stress-related parameters in male mice of two strains.

In socially unstable groups of male laboratory mice, individuals may experience a chronic stress situation. Previous experiments have shown that the transfer of specific olfactory cues during cage cleaning, and the provision of nesting material decrease aggression and stress in group-housed male mice. In this study, the combined effect of these husbandry procedures were tested for their long-term effect on stress in groups of moderately aggressive (BALB/c) and severely aggressive (CD-1) male mice. The physiological and behavioural stress-related parameters used were body weight, food and water intake, spleen and thymus weight, adrenal tyrosine hydroxylase activity, urine corticosterone levels and behaviour in a cage emergence test. Long-term provision of nesting material and its transfer during cage cleaning was found to influence several stress-related physiological parameters. Mice housed in cages enriched with nesting material had lower urine corticosterone levels and heavier thymuses, and they consumed less food and water than standard-housed mice. Furthermore, marked differences were found between strains. CD-1 mice were less anxious in the cage emergence test, weighed more, ate and drank more, and had heavier thymuses but lighter spleens and lower corticosterone levels than BALB/c mice. We conclude that the long-term provision of nesting material, including the transfer of nesting material during cage cleaning, reduces stress and thereby enhances the welfare of laboratory mice.

Effects of non-esterified fatty acids on bovine granulosa cells and developmental potential of oocytes in vitro.

High yielding dairy cows experience a negative energy balance (NEB) shortly after parturition, which is accompanied by high concentrations of non-esterified fatty acids (NEFA) in blood up to approximately 3 weeks post partum. We hypothesized that the elevated plasma NEFA concentration causes lower fertility by exerting negative effects on granulosa cells and oocytes in the ovary, leading to less viable embryos and insufficient corpora lutea. In two series of experiments, we studied the effects of a realistic NEFA (C18:1) concentration on both the proliferation and the progesterone production of follicular granulosa cells in vitro (part I) and on maturation, fertilization and developmental potential of oocytes (part II). For part I, granulosa cells were added to 4 groups of dishes with four different media and cultured for nine consecutive days. After a preculture period of 42h, the presence of NEFA had a negative effect on the proliferation of granulosa cells. No effect of NEFA on the amount of progesterone production per cell was observed. For part II, a total of 1804 cumulus-oocyte-complexes were collected from slaughterhouse ovaries. Using a subgroup of 690 COC, maturation medium with NEFA caused a delay in maturation. Using another 1114 COC, fertilization, cleavage, and embryonic development after maturation in presence of NEFA were significantly reduced. We concluded that the presence of NEFA in follicular fluid and blood of post partum cows may reduce fertility due to hampered embryonic development and subnormal CL function.

Attention deficits are not characteristic of schoolchildren with newly diagnosed idiopathic or cryptogenic epilepsy.

PURPOSE: To compare problems of attention in schoolchildren with newly diagnosed idiopathic or cryptogenic epilepsy with those in healthy classmates. METHODS: A computerized battery of tasks comprised Reaction Time (RT) measurement, Trail making (Color Trails 1 and 2), Manual Tapping and Steadiness, and a newly developed task of sustained attention (Balloon Piercing). SUBJECTS: Fifty-one children with epilepsy (age 7-16 years) and 48 gender- and age-matched classmates were assessed thrice: within 48 h after diagnosis [before start of antiepileptic drugs (AEDs)], and 3 and 12 months later. Significantly more children with epilepsy (51%) than control children (27%) had required special educational assistance at school. RESULTS: Children with epilepsy could not be distinguished from controls in execution times or motor speed. However, errors were more frequent among patients in a "go-no-go" RT task, and errors of omission in a task requiring sustained attention. Within the group of children with epilepsy, those with prior school or behavior difficulties and those whose parents reacted maladaptively to the onset and diagnosis of epilepsy performed worse than those without these adversities, in the sense that their RT increased inordinately with increasing task difficulty. Epilepsy-related variables did not explain any variance. Transient inordinately poor performances were found in 69% of patients and 40% of controls. CONCLUSIONS: Children with newly diagnosed "epilepsy only" do not have persistent attention deficits. AED treatment has no detrimental effect on attention. Prior school and behavior difficulties and a maladaptive reaction to the onset of epilepsy rather than epilepsy variables are related to decreased attentional efficiency.

Behavioral and physiological effects of biotechnology procedures used for gene targeting in mice.

The effects of gene-targeting procedures on the behavior and physiological development of (chimeric) mice have been investigated. We used six groups of mice, each of them undergoing specific aspects of the biotechnological procedure, including electroporation, microinjection, and/or blastocyst culture. Changes in behavior and physiological development of the progeny (age 4-30 weeks) were investigated. Besides increased body weights, no significant difference between the six treatment groups and untreated C57BL/6 controls could be attributed to the biotechnology procedures. Therefore, we conclude that these procedures per se do not induce significant discomfort for the offspring. Differences in behavior, observed for the two groups of chimeric mice [one derived from electroporated embryonic stem (ES) cells and the other from nonelectroporated ES cells] when compared to the other (nonchimeric) groups, are, at least partly, due to the genetic background of the 129/Ola strain from which the ES cells are derived rather than to the biotechnological manipulations of the ES cells and/or blastocysts. The occurrence of hermaphrodites (8%) and some other gross pathologies observed in both groups of chimeric animals seem to indicate that developmental problems may occur when cells from different origin are simultaneously contributing to the development of one individual. This implies that during the production of gene-targeted mice, health and welfare of chimeric animals must be carefully monitored.

Epilepsy-related ambiguity in rating the child behavior checklist and the teacher's report form.

Although the child behavior checklist (CBCL) and the teacher's report form (TRF) were not designed for diagnosing psychopathology in children with chronic illnesses, they have become extensively used research tools to assess behavioural problems in paediatric populations, including children with epilepsy. When applied to children with epilepsy, items like "staring blankly" or "twitching" can be rated on the basis of seizure features rather than behaviour and, hence, render behavioural scores ambiguous. The aims were detection, and evaluation of the impact, of CBCL and TRF items eliciting ambiguity when applied to children with "epilepsy only" (idiopathic or cryptogenic epilepsy, attending normal schools). Experts identified items that give rise to interpretational ambiguity of the ratings in epilepsy. By treating ratings on these items as missing values, their effect was evaluated in CBCL and TRF scores of 59 schoolchildren with "epilepsy only" and age and gender matched healthy classmates. Seven items of the CBCL gave rise to ambiguity of which items 5 co-occur on the TRF. Rescoring reduced psychopathology scores in children with "epilepsy only", but not in those of healthy children: the percentage of patients trespassing the clinical cut off score, on at least one of the subscales, reduced from 46 to 23% on the CBCL and from 18 to 15% on the TRF. Parents and teachers run the risk of confusing behaviour and seizure features when filling out the CBCL and TRF. In "epilepsy only", prevalence estimates of psychopathology based on the CBCL and TRF, should be considered with some reserve.

Parents' perceptions of adversity introduced by upheaval and uncertainty at the onset of childhood epilepsy.

PURPOSE: We report the parent's perceptions of and reactions to the onset of "epilepsy only" and the implications for continuity of parenting. METHODS: Content analysis was used to extract data on perceived (dis)continuity of parenting, from interviews held with parents of 69 schoolchildren in whom idiopathic or cryptogenic epilepsy ("epilepsy only") had recently been diagnosed. RESULTS: Almost half of the parents (42%) perceived neither themselves nor their child as having been thrown off balance by the onset of epilepsy. Quite a few parents (33%) perceived themselves rather than their child as having been thrown off balance. More parents of children with cryptogenic than with idiopathic epilepsy perceived themselves as being off balance. However, parents' perceptions of their children's reactions to the epilepsy-related changes were not influenced by any epilepsy variable. Rather, family trouble, long-standing behavioral problems, and adolescence contributed to the child's maladaptive reaction. Three extremely off-balance parents had children with seizures of "unclassifiable" epilepsy that later were found to be nonepileptic and psychogenic. CONCLUSIONS: The majority of the parents perceived their child as adapting well to the onset of epilepsy only. Children with seizure onset in adolescence and children with other adversities were perceived as adapting poorly to the additional adversity of epilepsy. Cryptogenic rather than idiopathic etiology leaves parents in great suspense. In behavioral studies, it is advisable to treat children with unclassifiable epilepsy as a separate group.

The half-life of infused factor VIII is shorter in hemophiliac patients with blood group O than in those with blood group A.

A considerable inter-individual variation in half-life of infused factor VIII is observed among patients with hemophilia A. The factors contributing to this wide range in factor VIII half-life are not known in detail. We analysed the pharmacokinetics of infused factor VIII in 32 patients with hemophilia A, comprising 20 brothers from 10 families, 3 and 4 brothers from 2 families, and 5 patients from 5 single families, respectively. Multiple linear regression analysis was used to assess the effect of several variables on factor VIII half-life. We found that the pre-infusion von Willebrand factor antigen levels (vWF:Ag) were positively correlated with factor VIII half-life (r = 0.52, p = 0.002), i.e., each variable was associated with about 27% of the variance of the other. In fraternal pairs, familial clustering was significant for ABO blood group (p < 0.001), but could not be detected for factor VIII half-lives or pre-infusion vWF:Ag levels. vWF:Ag level (p = 0.001) and ABO blood group (p = 0.003) significantly determined factor VIII half-life, whereas age, length, bodyweight, the presence or absence of a factor VIII gene inversion, and Rhesus phenotype did not. Patients with blood group O exhibited a statistically significant shorter factor VIII half-life than patients with blood group A (15.3 versus 19.7 h, respectively) (p = 0.003). Patients with blood group A and O differ in respect to the presence of anti-A antibodies in the latter. It is possible that these anti-A antibodies interact with endogenous vWF, thus affecting the half-life time of the factor VIII/vWF complex.

Analgesics in mice used in cancer research: reduction of discomfort?

During the last decades, an increase is apparent in the use of analgesics for laboratory animals in situations where this was previously considered unnecessary. Mice with advanced tumours often show clear signs of discomfort which may be a result of chronic pain or a result of general ill-being. The syngeneic murine tumour model most frequently used in our experiments was used to investigate whether this discomfort can be reduced with an analgesic. Twenty DBA/2 mice bearing SL2 lymphoma were given 0.5 mg/kg buprenorphine (Temgesic) in food gel twice daily, 20 tumour-bearing mice were given control food gel at the same times. Indicators of well-being were monitored daily. These included behavioural parameters such as exploration, grooming, and posture; food and water consumption and fur quality. All mice showed a clear increase of discomfort with time: explorative behaviours and grooming decreased, while sitting in hunched posture increased. Food and water consumption and fur quality also decreased. Major significant differences between the buprenorphine treated group and the control group were not apparent. In conclusion, we could not document a positive effect or buprenorphine on discomfort in mice as evaluated by our scoring system. It remains possible that pain itself was not the primary cause of the discomfort in mice bearing these tumours, or that the analgesic effect of buprenorphine was insufficient under these circumstances.