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PubMed2006

Intoxication-related fatalities in northern Germany.

BACKGROUND: Knowing what substances cause death in intoxicated patients is of medical, legal, and political relevance. Harmonized data documentation like TESS (Toxic Exposure Surveillance System) in the United States does not exist yet in Germany. However, the GIZ-Nord Poison Center in Göttingen issues an annual report that includes fatalities. The aim of this study was to obtain an overview of the substances resulting in fatal poisoning and to define risk factors. METHODS: In a retrospective study, all fatalities due to poisoning from January 1996 until March 2003 were analyzed. RESULTS: From 1996 to 2003, the GIZ-Nord Poison Center was consulted in 168,000 cases. There were 142 fatalities due to poisoning (0.08% of all consultations). In 79 cases, the lethal substance was a medical drug, mostly tricyclic antidepressants and cardiovascular drugs. Two immigrants of German origin from the former Soviet Union died after consuming Amanita mushrooms. Five elderly, disorientated patients died of respiratory failure due to aspiration of detergent products from soap or shampoo. CONCLUSION: Three groups of patients with a high risk of dying from intoxication can be defined: (1) suicidal patients with access to tricyclic antidepressants or cardiovascular drugs, (2) immigrants from the former Soviet Union who mistake toxic German mushrooms for edible species, and (3) elderly, disorientated patients who ingest large amounts of soap or shampoo.

Journal Article↗
PubMed2004

Distribution of peanut allergen in the environment.

BACKGROUND: Patients with peanut allergy can have serious reactions to very small quantities of peanut allergen and often go to extreme measures to avoid potential contact with this allergen. OBJECTIVE: The purpose of this study was to detect peanut allergen under various environmental conditions and examine the effectiveness of cleaning agents for allergen removal. METHODS: A monoclonal-based ELISA for Arachis hypogaea allergen 1 (Ara h 1; range of detection, 30-2000 ng/mL) was used to assess peanut contamination on cafeteria tables and other surfaces in schools, the presence of residual peanut protein after using various cleaning products on hands and tabletops, and airborne peanut allergen during the consumption of several forms of peanut. RESULTS: After hand washing with liquid soap, bar soap, or commercial wipes, Ara h 1 was undetectable. Plain water and antibacterial hand sanitizer left detectable Ara h 1 on 3 of 12 and 6 of 12 hands, respectively. Common household cleaning agents removed peanut allergen from tabletops, except dishwashing liquid, which left Ara h 1 on 4 of 12 tables. Of the 6 area preschools and schools evaluated, Ara h 1 was found on 1 of 13 water fountains, 0 of 22 desks, and 0 of 36 cafeteria tables. Airborne Ara h 1 was undetectable in simulated real-life situations when participants consumed peanut butter, shelled peanuts, and unshelled peanuts. CONCLUSION: The major peanut allergen, Ara h 1, is relatively easily cleaned from hands and tabletops with common cleaning agents and does not appear to be widely distributed in preschools and schools. We were not able to detect airborne allergen in many simulated environments.

Adult↗
PubMed2005

Preparation and colloidal stability of monodisperse magnetic polymer particles.

A previously proposed method was examined for producing monodisperse, submicrometer-sized magnetic polymer particles. The method applies soap-free emulsion polymerization during which Fe3O4 magnetic nanoparticles are heterocoagulated onto precipitated polymer nuclei. To chemically fix the magnetic particles to the polymer nuclei, vinyl groups were introduced on the Fe3O4 particles in a preliminary surface modification reaction with methacryloxypropyltrimethoxysilane, and methacryloxypropyldimethoxysilane (MPDMS) was added to reaction systems of the soap-free emulsion polymerization. The colloidal dispersion stability of magnetic polymer particles was improved by the addition of an ionic monomer, sodium p-styrenesulfonate (NaSS), during the polymerization. The polymerizations were carried out with styrene monomer and potassium persulfate initiator in ranges of NaSS concentrations (0-2.4 x 10(-3) M), NaSS addition times (60-80 min), and monomer concentrations (0.3-0.6 M) at fixed concentrations of 1.6 x 10(-2) M initiator and 1.3 x 10(-2) M MPDMS for pH 4.5 adjusted with a buffer system of [CH3COOH]/[NaOH]. The addition of NaSS during the polymerization could maintain the dispersion stability of magnetic polymer particles during the polymerization. Selection of the reaction conditions enabled the preparation of colloidally stable, submicrometer-sized magnetic polymer particles that had coefficients of variation of distribution smaller than the standard criterion for monodispersity, 10%.

Colloids↗
PubMed2006

Pansteatitis and severe hypocalcaemia in a cat.

A 13-year-old Siamese cat was presented for investigation of lethargy and progressive abdominal enlargement. Serum chemistry revealed severe reduction of total and ionised serum calcium. The omentum appeared hyperechoic with scattered hypoechoic foci on abdominal ultrasound examination. Elevated serum parathormone and low fractional excretion of calcium excluded a parathyroid disorder and renal loss of the electrolyte. During laparotomy the omentum appeared opaque, white and firm. Post-mortem examination revealed that the thoracic and subcutaneous fat was also affected. Histopathology confirmed the diagnosis of pansteatitis with diffuse calcium soaps formation. While, severe hypocalcaemia is occasionally seen in cats, the association with pansteatitis has not been reported previously. In man, a cause-and-effect relationship between calcium soaps and hypocalcaemia is recognised, though the association is rare.

Adipose Tissue↗
PubMed2005

Effectiveness of hand-cleansing formulations containing tea tree oil assessed ex vivo on human skin and in vivo with volunteers using European standard EN 1499.

The efficacy of formulations containing tea tree oil (TTO) has been assessed in vitro in previous studies. Products that passed the European suspension test guidelines were investigated further in this study, in vivo with volunteers using the European handwashing method (EN 1499) and ex vivo using freshly excised human skin samples. The activity of 5% TTO in 0.001% Tween 80, in a hygienic skin wash (HSW) and in an alcoholic hygienic skin wash (AHSW) was investigated and compared with that of a non-medicated soft soap (SS, control). These formulations were assessed against Escherichia coli K12 as recommended by the European standard. In-vivo results showed that 5% TTO in Tween 80 and the AHSW were significantly more active than the SS after 1 min of handwashing. When assessed ex vivo, these two products were also significantly more active than the reference soap after 1 min of rubbing. Both methods showed that 5% TTO in Tween 80 was generally, although not always, more active than a handwash formulation, and that the AHSW was generally more active than the HSW, although this difference was not significant. The formulations tested, as well as the SS, were more active when assessed in vivo than ex-vivo against E. coli, although only the SS and the HSW were significantly more active in vivo. There appeared to be a pattern in the comparison between ex vivo and in vivo results. The antiseptics tested were, on average, 1.28+/-0.06 times more active when assessed in-vivo than when assessed ex vivo. Nevertheless, the main outcome of the European handwashing method is for the formulation tested to be significantly more active than the SS; both 5% TTO in Tween 80 and the AHSW achieved this both in-vivo and ex-vivo. TTO in Tween 80 and in formulations met the European in-vivo method requirements.

Administration, Cutaneous↗
PubMed2006

Alcohol-based hand rub: influence of healthcare workers' knowledge and perception on declared use.

Handrubbing with alcohol-based hand rub (AHR) is a validated alternative to handwashing. The aims of this study were to compare knowledge and declared use of AHR between different categories of healthcare worker (HCW), and to assess factors associated with the use of AHR. A standardized questionnaire was sent to all HCWs in a tertiary care university hospital. The following data were collected for each HCW: job title (physician, nurse, nursing assistant or other), sources of information about AHR; knowledge and perception of AHR and declared use of AHR in daily practice instead of unmedicated or antiseptic soap. Of 5238 questionnaires, 1811 were returned. Physicians had better knowledge about AHR than other HCWs. HCWs' knowledge of AHR efficacy and skin tolerance were independently associated with the use of AHR instead of unmedicated or antiseptic soap. The declared use of AHR differed according to professional category.

Alcohols↗
PubMed1995

Automating clinical dietetics documentation.

A review of commonly used charting formats discussed in the dietetics literature revealed that the subjective, objective assessment and planning (SOAP) approach is most frequently used by dietitians. Formats reported in the nursing literature were charting by exception (CBE); problem, intervention, evaluation (PIE); and focus/data, action, response (Focus/DAR). The strengths and weaknesses of the charting styles as they apply to the needs of clinical dietetic specialists were reviewed. We then decided to test in house the Focus/DAR format by assessing chart entries for adherence to style, brevity, and physician response. Dietitians pilot tested all the methods, but found them time consuming to use. The consensus was that SOAP could be adapted to the documentation needs of the individual situation and required little additional staff training. Often because of time limitations, a narrative summary was most appropriate. Chart entry length was reduced as much as 200% when staff were given brief clinical communication as a goal, and a further reduction when line limits were imposed. The physician response was positive, with recommendations followed in 50% of charts, compared with 34% in a previous audit. A nutrition documentation system was developed by the researchers by reviewing medical chart structure, documentation standards, methods of risk identification, and terminology for clinical documentation style. The resulting system affected the decision making of physicians, who could now scan notes more quickly and implement nutrition recommendations in a more timely fashion.

Diet Records↗
PubMedDate not supplied

Wash resistance of insecticide-treated materials.

The effectiveness of insecticide-treated materials (ITMs) for malaria control is reduced by washing them. This research in Colombia and Bolivia investigated the resistance of different insecticide formulations and, in particular, a commercially available impregnated bednet (PermaNet) which provides chemical protection for the insecticide. The fabrics studied were all polyester; the pyrethroids used for impregnation were deltamethrin (tablet and suspension concentrate both at 25 mg/m2 target dose), lambdacyhalothrin (capsule suspension at 15 mg/m2; laboratory study only), alphacypermethrin (suspension concentrate at 40 mg/m2) and, in the case of PermaNet, deltamethrin (55 mg/m2). The indicator of wash resistance was Anopheles spp. mortality (using the bioassay cone method) before and after different numbers and intensities of washing. When the fabrics were washed under controlled conditions, gently with water and a bar of soap, the wash resistance of all formulations was good (100% Anopheles mortality after 3 washes). However, when the impregnated nets were soaked for 30-60 min and washed with soap powder and tap water by local women in the usual way, the mortality after 4 washes declined considerably (43.5% and 41.3% for deltamethrin tablets and liquid respectively when washing every second day). Alphacypermethrin showed slightly better results after 3 washes every 7th day compared to deltamethrin tablets (63.8% and 43.3% mortality, respectively). The wash resistance offered by PermaNet was much better and longer lasting: Anopheles mortality after 4 washes was 92.6%, after 10 washes 83.7% and after 20 washes 87.1%. The limitations of commercially available wash-resistant nets are, however, their limited accessibility and the difficulty of replacing all existing bednets with a new product.

Analysis of Variance↗
PubMed2001

Consumers and foodborne diseases: knowledge, attitudes and reported behavior in one region of Italy.

A survey was conducted to investigate knowledge, attitudes and related behavior on foodborne diseases and food-handling practices among consumers in one region of Italy. A self-administered questionnaire was offered to a random sample of mothers of children attending public schools. Of the 394 responding mothers, 36% knew about all the six foodborne pathogens investigated but only 11.1% correctly indicated six related different food vehicles; education level was a predictor of this knowledge. A positive attitude towards foodborne disease control, significantly higher in older and more educated women, was reported by the great majority, who agreed that improper storage of food represents a health hazard (95.7%), that washing hands before handling unwrapped raw or cooked food reduces the risk of food poisoning (93.2%), and that the awareness of the temperature of the refrigerator is crucial in reducing risk of food poisoning (90.1%). Only 53.9% reported washing hands before and after touching raw or unwrapped food and 50.4% reported using soap to wash hands. A total of 75.6% clean kitchen benches after every use and 81.1% use hot water and soap for this purpose. Only 25.6% thaw food in the refrigerator and 49.9% put leftovers in the refrigerator soon after meals. Washing hands before and after touching unwrapped food was significantly higher in women living in larger families and who had been informed by physicians about foodborne diseases. Educational programs and the counseling efforts of physicians, particularly focused to less educated subjects, are greatly needed.

Adult↗
PubMed1994

Hand washing frequency in an emergency department.

STUDY OBJECTIVE: Previous studies, conducted mainly in ICUs, have shown low compliance with hand-washing recommendations, with failure rates approaching 60%. Hand washing in the emergency department has not been studied. We examined the frequency and duration of hand washing in one ED and the effects of three variables: level of training, type of patient contact (clean, dirty, or gloved), and years of staff clinical experience. DESIGN: Observational. SETTING: ED of an 1,100-bed tertiary referral, central city, private teaching hospital. PARTICIPANTS: Emergency nurses, faculty, and resident physicians. Participants were informed that their activities were being monitored but were unaware of the exact nature of the study. INTERVENTIONS: An observer recorded the number of patient contacts and activities for each participant during three-hour observation periods. Activities were categorized as either clean or dirty according to a scale devised by Fulkerson. The use of gloves was noted and hand-washing technique and duration were recorded. A hand-washing break in technique was defined as failure to wash hands after a patient contact and before proceeding to another patient or activity. RESULTS: Eleven faculty, 11 resident physicians, and 13 emergency nurses were observed. Of 409 total contacts, 272 were clean, 46 were dirty, and 91 were gloved. Hand washing occurred after 32.3% of total contacts (SD, 2.31%). Nurses washed after 58.2% of 146 contacts (SD, 4.1%), residents after 18.6% of 129 contacts (SD, 3.4%), and faculty after 17.2% of 134 contacts (SD, 3.3%). Nurses had a significantly higher hand washing frequency than either faculty (P < .0001) or resident physicians (P < .0001). Hand washes occurred after 28.4% of 272 clean contacts (SD, 2.34%), which was significantly less (P < .0001) than 50.0% of 46 dirty contacts (SD, 7.4%) and 64.8% of 91 gloved contacts (SD, 5.0%). The number of years of clinical experience was not significantly related to hand-washing frequency (P = .82). Soap and water were used in 126 of the hand washes, and an alcohol preparation was used in the remaining six. The average duration of soap-and-water hand washes was 9.5 seconds. CONCLUSION: Compliance with hand washing recommendations was low in this ED. Nurses washed their hands significantly more often than either staff physicians or resident physicians, but the average hand-washing duration was less than recommended for all groups. Poor compliance in the ED may be due to the large number of patient contacts, simultaneous management of multiple patients, high illness acuity, and severe time constraints. Strategies for improving compliance with this fundamental method of infection control need to be explored because simple educational interventions have been unsuccessful in other health care settings.

Analysis of Variance↗
PubMed1995

Stethoscopes: a potential vector of infection?

STUDY OBJECTIVES: To survey emergency care providers about their stethoscope-cleaning measures and to determine the correlation between these measures and the extent of Staphylococcus carriage. DESIGN: Prospective cross-sectional analysis. SETTING: University-affiliated community hospital ED. PARTICIPANTS: One hundred fifty health care providers, comprising emergency medicine house staff and attending physicians (n = 50), ED nurses (n = 50), and prehospital personnel working in Kent County, Michigan (n = 50). INTERVENTIONS: Providers were asked how often they cleaned their stethoscopes and which cleaning agents were used. We then cultured each stethoscope by pressing the diaphragm on mannitol agar and incubating the culture aerobically for 48 hours. Staphylococcus aureus was identified by means of standard measures. We examined the effects of different cleaning agents on 24 stethoscopes. The numbers of colony-forming units (CFUs) before and after cleaning with alcohol, nonionic detergent, and antiseptic soap were noted. RESULTS: Overall, 48% of health care providers (74 of 150) cleaned their stethoscopes daily or weekly, 37% monthly, and 7% yearly; and 7% had never cleaned their stethoscopes. No significant differences were found in the hygiene routines of the three groups of providers surveyed. Use of an alcohol swab was the preferred method of cleaning. One hundred thirty-three stethoscopes (89%) grew staphylococci; 25 (19%) yielded S aureus. Mean staphylococcal bacterial counts ( +/- SD) were 52 +/- 78 CFUs per stethoscope among physicians, 46 +/- 92 CFUs among emergency medical service personnel, and 13 +/- 21 CFUs from the nursing staff (ANOVA, P = .01). Cleaning the stethoscope diaphragm resulted in immediate reduction in the bacterial count: by 94% with alcohol swabs, 90% with nonionic detergent, and 75% with antiseptic soap. CONCLUSION: Our results confirm that stethoscopes used in emergency practice are often contaminated with staphylococci and are therefore a potential vector of infection. This contamination is greatly reduced by frequent cleaning with alcohol or nonionic detergent.

Auscultation↗
PubMed1991

Comparison of cloth, paper, and warm air drying in eliminating viruses and bacteria from washed hands.

We compared the efficiency of paper, cloth, and electric warm air drying in eliminating rotaviruses and Escherichia coli remaining on finger pads washed with 70% isopropanol, a medicated liquid soap, an unmedicated liquid soap, or tap water alone. The contaminated area on the finger pads of a volunteer was exposed to the hand-washing agent for 10 seconds and then rinsed in 40 degrees C tap water. The washed areas were dried for 10 seconds by one of the three methods. Irrespective of the hand-washing agent used, electric air drying produced the highest and cloth drying the lowest reduction in the numbers of both test organisms. These findings indicate the importance of selecting the right means for drying washed hands, particularly when less effective hand-washing agents are used.

Disinfectants↗
PubMed1997

[Peracetic acid: alternative to the sterilization of bronchofibroscopes].

The Steris system for cold sterilization with peracetic acid was evaluated by effecting a series of contaminations of a fiberoptic bronchoscope (FB) with specimens of Pseudomonas aeruginosa, Acinetobacter baumanii and Mycobacterium kansasi. The FB was contaminated 24 times, 8 times by each microorganism, using specimens containing more than 10(8) cfu/ml. After fixing the secretions on the FB and washing it with enzyme soap, the BF was sterilized. Specimens were taken for culturing after contamination of the FB, after washing, immediately after sterilization and 1 hour after sterilization. No microorganism growth of any of the samples was detected either immediately after sterilization or one hour later. Microbiological data confirmed contamination of the FB after aspiration and fixation of the inoculate. Chemical and biological tests with B. stearothermophilus spores as specified by the manufacturer were correct in all cases: 24 contaminations and 52 processes of prior training. The efficacy of washing with enzyme soap before sterilization stands out. In 14 of the 24 samples, culture was negative after washing and in 7 the concentration of microorganisms was less than 500 cfu/ml, which confirms the need for appropriate washing before any disinfection or sterilization process is begun. In conclusion, the Steris system based on peracetic acid is an alternative to other systems for cold sterilization or high level disinfection.

Acinetobacter↗
PubMed2003

Lead-revealed lipid organization in human hair.

Human hair lipids form a complex mixture of composition close to that of sebum. Part of these lipids appears in an organized state that has been studied by diffraction techniques in the literature. Nevertheless, information on the structure of these lipids remains very scarce due to their low contribution to global hair diffraction pattern. Here we show that appropriate lead treatment considerably enhances organized lipid features observed by microbeam synchrotron radiation diffraction experiments. We attribute these features to the formation of lead soaps of free fatty acids. Specific orientation of hair "lipid crystals" in planes parallel to the hair axis is clearly demonstrated. Inclusion of these lipids in the bulk of the hair shaft is shown by diffraction experiments following removal of the cuticular outermost layer of hair. Moreover, microfluorescence and diffraction experiments are consistent with part of the lipids being present as calcium soaps in native hair. We therefore consider lead fixation as a powerful tool to evaluate the lipid organization in human hair for medical, environmental and archaeological purposes, including lead poisoning.

Calcium↗
PubMed2003

Structural properties of magnesium stearate pseudopolymorphs: effect of temperature.

A thorough review of the relevant literature reveals that the interaction between water vapour and magnesium stearate, in contrast to many other metal soaps, is not properly understood. The structural modifications associated with the up-take or loss of water of vegetable-derived commercial magnesium stearate powders exposed to humid air or vacuum at room temperature are investigated using standard powder X-ray diffractometry. It is found that in such conditions magnesium stearate reacts reversibly with the vapour phase with structural consequences very similar to the high temperature transition between the crystalline and rotator phases of other anhydrous metal soaps. When temperature is increased under dry nitrogen the diffraction band characteristic of the rotator phase shifts towards higher angle values and the corresponding lattice spacing increases at the rate of 6.9x10(-4)C(-1). Melting takes place gradually above 100 degrees C as revealed by the collapse of the diffraction band and the growth of the broader diffusion band characteristic of the liquid state. Full clarification of the structure of the hydrated and dried phases proves impossible based on powder diffraction spectra obtained with conventional high resolution X-ray diffraction equipment.

Chemical Phenomena↗
PubMed2000

Modern skin cleansers.

The course of development of skin cleansers has been one of continual improvement. Soap-based products, used since antiquity, offered improved cleansing over mechanical methods or water alone but could irritate and dry skin. Bars based on synthetic detergents that offer improved skin compatibility compared with soap have become available over the past several decades. Body washes have been growing in consumer popularity. Some of the first body washes introduced into the market offered a moisturization benefit in addition to mildness. Some second-generation body washes that are now on the market use even more sophisticated formulation schemes, such as coacervate technology, to deliver emulsified petrolatum to the skin during washing, providing mild cleansing and a significant dry skin improvement benefit. Consumer demand and the formulation possibilities provided by new product formats, new technologies, and new ingredients will undoubtedly lead to the delivery of even greater skin benefits in the future.

Humans↗
PubMedDate not supplied

Pharmaceutical care research and education project: pharmacists' interventions.

OBJECTIVES: To describe the processes of care used by community pharmacists participating in the Pharmaceutical Care Research and Education Project (PREP) in terms of drug-related problems (DRPs), pharmacists' recommendations, and status of DRPs at follow-up, and to determine characteristics associated with DRPs. DESIGN: Descriptive analysis of the treatment group from a larger randomized, controlled cluster design. SETTING: Five independent community pharmacies in Alberta. PARTICIPANTS: One hundred fifty-nine patients who were covered under Alberta Health and Wellness's senior drug benefit plan (i.e., 65 years or older), were taking three or more medications concurrently according to pharmacy records, were able to complete telephone interviews as determined by pharmacists, maintained residence in Alberta for 12 of the 15 study months, agreed to receive their prescription medications only from the study pharmacy during the study period, and provided informed consent. MAIN OUTCOME MEASURES: Frequency of DRPs, recommendations, status of DRPs, and analysis of clinical results as determined during pharmacists' follow-up care. RESULTS: In telephone surveys, patients reported taking 4.7 prescription medications per day, but pharmacists documented 8.7 prescription medications per day in their records. Pharmacists documented 559 DRPs, a mean (+/- SD) of 3.9+/-3.2 problems per patient. Approximately 39% of problems were actual DRPs, while 60% were potential DRPs. Medical conditions associated most frequently with a DRP involved the respiratory, cardiovascular, and musculoskeletal systems. The most common DRP categories were "patient requires drug therapy" or "patient requires influenza or pneumococcal vaccination." Pharmacists wrote 551 initial clinical notes using the subjective, objective, assessment, plan (SOAP) format, and they recorded 346 follow-up interventions, also using SOAP notes. Counseling, preventive consultations, and clinical monitoring represented 40% of their recommendations. In 80% of situations, the pharmacist made the recommendation directly to the patient. On follow-up, 40% of the 559 DRPs identified were resolved, controlled, or improved. Patients accepted 76% of pharmacists' recommendations, and physicians accepted 72% of pharmacists' suggested resolutions of DRPs. Pharmacists were more likely to follow up about actual DRPs, as compared with potential ones; overall, they followed up on 62% of identified DRPs. CONCLUSION: Pharmacists identified more DRPs for study patients than previous community-based, observational studies have reported. Undertreatment appears to be a prevalent DRP. Community pharmacists' recommendations to prevent and resolve DRPs were made primarily to patients and were well accepted. More follow-up was needed for all DRPs. When follow-up occurred, the DRP results generally showed improvement.

Aged↗
PubMed1998

Validation of computer-mediated open-ended standardized patient assessments.

Quantitative information regarding the development of students' clinical reasoning skills is valuable in assessing third- and fourth-year medical students' clinical knowledge. Standardized patient cases are often used to obtain this quantified information. These cases typically involve a post-patient examination consisting of a series of closed-ended multiple-choice questions. Many medical educators question whether the results from the closed-ended multiple-choice questions truly reflect students' clinical knowledge and reasoning proficiency. Since 1995, the Kirksville College of Osteopathic Medicine (KCOM) has used a computer program, SOAP Note Plus, for standardized patient assessment of students to automate the post-encounter documentation and evaluation. This paper describes the development of the SOAP Note Plus program and a validation study which was conducted to determine the empirical association between the computer-mediated closed-ended and open-ended post-encounter standardized patient assessments. Correlation and GENOVA statistics were used in the analysis of the performance of third-year medical students on the closed-ended and the open-ended assessments following standardized patient encounters and the relationship to their undergraduate GPA, first 2-year medical school GPA and the actual clinical rotation evaluations. The initial results show the positive relationship between the open-ended assessment and the actual clinical rotation evaluations. undergraduate GPA and the first two-years of medical school GPA.

Clinical Competence↗