A randomized trial of hypothesis-driven vs screening neurologic examination.

OBJECTIVE: We hypothesized that trainees would perform better using a hypothesis-driven rather than a traditional screening approach to the neurologic examination. METHODS: We randomly assigned 16 medical students to perform screening examinations of all major aspects of neurologic function or hypothesis-driven examinations focused on aspects suggested by the history. Each student examined 4 patients, 2 of whom had focal deficits. Outcomes of interest were the correct identification of patients with focal deficits, number of specific deficits detected, and examination duration. Outcomes were assessed by an investigator blinded to group assignments. The McNemar test was used to compare the sensitivity and specificity of the 2 examination methods. RESULTS: Sensitivity was higher with hypothesis-driven examinations than with screening examinations (78% vs 56%; p = 0.046), although specificity was lower (71% vs 100%; p = 0.046). The hypothesis-driven group identified 61% of specific examination abnormalities, whereas the screening group identified 53% (p = 0.008). Median examination duration was 1 minute shorter in the hypothesis-driven group (7.0 minutes vs 8.0 minutes; p = 0.13). CONCLUSIONS: In this randomized trial comparing 2 methods of neurologic examination, a hypothesis-driven approach resulted in greater sensitivity and a trend toward faster examinations, at the cost of lower specificity, compared with the traditional screening approach. Our findings suggest that a hypothesis-driven approach may be superior when the history is concerning for an acute focal neurologic process.

Switching devices based on interlocked molecules.

An architectural rationale and an experimental program aimed at the development of molecular electronics switching devices for memory and computing applications are discussed. Two-terminal molecular switch tunnel junctions are identified as the critical device components of molecular electronics-based circuitry. They can be tiled in two dimensions and are tolerant of manufacturing defects. Singly and multiply configurable solid-state switching devices that are based upon electrochemically switchable molecular and supramolecular systems are discussed in terms of both the synthesis of the molecular components and the fabrication and performance of the devices.

Toward interlocked molecules beyond catenanes and rotaxanes.

A linear bis secondary dialkylammonium ion-containing scaffold-based upon an anthracenyl core-has been synthesized. It has been demonstrated that it is possible to dock either one or two dibenzo[24]crown-8 (DB24C8) macrocycles onto this scaffold to afford either a [2]- or [3]pseudorotaxane, respectively. In solution, the association constants for the formation of each of these species has been quantified by employing (1)H NMR spectroscopy, and both species survive in the "gas phase" as evidenced by FAB mass spectrometry. Additionally, the X-ray crystal superstructure of the [3]pseudorotaxane has been determined.

Ammonium ion binding with pyridine-containing crown ethers.

Dipyrido[24]crown-8 (DP24C8) has been synthesized and shown to form [2]pseudorotaxanes spontaneously with dibenzylammonium ions. These complexes, which have been demonstrated by (1)H NMR spectroscopy to form faster in solution than when the macrocyclic polyether is dibenzo[24]crown-8 (DB24C8), are also stronger than their DB24C8 counterparts. One of the [2]pseudorotaxanes has been used to construct a [2]rotaxane (see above) comprising a dumbbell-shaped component based on a dibenzylammonium ion which is encircled by a DP24C8 macrocycle and terminated by (triphenylphosphonium)methyl stoppers.

Dynamic hemicarcerands and hemicarceplexes.

The reversible nature of the imine bond formation in CDCl(3) solution has been exploited to exchange substituted for unsubstituted m-phenylenediamine (MPD) units in hemicarcerand octaimines. Moreover, acid-catalyzed imine exchange has been shown to provide a novel mechanism whereby ferrocene (Fc) can be released as an entrapped guest from the hemicarceplex C(2)B(4)&crcldt;Fc dissolved in CDCl(3) to give the hemicarcerand C(2)B(4) when excess of both MPD and trifluoroacetic acid are present.