Script concordance test: an approach to the evaluation of clinical reasoning in uncertain contexts

Little research has been done in Brazilian medical education on the evaluation of clinical reasoning in situations of uncertainty. The most common tests are still multiple-choice, which are capable of evaluating skills when dealing with well-defined problems. However, in practice the majority of situations involve uncertainties. A method for the evaluation of clinical reasoning in contexts of uncertainty was developed on the basis of the cognitive script theory in relation to professional reasoning. The objectives of the research were to develop, apply, and analyze this methodology in a Brazilian educational setting, based on clinical situations in Geriatrics that involved diagnostic, therapeutic, or ethical dilemmas. A group of specialists in this area and a group of undergraduate students that were completing their training in the Geriatrics internship took the test. Comparison of the results led to evidence of the instrument's validity, capable of distinguishing clinical reasoning according to the participants' level of experience. The mean score for the specialists (80,41) was higher than that of students (70,71) (p < 0,001). In addition, analyses of the internal consistency and a G study design furnished results that are consistent with a scoring system that seeks to evaluate a professional skill. In conclusion, a proposal for a script concordance test in the Portuguese language, applied in a Brazilian teaching institution, may be a viable alternative for evaluating clinical reasoning in contexts of uncertainty.A avaliação do raciocínio clínico em situações de incerteza é pouco pesquisada na educação médica. Os testes escritos mais aplicados são de múltipla escolha, capazes de avaliar como se lida com problemas bem definidos. Porém, a maioria das situações contém incertezas. Um método de avaliação do raciocínio clínico em contextos de incerteza foi desenvolvido a partir da teoria de scripts, com situações em geriatria. Um grupo de especialistas e um grupo de estudantes de graduação resolveram o teste. Acomparação entre os resultados trouxe indícios da validade do instrumento, capaz de diferenciar o raciocínio relacionado ao nível de experiência profissional. A média dos escores dos especialistas (80,41) foi superior à dos estudantes (70,71), p < 0,001. As análises de consistência interna e um estudo G forneceram resultados que estão de acordo com metodologias que buscam avaliar uma competência profissional. Concluiu-se que uma proposta de teste de concordância de scripts em língua portuguesa aplicado em uma instituição de ensino brasileira pode ser uma alternativa para a avaliação do raciocínio clínico em contextos de incerteza.Universidade Federal de São Paulo (UNIFESP)UNIFESP, EPM, São Paulo, BrazilSciEL

Investment Incentives Under Emission Trading: An Experimental Study

This paper presents the results of an experimental investigation on incentives to adopt advanced abatement technology under emissions trading. Our experimental design mimics an industry with small asymmetric polluting firms regulated by different schemes of tradable permits. We consider three allocation/auction policies: auctioning off (costly) permits through an ascending clock auction, grandfathering permits with re-allocation through a single-unit double auction, and grandfathering with re-allocation through an ascending clock auction. Our results confirm both dynamic and static theoretical equivalence of auctioning and grandfathering. We nevertheless find that although the market institution used to reallocate permits does not impact the dynamic efficiency from investment, it affects the static efficiency from permit trading

Preliminary study on the utilization of Ca2+ and HCO3 − in karst water by different sources of Chlorella vulgaris

This article aims to present a picture of how a university discipline has been created in Lithuania, given the background of changes caused by the Lithuania’s emancipation from the Soviet Union. The theoretical frame of reference is provided by a modified model of Bronfenbrenners developmental ecology. Data collection has primarily been in the form of interviews with university staff from Lithuanian institutions for higher education. In addition to the interviews, literature lists, course schedules and other key documents have been collected and analysed. The analysis focuses on individual’s conceptualisation of three main areas. The study demonstrates how the creation of management and economics as a university discipline in Lithuania has been formed by a combination of political/ideological, economic, institutional and individual factors. One of the study’s main contributions is to highlight the significance of the concept of academic freedom and to focus on the paradox, where constraint under the old system is replaced by another form of constraint. In this case, where the rigidity of the old Soviet doctrine is replaced by a new freedom; but instead of being given greater opportunities to influence and change the subject, the academic staff are forced into a position where, once again they are subjugated to the influences of international sources

Computational and experimental study of aerosol dispersion in a ventilated room

For many respiratory diseases, a primary mode of transmission is inhalation via aerosols and droplets. The COVID-19 pandemic has accelerated studies of aerosol dispersion in indoor environments. Most studies of aerosol dispersion present computational fluid dynamics results, which rarely include detailed experimental verification, and many of the computations are complex, making them hard to scale to larger spaces. This study presents a comparison of computational simulations and measurements of aerosol dispersion within a typical ventilated classroom. Measurements were accomplished using a custom-built low-cost sensor network composed of 15 commercially available optical particle sizers, which provided size-resolved information about the number concentrations and temporal dynamics of 0.3–40 µm diameter particles. Measurement results are compared to the computed dispersal and loss rates from a steady-state Reynolds-Averaged Navier–Stokes k-epsilon model. The results show that a newly developed aerosol-transport-model can accurately simulate the dispersion of aerosols and faithfully predict measured aerosol concentrations at different locations and times. The computational model was developed with scalability in mind such that it may be adapted for larger spaces. The experiments highlight that the fraction of aerosol recycled in the ventilation system depends on the aerosol droplet size and cannot be predicted by the recycled-to-outside air ratio. Moreover, aerosol recirculation is not negligible, as some computational approaches assume. Both modeling and measurements show that, depending on the location within the room, the maximum aerosol concentration can be many times higher than the average concentration, increasing the risk of infection

Scalable production of large quantities of defect-free few-layer graphene by shear exfoliation in liquids

To progress from the laboratory to commercial applications, it will be necessary to develop industrially scalable methods to produce large quantities of defect-free graphene. Here we show that high-shear mixing of graphite in suitable stabilizing liquids results in large-scale exfoliation to give dispersions of graphene nanosheets. X-ray photoelectron spectroscopy and Raman spectroscopy show the exfoliated flakes to be unoxidized and free of basal-plane defects. We have developed a simple model that shows exfoliation to occur once the local shear rate exceeds 10(4) s(-1). By fully characterizing the scaling behaviour of the graphene production rate, we show that exfoliation can be achieved in liquid volumes from hundreds of millilitres up to hundreds of litres and beyond. The graphene produced by this method performs well in applications from composites to conductive coatings. This method can be applied to exfoliate BN, MoS2 and a range of other layered crystals

Anthropogenic perturbation of the carbon fluxes from land to ocean

A substantial amount of the atmospheric carbon taken up on land through photosynthesis and chemical weathering is transported laterally along the aquatic continuum from upland terrestrial ecosystems to the ocean. So far, global carbon budget estimates have implicitly assumed that the transformation and lateral transport of carbon along this aquatic continuum has remained unchanged since pre-industrial times. A synthesis of published work reveals the magnitude of present-day lateral carbon fluxes from land to ocean, and the extent to which human activities have altered these fluxes. We show that anthropogenic perturbation may have increased the flux of carbon to inland waters by as much as 1.0 Pg C yr-1 since pre-industrial times, mainly owing to enhanced carbon export from soils. Most of this additional carbon input to upstream rivers is either emitted back to the atmosphere as carbon dioxide (~0.4 Pg C yr-1) or sequestered in sediments (~0.5 Pg C yr-1) along the continuum of freshwater bodies, estuaries and coastal waters, leaving only a perturbation carbon input of ~0.1 Pg C yr-1 to the open ocean. According to our analysis, terrestrial ecosystems store ~0.9 Pg C yr-1 at present, which is in agreement with results from forest inventories but significantly differs from the figure of 1.5 Pg C yr-1 previously estimated when ignoring changes in lateral carbon fluxes. We suggest that carbon fluxes along the land–ocean aquatic continuum need to be included in global carbon dioxide budgets.Peer reviewe

An evidence-based framework for predicting the impact of differing autotroph-heterotroph thermal sensitivities on consumer-prey dynamics

Increased temperature accelerates vital rates, influencing microbial population and wider ecosystem dynamics, for example, the predicted increases in cyanobacterial blooms associated with global warming. However, heterotrophic and mixotrophic protists, which are dominant grazers of microalgae, may be more thermally sensitive than autotrophs, and thus prey could be suppressed as temperature rises. Theoretical and meta-analyses have begun to address this issue, but an appropriate framework linking experimental data with theory is lacking. Using ecophysiological data to develop a novel model structure, we provide the first validation of this thermal sensitivity hypothesis: increased temperature improves the consumer’s ability to control the autotrophic prey. Specifically, the model accounts for temperature effects on auto- and mixotrophs and ingestion, growth and mortality rates, using an ecologically and economically important system (cyanobacteria grazed by a mixotrophic flagellate). Once established, we show the model to be a good predictor of temperature impacts on consumer–prey dynamics by comparing simulations with microcosm observations. Then, through simulations, we indicate our conclusions remain valid, even with large changes in bottom-up factors (prey growth and carrying capacity). In conclusion, we show that rising temperature could, counterintuitively, reduce the propensity for microalgal blooms to occur and, critically, provide a novel model framework for needed, continued assessment

Population‐based cohort study of outcomes following cholecystectomy for benign gallbladder diseases

Background The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all‐cause 30‐day readmissions and complications in a prospective population‐based cohort. Methods Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all‐cause 30‐day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two‐level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics

Elevated Plasma Corticosterone Decreases Yolk Testosterone and Progesterone in Chickens: Linking Maternal Stress and Hormone-Mediated Maternal Effects

Despite considerable research on hormone-mediated maternal effects in birds, the underlying physiology remains poorly understood. This study investigated a potential regulation mechanism for differential accumulation of gonadal hormones in bird eggs. Across vertebrates, glucocorticoids can suppress reproduction by downregulating gonadal hormones. Using the chicken as a model species, we therefore tested whether elevated levels of plasma corticosterone in female birds influence the production of gonadal steroids by the ovarian follicles and thus the amount of reproductive hormones in the egg yolk. Adult laying hens of two different strains (ISA brown and white Leghorn) were implanted subcutaneously with corticosterone pellets that elevated plasma corticosterone concentrations over a period of nine days. Steroid hormones were subsequently quantified in plasma and yolk. Corticosterone-implanted hens of both strains had lower plasma progesterone and testosterone levels and their yolks contained less progesterone and testosterone. The treatment also reduced egg and yolk mass. Plasma estrogen concentrations decreased in white Leghorns only whereas in both strains yolk estrogens were unaffected. Our results demonstrate for the first time that maternal plasma corticosterone levels influence reproductive hormone concentrations in the yolk. Maternal corticosterone could therefore mediate environmentally induced changes in yolk gonadal hormone concentrations. In addition, stressful situations experienced by the bird mother might affect the offspring via reduced amounts of reproductive hormones present in the egg as well as available nutrients for the embryo

The regional and global significance of nitrogen removal in lakes and reservoirs

Author Posting. © The Author(s), 2008. This is the author's version of the work. It is posted here by permission of Springer for personal use, not for redistribution. The definitive version was published in Biogeochemistry 93 (2009): 143-157, doi:10.1007/s10533-008-9272-x.Human activities have greatly increased the transport of biologically available N through watersheds to potentially sensitive coastal ecosystems. Lentic water bodies (lakes and reservoirs) have the potential to act as important sinks for this reactive N as it is transported across the landscape because they offer ideal conditions for N burial in sediments or permanent loss via denitrification. However, the patterns and controls on lentic N removal have not been explored in great detail at large regional to global scales. In this paper we describe, evaluate, and apply a new, spatially explicit, annual-scale, global model of lentic N removal called NiRReLa (Nitrogen Retention in Reservoirs and Lakes). The NiRReLa model incorporates small lakes and reservoirs than have been included in previous global analyses, and also allows for separate treatment and analysis of reservoirs and natural lakes. Model runs for the mid-1990s indicate that lentic systems are indeed important sinks for N and are conservatively estimated to remove 19.7 Tg N yr-1 from watersheds globally. Small lakes (< 50 km2) were critical in the analysis, retaining almost half (9.3 Tg N yr-1) of the global total. In model runs, capacity of lakes and reservoirs to remove watershed N varied substantially (0-100%) both as a function of climate and the density of lentic systems. Although reservoirs occupy just 6% of the global lentic surface area, we estimate they retain approximately 33% of the total N removed by lentic systems, due to a combination of higher drainage ratios (catchment surface area : lake or reservoir surface area), higher apparent settling velocities for N, and greater N loading rates in reservoirs than in lakes. Finally, a sensitivity analysis of NiRReLa suggests that, on-average, N removal within lentic systems will respond more strongly to changes in land use and N loading than to changes in climate at the global scale.The NSF26 Research Coordination Network on denitrification for support for collaboration (award number DEB0443439 to S.P. Seitzinger and E.A. Davidson). This project was also supported by grants to J.A. Harrison from California Sea Grant (award number RSF8) and from the U.S. Geological Survey 104b program and R. Maranger (FQRNT Strategic Professor)