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PubMed2006

Computerized adaptive testing of diabetes impact: a feasibility study of Hispanics and non-Hispanics in an active clinic population.

BACKGROUND: Diabetes is a leading cause of death and disability in the US and is twice as common among Hispanic Americans as non-Hispanics. The societal costs of diabetes provide an impetus for developing tools that can improve patient care and delay or prevent diabetes complications. METHODS: We implemented a feasibility study of a Computerized Adaptive Test (CAT) to measure diabetes impact using a sample of 103 English- and 97 Spanish-speaking patients (mean age = 56.5, 66.5% female) in a community medical center with a high proportion of minority patients (28% African-American). The 37 items of the Diabetes Impact Survey were translated using forward-backward translation and cognitive debriefing. Participants were randomized to receive either the full-length tool or the Diabetes-CAT first, in the patient's native language. RESULTS: The number of items and the amount of time to complete the survey for the CAT was reduced to one-sixth the amount for the full-length tool in both languages, across disease severity. Confirmatory Factor Analysis confirmed that the Diabetes Impact Survey is unidimensional. The Diabetes-CAT demonstrated acceptable internal consistency reliability, construct validity, and discriminant validity in the overall sample, although subgroup analyses suggested that the English sample data evidenced higher levels of reliability and validity than the Spanish sample and issues with discriminant validity in the Spanish sample. Differential Item Function analysis revealed differences in responses tendencies by language group in 3 of the 37 items. Participant interviews suggested that the Spanish-speaking patients generally preferred the paper survey to the computer-assisted tool, and were twice as likely to experience difficulties understanding the items. CONCLUSIONS: While the Diabetes-CAT demonstrated clear advantages in reducing respondent burden as compared to the full-length tool, simplifying the item bank will be necessary for enhancing the feasibility of the Diabetes-CAT for use with low literacy patients.

Adult↗
PubMed1995

Assessment of physician competence in prehospital trauma care.

In an attempt to develop a model to measure the competence of physicians providing emergency care under difficult field conditions, 75 Israeli army medical corps physicians were evaluated through the use of four instruments: a debriefing interview, peer assessment, self-assessment and written examination. The special on-site assessment model was designed to examine actual events, enabling an assessment of performance in real situations rather than simulated cases. Significant positive correlations were found between the results of the written examination and the peer evaluation on two of four measures (r = 0.36, P = 0.001; r = 0.23, P = 0.05) as well as on the two measures regarding self-evaluation and peer evaluation (r = 0.54, P = 0.001; r = 0.38, P = 0.05). It was found that those physicians who were trained in the army's medical officer course scored significantly higher on the written examination (P = 0.001) and were rated more highly by their senior peers (P = 0.048) than those who did not receive such training. It was concluded that it is advantageous to use a combination of knowledge (written examination) and performance (peer assessment or self-assessment) measures in order to arrive at a more comprehensive assessment of competence. In addition, the written examination format should be expanded and developed to include more clinical vignettes requiring treatment decisions, making this instrument a more clinically oriented measure of physician competence in trauma care.

Clinical Competence↗
PubMed1993

Reinforcing effects of extended inhalation of a low nitrous oxide concentration in humans.

The reinforcing, subjective, and psychomotor effects of 30 min of inhalation of 20% nitrous oxide were determined in 12 healthy volunteers using a choice paradigm with 100% oxygen as placebo. Nitrous oxide was chosen on only 22% of choice occasions, indicating that, in general, this concentration did not function as a reinforcer. Nitrous oxide produced changes in mood, but had no effect on psychomotor performance. Three out of the 12 subjects chose nitrous oxide on at least two out of the three choice sessions, and during a poststudy debriefing interview, reported pleasant effects of the drug. The other nine subjects reported unpleasant acute effects of the drug (e.g., drowsiness) or residual (postsession) effects of the drug which, they said, influenced their drug choice. The present results are compared to those results obtained in a previous study in which higher concentrations of nitrous oxide (30 and 40%) also produced relatively low choice rates. The apparent lack of reinforcing effects of extended inhalation of nitrous oxide is discussed.

Adult↗
PubMed1993

Comparison of treatment strategies for Space Motion Sickness.

Treatment strategies for Space Motion Sickness (SMS) were compared using the results of postflight oral debriefings. Standardized questionnaires were administered to all crewmembers immediately following Space Shuttle flights by NASA flight surgeons. Cases of SMS were graded as mild, moderate, or severe based on published criteria, and medication effectiveness was judged based on subjective reports of symptom relief. Since October 1989, medication effectiveness is reported inflight through Private Medical Conferences with the crew. A symptom matrix was analyzed for 19 crewmembers treated with oral combination of scopolamine and dextroamphetamine (scopdex) and 15 crewmembers treated with promethazine delivered by intramuscular i.m. or suppository routes. Scopdex has been given preflight as prophylaxis for SMS, but analysis showed delayed symptom presentation in 9 crewmembers or failed to prevent symptoms in 7. Only 3 crewmembers who took scopdex had no symptoms inflight. Fourteen out of 15 crewmembers treated with i.m. promethazine and 6 of 8 treated with promethazine suppositories after symptom development had immediate (within 1-2 h) symptom relief and required no additional medication. There were no cases of delayed symptom presentation in the crewmembers treated with promethazine. This response is in contrast to untreated crewmembers who typically have slow symptom resolution over 72-96 h. We conclude that promethazine is an effective treatment of SMS symptoms inflight. NASA policy currently recommends treating crewmembers with SMS after symptom development, and no longer recommends prophylaxis with scopdex due to delayed symptom development and apparent variable absorption of oral medications during early flight days.

Aerospace Medicine↗
PubMed1993

The 'control' question 'test' (CQT) polygrapher's dilemma: logico-ethical considerations for psychophysiological practitioners and researchers.

The so-called 'control' question 'test' (CQT) has been criticized on methodological and ethical grounds by psychophysiologists. The ethical analyses have focussed on the possibility that the CQT's interrogative features may elicit false confessions, but an empirical problem is that the rate of these false confessions is difficult to establish. In this conceptual note, this author raises a logico-ethical problem for the CQT, called the Polygrapher's Dilemma (PD). The two horns of the PD are to damage the innocent examinee classified as deceptive and damage to those examinees' psychological well being who are classified as non-deceptive to the relevant questions and who are not even debriefed concerning their feelings of unease about issues raised by the comparison, so-called 'control' questions. Although there may be arguments about which of the PD's two horns are more serious, there is no doubt that both are, in an absolute sense, ethically negative. Nor is there an ethically justifiable third alternative available. It is also contended that not only practitioners but also researchers (who use the CQT in laboratory, 'mock-crime' situations) are affected by PD. Finally, it is noted that PD exists only for the CQT procedure and not for the more standardized and scientifically based Guilty Knowledge Technique.

Ethics, Professional↗
PubMed1993

Burn victims after a major disaster: reactions of patients and their care-givers.

There have been considerable advances in the physical management of burns, and there is a greater awareness of their psychological impact. However, much less attention has been given to the staff who have to deal with burn victims. Disasters are critical incidents which offer a magnified opportunity to appreciate with what care-givers have to cope and how they do so. This paper identifies how complex are the psychological and emotional reactions associated with burn care, and it advocates that more should be done, by means of debriefing, to cater for the needs of staff after critical incidents.

Accidents, Occupational↗
PubMed1996

The premenstrual phase and reactions to aversive events: a study of hormonal influences on emotionality.

Fifty-eight normal cycle, healthy women were confronted with an aversive, anger-provoking situation in the laboratory. Eighteen women were tested in their follicular phase. A further 40 women were tested in the premenstrual phase, half of whom reported suffering from complaints of premenstrual emotional lability and irritation, the other half reported being without premenstrual problems. Apart from a strong effect of emotion induction on cardiovascular arousal and anger-related moods in the follicular and premenstrual groups, a premenstrual phase effect was also demonstrated, with premenstrual women showing evidence of being more affected by the manipulations on systolic blood pressure and intensity of angry behaviour during anger provocation. Furthermore, some differences were found between those subjects who reported suffering from premenstrual complaints and those free of such complaints, among the most interesting ones being differences in cortisol level preceding the experimental session, in intensity of angry behaviour, and in report of anger intensity at debriefing. The study indicates that the premenstrual phase may have the effect of making women more susceptible to responding emotionally to negative life events.

Adult↗
PubMed1993

Assessing the behavioral effects and abuse potential of propofol bolus injections in healthy volunteers.

Propofol is a recently introduced intravenous anesthetic agent, commonly administered to surgical patients because it induces anesthesia smoothly (i.e., provides loss of consciousness rapidly and usually with no complications) and is associated with rapid recovery. Propofol has psychoactive effects that could be construed as pleasant, although little abuse liability testing has been done on this agent in humans. Accordingly, we examined various effects of this agent at different subanesthetic doses (0.2-0.6 mg/kg) in order to characterize this drug's abuse potential (for recreational use or potential for diversion). Using a double-blind, randomized, crossover design, healthy normal volunteers (N = 10) were injected intravenously with the drug or with placebo. Before the injection and for up to 1 h afterwards, mood (including drug liking), memory and psychomotor performance were assessed. Propofol impaired memory and psychomotor performance and produced changes in 10 of 20 VAS mood ratings. Although there was variability in self-reported drug liking, some subjects clearly liked the effects of propofol, especially at the two higher doses. At the debriefing interview held after completion of the study, five subjects said if they had to participate in one more session in which they were given a choice between being injected with the highest dose (0.6 mg/kg) or a placebo, they would choose propofol. These preliminary results suggest that this agent may have some potential for abuse/diversion and perhaps stricter accountability procedures should be established for this drug in settings where general anesthesia or conscious sedation procedures are done.

Adult↗
PubMedDate not supplied

IRIS: an experimental multimedia workstation linking the departments of emergency medicine and radiological sciences.

An experimental version of a multimedia medical communication system called IRIS (Integrated Radiological Information System) operated between the Department of Emergency Medicine and the Department of Radiological Sciences at the Ottawa Civic Hospital for 7 weeks during April and May 1989. IRIS is being developed to enhance communication between clinicians and radiology consultants to improve diagnosis and reporting. IRIS supports the capture and distribution of digitized x-ray images and voice reports in the form of "electronic" patient folders that can be accessed at physician workstations throughout the hospital. It also supports on-line consultation between the radiologist and clinician through synchronized workstation operation. Each workstation has 1) a high resolution image screen to display documents and x-ray images; 2) a control screen to access patient folders; 3) a hands-free telephone to dictate, play back reports, and enable realtime consultation between physicians. From an emergency physician's (EP) perspective, such an involved system must allow the viewing and manipulation of images in order to reach diagnostic conclusions and support efficient interchange between the clinician and the consultant radiologist, yet be easy to learn and use without disruption of clinical services. After a briefing session, the trial took place and analogue and digital images were compared. An observer-assistant recorded how EPs used the system and was available to assist the EP. After the trial, six EPs participated in an extensive debriefing interview in order to evaluate the system. Overall, the system was found to be easy to learn and to use, and there was a clear benefit to the full consultation report and the ability to directly consult with the radiologist located at a remote station.

Computer Communication Networks↗
PubMed1995

Anesthesia crisis resource management: real-life simulation training in operating room crises.

Little formal training is provided in anesthesiology residency programs to help acquire, develop, and practice skills in resource management and decision making during crises in practice. Using anesthesia crisis resource management (ACRM) principles developed at another institution, 68 anesthesiologists and 4 nurse-anesthetists participated in an ACRM training course held over a 2 and a half-month period. The anesthesia environment was recreated in a real operating room, with standard equipment and simulations requiring actual performance of clinical interventions. Scenarios included overdose of inhalation anesthetic, oxygen source failure, cardiac arrest, malignant hyperthermia, tension pneumothorax, and complete power failure. A detailed questionnaire was administered following the debriefing and completed by all participants, documenting their immediate impressions. Participants rated themselves as having performed well in the simulator. Senior attendings and residents rated themselves more highly than did their junior counterparts. The potential benefit of this course for anesthesiologists to practice anesthesia more safely in a controlled exercise environment, was rated highly by both groups. Over one half of respondents in all categories felt that the course should be taken once every 12 months; another third of each group felt that the course should be taken once every 24 months. While no senior attendings believed that the course should be taken once every 6 months, approximately 10% of respondents in other categories that it should. Of respondents in the senior and junior attending category, 5% felt the course should never be taken. Although attendings were less favorable than residents in their rating of the value of the course, both groups were still enthusiastic.

Anesthesia↗
PubMed2004

Guilt, shame and need for a container: a study of post-traumatic stress among ambulance personnel.

Post-traumatic stress symptoms among ambulance personnel are regarded as a natural behaviour and reaction to working with the severely injured, suicides, injured children and dead people. The findings show that post-traumatic stress symptoms, guilt, shame and self-reproach are common after duty-related traumatic events. To handle these overwhelming feelings it is necessary to talk about them with fellow workers, friends or family members. By using another person as a container it is possible to internalise the traumatic experience. Poor and un-emphatic behaviour towards a patient and their relatives can have its origin in untreated traumatic experiences. Personnel in ambulance organisations who perform defusing, debriefing and counselling have to be informed of the importance that the roll of guilt and shame may play in the developing of post-traumatic stress symptoms.

Adaptation, Psychological↗
PubMed2004

Symptom validity testing of feigned amnesia for a mock crime.

Perpetrators sometimes claim loss of memory for the crimes they have committed. For the neuropsychologist, the veracity of such crime-related amnesia is difficult to assess. The aim of the present study was to investigate whether Symptom Validity Testing (SVT) can be used to detect feigning of crime-related amnesia. Undergraduate students (N = 39) were instructed to commit a mock crime and asked to feign complete amnesia for the event. Subsequently, they were given 25 forced-choice items about the "crime" that were always followed by the correct answer and an equally plausible alternative. To counteract chance performance, test items were intermixed with 25 bogus questions that contained two equally plausible alternatives. Results show that a majority of participants (59%) scored below chance level on the critical items of the SVT. In addition, debriefing interviews showed that understanding the rationale behind the SVT was not related to chance performance. SVT procedures therefore might be helpful in identifying feigned crime-related amnesia.

Adolescent↗
PubMed2004

Abilities and strategies of blind and sighted subjects in visuo-spatial imagery.

An active visuo-spatial memory task was used in order to determine the characteristics of mental imagery in subjects with and without visual experience. Subjects were instructed to generate a mental representation of verbally presented 2D patterns that were placed in a grid and to indicate how many pattern elements were in corresponding positions in the two halves of the grid according to a specific grid axis (vertical or horizontal). Unexpectedly, results showed a similar performance in early blind, late blind and sighted subjects. However, subjects' debriefing showed that the three groups used different strategies. The sighted and the late blind subjects took advantage of a visuo-spatial strategy. They generated a mental image of the matrix and they simplified this image to maintain only the relevant information in memory. In contrast, the early blind subjects encoded each pattern element by its location in a (X,Y) coordinate system without visual representation. This indicates that both early and late blind subjects are able to perform an active visuo-spatial imagery task as well as sighted subjects although they use different strategies.

Adult↗
PubMed2006

Nurses and emergency disasters: what is known.

Following the events of September 11, 2001, the threat of bioterrorism events has become a realistic concern for health care workers in the United States. Bioterrorism events caused by infectious agents will be challenging because nurses will need to recognize unfamiliar infections and work long hours with limited resources in stressful conditions. During a bioterrorism event caused by biologic agents, nurses will be expected to provide care to infected patients and may fear that they, or their families, could also become infected. A review of literature suggests that nurses' response to working during a bioterrorism event is not well described. The limited number of studies regarding nurses' concerns, fears, and anxieties is focused on nurses' experiences in natural disaster or war situations. Additional studies are needed to validate the appropriateness of applying findings from disaster response studies to bioterrorism events. During bioterrorism events, nurses will be expected to provide physical care and emotional and psychologic support for victims and victims' families. Realistic bioterrorism plans should incorporate strategies to support nurses and address their physical, psychologic, and emotional issues. Strategies to optimize safe working conditions and minimize psychologic trauma such as technical training regarding bioterrorism agents and debriefing opportunities should be included.

Attitude of Health Personnel↗
PubMed2005

Implementation and evaluation of a genetics curriculum to improve obstetrician-gynecologist residents' knowledge and skills in genetic diagnosis and counseling.

OBJECTIVE: This study was undertaken to develop, implement, and evaluate a genetics curriculum for obstetrician-gynecologist residents. STUDY DESIGN: We prospectively evaluated the effect of a genetics curriculum on obstetrician-gynecologist residents' knowledge and skills. Residents completed a needs assessment and pretest. Educational intervention included 2 3-hour didactic sessions with 1 hour of lecture followed by case discussion and 1 3-hour session of experiential learning using standardized patients who evaluated residents' knowledge and skills in taking family history, drawing genetic pedigrees, and counseling patients. Posttest scores were compared with pretest scores. RESULTS: Needs assessment was completed by all 40 obstetrics and gynecology residents and identified limited and variable genetics education in medical school. Twenty-eight of 40 residents attended the entire educational intervention and completed the pretest and posttest, and 25 of 28 showed improved test scores. Residents stated that they were more confident in their ability to take a family history, record a 3-generation pedigree, and counsel patients about genetic conditions after completion of the genetics curriculum. CONCLUSION: This multifaceted genetics curriculum improved residents' knowledge of genetics as well as their confidence in applying genetic concepts as assessed by the pretest and posttest and by their comments in the debrief session.

Clinical Competence↗
PubMedDate not supplied

Medical helicopters in wilderness search and rescue operations.

Medical helicopters may be asked to assist in wilderness search and rescue (SAR) operations to quickly reach patients in remote areas and provide medical care and transport of sick or injured persons. The number 1 priority for any medical helicopter involved in an SAR operation is safety, which is considered at each decision point. The involvement of a medical helicopter service begins with a request from a local agency for support. Obtaining key information about the SAR operation from the local agency is essential for deciding whether to accept the mission and for making appropriate preparations for the mission. While en route to the SAR location, the medical crew can review the information regarding location and patient status. Once on location, the crew can survey the scene from the air before landing at the command post to brief with SAR personnel regarding the mission. An initial survey of the scene from the air is important for identifying landing zones and evaluating the terrain where the rescue will occur. A face-to-face briefing with SAR personnel is preferable to learn specifically what type of mission is requested. The medical helicopter crew is empowered to decline the mission for safety reasons at any step. The actual rescue may be done by inserting the helicopter at the scene in nontechnical terrain or by having SAR personnel extricate the patient and deliver him or her to the medical helicopter crew at the nearest safe landing zone. Medical care and transport of the patient as indicated by injuries or illness then occurs. Finally, a postmission debriefing is essential for identifying problems that occurred during the mission and implementing corrections for improvement.

Air Ambulances↗
PubMed2005

Management of adverse surgical events: a structured education module for residents.

BACKGROUND: This pilot project involved the development of a structured, experiential, educational module using a bench model technical skills simulation and standardized patients. It integrated teaching and assessment of clinical, technical, and interpersonal skills, as well as professionalism within the context of an adverse surgical event. METHODS: General surgery residents (postgraduate year [PGY] 2, 3) were asked to participate in the pre-, intra-, and postoperative management of a patient with a retroperitoneal sarcoma. Residents' performances during the module were assessed by standardized patients and faculty, and residents were provided feedback during debriefing sessions. RESULTS: Resident performance during the module was appropriate for the level of training. Residents found this module to be a realistic, challenging, and beneficial learning experience. CONCLUSIONS: Novel educational modules such as this one may serve as a useful addition to resident education in surgery residency programs, particularly in addressing patient safety and the core competencies. Reliability of the model may be enhanced by modifications of the module.

Clinical Competence↗
PubMed2006

Implicit emotion during recollection of past events: a nonverbal fMRI study.

Faces of other significant people are highly self-relevant and close to our everyday way of recollecting past events. We chose such stimuli to probe the emotional component of autobiographical memory retrieval. Photographs were collected from family members without the participant's involvement, thereby avoiding refreshment of the memory trace prior to the scanning session. We asked the subjects to spontaneously evoke a unique autobiographical episode following the presentation of relatives' and friends' faces. Famous faces recognition was used as a semantic memory control task. We carried out a post-fMRI debriefing session to collect participants' memories and their emotional intensity. The post-scanning behavioural data together with the neuroimaging data provided evidence that emotional aspects were implicitly involved during recollections. Our findings suggest that the use of highly self-relevant stimuli and the collection of data with no previous refreshment of the memory trace influence the right lateralisation of activations in the medial temporal lobe (MTL).

Adult↗