Anaphylaxis in a Swiss university emergency department: clinical characteristics and supposed triggers.

BACKGROUND: Anaphylaxis is the most severe form of acute systemic and potentially life-threatening reactions triggered by mast and basophilic cells. Recent studies show a worldwide incidence between 50 and 112 occurrences per 100,000 person-years. The most identified triggers are food, medications, and insect venoms. We aimed to analyze triggers and clinical symptoms of patients presenting to a Swiss university emergency department for adults. METHODS: Six-year retrospective analysis (01/2013 to 12/2018) of all patients (> 16 years of age) admitted with moderate or severe anaphylaxis (classification of Ring and Messmer ≥ 2) to the emergency department. Patient and clinical data were extracted from the electronic medical database of the emergency department. RESULTS: Of the 531 includes patients, 53.3% were female, the median age was 38 [IQR 26-51] years. The most common suspected triggers were medications (31.8%), food (25.6%), and insect stings (17.1%). Organ manifestations varied among the different suspected triggers: for medications, 90.5% of the patients had skin symptoms, followed by respiratory (62.7%), cardiovascular (44.4%) and gastrointestinal symptoms (33.7%); for food, gastrointestinal symptoms (39.7%) were more frequent than cardiovascular symptoms (36.8%) and for insect stings cardiovascular symptoms were apparent in 63.8% of the cases. CONCLUSIONS: Average annual incidence of moderate to severe anaphylaxis during the 6-year period in subjects > 16 years of age was 10.67 per 100,000 inhabitants. Medications (antibiotics, NSAID and radiocontrast agents) were the most frequently suspected triggers. Anaphylaxis due to insect stings was more frequently than in other studies. Regarding clinical symptoms, gastrointestinal symptoms need to be better considered, especially that initial treatment with epinephrine is not delayed.

Inconsistencies in rater-based assessments mainly affect borderline candidates: but using simple heuristics might improve pass-fail decisions.

INTRODUCTION: Research in various areas indicates that expert judgment can be highly inconsistent. However, expert judgment is indispensable in many contexts. In medical education, experts often function as examiners in rater-based assessments. Here, disagreement between examiners can have far-reaching consequences. The literature suggests that inconsistencies in ratings depend on the level of performance a to-be-evaluated candidate shows. This possibility has not been addressed deliberately and with appropriate statistical methods. By adopting the theoretical lens of ecological rationality, we evaluate if easily implementable strategies can enhance decision making in real-world assessment contexts. METHODS: We address two objectives. First, we investigate the dependence of rater-consistency on performance levels. We recorded videos of mock-exams and had examiners (N=10) evaluate four students' performances and compare inconsistencies in performance ratings between examiner-pairs using a bootstrapping procedure. Our second objective is to provide an approach that aids decision making by implementing simple heuristics. RESULTS: We found that discrepancies were largely a function of the level of performance the candidates showed. Lower performances were rated more inconsistently than excellent performances. Furthermore, our analyses indicated that the use of simple heuristics might improve decisions in examiner pairs. DISCUSSION: Inconsistencies in performance judgments continue to be a matter of concern, and we provide empirical evidence for them to be related to candidate performance. We discuss implications for research and the advantages of adopting the perspective of ecological rationality. We point to directions both for further research and for development of assessment practices.

No knowledge gap in human physiology after remote teaching for second year medical students throughout the Covid-19 pandemic.

The COVID-19 pandemic had a disruptive effect on higher education. A critical question is whether these changes affected students' learning outcomes. Knowledge gaps have consequences for future learning and may-in health professionals' education-also pose a threat to patient safety. Current research has shortcomings and does not allow for clear-cut interpretation. Our context is instruction in human physiology in an undergraduate medical program from high stakes end of term examinations. The sequence of imposed measures to slow the COVID-19 pandemic created a natural experiment, allowing for comparisons in performance during in-person versus remote instruction.In a two-factorial design, mode of instruction (in-person vs. remote) and mode of assessment (in-person vs. remote) were analyzed using both basic (non-parametric statistics, T-tests) and advanced statistical methods (linear mixed-effects model; resampling techniques). Test results from a total of N = 1095 s-year medical students were included in the study.We did not find empirical evidence of knowledge gaps; rather, students received comparable or higher scores during remote teaching. We interpret these findings as empirical evidence that both students and teachers adapted to pandemic disruption in a way that did not lead to knowledge gaps.We conclude that highly motivated students had no reduction in academic achievement. Moreover, we have developed an accessible digital exam system for secure, fair, and effective assessments which is sufficiently defensible for making pass/fail decisions.

Exploring objective measures for assessing team performance in healthcare: an interview study.

Introduction: Effective teamwork plays a critical role in achieving high-performance outcomes in healthcare. Consequently, conducting a comprehensive assessment of team performance is essential for providing meaningful feedback during team trainings and enabling comparisons in scientific studies. However, traditional methods like self-reports or behavior observations have limitations such as susceptibility to bias or being resource consuming. To overcome these limitations and gain a more comprehensive understanding of team processes and performance, the assessment of objective measures, such as physiological parameters, can be valuable. These objective measures can complement traditional methods and provide a more holistic view of team performance. The aim of this study was to explore the potential of the use of objective measures for evaluating team performance for research and training purposes. For this, experts in the field of research and medical simulation training were interviewed to gather their opinions, ideas, and concerns regarding this novel approach. Methods: A total of 34 medical and research experts participated in this exploratory qualitative study, engaging in semi-structured interviews. During the interview, experts were asked for (a) their opinion on measuring team performance with objective measures, (b) their ideas concerning potential objective measures suitable for measuring team performance of healthcare teams, and (c) their concerns regarding the use of objective measures for evaluating team performance. During data analysis responses were categorized per question. Results: The findings from the 34 interviews revealed a predominantly positive reception of the idea of utilizing objective measures for evaluating team performance. However, the experts reported limited experience in actively incorporating objective measures into their training and research. Nevertheless, they identified various potential objective measures, including acoustical, visual, physiological, and endocrinological measures and a time layer. Concerns were raised regarding feasibility, complexity, cost, and privacy issues associated with the use of objective measures. Discussion: The study highlights the opportunities and challenges associated with employing objective measures to assess healthcare team performance. It particularly emphasizes the concerns expressed by medical simulation experts and team researchers, providing valuable insights for developers, trainers, researchers, and healthcare professionals involved in the design, planning or utilization of objective measures in team training or research.

Longitudinal Covid-19 effects on child mental health: vulnerability and age dependent trajectories.

BACKGROUND: Few longitudinal studies have investigated the extended long-term impact of the Covid-19 pandemic for children's and adolescents' mental health, and a lack of uniform findings suggest heterogeneity in the impact of the pandemic. METHODS: This study investigated child and adolescent mental health symptoms across four occasions (pre-pandemic, initial lockdown, second lockdown, and society post reopening) using data from the Dynamics of Family Conflict study. Child and adolescent depressive vulnerability, age, and sex were explored as trajectory moderators. Children and adolescents (N = 381, Mage = 13.65, SD = 1.74) self-reported their anxiety, depression, and externalizing symptoms. Mixed effects analyses were performed to investigate trajectories across measurement occasions and interaction terms between occasion and moderator variables were included to better understand the heterogeneity in the impact of the pandemic. RESULTS: Children and adolescents reported increases in anxiety symptoms at the second lockdown (t(523) = -3.66, p < .01) and when society had reopened (t(522) = -4.90, p < .001). An increase in depression symptoms was seen when society had reopened relative to the three previous measurement occasions (ps < 0.01). Depressive vulnerability moderated the trajectory for anxiety symptoms (F(3,498) = 3.05, p = .028), while age moderated the trajectory for depression symptoms (F(3,532) = 2.97, p = .031). CONCLUSION: The delayed and negative impact on children's and adolescents' mental health underscores the need for continued monitoring, and implementation of support systems to help and mitigate further deterioration.

Children With Developmental Language Disorder Have Lower Quality of Life Than Children With Typical Development and Children With Cochlear Implants.

PURPOSE: The purpose of this study was to examine quality of life (QOL) and its relation to language skills in children with developmental language disorder (DLD). This was examined by comparing QOL to a control group of children with typical development (TD), as well as children with cochlear implants (CIs), who potentially struggle with language for language, although for a different reason than children with DLD. METHOD: Two groups of children, a group with TD (n = 29) and a group of children with CIs (n = 29), were matched to the DLD group (n = 29) on chronological age, gender, nonverbal IQ, and parental educational level through a propensity matching procedure. A third group consisting of children with CIs was also matched to the DLD group but additionally matched on language abilities. QOL scores were compared across groups, and the association between language skills and QOL was examined in the DLD group. RESULT: The DLD group was reported by parents to have statistically significantly poorer QOL scores than peers with TD or CIs. When controlling for language skills, either statistically or through an additional CI group matched on language abilities, there were no statistically significant differences in QOL scores across groups. In the DLD group, language skills explained 16% of the variation in QOL. CONCLUSION: DLD is associated with the children's overall QOL, and the degree of reduced QOL relates to the severity of the language impairment.

Is language an issue? Accuracy of the German computerized diagnostic decision support system ISABEL and cross-validation with the English counterpart.

OBJECTIVES: Existing computerized diagnostic decision support tools (CDDS) accurately return possible differential diagnoses (DDx) based on the clinical information provided. The German versions of the CDDS tools for clinicians (Isabel Pro) and patients (Isabel Symptom Checker) from ISABEL Healthcare have not been validated yet. METHODS: We entered clinical features of 50 patient vignettes taken from an emergency medical text book and 50 real cases with a confirmed diagnosis derived from the electronic health record (EHR) of a large academic Swiss emergency room into the German versions of Isabel Pro and Isabel Symptom Checker. We analysed the proportion of DDx lists that included the correct diagnosis. RESULTS: Isabel Pro and Symptom Checker provided the correct diagnosis in 82 and 71 % of the cases, respectively. Overall, the correct diagnosis was ranked in 71 , 61 and 37 % of the cases within the top 20, 10 and 3 of the provided DDx when using Isabel Pro. In general, accuracy was higher with vignettes than ED cases, i.e. listed the correct diagnosis more often (non-significant) and ranked the diagnosis significantly more often within the top 20, 10 and 3. On average, 38 ± 4.5 DDx were provided by Isabel Pro and Symptom Checker. CONCLUSIONS: The German versions of Isabel achieved a somewhat lower accuracy compared to previous studies of the English version. The accuracy decreases substantially when the position in the suggested DDx list is taken into account. Whether Isabel Pro is accurate enough to improve diagnostic quality in clinical ED routine needs further investigation.

The linguistic complexity of adult and child contextualized and decontextualized talk.

The association between decontextualized talk (DT; i.e., talk extending beyond immediate context) and child language outcomes is well-attested but not well-understood. This study tested the hypothesis that DT is more linguistically complex than contextualized talk (CT). Thirty-eight Norwegian children (Mage = 5.5 years; 25 girls; 30 Norwegian-speaking monolinguals and eight multilinguals) and their teachers were videotaped during picture book reading, story card conversations and toy play (collected 2010-2011 and 2017). Results show that DT was more complex than CT among children and teachers. Both types of talk were more complex during book reading and story conversations than during play. The conversational context should be accounted for when theorizing about the role of DT in language development.

Effects of a computerised diagnostic decision support tool on diagnostic quality in emergency departments: study protocol of the DDx-BRO multicentre cluster randomised cross-over trial.

INTRODUCTION: Computerised diagnostic decision support systems (CDDS) suggesting differential diagnoses to physicians aim to improve clinical reasoning and diagnostic quality. However, controlled clinical trials investigating their effectiveness and safety are absent and the consequences of its use in clinical practice are unknown. We aim to investigate the effect of CDDS use in the emergency department (ED) on diagnostic quality, workflow, resource consumption and patient outcomes. METHODS AND ANALYSIS: This is a multicentre, outcome assessor and patient-blinded, cluster-randomised, multiperiod crossover superiority trial. A validated differential diagnosis generator will be implemented in four EDs and randomly allocated to a sequence of six alternating intervention and control periods. During intervention periods, the treating ED physician will be asked to consult the CDDS at least once during diagnostic workup. During control periods, physicians will not have access to the CDDS and diagnostic workup will follow usual clinical care. Key inclusion criteria will be patients' presentation to the ED with either fever, abdominal pain, syncope or a non-specific complaint as chief complaint. The primary outcome is a binary diagnostic quality risk score composed of presence of an unscheduled medical care after discharge, change in diagnosis or death during time of follow-up or an unexpected upscale in care within 24 hours after hospital admission. Time of follow-up is 14 days. At least 1184 patients will be included. Secondary outcomes include length of hospital stay, diagnostics and data regarding CDDS usage, physicians' confidence calibration and diagnostic workflow. Statistical analysis will use general linear mixed modelling methods. ETHICS AND DISSEMINATION: Approved by the cantonal ethics committee of canton Berne (2022-D0002) and Swissmedic, the Swiss national regulatory authority on medical devices. Study results will be disseminated through peer-reviewed journals, open repositories and the network of investigators and the expert and patients advisory board. TRIAL REGISTRATION NUMBER: NCT05346523.

Use of epinephrine in anaphylaxis: a retrospective cohort study at a Swiss university emergency department.

AIMS OF THE STUDY: Anaphylaxis is a medical emergency and requires prompt treatment to prevent life-threatening conditions. Epinephrine, considered as the first-line drug, is often not administered. We aimed first to analyse the use of epinephrine in patients with anaphylaxis in the emergency department of a university hospital and secondly to identify factors that influence the use of epinephrine. METHODS: We performed a retrospective analysis of all patients admitted with moderate or severe anaphylaxis to the emergency department between 1 January 2013 and 31 December 2018. Patient characteristics and treatment information were extracted from the electronic medical database of the emergency department. RESULTS: A total of 531 (0.2%) patients with moderate or severe anaphylaxis out of 260,485 patients admitted to the emergency department were included. Epinephrine was administered in 252 patients (47.3%). In a multivariate logistic regression, cardiovascular (Odds Ratio [OR] = 2.94, CI 1.96-4.46, p <0.001) and respiratory symptoms (OR = 3.14, CI 1.95-5.14, p<0.001) were associated with increased likelihood of epinephrine administration, in contrast to integumentary symptoms (OR = 0.98, CI 0.54-1.81, p = 0.961) and gastrointestinal symptoms (OR = 0.62, CI 0.39-1.00, p = 0.053). CONCLUSIONS: Less than half of the patients with moderate and severe anaphylaxis received epinephrine according to guidelines. In particular, gastrointestinal symptoms seem to be misrecognised as serious symptoms of anaphylaxis. Training of the emergency medical services and emergency department medical staff and further awareness are crucial to increase the administration rate of epinephrine in anaphylaxis.

Social communication and quality of life in children using hearing aids.

OBJECTIVES: This study compared the parent-reported structural language and social communication skills-measured with the Children's Communication Checklist-2 (CCC-2)-and health-related quality of life (HR-QOL)-measured with the Pediatric Quality of Life Inventory (PedsQL)-of children who use hearing aids (HAs) and their typical-hearing (TH) peers. DESIGN: The participants were 88 children (age range of 5; 6 to 13; 1 (years; months)) and their parents: 45 children with bilateral moderate to severe hearing loss using HAs who had no additional disabilities and 43 children with typical hearing. The groups were matched based on chronological age, gender, nonverbal IQ, and parental education level. The parents completed questionnaires related to their children's communication skills, including subdomains structural language and social communication, and HR-QOL. RESULTS: The HA group had significantly poorer overall communication skills than the TH group (r = 0.49). The children in the HA group scored significantly lower than the TH group on both structural language (r = 0.37) and social communication (r = 0.41). Half of the children in the HA group had overall communication scores that either indicated concern or required further investigation according to the instrument's manual. In terms of psychosocial functioning, which was measured as HR-QOL, the subdomain school functioning was the main driver of the difference between groups, with the HA group being at least twice as likely (OR = 2.52) as the TH group to have poor HR-QOL in the school domain. Better parent-reported social communication was associated with better parent-reported psychosocial functioning in the children using HAs-even when background variables were taken into account. CONCLUSION: The results suggest that traditional assessments and interventions targeting structural aspects of language may overlook social communication difficulties in children with HAs, even those with no additional disabilities. As school functioning stood out as the most problematic domain for children with HAs, efforts to improve the well-being of these children should focus on this area.

Differential diagnosis checklists reduce diagnostic error differentially: A randomised experiment.

INTRODUCTION: Wrong and missed diagnoses contribute substantially to medical error. Can a prompt to generate alternative diagnoses (prompt) or a differential diagnosis checklist (DDXC) increase diagnostic accuracy? How do these interventions affect the diagnostic process and self-monitoring? METHODS: Advanced medical students (N = 90) were randomly assigned to one of four conditions to complete six computer-based patient cases: group 1 (prompt) was instructed to write down all diagnoses they considered while acquiring diagnostic test results and to finally rank them. Groups 2 and 3 received the same instruction plus a list of 17 differential diagnoses for the chief complaint of the patient. For half of the cases, the DDXC contained the correct diagnosis (DDXC+), and for the other half, it did not (DDXC-; counterbalanced). Group 4 (control) was only instructed to indicate their final diagnosis. Mixed-effects models were used to analyse results. RESULTS: Students using a DDXC that contained the correct diagnosis had better diagnostic accuracy, mean (standard deviation), 0.75 (0.44), compared to controls without a checklist, 0.49 (0.50), P < 0.001, but those using a DDXC that did not contain the correct diagnosis did slightly worse, 0.43 (0.50), P = 0.602. The number and relevance of diagnostic tests acquired were not affected by condition, nor was self-monitoring. However, participants spent more time on a case in the DDXC-, 4:20 min (2:36), P ≤ 0.001, and DDXC+ condition, 3:52 min (2:09), than in the control condition, 2:59 min (1:44), P ≤ 0.001. DISCUSSION: Being provided a list of possible diagnoses improves diagnostic accuracy compared with a prompt to create a differential diagnosis list, if the provided list contains the correct diagnosis. However, being provided a diagnosis list without the correct diagnosis did not improve and might have slightly reduced diagnostic accuracy. Interventions neither affected information gathering nor self-monitoring.

Do different response formats affect how test takers approach a clinical reasoning task? An experimental study on antecedents of diagnostic accuracy using a constructed response and a selected response format.

The use of response formats in assessments of medical knowledge and clinical reasoning continues to be the focus of both research and debate. In this article, we report on an experimental study in which we address the question of how much list-type selected response formats and short-essay type constructed response formats are related to differences in how test takers approach clinical reasoning tasks. The design of this study was informed by a framework developed within cognitive psychology which stresses the importance of the interplay between two components of reasoning-self-monitoring and response inhibition-while solving a task or case. The results presented support the argument that different response formats are related to different processing behavior. Importantly, the pattern of how different factors are related to a correct response in both situations seem to be well in line with contemporary accounts of reasoning. Consequently, we argue that when designing assessments of clinical reasoning, it is crucial to tap into the different facets of this complex and important medical process.

How sure can we be that a student really failed? On the measurement precision of individual pass-fail decisions from the perspective of Item Response Theory.

BACKGROUND: In high-stakes assessments in medical education, the decision to let a particular participant pass or fail has far-reaching consequences. Reliability coefficients are usually used to support the trustworthiness of assessments and their accompanying decisions. However, coefficients such as Cronbach's Alpha do not indicate the precision with which an individual's performance was measured. OBJECTIVE: Since estimates of precision need to be aligned with the level on which inferences are made, we illustrate how to adequately report the precision of pass-fail decisions for single individuals. METHOD: We show how to calculate the precision of individual pass-fail decisions using Item Response Theory and illustrate that approach using a real exam. In total, 70 students sat this exam (110 items). Reliability coefficients were above recommendations for high stakes test (> 0.80). At the same time, pass-fail decisions around the cut score were expected to show low accuracy. CONCLUSIONS: Our results illustrate that the most important decisions-i.e. those based on scores near the pass-fail cut-score-are often ambiguous, and that reporting a traditional reliability coefficient is not an adequate description of the uncertainty encountered on an individual level.

Barriers to seeking emergency care during the COVID-19 pandemic may lead to higher morbidity and mortality - a retrospective study from a Swiss university hospital.

AIMS OF THE STUDY: While COVID-19 significantly overburdens emergency rooms (ERs) and hospitals in affected areas, ERs elsewhere report a marked decrease in patient numbers. This study aimed to investigate the assumption that patients with urgent problems currently avoid the ER. METHODS: Electronic health records from the ER of a large Swiss university hospital were extracted for three periods: first, the awareness phase (ap) from the publication of the national government’s initiative “How to protect ourselves” on 1 March 2020 to the lockdown of the country on 16 March; second, the mitigation phase (mp) from 16–30 March; finally, patients presenting in March 2019 were used as a control group. We compared parameters including a critical illness as the discharge diagnosis (e.g., myocardial infarction, stroke, sepsis and ER death) using logistic and linear regression, as well as 15-day bootstrapped means and 95% confidence intervals for the control group. RESULTS: In the three periods, a total of 7143 patients were treated. We found a 24.9% (42.5%) significant decline in the number of patients presenting during the ap (mp). Patients presenting during the mp were more likely to be critically ill. There was an increase of 233% and 367% (ap and mp, respectively) of ER deaths (none related to COVID-19) compared with the control period. Apart from polytrauma (increase of 5% in the mp), all other critical illnesses as discharge diagnosis showed a lower incidence in descriptive analysis. Significantly more patients died in the ER in both the ap and mp. CONCLUSIONS: Barriers to seeking emergency care during COVID-19 pandemic may lead to higher morbidity and mortality. Healthcare authorities and hospitals must ensure low barriers to treatment and business as usual for all patients.

Progress testing anytime and anywhere - Does a mobile-learning approach enhance the utility of a large-scale formative assessment tool?

BACKGROUND: The widespread use of mobile devices among students favors the use of mobile learning scenarios at universities. In this study, we explore whether a time- and location-independent variant of a formative progress test has an impact on the students' acceptance, its validity and reliability and if there is a difference in response processes between the two exam conditions. METHODS: Students were randomly assigned to two groups of which one took the test free of local or temporal fixations, while the other group took the test at the local testing center under usual examination conditions. Beside the generated test data, such as test score, time-on-test, and semester status, students also evaluated the settings. RESULTS: While there was no significant effect on the test score between the two groups, students in the mobile group spent more time on the test and were more likely to use the help of books or online resources. The results of the evaluation show that the acceptability among students is increased by a mobile version of the formative progress test. CONCLUSIONS: The results suggest that the acceptance and motivation to participate in formative tests is enhanced by lifting local and temporal restrictions. The mobile version nonetheless does not have an impact on the students' performance.

What determines diagnostic resource consumption in emergency medicine: patients, physicians or context?

OBJECTIVES: A major cause for concern about increasing ED visits is that ED care is expensive. Recent research suggests that ED resource consumption is affected by patients' health status, varies between physicians and is context dependent. The aim of this study is to determine the relative proportion of characteristics of the patient, the physician and the context that contribute to ED resource consumption. METHODS: Data on patients, physicians and the context were obtained in a prospective observational cohort study of patients hospitalised to an internal medicine ward through the ED of the University Hospital Bern, Switzerland, between August and December 2015. Diagnostic resource consumption in the ED was modelled through a multilevel mixed effects linear regression. RESULTS: In total, 473 eligible patients seen by one of 38 physicians were included in the study. Diagnostic resource consumption heavily depends on physicians' ratings of case difficulty (p<0.001, z-standardised regression coefficient: 147.5, 95% CI 87.3 to 207.7) and-less surprising-on patients' acuity (p<0.001, 126.0, 95% CI 65.5 to 186.6). Neither the physician per se, nor their experience, the patients' chronic health status or the context seems to have a measurable impact (all p>0.05). CONCLUSIONS: Diagnostic resource consumption in the ED is heavily affected by physicians' situational confidence. Whether we should aim at altering physician confidence ultimately depends on its calibration with accuracy.

Measurement precision at the cut score in medical multiple choice exams: Theory matters.

INTRODUCTION: In high-stakes assessment, the measurement precision of pass-fail decisions is of great importance. A concept for analyzing the measurement precision at the cut score is conditional reliability, which describes measurement precision for every score achieved in an exam. We compared conditional reliabilities in Classical Test Theory (CTT) and Item Response Theory (IRT) with a special focus on the cut score and potential factors influencing conditional reliability at the cut score. METHODS: We analyzed 32 multiple-choice exams from three Swiss medical schools comparing conditional reliability at the cut score in IRT and CCT. Additionally, we analyzed potential influencing factors such as the range of examinees' performance, year of study, and number of items using multiple regression. RESULTS: In CTT, conditional reliability was highest for very low and very high scores, whereas examinees with medium scores showed low conditional reliabilities. In IRT, the maximum conditional reliability was in the middle of the scale. Therefore, conditional reliability at the cut score was significantly higher in IRT compared with CTT. It was influenced by the range of examinees' performance and number of items. This influence was more pronounced in CTT. DISCUSSION: We found that conditional reliability shows inverse distributions and conclusions regarding the measurement precision at the cut score depending on the theory used. As the use of IRT seems to be more appropriate for criterion-oriented standard setting in the framework of competency-based medical education, our findings might have practical implications for the design and quality assurance of medical education assessments.

Long-Term Language Development in Children With Early Simultaneous Bilateral Cochlear Implants.

OBJECTIVES: This longitudinal study followed the language development of children who received the combination of early (5 to 18 months) and simultaneous bilateral cochlear implants (CIs) throughout the first 6 years after implantation. It examined the trajectories of their language development and identified factors associated with language outcomes. DESIGN: Participants were 21 Norwegian children who received bilateral CIs between the ages of 5 and 18 mo and 21 children with normal hearing (NH) who were matched to the children with CIs on age, sex, and maternal education. The language skills of these two groups were compared at 10 time points (3, 6, 9, 12, 18, 24, 36, 48, 60, and 72 months after implantation) using parent reports and standardized measures of general language skills, vocabulary, and grammar. In addition, assessments were made of the effects of age at CI activation, speech recognition abilities, and mothers' education on language outcomes 6 years after implantation. RESULTS: During the first 4 years after implantation, the gap in general expressive and receptive language abilities between children with CIs and children with NH gradually closed. While at the initial five to six assessments (3 to 36 months after implantation), significant differences between children with CIs and children with NH were observed; at 4 years after implantation, there were no longer any significant group differences in general language skills and most children with CIs achieved scores within 1 SD of the tests' normative means. From 2 to 3 years after implantation onward, expressive vocabulary and receptive grammar skills of children with CIs were similar to those of the reference group. However, from 4 years after implantation until the end of the observation period, 6 years after implantation, expressive grammar skills of children with CIs were lower than those of children with NH. In addition, a gap in receptive vocabulary appeared and grew increasingly larger from 4 to 6 years postimplantation. At the final assessment, the children with CIs had an average receptive vocabulary score around 1 SD below the normative mean. Regression analysis indicated that the children's language outcomes at 6 years after implantation were related to their speech recognition skills, age at CI activation, and maternal education. CONCLUSIONS: In the first 4 years after implantation, the language performance of children with CIs became increasingly similar to that of their NH peers. However, between 4 and 6 years after implantation, there were indications of challenges with certain aspects of language, specifically receptive vocabulary and expressive grammar. Because these challenges first appeared after the 4-year assessment, the findings underline the importance of long-term language intervention to increase the chances of a continued language development comparable to that of NH peers. They also indicate that there is a need for comprehensive longitudinal studies of the language development of children with CIs beyond 4 years after implantation.