REACT: Rapid Evaluation Assessment of Clinical Reasoning Tool.

INTRODUCTION: Clinical reasoning encompasses the process of data collection, synthesis, and interpretation to generate a working diagnosis and make management decisions. Situated cognition theory suggests that knowledge is relative to contextual factors, and clinical reasoning in urgent situations is framed by pressure of consequential, time-sensitive decision-making for diagnosis and management. These unique aspects of urgent clinical care may limit the effectiveness of traditional tools to assess, teach, and remediate clinical reasoning. METHODS: Using two validated frameworks, a multidisciplinary group of clinicians trained to remediate clinical reasoning and with experience in urgent clinical care encounters designed the novel Rapid Evaluation Assessment of Clinical Reasoning Tool (REACT). REACT is a behaviorally anchored assessment tool scoring five domains used to provide formative feedback to learners evaluating patients during urgent clinical situations. A pilot study was performed to assess fourth-year medical students during simulated urgent clinical scenarios. Learners were scored using REACT by a separate, multidisciplinary group of clinician educators with no additional training in the clinical reasoning process. REACT scores were analyzed for internal consistency across raters and observations. RESULTS: Overall internal consistency for the 41 patient simulations as measured by Cronbach's alpha was 0.86. A weighted kappa statistic was used to assess the overall score inter-rater reliability. Moderate reliability was observed at 0.56. DISCUSSION: To our knowledge, REACT is the first tool designed specifically for formative assessment of a learner's clinical reasoning performance during simulated urgent clinical situations. With evidence of reliability and content validity, this tool guides feedback to learners during high-risk urgent clinical scenarios, with the goal of reducing diagnostic and management errors to limit patient harm.

A Lagerstätte from Australia provides insight into the nature of Miocene mesic ecosystems.

Reduced precipitation in the Miocene triggered the geographic contraction of rainforest ecosystems around the world. In Australia, this change was particularly pronounced; mesic rainforest ecosystems that once dominated the landscape transformed into the shrublands, grasslands, and deserts of today. A lack of well-preserved fossils has made it difficult to understand the nature of Australian ecosystems before the aridification. Here, we report on an exceptionally well-preserved rainforest biota from New South Wales, Australia. This Konservat-Lagerstätte hosts a rich diversity of microfossils, plants, insects, spiders, and vertebrate remains preserved in goethite. We document evidence for several species interactions including predation, parasitism, and pollination. The fossils are indicative of an oxbow lake in a mesic rainforest and suggest that rainforest distributions have shifted since the Miocene. The variety of fossils preserved, together with high fidelity of preservation, allows for unprecedented insights into the mesic ecosystems that dominated Australia during the Miocene.

Lessons in clinical reasoning ‒ pitfalls, myths, and pearls: a case of confusion, disequilibrium, and "picking at the air".

OBJECTIVES: Defects in human cognition commonly result in clinical reasoning failures that can lead to diagnostic errors. CASE PRESENTATION: A 43-year-old female was brought to the emergency department with 4-5 days of confusion, disequilibrium resulting in several falls, and hallucinations. Further investigation revealed tachycardia, diaphoresis, mydriatic pupils, incomprehensible speech and she was seen picking at the air. Given multiple recent medication changes, there was initial concern for serotonin syndrome vs. an anticholinergic toxidrome. She then developed a fever, marked leukocytosis, and worsening encephalopathy. She underwent lumbar puncture and aspiration of an identified left ankle effusion. Methicillin sensitive staph aureus (MSSA) grew from blood, joint, and cerebrospinal fluid cultures within 18 h. She improved with antibiotics and incision, drainage, and washout of her ankle by orthopedic surgery. CONCLUSIONS: Through integrated commentary on the diagnostic reasoning process from clinical reasoning experts, this case underscores how multiple cognitive biases can cascade sequentially, skewing clinical reasoning toward erroneous conclusions and driving potentially inappropriate testing and treatment. A fishbone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic error. A case discussant describes the importance of structured reflection, a tool to promote metacognitive analysis, and the application of knowledge organization tools such as illness scripts to navigate these cognitive biases.

Cardiovascular Screening in the U.S. Military: Time to Reconsider the Electrocardiogram.

INTRODUCTION: The US Department of Defense (DoD) has adopted a model concept of the warrior athlete. Identifying latent disease that could compromise the military operator is critical to the warrior athlete concept. Cardiovascular complaints are the important problem recognized in service members evacuated from combat zones, and the incidence of sudden cardiac death in U.S. military recruits is comparable to or greater than that among National Collegiate Athletic Association Athletes. Nevertheless, the mandatory electrocardiogram (ECG) was removed from official U.S. military accession screening policy in 2002. Inclusion of ECG screening in high risk athletics is increasingly recognized as appropriate by professional organizations such as the American Heart Association and American Medical Society for Sports Medicine, though neither recommends ECG for generalized screening in large, low-risk populations. MATERIALS AND METHODS: The appropriate DoD instructions were reviewed in the context of recent literature regarding the sensitivity and specificity of ECG screening for prevention of sudden cardiac arrest or debilitating arrhythmias. RESULTS: Challenges to implementation of ECG as a screening modality in U.S. military accessions include clinician interpretation validity and reliability. Modern interpretation criteria and new interpretation technology each serve to mitigate these recognized limitations. Outside experience with implementation of modern ECG suggest potential benefits are significant in the highest risk military groups. CONCLUSION: Prospective study of ECG screening is needed to determine the impact on cardiovascular outcomes in U.S. military populations.

Analysis of elemental and isotopic variation in glass frictionators from 0.22 rimfire primers.

The majority of 0.22 calibre rimfire ammunition available in Australia, and overseas, tends to use glass powder rather than antimony sulfide frictionator in the primer. This glass can be the nucleus of a GSR particle, with other primer components condensing around and onto the glass structure. As the composition of glass frictionator remains largely unaltered during ammunition discharge [1] there is the possibility that frictionator composition could be used in GSR examinations to either correlate or discriminate between samples, thereby providing valuable information to an investigation. In this study, the composition of glass frictionator from a wide variety of ammunition was analysed by time-of-flight - secondary ion mass spectrometry (ToF-SIMS), sensitive high-resolution ion microprobe (SHRIMP) and scanning electron microscopy - energy dispersive X-ray spectrometry (SEM-EDS). Refractive index (RI) was measured using glass refractive index measurement (GRIM). Across the population of ammunition studied, it was found that the elemental and isotopic composition of frictionator varied. ToF-SIMS was able to discriminate 94.1% of brands in a pairwise comparison and SEM-EDS achieved a pairwise discrimination power of 79.4%. If SHRIMP was combined with the other two techniques, 95.6% of brands could be discriminated. Refractive index measurements supported the elemental data showing that there appeared, in most cases, to be only one population of glass within a cartridge. The results suggest that there is scope for frictionator analysis to contribute valuable, new capability to forensic GSR examinations.

Physical Effects of Anabolic-androgenic Steroids in Healthy Exercising Adults: A Systematic Review and Meta-analysis.

Many athletes use anabolic-androgenic steroids (AAS) for physical enhancement but the magnitude of these gains and associated adverse effects has not been rigorously quantified. MEDLINE, EMBASE, Cochrane, SPORTDiscus, and PsycINFO were searched to identify randomized placebo-controlled trials of AAS in healthy exercising adults that reported one of the following outcomes: muscular strength, body composition, cardiovascular endurance, or power. Two authors appraised abstracts to identify studies for full-text retrieval; these were reviewed in duplicate to identify included studies. Study quality was assessed using the Cochrane method. Data were extracted in duplicate and pooled using the DerSimonian and Laird random effects model and to calculate the ratio of mean outcome improvement where possible. Pooled standardized mean difference (SMD) in muscle strength between AAS and placebo was 0.27 (95% confidence interval, 0.07-0.47; I = 12.7%; 21 studies). Change in strength was 52% greater in the AAS group compared to placebo. The SMD for change in lean mass between AAS and placebo was 0.62 (95% confidence interval, 0.35-0.89; I = 26%; 14 studies). Due to missing data, fat mass, cardiovascular endurance, power, and adverse effects were summarized qualitatively. Only 13 of 25 studies reported adverse effects including increased low density lipoprotein (LDL), decreased high density lipoprotein (HDL), irritability, and acne. In healthy exercising adults, AAS use is associated with a small absolute increase in muscle strength and moderate increase in lean mass. However, the transparency and completeness of adverse effect reporting varied, most studies were of short duration, and doses studied may not reflect actual use by athletes.

Guerilla Warfare on the Pancreas? A Case of Acute Pancreatitis From a Supplement Known to Contain Anabolic-Androgenic Steroids.

INTRODUCTION: Performance-enhancing drugs (PEDs) are commonly consumed in the United States with high prevalence of use in athlete populations and increased use by deployed service members. Many PEDs may contain anabolic-androgenic steroids (AAS), which are legally restricted and prohibited by many agencies due to their health risk. CASE DESCRIPTION: A unique case of acute pancreatitis associated with the use of the PED "Guerilla Warfare," a labeled AAS-containing supplement, is presented. The patient is a healthy 20-year-old male Marine who presented with multiple episodes of abdominal cramps each day for a month with decreased appetite and nonbilious vomiting. He reported a 6-week history of "Guerilla Warfare" PED use and review of systems identified fatigue and 12 lb reported weight loss. He presented with normal vital signs, tenderness in upper abdominal quadrants, elevated lipase (909 units/L), lactate dehydrogenase (193 units/L), and an enlarged pancreas with surrounding inflammation on computed tomography. SUMMARY: This constitutes the first report of acute pancreatitis with the use of "Guerilla Warfare," and the second reported case with the use of any AAS-containing PED. Increased awareness of significant PED-associated adverse effects by both the civilian and military communities is needed to better characterize these risks moving forward.

Mission Compromised? Drug-Induced Liver Injury From Prohormone Supplements Containing Anabolic-Androgenic Steroids in Two Deployed U.S. Service Members.

BACKGROUND: Supplement adulteration with anabolic-androgenic steroids (AAS) has been reported and AAS-associated drug-induced liver injury is clinically variable. OBJECTIVES: We present two cases of AAS-associated drug-induced liver injury in deployed service members, including the first report of clinical hepatotoxicity with desoxymethyltestosterone. We highlight variable hepatotoxicity patterns of AAS, raise concern with inaccurate supplement labeling and identify educational resources. METHODS: The first case presents with cholestatic jaundice following 10 weeks of prohormone use. Hepatobiliary imaging was unrevealing. Viral, autoimmune, and metabolic etiologies were excluded. Bilirubin normalized by 8 weeks after stopping the supplement. The second case presents with asymptomatic hepatocellular toxicity and marked dyslipidemia identified on service-related physical following 21 days of prohormone use. Aspartate aminotransferase and alanine aminotransferase normalized 4 weeks after supplement cessation; high-density lipoprotein and low-density lipoprotein returned to baseline at 8 weeks. Each supplement was volunteered for analytic testing. RESULTS: Supplement label contents did not match gas chromatography/mass spectrometry analysis; 3 of 4 supplements contained federally regulated AAS. CONCLUSIONS: AAS hepatotoxicity is clinically variable and dyslipidemia may be an important clinical indicator. False labeling introduces clinical risk and threatens mission readiness. Educational resources are available to facilitate information sharing. Supplement analysis informs of clinical risk of specific supplements and facilitates shared clinical decision-making.

Fractional Third and Fourth Dose of RTS,S/AS01 Malaria Candidate Vaccine: A Phase 2a Controlled Human Malaria Parasite Infection and Immunogenicity Study.

BACKGROUND: Three full doses of RTS,S/AS01 malaria vaccine provides partial protection against controlled human malaria parasite infection (CHMI) and natural exposure. Immunization regimens, including a delayed fractional third dose, were assessed for potential increased protection against malaria and immunologic responses. METHODS: In a phase 2a, controlled, open-label, study of healthy malaria-naive adults, 16 subjects vaccinated with a 0-, 1-, and 2-month full-dose regimen (012M) and 30 subjects who received a 0-, 1-, and 7-month regimen, including a fractional third dose (Fx017M), underwent CHMI 3 weeks after the last dose. Plasmablast heavy and light chain immunoglobulin messenger RNA sequencing and antibody avidity were evaluated. Protection against repeat CHMI was evaluated after 8 months. RESULTS: A total of 26 of 30 subjects in the Fx017M group (vaccine efficacy [VE], 86.7% [95% confidence interval [CI], 66.8%-94.6%]; P < .0001) and 10 of 16 in the 012M group (VE, 62.5% [95% CI, 29.4%-80.1%]; P = .0009) were protected against infection, and protection differed between schedules (P = .040, by the log rank test). The fractional dose boosting increased antibody somatic hypermutation and avidity and sustained high protection upon rechallenge. DISCUSSIONS: A delayed third fractional vaccine dose improved immunogenicity and protection against infection. Optimization of the RTS,S/AS01 immunization regimen may lead to improved approaches against malaria. CLINICAL TRIALS REGISTRATION: NCT01857869.

Electronic health records improve clinical note quality.

BACKGROUND AND OBJECTIVE: The clinical note documents the clinician's information collection, problem assessment, clinical management, and its used for administrative purposes. Electronic health records (EHRs) are being implemented in clinical practices throughout the USA yet it is not known whether they improve the quality of clinical notes. The goal in this study was to determine if EHRs improve the quality of outpatient clinical notes. MATERIALS AND METHODS: A five and a half year longitudinal retrospective multicenter quantitative study comparing the quality of handwritten and electronic outpatient clinical visit notes for 100 patients with type 2 diabetes at three time points: 6 months prior to the introduction of the EHR (before-EHR), 6 months after the introduction of the EHR (after-EHR), and 5 years after the introduction of the EHR (5-year-EHR). QNOTE, a validated quantitative instrument, was used to assess the quality of outpatient clinical notes. Its scores can range from a low of 0 to a high of 100. Sixteen primary care physicians with active practices used QNOTE to determine the quality of the 300 patient notes. RESULTS: The before-EHR, after-EHR, and 5-year-EHR grand mean scores (SD) were 52.0 (18.4), 61.2 (16.3), and 80.4 (8.9), respectively, and the change in scores for before-EHR to after-EHR and before-EHR to 5-year-EHR were 18% (p<0.0001) and 55% (p<0.0001), respectively. All the element and grand mean quality scores significantly improved over the 5-year time interval. CONCLUSIONS: The EHR significantly improved the overall quality of the outpatient clinical note and the quality of all its elements, including the core and non-core elements. To our knowledge, this is the first study to demonstrate that the EHR significantly improves the quality of clinical notes.

Postoperative myocardial infarction and cardiac arrest following primary total knee and hip arthroplasty: rates, risk factors, and time of occurrence.

BACKGROUND: Cardiac complications are a major cause of postoperative morbidity. The purpose of this study was to determine the rates, risk factors, and time of occurrence for cardiac complications within thirty days after primary unilateral total knee arthroplasty and total hip arthroplasty. METHODS: The American College of Surgeons National Surgical Quality Improvement Program data set from 2006 to 2011 was used to identify all total knee arthroplasties and total hip arthroplasties. Cardiac complications occurring within thirty days after surgery were the primary outcome measure. Patients were designated as having a history of cardiac disease if they had a new diagnosis or exacerbation of chronic congestive heart failure or a history of angina within thirty days before surgery, a history of myocardial infarction within six months, and/or any percutaneous cardiac intervention or other major cardiac surgery at any time. An analysis of the occurrence of all major cardiac complications and deaths within the thirty-day postoperative time frame was performed. RESULTS: For the 46,322 patients managed with total knee arthroplasty or total hip arthroplasty, the cardiac complication rate was 0.33% (n = 153) at thirty days postoperatively. In both the total knee arthroplasty and total hip arthroplasty groups, an age of eighty years or more (odds ratios [ORs] = 27.95 and 3.72), hypertension requiring medication (ORs = 4.74 and 2.59), and a history of cardiac disease (ORs = 4.46 and 2.80) were the three most significant predictors for the development of postoperative cardiac complications. Of the patients with a cardiac complication, the time of occurrence was within seven days after surgery for 79% (129 of the 164 patients for whom the time of occurrence could be determined). CONCLUSIONS: An age of eighty years or more, a history of cardiac disease, and hypertension requiring medication are significant risk factors for developing postoperative cardiac complications following primary unilateral total knee arthroplasty and total hip arthroplasty. Consideration should be given to a preoperative cardiology evaluation and co-management in the perioperative period for individuals with these risk factors.

What aspects of letters of recommendation predict performance in medical school? Findings from one institution.

PURPOSE: To study medical students' letters of recommendation (LORs) from their applications to medical school to determine whether these predicted medical school performance, because many researchers have questioned LORs' predictive validity. METHOD: A retrospective cohort study of three consecutive graduating classes (2007-2009) at the Uniformed Services University of the Health Sciences was performed. In each class, the 27 students who had been elected into the Alpha Omega Alpha (AOA) Honor Medical Society were defined as top graduates, and the 27 students with the lowest cumulative grade point average (GPA) were designated as "bottom of the class" graduates. For each student, the first three LORs (if available) in the application packet were independently coded by two blinded investigators using a comprehensive list of 76 characteristics. Each characteristic was compared with graduation status (top or bottom of the class), and those with statistical significance related to graduation status were inserted into a logistic regression model, with undergraduate GPA and Medical College Admission Test score included as control variables. RESULTS: Four hundred thirty-seven LORs were included. Of 76 LOR characteristics, 7 were associated with graduation status (P ≤ .05), and 3 remained significant in the regression model. Being rated as "the best" among peers and having an employer or supervisor as the LOR author were associated with induction into AOA, whereas having nonpositive comments was associated with bottom of the class students. CONCLUSIONS: LORs have limited value to admission committees, as very few LOR characteristics predict how students perform during medical school.

Reliability and validity of clinician ECG interpretation for athletes.

BACKGROUND: Electrocardiogram (ECG) with preparticipation evaluation (PPE) for athletes remains controversial in the United States and diagnostic accuracy of clinician ECG interpretation is unclear. This study aimed to assess reliability and validity of clinician ECG interpretation using expert-validated ECGs according to the 2010 European Society of Cardiology (ESC) interpretation criteria. METHODS: This is a blinded, prospective study of diagnostic accuracy of clinician ECG interpretation. Anonymized ECGs were validated for normal and abnormal patterns by blinded expert interpreters according to the ESC interpretation criteria from October 2011 through March 2012. Six pairs of clinician interpreters were recruited from relevant clinical specialties in an academic medical center in March 2012. Each clinician interpreted 85 ECGs according to the ESC interpretation guidelines. Cohen and Fleiss' kappa, sensitivity, and specificity were calculated within specialties and across primary care and cardiology specialty groups. RESULTS: Experts interpreted 189 ECGs yielding a kappa of 0.63, demonstrating "substantial" inter-rater agreement. A total of 85 validated ECGs, including 26 abnormals, were selected for clinician interpretation. The kappa across cardiology specialists was "substantial" and "moderate" across primary care (0.69 vs 0.52, respectively, P < 0.001). Sensitivity and specificity to detect abnormal patterns were similar between cardiology and primary care groups (sensitivity 93.3% vs 81.3%, respectively, P = 0.31; specificity 88.8% vs 89.8%, respectively, P = 0.91). CONCLUSIONS: Clinician ECG interpretation according to the ESC interpretation criteria appears to demonstrate limited reliability and validity. Before widespread adoption of ECG for PPE of U.S. athletes, further research of training focused on improved reliability and validity of clinician ECG interpretation is warranted.

QNOTE: an instrument for measuring the quality of EHR clinical notes.

BACKGROUND AND OBJECTIVE: The outpatient clinical note documents the clinician's information collection, problem assessment, and patient management, yet there is currently no validated instrument to measure the quality of the electronic clinical note. This study evaluated the validity of the QNOTE instrument, which assesses 12 elements in the clinical note, for measuring the quality of clinical notes. It also compared its performance with a global instrument that assesses the clinical note as a whole. MATERIALS AND METHODS: Retrospective multicenter blinded study of the clinical notes of 100 outpatients with type 2 diabetes mellitus who had been seen in clinic on at least three occasions. The 300 notes were rated by eight general internal medicine and eight family medicine practicing physicians. The QNOTE instrument scored the quality of the note as the sum of a set of 12 note element scores, and its inter-rater agreement was measured by the intraclass correlation coefficient. The Global instrument scored the note in its entirety, and its inter-rater agreement was measured by the Fleiss κ. RESULTS: The overall QNOTE inter-rater agreement was 0.82 (CI 0.80 to 0.84), and its note quality score was 65 (CI 64 to 66). The Global inter-rater agreement was 0.24 (CI 0.19 to 0.29), and its note quality score was 52 (CI 49 to 55). The QNOTE quality scores were consistent, and the overall QNOTE score was significantly higher than the overall Global score (p=0.04). CONCLUSIONS: We found the QNOTE to be a valid instrument for evaluating the quality of electronic clinical notes, and its performance was superior to that of the Global instrument.

The R.O.A.D. confirmed: ratings of specialties' lifestyles by fourth-year US medical students with a military service obligation.

BACKGROUND AND OBJECTIVES: Lifestyle factors influence medical specialty choice, but which specialties are perceived to have the best lifestyles is poorly described in scientific literature. The objective of the study was to determine the rating of specialties by lifestyle. METHODS: All fourth-year US medical students with a Department of Defense service obligation who participated in the 2008/2009 military Match were invited to participate in a survey following the Match. The survey listed 18 specialties and asked students to rate the lifestyle of each one on a 9-point scale, and the mean score was used as the rating. Students also listed their specialty choice in the Match. RESULTS: The response rate was 52%, as 418 of the 797 eligible students responded and provided a rating for at least nine of the 18 specialties. The four specialties rated highest for lifestyle (1--9, with 9 being highest) were dermatology (8.4), radiology (8.1), ophthalmology (8.0), and anesthesia (7.5). The four specialties rated lowest were orthopedics (4.0), neurosurgery (3.1), general surgery (2.6), and obstetrics-gynecology (2.5). Family medicine (5.7) was the top-rated primary care specialty, followed by pediatrics (5.3) and internal medicine (4.7). Students rated the lifestyle of their own specialty only slightly higher (range 0.02 to 1.8) than all other students. CONCLUSIONS: The R.O.A.D. specialties (radiology, ophthalmology, anesthesia, and dermatology) are the top specialties with respect to lifestyle as viewed by current students. Students perceive their own specialty's lifestyle realistically. Research determining why a specialty perceived as having a lower-rated lifestyle is acceptable to some students and not others is needed.

NO-Xplode: a case of supplement-associated ischemic colitis.

The most common cause of ischemic colitis (IC) is a sudden and transient reduction in splanchnic perfusion. In the younger population, medications are an increasingly recognized cause of ischemic bowel disease. Over-the-counter supplements may also lead to the development of ischemic colitis through similar effects. We present a case of ischemic colitis in a 42-year-old active duty service member after using the performance-enhancing supplement, NO-Xplode. In this report, we review the pharmacology of this supplement and its proposed mechanism of injury.