The influence of viewing time on visual diagnostic accuracy: Less is more

BACKGROUND

Understanding the factors that contribute to diagnostic errors is critical if we are to correct or prevent them. Some scholars influenced by the default interventionist dual-process theory of cognition (dual-process theory) emphasise a narrow focus on individual clinician's faulty reasoning as a significant contributor. In this paper, we examine the validity of claims that dual process theory is a key to error reduction.

METHODS

We examined the relationship between a clinical experience (staff and resident physicians) and viewing time on accuracy for categorising chest X-rays (CXRs) and electrocardiograms (ECGs). In two studies, participants categorised images as normal or abnormal, presented at viewing times of 175, 250, 500 and 1000 ms, to encourage System 1 processing. Study 2 extended viewing times to 1, 5, 10 and 20 s to allow time for System 2 processing and a diagnosis. Descriptives and repeated measures analysis of variance were used to analyse the proportion of true and false positive rates (TP and FP) as well as correct diagnoses.

RESULTS

In Study 1, physicians were able to detect abnormal CXRs (0.78) and ECGs (0.67) with relatively high accuracy. The effect of experience was found for ECGs only, as staff physicians (0.71, 95% CI = 0.66-0.75) had higher ECG TP than resident physicians (0.63, 95% CI = 0.58-0.68) in Study 1, and staff had lower ECG FP (0.10, 95% CI = 0.03-0.18) than resident physicians (0.27, 95% CI = 0.20-0.33) in Study 2. In other comparisons, experience was equivocal for ECG FPs and CXR TPs and FPs. In Study 2, overall diagnostic accuracy was similar for both ECGs and CXRs, (0.74). There were small interactions between experience and time for TP in ECGs and FP in CXRs, which are discussed further in the discussion and offer insights into the relationship between processing and experience.

CONCLUSION

Overall, our findings raise concerns about the practical application of models that link processing type to diagnostic error, or to specific diagnostic error reduction strategies.

Prevalence of frailty and its association with lifestyle factors among elderly in rural Bengaluru

Background:

There are nearly 10.4 crores elderly in India, with 65% of them living in rural areas. Accessibility to healthcare is limited in rural areas. Primary care physicians deal with a fairly large number of patients from the geriatric age group. With the steady increase in the proportion of elderly, there is a corresponding increase in the prevalence of frailty. Frailty among the elderly leads to increased dependency, adverse health outcomes and mortality. Early identification and targeted interventions by primary care physicians could prevent these adverse outcomes and even reverse its occurrence. Knowledge about environmental and lifestyle influences on frailty would further assist primary care physicians to prevent and manage it optimally

Methods:

We interviewed 502 participants (>60 years of age) from four taluks of rural Bengaluru. Participants with frailty scores of 3 and above were considered frail, scores of 1-2 were considered prefrail. Association of frailty with lifestyle and environmental factors were tested using the Chi-square test. A value of P < 0.05 was considered significant

Results:

Prevalence of frailty was 24.70% and prefrailty was 62.75%. Elders in age group 60 to 74 years, those living alone or with others (other than the spouse), illiterate, working elders, elderly with less than two diagnosed comorbidities, elderly with low social score and low physical activity were associated with frailty

Conclusion:

The young old population seems vulnerable to frailty. Health programs aimed at prevention, early detection and treatment of morbidities and frailty will improve their health.

Properties of aqueous 1,4-dioxane solution via molecular dynamics

Polyethers are promising compounds for the creation of electrochemical energy storage systems. The molecular dynamics method can facilitate the search of compounds that have the most potential. However, the application of this method requires verification of the force fields. We perform molecular dynamics calculations of the physical properties of the aqueous 1,4-dioxane solution (density, enthalpy of mixing, and viscosity) and compare them to the available experimental data. In addition, we confirm the idea that the solution structure depends on the dioxane molar fraction, proposed in the experiment of Takamuku et al. [J. Mol. Liq. 83(1-3), 163-177 (1999)]. The hydrogen bonds between dioxane and water are analyzed. The correlation between the excess viscosity and enthalpy of mixing is demonstrated.

Do you hear what you see? Utilizing phonocardiography to enhance proficiency in cardiac auscultation

INTRODUCTION

Cardiac auscultation skills have proven difficult to train and maintain. The authors investigated whether using phonocardiograms as visual adjuncts to audio cases improved first-year medical students' cardiac auscultation performance.

METHODS

The authors randomized 135 first-year medical students using an email referral link in 2018 and 2019 to train using audio-only cases (audio group) or audio with phonocardiogram tracings (combined group). Training included 7 cases with normal and abnormal auscultation findings. The assessment included feature identification and diagnostic accuracy using 14 audio-only cases, 7 presented during training, and 7 alternate versions of the same diagnoses. The assessment-administered immediately after training and repeated 7 days later-prompted participants to identify the key features and diagnoses for 14 audio-only cases. Key feature scores and diagnostic accuracy were compared between groups using repeated measures ANOVA.

RESULTS

Mean key feature scores were statistically significantly higher in the combined group (70%, 95% CI 67-75%) compared to the audio group (61%, 95% CI 56-66%) (F(1,116) = 6.144, p = 0.015, d_s = 0.45). Similarly, mean diagnostic accuracy in the combined group (68%, 95% CI 62-73%) was significantly higher than the audio group, although with small effect size (59%, 95% CI 54-65%) (F(1,116) = 4.548, p = 0.035, d_s = 0.40). Time on task for the assessment and prior auscultation experience did not significantly impact performance on either measure.

DISCUSSION

The addition of phonocardiograms to supplement cardiac auscultation training improves diagnostic accuracy and heart sound feature identification amongst novice students compared to training with audio alone.

The effect of prior experience on diagnostic reasoning: exploration of availability bias

Objectives Diagnostic reasoning has been shown to be influenced by a prior similar patient case. However, it is unclear whether this process influences diagnostic error rates or whether clinicians at all experience levels are equally susceptible. The present study measured the influence of specific prior exposure and experience level on diagnostic accuracy. Methods To create the experience of prior exposure, participants (pre-clerkship medical students, emergency medicine residents, and faculty) first verified diagnoses of clinical vignettes. The influence of prior exposures was measured using equiprobable clinical vignettes; indicating two diagnoses. Participants diagnosed equiprobable cases that were: 1) matched to exposure cases (in one of three conditions: a) similar patient features, similar clinical features; b) dissimilar patient features, similar clinical features; c) similar patient features, dissimilar clinical features), or 2) not matched to any prior case (d) no exposure). A diagnosis consistent with a matched exposure case was scored correct. Cases with no prior exposure had no matched cases, hence validated the equiprobable design. Results Diagnosis A represented 47% of responses in condition d, but there was no influence of specific similarity of patient characteristics for Diagnosis A, F(3,712)=7.28, p=0.28 or Diagnosis B, F(3,712)=4.87, p=0.19. When re-scored based on matching both equiprobable diagnoses, accuracy was high, but favored faculty (n=40) 98%, and residents (n=39) 98% over medical students (n=32) 85%, F(2,712)=35.6, p<0.0001. Accuracy for medical students was 84, 87, 94, and 73% for conditions a-d, respectively, interaction F(2,712)=3.55, p<0.002. Conclusions The differential diagnosis of pre-clerkship medical students improved with prior exposure, but this was unrelated to specific case or patient features. The accuracy of medical residents and staff was not influenced by prior exposure.

Effectiveness of an mHealth application to improve hypertension health literacy in India

AIM

The purpose of this research was to determine the effectiveness of a mobile health or mHealth application to improve hypertension health literacy among vulnerable populations in India. Additionally, we sought to estimate relationships between participant knowledge on hypertension and sociodemographic variables.

BACKGROUND

The World Health Organization advocates for the use of mobile technology to improve public health outcomes.

INTRODUCTION

The incidence of hypertension is on the rise in India, and effective and sustainable interventions are needed.

METHODS

A quantitative single arm pre-test post-test interventional and correlational design was used to test the hypertension mHealth application among participants in a limited resource setting. A paired t-test was performed to compare pre- and post-test results after participant use of the mHealth application. A regression model was used to estimate relationships between participant hypertension health literacy and sociodemographic variables.

RESULTS

A statistically significant improvement in test scores among participants after use of the mHealth app was found. Sociodemographic characteristics such as living in an urban environment, married, increased number of people living in household and alcohol use were determined to have a statistically significant effect on improvement of test score.

DISCUSSION

Results indicated the application was effective among participants with varied literacy and health literacy levels. These findings contribute to the potential widespread scalability of the app among populations with varied demographics.

CONCLUSION

This application provides an effective and valuable culturally tailored educational resource for nurses and other health providers to use to improve hypertension health literacy among vulnerable populations in India.

IMPLICATIONS FOR NURSING PRACTICE AND HEALTH POLICY

This study contributes to nursing and health policy by answering a call from the World Health Organization to implement and research mHealth interventions to improve health outcomes, particularly in a low and middle income country where preventive health access is limited.

Effectiveness of psychosocial interventions for the prevention and treatment of foot ulcers in people with diabetes: a systematic review

AIM

To identify and synthesize the evidence for the effectiveness of psychosocial interventions to promote the healing, and/or reduce the occurrence of, foot ulceration in people with diabetes.

METHODS

In March 2019 we searched CENTRAL, Medline, Embase and PsycInfo for randomized controlled trials of interventions with psychosocial components for people with diabetes. The primary outcomes of this review were foot ulceration and healing. We assessed studies using the Cochrane risk-of-bias tool, the TIDieR checklist and GRADE. We conducted narrative synthesis and random-effects meta-analysis.

RESULTS

We included 31 randomized controlled trials (4511 participants), of which most (24 randomized controlled trials, 4093 participants) were prevention studies. Most interventions were educational with a modest psychosocial component. Ulceration and healing were not reported in most studies; secondary outcomes varied. Evidence was of low or very low quality because of high risks of bias and imprecision, and few studies reported adherence or fidelity. In groups where participants had prior ulceration, educational interventions had no clear effect on new ulceration (low-quality evidence). Two treatment studies, assessing continuous pharmacist support and an intervention to promote understanding of well-being, reported healing but their evidence was also of very low quality.

CONCLUSION

Most psychosocial intervention randomized controlled trials assessing foot ulcer outcomes in people with diabetes were prevention studies, and most interventions were primarily educational. Ulcer healing and development were not well reported. There is a need for better understanding of psychological and behavioural influences on ulcer incidence, healing and recurrence in people with diabetes. Randomized controlled trials of theoretically informed interventions, which assess clinical outcomes, are urgently required. (PROSPERO registration: CRD42016052960).

Psychosocial and behavioural prognostic factors for diabetic foot ulcer development and healing: a systematic review

AIM

To investigate whether ulceration, amputation and healing of foot ulcers in people living with diabetes are associated with psychosocial and behavioural factors.

METHODS

We searched MEDLINE, Embase, PsychINFO, CINAHL and The Cochrane Library to March 2019 for longitudinal studies with multivariable analyses investigating independent associations. Two reviewers extracted data and assessed risk of bias.

RESULTS

We identified 15 eligible studies involving over 12 000 participants. Clinical and methodological heterogeneity precluded meta-analysis, so we summarize narratively. Risk of bias was moderate or high. For ulceration, we found significantly different results for people with and without an ulcer history. For those with no ulcer history, moderate quality evidence suggests depression increases ulcer risk [three studies; e.g. hazard ratio (HR) 1.68 (1.20, 2.35) per Hospital Anxiety and Depression Scale (HADS) standard unit]. Better foot self-care behaviour reduces ulcer risk [HR 0.61 (0.40, 0.93) per Summary of Diabetes Self-Care Activities scale standard unit; one study]. For people with diabetes and previous ulcers, low- or very low-quality evidence suggests little discernible association between ulcer recurrence and depression [e.g. HR 0.88 (0.61, 1.27) per HADS standard unit], foot self-care, footwear adherence or exercise. Low-quality evidence suggests incomplete clinic attendance is strongly associated with amputation [odds ratio (OR) 3.84 (1.54, 9.52); one study]. Evidence for the effects of other psychosocial or behavioural factors on ulcer healing and amputation is very low quality and inconclusive.

CONCLUSIONS

Psychosocial and behavioural factors may influence the development of first ulcers. More high quality research is needed on ulcer recurrence and healing. (Open Science Framework Registration: https://osf.io/ej689).

It's the destination: diagnostic accuracy and reasoning

While multiple theories exist to explain the diagnostic process, there are few available assessments that reliably determine diagnostic competence in trainees. Most methods focus on aspects of the process of diagnostic reasoning, such as the relation between case features and diagnostic hypotheses. Inevitably, detailed elucidation of aspects of the process requires substantial time per case and limits the number of cases that can be examined given a limited testing time. Shifting assessment to the outcome of diagnostic reasoning, accuracy of the diagnosis, may serve as a reliable measure of diagnostic competence and would allow increased sampling across cases. The present study is a retrospective analysis of 7 large studies, conducted by 3 research teams, that all used a series of brief written cases to examine the outcome of diagnostic reasoning-the diagnosis. The studies involved over 600 clinicians ranging from final year medical students to practicing emergency physicians. For 4 studies with usable reliability data, reliability for a 2 h test ranged from .63 to .94. On average speeded tests were more reliable (.85 vs. .73).To achieve a reliability of .75 required an average test time of 1.11 h for speeded tests and 1.99 for unspeeded tests. The measure was shown to be positively correlated with both written knowledge tests and measures of problem solving derived from OSCE performance tests. This retrospective analysis provides evidence to support the implementation of outcome-based assessments of clinical reasoning.

Critical thinking, biases and dual processing: The enduring myth of generalisable skills

CONTEXT

The myth of generalisable thinking skills in medical education is gaining popularity once again. The implications are significant as medical educators decide on how best to use limited resources to prepare trainees for safe medical practice. This myth-busting critical review cautions against the proliferation of curricular interventions based on the acquisition of generalisable skills.

STRUCTURE

This paper begins by examining the recent history of general thinking skills, as defined by research in cognitive psychology and medical education. We describe three distinct epochs: (a) the Renaissance, which marked the beginning of cognitive psychology as a discipline in the 1960s and 1970s and was paralleled by educational reforms in medical education focused on problem solving and problem-based learning; (b) the Enlightenment, when an accumulation of evidence in psychology and in medical education cast doubt on the assumption of general reasoning or problem-solving skill and shifted the focus to consideration of the role of knowledge in expert clinical performance; and (c) the Counter-Enlightenment, in the current time, when the notion of general thinking skills has reappeared under different guises, but the fundamental problems related to lack of generality of skills and centrality of knowledge remain.

CONCLUSIONS

The myth of general thinking skills persists, despite the lack of evidence. Progress in medical education is more likely to arise from devising strategies to improve the breadth and depth of experiential knowledge.

McMaster at 50: lessons learned from five decades of PBL

Although educators frequently act as if curricula are as standardized as drug doses (300 mg of PBL t.i.d.), such is not the case. As a case in point, at its inception, Problem Based Learning was hailed as a major curriculum innovation, with the promise of enormous gains in learning outcomes. Very quickly, ecclesiastical debates arose as what was true PBL and what was "modified PBL". Ironically, systematic reviews conducted fairly early in its evolution showed that the gains in learning outcome from PBL were neither large nor uniform (Vernon and Blake in Acad Med 68:550-563, 1993), and the most consistent finding was greater student satisfaction. In this paper, we review five decades of experience with the first PBL curriculum at McMaster. We point out how the curriculum has evolved, both theoretically and practically, in response to external influences, based both on empirical evidence and practical demands. We describe these changes in four broad domains-theoretical rationale, the curriculum, assessment and admissions.

Experienced physician descriptions of intuition in clinical reasoning: a typology

Background

Diagnostic intuition is a rapid, non-analytic, unconscious mode of reasoning. A small body of evidence points to the ubiquity of intuition, and its usefulness in generating diagnostic hypotheses and ascertaining severity of illness. Little is known about how experienced physicians understand this phenomenon, and how they work with it in clinical practice.

Methods

Descriptions of how experienced physicians perceive their use of diagnostic intuition in clinical practice were elicited through interviews conducted with 30 physicians in emergency, internal and family medicine. Each participant was asked to share stories of diagnostic intuition, including times when intuition was both correct and incorrect. Multiple coders conducted descriptive analysis to analyze the salient aspects of these stories.

Results

Physicians provided descriptions of what diagnostic intuition is, when it occurs and what type of activity it prompts. From stories of correct intuition, a typology of four different types of intuition was identified: Sick/Not Sick, Something Not Right, Frame-shifting and Abduction. Most physician accounts of diagnostic intuition linked this phenomenon to non-analytic reasoning and emphasized the importance of experience in developing a trustworthy sense of intuition that can be used to effectively engage analytic reasoning to evaluate clinical evidence.

Conclusions

The participants recounted myriad stories of diagnostic intuition that alerted them to unusual diagnoses, previous diagnostic error or deleterious trajectories. While this qualitative study can offer no conclusions about the representativeness of these stories, it suggests that physicians perceive clinical intuition as beneficial for correcting and advancing diagnoses of both common and rare conditions.

The 3 faces of clinical reasoning: Epistemological explorations of disparate error reduction strategies

There is general consensus that clinical reasoning involves 2 stages: a rapid stage where 1 or more diagnostic hypotheses are advanced and a slower stage where these hypotheses are tested or confirmed. The rapid hypothesis generation stage is considered inaccessible for analysis or observation. Consequently, recent research on clinical reasoning has focused specifically on improving the accuracy of the slower, hypothesis confirmation stage. Three perspectives have developed in this line of research, and each proposes different error reduction strategies for clinical reasoning. This paper considers these 3 perspectives and examines the underlying assumptions. Additionally, this paper reviews the evidence, or lack of, behind each class of error reduction strategies. The first perspective takes an epidemiological stance, appealing to the benefits of incorporating population data and evidence-based medicine in every day clinical reasoning. The second builds on the heuristic and bias research programme, appealing to a special class of dual process reasoning models that theorizes a rapid error prone cognitive process for problem solving with a slower more logical cognitive process capable of correcting those errors. Finally, the third perspective borrows from an exemplar model of categorization that explicitly relates clinical knowledge and experience to diagnostic accuracy.

Lies, damned lies, and statistics

None

Managing Multiplicity: Conceptualizing Physician Cognition in Multipatient Environments

PURPOSE

Emergency physicians (EPs) regularly manage multiple patients simultaneously, often making time-sensitive decisions around priorities for multiple patients. Few studies have explored physician cognition in multipatient scenarios. The authors sought to develop a conceptual framework to describe how EPs think in busy, multipatient environments.

METHOD

From July 2014 to May 2015, a qualitative study was conducted at McMaster University, using a think-aloud protocol to examine how 10 attending EPs and 10 junior residents made decisions in multipatient environments. Participants engaged in the think-aloud exercise for five different simulated multipatient scenarios. Transcripts from recorded interviews were analyzed inductively, with an iterative process involving two independent coders, and compared between attendings and residents.

RESULTS

The attending EPs and junior residents used similar processes to prioritize patients in these multipatient scenarios. The think-aloud processes demonstrated a similar process used by almost all participants. The cognitive task of patient prioritization consisted of three components: a brief overview of the entire cohort of patients to determine a general strategy; an individual chart review, whereby the participant created a functional patient story from information available in a file (i.e., vitals, brief clinical history); and creation of a relative priority list. Compared with residents, the attendings were better able to construct deeper and more complex patient stories.

CONCLUSIONS

The authors propose a conceptual framework for how EPs prioritize care for multiple patients in complex environments. This study may be useful to teachers who train physicians to function more efficiently in busy clinical environments.

Failure to flow: An exploration of learning and teaching in busy, multi-patient environments using an interpretive description method

INTRODUCTION

As patient volumes continue to increase, more attention must be paid to skills that foster efficiency without sacrificing patient safety. The emergency department is a fertile ground for examining leadership and management skills, especially those that concern prioritization in multi-patient environments. We sought to understand the needs of emergency physicians (EPs) and emergency medicine junior trainees with regards to teaching and learning about how best to handle busy, multi-patient environments.

METHOD

A cognitive task analysis was undertaken, using a qualitative approach to elicit knowledge of EPs and residents about handling busy emergency department situations. Ten experienced EPs and 10 junior emergency medicine residents were interviewed about their experiences in busy emergency departments. Transcripts of the interviews were analyzed inductively and iteratively by two independent coders using an interpretive description technique.

RESULTS

EP teachers and junior residents differed in their perceptions of what makes an emergency department busy. Moreover, they focused on different aspects of patient care that contributed to their busyness: EP teachers tended to focus on volume of patients, junior residents tended to focus on the complexity of certain cases. The most important barrier to effective teaching and learning of managerial skills was thought to be the lack of faculty development in this skill set.

CONCLUSIONS

This study presents qualitative data that helps us elucidate how patient volumes affect our learning environments, and how clinical teachers and residents operate within these environments.

Eyeballing: the use of visual appearance to diagnose 'sick'

CONTEXT

Prior studies suggest that clinicians can categorise patients in an emergency room as 'sick' or 'not sick' using rapid visual assessment. The rapid nature of these decisions suggests clinicians are relying on pattern recognition or System 1 processing; however, this has not been studied experimentally. In this study, we explore the accuracy of these decisions using patient disposition (discharge, admission to ward or admission to critical care) as an objective outcome, and collect evidence to argue for the use of System 1 processing in the 'sick' or 'not sick' decision process.

METHODS

Fourteen practising emergency physicians reviewed 25 videos of patients presenting to the emergency room. They were asked to predict patient disposition (discharge, admission to ward or admission to critical care) and estimate whether they were 'sick' or 'not sick' using a continuous slider on a 'sick' scale from 'not sick' (0) to 'sick' (100). We collected decision time and asked physicians to identify how they came to the decision using a continuous slider on a 'system processing' scale from 'knew immediately' (0) to 'deliberated intently' (1).

RESULTS

Inter-rater reliability judging 'sick' was computed as an intraclass correlation coefficient (ICC) of 0.54. Agreement among physicians in predicting disposition was 68% with ICC of 0.44, and accuracy at predicting disposition was 55%. Physicians made their decision in an average of 10 - 11 seconds and rated 70% of their decisions as < 0.5 on the scale from 'knew immediately' (0) to 'deliberated intently' (1).

CONCLUSIONS

Experienced emergency physicians are able to visually assess patients rapidly and predict disposition in a very short time, albeit with fair reliability and lower accuracy than reported previously. Subjectively, they reported that the majority of decisions were on the side of 'knew immediately', consistent with the application of System 1 processing.

Examining the Influence of Context and Professional Culture on Clinical Reasoning Through Rhetorical-Narrative Analysis

According to the dual process model of reasoning, physicians make diagnostic decisions using two mental systems: System 1, which is rapid, unconscious, and intuitive, and System 2, which is slow, rational, and analytical. Currently, little is known about physicians' use of System 1 or intuitive reasoning in practice. In a qualitative study of clinical reasoning, physicians were asked to tell stories about times when they used intuitive reasoning while working up an acutely unwell patient, and we combine socio-narratology and rhetorical theory to analyze physicians' stories. Our analysis reveals that in describing their work, physicians draw on two competing narrative structures: one that is aligned with an evidence-based medicine approach valuing System 2 and one that is aligned with cooperative decision making involving others in the clinical environment valuing System 1. Our findings support an understanding of clinical reasoning as distributed, contextual, and influenced by professional culture.

Brewster angle and reflectivity of optically nonuniform dense plasmas

We provide theoretical analysis of the reflectance of shock-compressed plasmas and warm dense matter for normal incidence of laser radiation as well as for the dependence of s- and p-polarized reflectivity on the incidence angle. The self-consistent approach for the calculation of the optical and electronic properties of warm dense matter and nonideal plasmas developed in our previous works is extended for the description of normal and polarized reflectivity from the broadened optically nonuniform medium. Two methods are applied for the calculation of the reflectivity from spatially broadened optically nonuniform medium. The first one is based on the solution of the Helmholtz equation for the amplitudes of the electromagnetic field. Another one is based on Drude theory of reflection. It allows us to calculate the ratio of the s- and p-polarized reflectivity if dependence of the dielectric function on distance is known. For the case of the polarized reflectivity, the particular attention is concentrated on the Brewster angle. The calculation results for the dielectric function, obtained within the framework of the density-functional theory with the longitudinal expression for the dielectric tensor, are applied for the calculation of the reflectivity. Comparison with the experimental data for shock-compressed xenon is performed.

Comparison of dual energy subtraction chest radiography and traditional chest X-rays in the detection of pulmonary nodules

BACKGROUND

Dual energy subtraction (DES) radiography is a powerful but underutilized technique which aims to improve the diagnostic value of an X-ray by separating soft tissue from bones, producing two different images. Compared to traditional chest X-rays, DES requires exposure to higher doses of radiation but may achieve higher accuracy. The objective of this study was to assess the clinical benefits of DES radiography by comparing the speed and accuracy of diagnosis of pulmonary nodules with DES versus traditional chest X-rays.

METHODS

Five radiologists and five radiology residents read the DES and traditional chest X-rays of 51 patients, 34 with pulmonary nodules and 17 without. Their accuracy and speed in the detection of nodules were measured using specialized image display software.

RESULTS

DES radiography reduced reading time from 13 to 10 sec (P<0.0001) in staff and from 21 to 15 sec in residents (P<0.0001). There was also a small increase in sensitivity 0.58 to 0.67 overall (P<0.10) with no change in specificity (0.85 overall).

CONCLUSIONS

By eliminating rib shadows in soft tissue images, DES improved the speed and accuracy of radiologists in the diagnosis of pulmonary nodules.

Outcomes of a 1-year randomized controlled trial to evaluate a behavioral 'stepped-down' weight loss intervention for adolescent patients with obesity

BACKGROUND

Stepped-care approaches to weight loss have shown some success among adults. A 'stepped-down' version of the stepped-care approach to adolescent weight loss has never been evaluated.

OBJECTIVES

We conducted a one-year randomized controlled trial to compare a stepped-down weight loss intervention versus enhanced usual care (EUC).

METHODS

Study participants were obese adolescents age 11-13 (N = 106, 51% girls, and 82% Hispanic) recruited from primary care clinics in San Diego, California. The stepped-down intervention was delivered through clinician and health educator counseling (in-person and by phone) and mailed content. The intervention consisted of four-month 'steps' beginning with the most intensive contact followed by reduced contact if treatment goals were met. The EUC group received an initial physician visit, one session with a health counselor, and monthly mailed materials. Body mass index (BMI kg/m(2) ) was measured at baseline, 4, 8, and 12 months. Mixed-model regression analyses were stratified by sex.

RESULTS

Results indicated a clinically significant treatment effect for boys on BMI (p < 0.001) but not girls. No between group differences were found for adiposity and biometric outcomes. Only 13% of intervention participants succeeded in stepping down from step 1 to step 2 or step 3.

CONCLUSIONS

A stepped-down approach to weight loss showed some evidence of efficacy for weight loss in boys but not girls. The findings suggest the program as designed was not intensive enough to result in weight loss in this population segment.

Readiness of hospital-based internists to embrace and discuss high-value care with patients and family members: a single-centre cross-sectional survey study

BACKGROUND

Choosing Wisely Canada is a campaign that fosters conversations between physicians and patients about high-value health care. However, little is known about physicians' readiness to have these conversations. Our objective was to determine how ready practising internists were to embrace and openly address high-value care during conversations with patients or their families.

METHODS

Practising internists in hospitals affiliated with McMaster University, Hamilton, Ontario, were invited to complete an electronic survey with 3 clinical scenarios: each had 3 low-value interventions that had been requested by the patient or family member. For each request, participants chose 1 of 3 statements reflecting how they would respond: a low-value statement agreeing to provide the intervention, an implicit high-value statement declining to provide the intervention without mentioning value or an explicit high-value statement declining to provide the intervention with mention of value.

RESULTS

Forty-four of 62 eligible physicians (71.0% response rate) participated in the survey. High-value statements were selected in 91% of cases. The implicit high-value statement was chosen more often than the explicit high-value statement (65.7% v. 25.5% of all responses, respectively; χ2 range 4.46-56.23, p < 0.05).

INTERPRETATION

Physicians favoured high-value care but frequently chose not to explicitly address value in their statements. Physicians seemed ready to embrace high-value health care practice, although they were not ready to openly discuss it with patients and their families.

Risk factors for mortality in cattle during live export from Australia by sea

OBJECTIVE

This study investigated mortality trends and risk factors for death for cattle exported live from Australia by sea.

METHODS

Mortality data for all voyages from Australia to all destinations between 1995 and 2012 were analysed retrospectively. Daily mortality trends were assessed for 20 long-haul voyages from Australia to the Middle East and to the Russian Federation between 2010 and 2012.

RESULTS

The overall voyage mortality percentage was 0.17% across the 13 million cattle exported on 6447 voyages. Mortality rates decreased significantly after 2000 and stabilised at low levels from 2003. The mortality rate for voyages to the Middle East and north Africa (0.44%) was significantly higher than for voyages to south-east Europe (0.28%), north-east Asia (0.12%) and south-east Asia (0.09%). Cattle exported from ports in southern Australia carried a higher mortality risk than those exported from northern ports for both long- and short-haul voyages. The daily mortality rate on long-haul voyages peaked at 3-4 weeks post-departure, although there was a smaller peak at 1-2 weeks.

CONCLUSION

The marked reduction in mortality rate since 2000 is related to a number of factors, including industry initiatives, government legislation and market demand, that have resulted in changes to both the selection of cattle for export and the management of cattle prior to and during voyages. Routine collection of animal performance data, combined with NLIS records and use of methods described here, have the potential to contribute to more effective management of mortality risks across the export chain.

Assessing the quality of published genetic association studies in meta-analyses: the quality of genetic studies (Q-Genie) tool

Background

Advances in genomics technology have led to a dramatic increase in the number of published genetic association studies. Systematic reviews and meta-analyses are a common method of synthesizing findings and providing reliable estimates of the effect of a genetic variant on a trait of interest. However, summary estimates are subject to bias due to the varying methodological quality of individual studies. We embarked on an effort to develop and evaluate a tool that assesses the quality of published genetic association studies. Performance characteristics (i.e. validity, reliability, and item discrimination) were evaluated using a sample of thirty studies randomly selected from a previously conducted systematic review.

Results

The tool demonstrates excellent psychometric properties and generates a quality score for each study with corresponding ratings of ‘low’, ‘moderate’, or ‘high’ quality. We applied our tool to a published systematic review to exclude studies of low quality, and found a decrease in heterogeneity and an increase in precision of summary estimates.

Conclusion

This tool can be used in systematic reviews to inform the selection of studies for inclusion, to conduct sensitivity analyses, and to perform meta-regressions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12863-015-0211-2) contains supplementary material, which is available to authorized users.