Diagnostic uncertainty is common in clinical practice and affects both providers and patients on a daily basis. Yet, a unifying model describing uncertainty and identifying the best practices for how to teach about and discuss this issue with trainees and patients is lacking. In this paper, we explore the intersection of uncertainty and expertise. We propose a 2 × 2 model of diagnostic accuracy and certainty that can be used in discussions with trainees, outline an approach to communicating diagnostic uncertainty with patients, and advocate for teaching trainees how to hold such conversations with patients.
Our results support the concept that providing residents with an individualized learning pathway focusing on clinical outcomes research during residency enables them to successfully publish manuscripts and access mentorship, and may influence subsequent career choice. Implementation of individualized residency program tracks that nurture academic interests along with clinical skills can support career development within medicine residency programs.
Diagnostic error is a challenging problem; addressing it effectively will require innovation across multiple domains of health care, including medical education. Diagnostic errors often relate to problems with clinical reasoning, which involves the cognitive and relational steps up to and including establishing a diagnostic and therapeutic plan with a patient. However, despite a call from the National Academies of Sciences for medical educators to improve the teaching and assessment of clinical reasoning, the creation of explicit, theory-informed clinical reasoning curricula, faculty development resources, and assessment tools has proceeded slowly in both undergraduate and graduate medical education. To accelerate the development of this critical element of health professions education and to promote needed research and innovation in clinical reasoning education, the Accreditation Council for Graduate Medical Education (ACGME) should revise its core competencies to include clinical reasoning. The core competencies have proven to be an effective means of expanding educational innovation across the United States and ensuring buy-in across a diverse array of institutions and disciplines. Reformulating the ACGME core competencies to include clinical reasoning would spark much-needed educational innovation and scholarship in graduate medical education, as well as collaboration across institutions in this vital aspect of physicianship, and ultimately, could contribute to a reduction of patient suffering by better preparing trainees to build individual, team-based, and system-based tools to monitor for and avoid diagnostic error.
Aerosol samples were collected at the Mauna Loa Observatory in Hawaii from February 1979 to May 1985. The samples were analyzed via instrumental neutron activation analysis (INAA) for up to 47 elements and via ion chromatography for sulfate. The data are dominated by crustal dust that arrives via long‐range transport from Asia each spring, thus creating a “dust season.” Of the 47 elements detected, 37 have a notably higher mass average during the dust season. The data record is explored using enrichment factors, principal component analysis, and chemical mass balances (receptor modeling). The crustal material accounts for 60–70% of the overall aerosol mass during dust seasons, yet only 15–20% during nondust seasons. It is by far the largest contributor to the natural variation dominating the principal component analysis by describing greater than 60% of the overall variance. Particulate sulfate is another major component accounting for 10–40% of the aerosol mass during dust seasons and 60–75% of the mass during nondust seasons. Particulate sulfate can be derived from crustal material and sea salt. Anthropogenic activity also can produce particulate sulfate or its precursors that can adhere to the surface of crustal material that travels over a polluted area. Minor components in the downslope winds are marine sea‐salt aerosol contributing less than 3% of the aerosol mass during the dust season and 5–6% during the nondust season. Local basalt is considered to contribute less than 2% during the dust season and 3–4% during the nondust season. (Carbon mass is not determined and therefore no carbon‐based aerosols such as soot or organic aerosols are considered in the total aerosol mass.)
BackgroundInterferon-gamma release assays may be used as an alternative to the tuberculin skin test for detection of M. tuberculosis infection. However, the risk of active tuberculosis disease following screening using interferon-gamma release assays in immigrants is not well defined. To address these uncertainties, we determined the incidence rates of active tuberculosis disease in a cohort of high-risk immigrants with Class B TB screened with interferon-gamma release assays (IGRAs) upon arrival in the United States.MethodsUsing a retrospective cohort design, we enrolled recent U.S. immigrants with Class B TB who were screened with an IGRA (QuantiFERON ® Gold or Gold In-Tube Assay) at the San Francisco Department of Public Health Tuberculosis Control Clinic from January 2005 through December 2010. We reviewed records from the Tuberculosis Control Patient Management Database and from the California Department of Public Health Tuberculosis Case Registry to determine incident cases of active tuberculosis disease through February 2015.ResultsOf 1233 eligible immigrants with IGRA screening at baseline, 81 (6.6 %) were diagnosed with active tuberculosis disease as a result of their initial evaluation. Of the remaining 1152 participants without active tuberculosis disease at baseline, 513 tested IGRA-positive and 639 tested IGRA-negative. Seven participants developed incident active tuberculosis disease over 7730 person-years of follow-up, for an incidence rate of 91 per 100,000 person-years (95 % CI 43–190). Five IGRA-positive and two IGRA-negative participants developed active tuberculosis disease (incidence rates 139 per 100,000 person-years (95 % CI 58–335) and 48 per 100,000 person-years (95 % CI 12–193), respectively) for an unadjusted incidence rate ratio of 2.9 (95 % CI 0.5–30, p = 0.21). IGRA test results had a negative predictive value of 99.7 % but a positive predictive value of only 0.97 %.ConclusionsAmong high-risk immigrants without active tuberculosis disease at the time of entry into the United States, risk of progression to active tuberculosis disease was higher in IGRA-positive participants compared with IGRA-negative participants. However, these findings did not reach statistical significance, and a positive IGRA at enrollment had a poor predictive value for progressing to active tuberculosis disease. Additional research is needed to identify biomarkers and develop clinical algorithms that can better predict progression to active tuberculosis disease among U.S. immigrants.
Kappa opioid receptor (KOR) ligands alter nociceptive responses when applied to the rostral ventromedial medulla (RVM). However, the effects of kappa opioid receptor ligands are distinct in males and females. The present study examined the distribution of kappa opioid receptor immunoreactivity in the RVM of male and female rats. KOR immunoreactivity was found at pre- and postsynaptic sites within the RVM of both sexes. The most common KOR-immunoreactive (KOR-ir) neuronal structures were unmyelinated axons, followed by axon terminals, dendrites, and somata. Different proportions of KOR-ir axon terminals and dendrites were found in females at different estrous stages. Specifically, dendrites containing KOR immunoreactivity were less abundant in proestrus females compared with estrus females and showed a trend toward being less abundant in males, suggesting that KOR ligands applied to the RVM may be less potent in proestrus females. These findings suggest that the distribution of KORs in the RVM may be influenced by reproductive hormone levels. We also found KOR immunoreactivity in many spinally projecting neurons within the RVM of female rats. These findings are consistent with the hypothesis that KOR ligands influence nociceptive behaviors by altering the activity of specific populations of neurons within the RVM. The abundance of KOR in axons and axon terminals in RVM indicates a substantial role for presynaptic effects of KOR ligands through pathways that have not been clearly delineated. Altering the balance between pre- and postsynaptic receptive sites may underlie differences in the effects of KOR agonists on nociceptive responses in males and females.
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