The effect of simulator training on clinical skills acquisition, retention and transfer

Context  Prior research has demonstrated that residents have poor clinical skills in cardiology and respirology. It is not clear how these skills can be improved because the number of patients with suitable clinical findings whose cooperation might help residents to better develop these clinical skills is limited.
Objectives  Our objective was to evaluate the effect of training on a cardiorespiratory simulator (CRS) on skills acquisition, retention and transfer.
Methods  We randomly allocated 146 students to CRS training in either chest pain or dyspnoea and compared each student's performance on the clinical presentation in which he or she had received CRS training with performance on the control presentation.
Results  Immediately after training, students were more accurate in identifying abnormal clinical findings on the CRS (70.0% versus 52.2%; d = 7.6, P  < 0.0001) and showed improved diagnostic performance (72.1% versus 55.6%; d = 4.3, P  = 0.0007) on the training clinical presentation. At the end of the course they were still better at identifying abnormal findings (57.1% versus 51.7%; d = 2.5, P  = 0.004) and diagnosing correctly (50.0% versus 38.1%; d = 3.0, P  = 0.002) on problems included in the training clinical presentation. However, they showed no difference between training and control presentations in diagnostic performance when required to transfer their skills between problems (45.9% versus 43.8%; P  = 0.5) or in performance on multiple-choice questions (64.1% versus 63.6%; P  = 0.8).
Conclusions  Students can acquire and retain clinical skills with CRS training, but demonstrate limited ability to transfer these to other problems. Further studies are needed to explore ways of improving learning and transfer with CRS training.     

The 'Functional Muscle-Bone Unit': probing the relevance of mechanical signals for bone development in children and adolescents.

The present text deals with the relationship of muscle force and mass to bone mass and geometry in the developing skeleton of children and adolescents. Recent results of the last ten years are discussed with reflection on Harold Frost's 'mechanostat hypothesis'. Bone mass and geometry follow the development of body size and muscle force in children and adolescents. Thereby, bone is adapted to the tissue strain due to biomechanical forces. This process is modified by hormonal signals (i.e., estrogens and androgens). Therefore, the quantified relationship of muscle force to bone stability is a reasonable approach to distinguish between primary and secondary bone diseases. Primary bone diseases are characterized by a disturbed adaptation of bone to biomechanical forces. In contrast, secondary bone diseases show a correct adaptation of bone to loaded forces in combination with a decline of muscle force. Therefore, the 'Functional Muscle-Bone Unit' was introduced into the diagnostics of pediatric bone diseases. The ratio of two parameters--referred to bone strength on the one and to biomechanical forces on the other side--is a reasonable diagnostic approach to distinguish between primary and secondary bone diseases.     

School nurses' support for bereaved students: a pilot study.

Children may have difficulty with schoolwork because of grief over the death of an important person in their lives. School nurses provide support to these children. This pilot study consisted of a Web-based survey completed by 6 school nurses in a 3-county area in Washington state. The purpose of this pilot study was to assess the need for additional support for bereaved children and the extent to which school nurses meet the needs of these students. Results indicated that many school nurses have large caseloads that preclude spending as much time with bereaved students as the nurses feel is necessary. Bereaved students exhibit a wide variety of grief symptoms that may interfere with learning. In addition, rural areas do not have adequate community bereavement resources that nurses can use to refer students who need help beyond that offered at school. Nurses must be more active in supporting students within the school setting despite limited resources.     

Hodgkin's lymphoma of the thyroid: a clinicopathologic study of five cases and review of the literature.

Hodgkin's lymphoma rarely involves the thyroid gland. We report the clinical and pathologic features of five cases of Hodgkin's lymphoma that presented as thyroid lesions. All five patients were females, aged 29-59 years. Three patients had a history of chronic thyroiditis and hypothyroidism and two were euthyroid. One patient had a remote history of Hodgkin's lymphoma. Imaging studies showed a 'cold' nodule (three cases) or a diffusely enlarged thyroid gland, resembling goiter or fibrosclerosing thyroiditis (two cases). Thyroid fine-needle aspiration was performed before thyroidectomy in all cases; three of these cases contained some atypical cells, raising the possibility of Hodgkin's lymphoma. Histologically, all cases were classical Hodgkin's lymphoma, nodular sclerosis subtype. The four patients with primary thyroid lymphoma had Stage IIE disease. All patients were treated with surgical excision and chemotherapy, with or without radiation therapy, and were alive after 2 months to 7 years of follow-up. A review of the English literature between 1962 and 2005 revealed 16 cases of thyroid Hodgkin's lymphoma, with a female preponderance and generally favorable outcome similar to the cases in our series. Hodgkin's lymphoma of the thyroid is rare and can mimic a primary thyroid epithelial tumor or thyroiditis clinically. Histologic diagnosis may be difficult due to marked fibrosis. Hodgkin's lymphoma should be considered in the differential diagnosis of thyroid neoplasms.     

Forming your phase III trial's data and safety monitoring board: a perspective on safety.

A data safety monitoring board (DSMB) established in a phase III trial to monitor the safety of participants in a clinical trial views itself as protecting participants and ensuring the integrity of the study. The DSMB should operate under a clear charter, with expectations understood by all members of the Board, the sponsor, and the investigators. Sponsors must trust their DSMBs. The sponsor must give the DSMB the tools and the data that it needs to operate effectively in protecting the safety of the participants.     

Inter-rater reliability of the original and modified Barthel Index,and a comparison with the Functional Independence Measure

The Barthel Index (BI), the Modified Barthel Index (MBI) and the Functional Independence Measure (FIM) are all widely used by occupational therapists as assessment tools for clinical decision-making and outcome measurement. All of these tools have demonstrated validity and the BI and the FIM have demonstrated inter-rater reliability. The MBI has been modified to increase sensitivity; however, there have been no publications on the inter-rater reliability of this tool following the changes. The purpose of this research was to examine the inter-rater reliability of two versions of the Barthel Index, and draw some comparisons between this assessment tool and the FIM. Twenty-five patients with neurological and orthopaedic conditions were assessed by three occupational therapists using the three tools. The method of analysis selected was percentage agreement and intraclass correlation coefficient. The results indicated that both the original and modified versions of the Barthel Index possess good inter-rater reliability. As all three tools have demonstrated adequate reliability and validity, it is suggested that clinicians select the most sensitive tool that best meets their clinical needs, and use this assessment tool in its standardized format.     

Social networks of residents in supportive housing

One goal of supportive housing is to enlarge and improve the functioning of the social support networks of residents. The networks of a convenience sample of 42 residents were assessed using scales developed by Barrera. The size of the networks (11.5) was no larger than that reported for similar clients living in other types of community settings but the composition differed. Staff and co-residents appear to partially replace rather than add to family and friends. This is of concern because friends are uniquely important determinants of satisfaction. An association between perceived need for support and network size was also found. These findings suggest some positive influences but also raise questions about unintended negative consequences of living in artificially constructed social environments.When this project was undertaken, Dr. Goering, Janet Durbin, Bill Lancee and Taras Babiak were all members of the Social and Community Psychiatry Section, Clarke Institute. Robert Foster was Executive Director of Regeneration House, Inc., where Susan Boyles is Assistant Executive Director.