Objectives
Well‐designed studies on the impact of a family medicine rotation on medical students are rare, and very few studies include a qualitative component. This study aimed to determine the ...improvement of medical students’ knowledge, communication skills and attitude towards primary care and explore their perceptions after rotations, in comparison with a control group.
Methods
We used a mixed‐methods design, comprising a pre‐test–post‐test comparison between a sample of trained students who took family medicine rotations and a control group and a qualitative survey. The measurement of improvement included (i) multiple choice question testing, (ii) objective structured checklist examinations, (iii) self‐reporting and (iv) interviews and focus group discussions. Data were collected from August 2017 to June 2018.
Results
There were 696 students in the trained group and 617 controls. The two groups’ baseline scores in knowledge, communication skills and attitude were not significantly different. Knowledge covering five domains of family medicine (Pearson's r from 0.6 to 0.9) improved significantly, as did attitudes towards primary care in the trained group. There were no differences in communication and counselling skills between the two groups for four situations, but for two–health check‐ups and mental health care–skills were significantly improved (Pearson's r from 0.28 to 0.43). The qualitative survey showed highly positive feedback from trained students.
Conclusions
The family medicine rotation significantly improved students’ knowledge and attitude towards primary care and some communication skills. Further studies should investigate students’ interest in and career choice for this discipline.
Objectifs
Des études bien conçues sur l'impact d'une rotation de la médecine familiale sur les étudiants en médecine sont rares et très peu d'études comprennent une composante qualitative. Cette étude visait à mesurer l'amélioration des connaissances, des compétences en communication et de l'attitude des étudiants en médecine à l'égard des soins primaires, et à explorer leurs perceptions après les rotations, en comparaison avec un groupe témoin.
Méthodes
Nous avons utilisé un concept de méthodes mixtes, comprenant une comparaison pre‐test et post‐test entre un échantillon d'étudiants formés qui ont effectué des rotations de la médecine familiale et un groupe témoins, et une enquête qualitative. La mesure de l'amélioration comprenait (1) des tests de questions à choix multiples, (2) des examens objectifs structurés de listes, (3) des rapports personnels et (4) des entretiens et des discussions focalisées de groupes. Les données ont été collectées d'août 2017 à juin 2018.
Résultats
Il y avait 696 élèves dans le groupe formé et 617 témoins. Les scores de référence des deux groupes en termes de connaissances, de communication et d'attitude n'étaient pas significativement différents. Les connaissances couvrant cinq domaines de la médecine familiale se sont considérablement améliorées (r de Pearson de 0,6 à 0,9), tout comme l'attitude à l’égard des soins primaires dans le groupe formé. Il n'y avait pas de différence dans les compétences de communication et de conseil entre les deux groupes pour quatre situations, mais pour deux (bilan de santé et soins de santé mentale) les compétences ont été significativement améliorées (r de Pearson de 0. 28 à 0. 43). L'enquête qualitative a montré une rétroaction très positive des étudiants formés.
Conclusions
La rotation de la médecine familiale a amélioré de manière significative la connaissance et l’attitude des étudiants à l'égard des soins primaires et certaines compétences de communications. Des études ultérieures devraient examiner l'intérêt des étudiants et le choix de carrière pour cette discipline.
Abstract
Aims
We hypothesized that the modified Diamond–Forrester (D-F) prediction model overestimates probability of coronary artery disease (CAD). The aim of this study was to update the prediction ...model based on pre-test information and assess the model’s performance in predicting prognosis in an unselected, contemporary population suspected of angina.
Methods and results
We included 3903 consecutive patients free of CAD and heart failure and suspected of angina, who were referred to a single centre for assessment in 2012–15. Obstructive CAD was defined from invasive angiography as lesion requiring revascularization, >70% stenosis or fractional flow reserve <0.8. Patients were followed (mean follow-up 33 months) for myocardial infarction, unstable angina, heart failure, stroke, and death. The updated D-F prediction model overestimated probability considerably: mean pre-test probability was 31.4%, while only 274 (7%) were diagnosed with obstructive CAD. A basic prediction model with age, gender, and symptoms demonstrated good discrimination with C-statistics of 0.86 (95% CI 0.84–0.88), while a clinical prediction model adding diabetes, family history, and dyslipidaemia slightly improved the C-statistic to 0.88 (0.86–0.90) (P for difference between models <0.0001). Quartiles of probability of CAD from the clinical prediction model provided good diagnostic and prognostic stratification: in the lowest quartiles there were no cases of obstructive CAD and cumulative risk of the composite endpoint was less than 3% at 2 years.
Conclusion
The pre-test probability model recommended in current ESC guidelines substantially overestimates likelihood of CAD when applied to a contemporary, unselected, all-comer population. We provide an updated prediction model that identifies subgroups with low likelihood of obstructive CAD and good prognosis in which non-invasive testing may safely be deferred.
Abstract
Aims
To determine the ranges of pre-test probability (PTP) of coronary artery disease (CAD) in which stress electrocardiogram (ECG), stress echocardiography, coronary computed tomography ...angiography (CCTA), single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance (CMR) can reclassify patients into a post-test probability that defines (>85%) or excludes (<15%) anatomically (defined by visual evaluation of invasive coronary angiography ICA) and functionally (defined by a fractional flow reserve FFR ≤0.8) significant CAD.
Methods and results
A broad search in electronic databases until August 2017 was performed. Studies on the aforementioned techniques in >100 patients with stable CAD that utilized either ICA or ICA with FFR measurement as reference, were included. Study-level data was pooled using a hierarchical bivariate random-effects model and likelihood ratios were obtained for each technique. The PTP ranges for each technique to rule-in or rule-out significant CAD were defined. A total of 28 664 patients from 132 studies that used ICA as reference and 4131 from 23 studies using FFR, were analysed. Stress ECG can rule-in and rule-out anatomically significant CAD only when PTP is ≥80% (76–83) and ≤19% (15–25), respectively. Coronary computed tomography angiography is able to rule-in anatomic CAD at a PTP ≥58% (45–70) and rule-out at a PTP ≤80% (65–94). The corresponding PTP values for functionally significant CAD were ≥75% (67–83) and ≤57% (40–72) for CCTA, and ≥71% (59–81) and ≤27 (24–31) for ICA, demonstrating poorer performance of anatomic imaging against FFR. In contrast, functional imaging techniques (PET, stress CMR, and SPECT) are able to rule-in functionally significant CAD when PTP is ≥46–59% and rule-out when PTP is ≤34–57%.
Conclusion
The various diagnostic modalities have different optimal performance ranges for the detection of anatomically and functionally significant CAD. Stress ECG appears to have very limited diagnostic power. The selection of a diagnostic technique for any given patient to rule-in or rule-out CAD should be based on the optimal PTP range for each test and on the assumed reference standard.
Technology and our conceptions of reality have both been significantly impacted by modern physics. However, due to a variety of issues, such as disparities in educational resources, differing ...emphasis on science education, cultural attitudes, and language obstacles, students in Latin America, including Ecuador, have a limited understanding of modern physics. The present work exposes a pre-test methodology to evaluate students' knowledge and pinpoint their areas of weakness. The analysis of the results indicates that most students received lower grades, while a smaller proportion obtained higher scores. Our findings reveal significant knowledge gaps, misconceptions, and uncertainty among the participants regarding various topics related to the constituent and stability of the nucleus, quantum behavior, nuclear models, radioactive decay, and natural radioactive sources. Additionally, it was statistically demonstrated (Kruskal-Wallis H test) that misconceptions, uncertainties, and knowledge gaps are not significantly related to learning styles. The type of college substantially impacts academics, with private university students typically receiving higher grades. These results offer insightful information about student performance, how learning styles and college types affect academic achievement in modern physics, and the effects of living area and academic level. Doi: 10.28991/ESJ-2024-SIED1-01 Full Text: PDF
Genetic and genomic technologies can effectively diagnose numerous genetic disorders. Patients benefit when genetic counselling accompanies genetic testing and international guidelines recommend pre‐ ...and post‐test genetic counselling with genome‐wide sequencing. However, there is a gap in knowledge regarding the unique genetic counselling considerations with different types of genetic testing in the Neonatal Intensive Care Unit (NICU) and the Pediatric Intensive Care Unit (PICU). This scoping review was conducted to identify the gaps in care with respect to genetic counselling for infants/pediatric patients undergoing genetic and genomic testing in NICUs and PICUs and understand areas in need of improvement in order to optimize clinical care for patients, caregivers, and healthcare providers. Five databases (MEDLINE Ovid, Embase Ovid, PsycINFO Ebsco, CENTRAL Ovid, and CINHAL Ebsco) and grey literature were searched. A total of 170 studies were included and used for data extraction and analysis. This scoping review includes descriptive analysis, followed by a narrative account of the extracted data. Results were divided into three groups: pre‐test, post‐test, and comprehensive (both pre‐ and post‐test) genetic counselling considerations based on indication for testing. More studies were conducted in the NICU than the PICU. Comprehensive genetic counselling was discussed in only 31% of all the included studies demonstrating the need for both pre‐test and post‐test genetic counselling for different clinical indications in addition to the need to account for different cultural aspects based on ethnicity and geographic factors.
Considerations for optimizing genetic counselling (both pre‐ and post‐test) in intensive care settings.
The prevalence of obstructive coronary artery disease (CAD) in symptomatic patients referred for diagnostic testing has declined, warranting optimization of individualized diagnostic strategies.
This ...study sought to present a simple, clinically applicable tool enabling estimation of the likelihood of obstructive CAD by combining a pre-test probability (PTP) model (Diamond-Forrester approach using sex, age, and symptoms) with clinical risk factors and coronary artery calcium score (CACS).
The new tool was developed in a cohort of symptomatic patients (n = 41,177) referred for diagnostic testing. The risk factor–weighted clinical likelihood (RF-CL) was calculated through PTP and risk factors, while the CACS–weighted clinical likelihood (CACS-CL) added CACS. The 2 calculation models were validated in European and North American cohorts (n = 15,411) and compared with a recently updated PTP table.
The RF-CL and CACS-CL models predicted the prevalence of obstructive CAD more accurately in the validation cohorts than the PTP model, and markedly increased the area under the receiver-operating characteristic curves of obstructive CAD: for the PTP model, 72 (95% confidence intervals CI: 71 to 74); for the RF-CL model, 75 (95% CI: 74 to 76); and for the CACS-CL model, 85 (95% CI: 84 to 86). In total, 38% of the patients in the RF-CL group and 54% in the CACS-CL group were categorized as having a low clinical likelihood of CAD, as compared with 11% with the PTP model.
A simple risk factor and CACS-CL tool enables improved prediction and discrimination of patients with suspected obstructive CAD. The tool empowers reclassification of patients to low likelihood of CAD, who need no further testing.
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•This meta-analysis examined the effects of acute exercise on executive function.•Acute aerobic exercise had beneficial effects on cognitive performance.•The beneficial effects were greater in lower ...pre-test performers.•The beneficial effects are general irrespective of executive function demands.
An increasing number of studies has focused on the after-effects of acute aerobic exercise on executive function. To date, empirical evidence lacks consensus regarding whether acute aerobic exercise has beneficial effects on executive function. To identify possible sources of this discrepancy, the present study focused on executive function demands and pre-test cognitive performance, and performed the first meta-analysis of individual participant data (IPD meta-analysis) in this area of research. Results indicated that the beneficial after-effects of acute aerobic exercise on cognitive performance were greater in participants with lower cognitive performance at pre-test. Acute aerobic exercise offered general benefits to cognitive performance irrespective of executive function demands, when pre-test cognitive performance was appropriately controlled. Thus, the present IPD meta-analysis suggests that pre-test cognitive performance is one possible source of the conflicting findings in acute exercise studies. Future research is encouraged to consider pre-test cognitive performance to avoid underestimating the beneficial after-effects of acute exercise.
Background
Diagnosis of heparin‐induced thrombocytopenia (HIT) requires pretest probability assessment and dedicated laboratory assays.
Objective
To develop a pretest score for HIT.
Design
...Observational; analysis of prospectively collected data of hospitalized patients suspected with HIT (ClinicalTrials.gov NCT00748839).
Setting
Thirty‐one tertiary hospitals in France, Switzerland, and Belgium.
Patients
Patients tested for HIT antibodies (2280 evaluable), randomly allocated to derivation and validation cohorts.
Measurements
Independent adjudicators diagnosed HIT based on the prospectively collected data and serotonin release assay results.
Results
Heparin‐induced thrombocytopenia was diagnosed in 234 (14.7%) and 99 (14.5%) patients in the two cohorts. Eight features were associated with HIT (in brackets, points assigned for score calculation of the score): unfractionated heparin (1); therapeutic‐dose heparin (1); cardiopulmonary bypass (cardiac surgery) (2); major trauma (3); 5‐ to 21‐day interval from anticoagulation initiation to suspicion of HIT (4); ≥40% decrease in platelet count over ≤6 days (3); thrombotic event, arterial (3) or venous (3). The C‐statistic was 0.79 (95% CI, 0.76–0.82). In the validation cohort, the area under the receiver operating characteristic curve was 0.77 (95% CI, 0.74–0.80). Three groups of scores were defined; HIT prevalence reached almost 30% in the high‐probability group.
Limitation
The performance of the score may depend on settings and practices.
Conclusion
The objective, easy‐to‐collect, clinical features of HIT we evidenced were incorporated into a pretest score, which may guide clinical decisions regarding diagnostic testing and anticoagulation.
Objective
To determine if clinicopathologic (CP) factors could identify patients at “very low” and/or “very high” pretest probability of a high Oncotype DX (ODX) score.
Methods
A retrospective ...analysis of all patients that had ODX testing 2008‐2018 at a single institution.
Results
Of 215 patients, all 16 (7.4%) with “all high” risk CP factors had high ODX scores, and all 45 (20.9%) over age 50 with “all low” risk CP factors had ODX recommendations for no chemotherapy.
Conclusions
Oncotype DX results did not change chemotherapy recommendations in those with “very low” or “very high” pretest probability of high ODX scores.
Background
To increase the clinical usefulness of the D‐dimer test in diagnosis of deep vein thrombosis (DVT), two strategies have been proposed: the age‐adjusted, and the clinical pre‐test ...probability (CPTP) adjusted interpretation. However, it is not known which of these strategies is superior.
Objective
To conduct an individual patient data (IPD) meta‐analysis that compares the sensitivity, specificity, negative predictive value (NPV), and utility (the proportion of all patients who have a negative D‐dimer test) when the two strategies are used to interpret D‐dimer results.
Methods
Using an established IPD database, we conducted a meta‐analysis to compare the two strategies. A bivariate random effects regression model was used to estimate and compare the pooled sensitivity and specificity simultaneously. The pooled NPV and utility of the two strategies was compared using a univariate random effects model.
Results
Four studies were eligible for this analysis, with a total of 2554 patients. Overall prevalence of DVT was 12% with substantial heterogeneity between studies (P value < .001). Both strategies have high pooled NPVs (99.8%) with a difference of 0% (95% confidence interval CI: −0.1, 0.1). The difference between the pooled specificity of the CPTP‐adjusted strategy (57.3%) and the age‐adjusted strategy (54.7%) was 2.6% (95% CI: −7.7, 12.8). The CPTP‐adjusted strategy (49.4%) has a marginally greater pooled utility compared with the age‐adjusted approach (47.4%), with a pooled difference of 1.9% (95% CI: −0.1, 3.9).
Conclusions
Both D‐dimer interpretation strategies were associated with a high and similar NPV, and similar utility.
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