Comprehensive clinical assessment as the cornerstone of an accurate diagnosis - hypertrophic cardiomyopathy unmasked by mephedrone exposure in a young male.

Curriculum Management and Governance Structure ♦ The medical school adopted a centralized governance structure with its revised curriculum in 1992. ♦ Centralized governance has worked very well to ensure student achievement, interdisciplinary approaches to teaching and learning, ample and centralized support for medical education, and high-quality courses and instructors. ♦ Under the guidance of the associate dean for medical education, the curriculum is managed by directors in Component I, Component II, and Components III and IV, who all meet biweekly as a working committee. ♦ Component directors and assistant directors are appointed and funded by the associate dean for medical education. ♦ Major policy issues are managed by the Curriculum Policy Committee (CPC), which is composed of elected and appointed faculty members and medical students. ♦ A rigorous evaluation system, managed by a distinct office and staff with direction from a medical school faculty member, is monitored by the CPC. Office of Education ♦ The school's centralized governance structure for undergraduate medical education is administered through the Office of Medical Education. ♦ The associate dean for medical education has consolidated all activities in support of the curriculum for the MD degree in the medical school's Learning Resource Center (LRC), where students and faculty have access to support staff and resources, computers and printers, professional computer consultants, computer-based faculty development stations, small-group study rooms, classrooms and lecture halls, microscopes, the standardized patient program, and clinical skills examination rooms. Budget to Support Educational Programs ♦ The associate dean for medical education provides guidance and funding to faculty who lead each of the components of the curriculum (component directors and assistant directors), as well as the director and assistant directors of the Introduction to the Patient course, the standardized patient program, and the comprehensive clinical assessment. ♦ There is also centralized funding available for curriculum innovations and improvements, including development of new courses, sequences, and electives; new approaches to education and assessment; and computer-based enhancements and exercises. Funding for the curriculum and curriculum leaders was established in 1992 and has been increased by the dean over the last several years. ♦ In 1997, the school began quantifying the cost of medical education using an activity-based cost-accounting model. With information from faculty and administrators applied to the model, the school is now redistributing funding to departments based on actual educational costs, and also centralizing additional funding to support medical education under the aegis of the associate dean for medical education. Valuing Teaching ♦ The dean's office directly funds faculty members who are key leaders and administrators in the medical school curriculum. ♦ In the first two years, every faculty member with three or more contact hours in the curriculum is evaluated by students; in the clinical years students evaluate residents and faculty with whom they work. ♦ Individual faculty, course/clerkship directors, and department chairs may request student evaluations at any time. ♦ Documentation of the amount and quality of teaching provided is required by the medical school's promotion committees; a teaching portfolio template is provided via the Web for faculty to document their teaching contributions. ♦ All teaching faculty are encouraged to use evaluations of their courses and access to educational experts and computer consultants to develop innovative approaches to teaching and learning. Funding for such efforts is provided to faculty by the associate dean for medical education. ♦ The medical school has expanded its recognition of teaching by adding the Medical Student Award for Teaching Excellence to its more traditional awards. This award recognizes those faculty evaluated most highly by the medical students for their outstanding teaching, and is bestowed on eight faculty each year. CURRICULUM RENEWAL PROCESS Learning Outcomes ♦ The school's goals of medical education were created by the faculty in 1991, prior to development of the revised curriculum. The goals state specifically expectations for medical student progress and achievement in the curriculum. ♦ The goals were reviewed and formally reaffirmed by the faculty and the medical school executive committee in 1996. ♦ A curriculum blueprint, updated by faculty every two or three years, identifies specific knowledge, skills, and competencies every medical student must possess prior to graduation from medical school. This blueprint is used as a guide for content in all four years of the curriculum. ♦ Each course, sequence, and clerkship has specific published objectives to be met by medical students as measured by the course director; each clerkship director also has responsibility for ensuring student learning in specific areas (e.g., signs and symptoms) identified and agreed upon by the faculty director of the clinical years and the clerkship directors. Changes in Pedagogy Over the past decade biomedical research has become less based in the traditional scientific disciplines, and more integrative, especially with the expansion of knowledge in molecular biology and medical genetics. Further, learning occurs most effectively in a context that simulates the setting in which knowledge and skills will be applied. ♦ The first- and second-year medical curriculum is designed to enhance integration across the biomedical sciences with presentation of material and learning experiences in a clinical context, including communication and physical examination skills. ♦ Small-group discussions, laboratories, and computer/Web-based exercises augment traditional instruction, and weekly clinically-based multidisciplinary conferences re-inforce learning. ♦ The school is in the process of integrating specific disciplines into segments of the curriculum across all four years. ♦ Multiculturalism, complementary medicine, and geriatrics are just a few of the topics that are being integrated into the context of existing courses and sequences, with a focus on the patient's perspective. The topics are presented to students in the manner in which patients will present their medical problems to their physicians. This approach will encompass traditional and computer/Web-based instruction, standardized patient exercises, and patients and role models in clinics and hospitals. ♦ The effectiveness of the core curriculum and its integration into existing educational programs is assessed annually; methods will include the Comprehensive Clinical Assessment. ♦ An “educational consultant” model will also be implemented, which will allow students who have seen a particular patient in the clinic or who have worked through a case to present questions via the Web to a UM specialist, who will respond within 24 hours. ♦ Student progress in the specific disciplines is assessed at least once a year, and models to allow students to assess their own knowledge and skill in these areas are being developed. ♦ Instructional modules available via the Web have been introduced in several of the required clerkships to ensure consistent student learning and mastery of required material. The modules were developed by clerkship directors and their colleagues with computer consultants in the Office of Medical Education; they are case-based, interactive, and incorporate self-paced instruction and self-assessment components. ♦ Instructional standardized patient instructor (SPI) exercises have been incorporated across all four years of the curriculum; SPIs are also used for assessment of student knowledge and skills in most of the stations on the Comprehensive Clinical Assessment. ♦ All of the student encounters are videotaped, and students with marginal or failing performances return to review and discuss their encounters with the faculty director of the SPI program, prior to repeating the exercise. ♦ Communications skills and professionalism in encounters with SPIs are reviewed separately, and students must perform satisfactorily to receive a passing grade. Students must pass all SPI exercises to be promoted and to graduate. Application of Computer Technology ♦ Medical students are not required to own their own computers, but support is available to those who bring computers with them to medical school. ♦ There are 90 computers in the Learning Resource Center (LRC), another 26 computers in medical student study areas to which they have access 24 hours a day, seven days a week, and 15 computers in the UM Hospitals medical student call rooms. There are also “E-mail express” computers available to students in the LRC and the student study areas. ♦ The school has created Web-based “Coursepages” for medical students, through which students have access to a variety of information, services, and original educational materials developed by LRC computer consultants with medical school faculty. Using the Coursepages, students can access a variety of administrative and educational materials, including interactive educational materials developed by medical school faculty, calendars and schedules, and quiz and exam scores. They can submit “queries” about exam items, check course and clerkship grades, complete course and teacher evaluations, submit changes of their addresses, check their university accounts, and access Medline and other Web-based resources. Students can use and take practice quizzes. ♦ Required first-year quizzes are administered weekly to students via the Web in the LRC. The third-year pattern-recognition examinations, administered five times throughout the year, are also available to students via the Web. ♦ The LRC's faculty development stations provide faculty with state-of-the-art hardware, software, and professional consultation to introduce them to technology they can use to upgrade existing teaching materials or create new computer-based materials for use in the classroom. There is no charge to the faculty for use of the stations or for consultation. Changes in Assessment ♦ The Comprehensive Clinical Assessment (CCA), an OSCE-format examination, measures knowledge, skills, and competencies the faculty have identified as fundamental for graduation. ♦ The CCA is a four-hour examination comprising 12 stations that each student undergoes early in the fourth year. ♦ Content varies year to year to ensure appropriate sampling of critical clinical skills and competencies, and is determined by a faculty director and committee using the curriculum blueprint as a guide. ♦ To graduate, students must pass each station and the CCA overall, and must also pass a cross-station professional-skills component of the exam. ♦ With funding from the National Board of Medical Examiners Medical Education Research Fund, the school has expanded efforts to learn more about medical student self-assessment. Over the last several years, the school has examined self-assessment in each year of medical school and across a wide range of tasks, and has also explored predictors and behavioral implications of self-assessment accuracy. Studies to date have yielded a number of findings, including (1) self-assessment accuracy does not appear to relate to personal or academic variables, including academic performance, academic background or preparation, ethnicity, or gender, and (2) self-assessment accuracy may be slightly greater with more familiar tasks, suggesting a possible role for learning and experience. Upcoming studies focus on the dynamics of self-assessment and self-directed learning in medical education, and begin to examine interventions that might augment these skills. One study extends previous work from undergraduate medical education into graduate medical education, and another compares problem-based learning with learning in a more traditional curriculum to study both generalizability of previous results and the impact of curricular format on self-assessment and self-directed learning. Clinical Experiences ♦ Clinical experiences begin early in the first year with students' shadowing physicians in physicians' offices and clinic settings. Small-group discussions of specific topics, with each group facilitated by a physician and an educational expert, augment the shadowing experience. ♦ In the second year, each student is assigned to a clinical skills instructor (CSI) with whom the student will conduct five histories and physical exams throughout the year. There are two new models in place for the CSI experiences: The first model is focused on early clinical skills and is predicated on bringing the patient and the physician—teacher to the student in a student-centered educational setting within the LRC. Physicians and their patients meet with individual students in the LRC clinical skills laboratories. Students do a history and physical exam on the patient under supervision, write up findings/observations, and present the patient to the faculty. This approach provides the opportunity for direct real-time feedback to the students, with videotaping availability to critique student—patient interactions, including communication skills. The second model is based at the Northeast Ann Arbor ambulatory care facility, and is designed to enhance clinical education in the ambulatory setting in a structured rotation involving student, patient, and physician. Again, the experience is centered on the student—patient interaction, with supervision and feedback from the physician—teacher. Students spend one half day in clinic with physicians. Each student meets independently with a patient and conducts a history and physical exam. While the student writes up findings and observations, the physician examines the patient the student has seen. The student then presents the patient to the physician, who provides direct real-time feedback/instruction to the student, which may include returning to meet with the patient. ♦ Each of the clinical clerkships provides students with in-patient and outpatient educational experiences to ensure that specific learning objectives are met. “Educational consultants” (see changes in Pedagogy section above) who are specialists in specific domains will augment learning that occurs as students encounter real patients in the hospitals and clinics. Clerkship faculty can also develop computer- and patient-based cases; students can work through the cases to ensure mastery of specific competencies and seek input and guidance from the Educational Consultants. Curriculum Review Process ♦ In 1992 the school developed and adopted a centralized system for evaluation of the curriculum and teaching. ♦ The Curriculum Evaluation Office is managed by the director of the Office of Educational Resources and Research (OERR), who provides analyses of evaluation data and information and recommendations to faculty curriculum directors, the associate dean for medical education, and the Curriculum Policy Committee. A research associate manages the curriculum evaluation process and data, with assistance from an academic secretary. ♦ The Curriculum Policy Committee oversees the evaluation process and receives and acts on evaluation reports. ♦ The school evaluates six distinct areas of the curriculum, using a variety of internal and external measurements. Data are collected throughout each of the four years and at the conclusion of each academic year, and a full evaluation cycle is completed every four years. Follow-up evaluations of students by residency program directors occur one and three years after graduation. See Table 1 for more information about the evaluation process.TABLE 1: The Evaluation Process♦ Evaluation instruments. The annual survey instruments are organized to measure achievement of the ten goals of medical education. To facilitate the comparison of students' educational experiences across all four components, comparable evaluation instruments are structured with a core of common items. Though different evaluation forms are used to assess clinical and basic science teaching, core evaluation items are included on all forms. Course, sequence, and clerkship directors may add additional items to their course, sequence, or clerkship evaluation instruments in order to capture information relevant to their unique educational offerings. ♦ Student evaluations of teachers and curriculum Components I and II: Students are randomly assigned to four different cohorts (approximately 42 students per cohort), each of which is responsible for evaluating selected educational experiences during a half semester. Thus, 100% of the class is involved in the evaluation process, but no student is involved for more than half of a term. During their assigned half-term, students are asked to complete evaluations of faculty presentations, courses, and multidisciplinary conferences. All faculty with three or more hours of contact with students are evaluated, and faculty with fewer contact hours can request to be evaluated. All students participate in end-of-year component surveys. Components III and IV: In Component III, all students complete clerkship and clinical faculty teaching evaluations at the conclusion of each of the required clerkships. Each Friday, all students complete an evaluation on the Component III weekly seminars. The overall Component III experience is evaluated at the middle and end of the academic year by all students. In Component IV, all students are asked to complete an evaluation of their first six months of clinical rotations. At the end of Component IV, students are asked to complete an evaluation of Component IV overall, and also to share their impressions of the four-year curriculum. Two years ago, the school shifted its evaluation process from paper-and-pencil to Web entry. Students can now enter their evaluations and comments directly via the Web, and the program allows easy tracking of students to remind those who have not completed their evaluations. Program in Professionalism ♦ The University of Michigan Medical School has developed a comprehensive program to ensure that students understand the importance of professionalism in medical practice and acquire appropriate professional skills prior to graduation. ♦ The program begins during orientation to medical school with an oncologist who presents one of his or her patients and the patient's spouse. They all speak candidly to the class about the patient's cancer, the patient's relationship with the physician, the patient's personal and medical experiences since diagnosis, and the effects of the illness on the patient's life and family. Students are then encouraged to participate, and many ask probing and thoughtful questions about the difficulty of breaking bad news to patients, the essence and significance of the physician—patient—family relationship, trust, compassion, ethics, and personal and professional values and beliefs. ♦ The program in professionalism is incorporated throughout the four years of medical school, with assessments and feedback along the way. Specific components are physician—patient presentations (in the first and second years) small-group discussions (based on specific cases and experiences) scripted encounters with standardized patients (in all four years) role models (in all four years) concern/commendation cards assessment of professional behavior on all clinical clerkships assessment of professional behavior on the annual Comprehensive Clinical Assessment formal presentations by physicians about professional behavior (orientation, seminars in medicine, specific course/clerkship exercises) ♦ During the standardized patient encounters, the clinical clerkships, and the Comprehensive Clinical Assessment, student professionalism is assessed as a separate domain and followed longitudinally. Those students whose skills are below a certain level are provided with feedback and required to complete and pass remedial exercises. Demonstration of appropriate and consistent professional characteristics is a stated and published requirement for graduation. Future Goals and Challenges ♦ There will be an increased emphasis on the development of communication skills and recognition of the importance of the personal and social context in providing health care to patients. ♦ There will be a continued emphasis on and assessment of professionalism and professional characteristics. ♦ There will be incorporation of additional student-centered learning approaches into the curriculum (e.g., the Educational Consultant model). ♦ The integration of specific topics and assessment of mastery throughout the four-year curriculum will be continued. ♦ There will be continued development of educational experiences to prepare students for practice in evolving health care delivery settings and medical management models.

Overactive bladder is a common problem affecting the UnitedKingdom adult female population. Symptoms include urinary urgency, with or without urgency incontinence, increased daytime urinary frequency and nocturia. Initial conservative treatments for overactive bladder are unsuccessful in 25-40% of women (refractory overactive bladder). Before considering invasive treatments, such as botulinum toxin injection-A or sacral neuromodulation, guidelines recommend urodynamics to confirm diagnosis of detrusor overactivity. However, the clinical and cost effectiveness of urodynamics has never been robustly assessed. To compare the clinical and cost effectiveness of urodynamics plus comprehensive clinical assessment versus comprehensive clinical assessment only in the management of refractory overactive bladder in women. Parallel-group, multicentre, superiority, open-label, randomised controlled trial. Allocation by remote web-based randomisation (1 : 1 ratio). The cost-effectiveness analysis took the National Health Service perspective with a model-based lifetime time horizon, as informed by a within-trial analysis. Sixty-three UnitedKingdom secondary and tertiary hospitals. Women aged ≥ 18 years with refractory overactive bladder or urgency-predominant mixed urinary incontinence who had failed conservative management and pharmacological treatment and were being considered for invasive treatment. Women were excluded if any of the following criteria were met: predominant stress urinary incontinence; previous urodynamics in last 12 months; current pelvic malignancy or clinically significant pelvic mass; bladder pain syndrome; neurogenic bladder; urogenital fistulae; previous treatment with botulinum toxin injection-A or sacral neuromodulation for urinary incontinence; previous pelvic radiotherapy; prolapse beyond introitus; pregnant or planning pregnancy; recurrent urinary tract infection where a significant pathology has not been excluded; and inability to give an informed consent. Urodynamics plus comprehensive clinical assessment (urodynamics arm) versus comprehensive clinical assessment only. Participant-reported success at the last follow-up time point as measured by the Patient Global Impression of Improvement. Primary economic outcome was incremental cost per quality-adjusted life-year gained as modelled over the lifetime of participants. A total of 1099 participants were included: 550 randomised to the urodynamics arm and 549 to the comprehensive clinical assessment only arm. At the final follow-up time point, participant-reported success rates of 'very much improved' and 'much improved' were not superior in the urodynamics arm (117 participants; 23.6%) comparedto the comprehensive clinical assessment only arm (114 participants; 22.7%) [adjusted odds ratio 1.12 (95% confidence interval 0.73 to 1.74); p = 0.601]. Serious adverse events were low and similar between groups. Based on the estimated incremental costs and quality-adjusted life-years of urodynamics (£463 and 0.011, respectively), the incremental cost-effectiveness ratio was £42,643 per quality-adjusted life-year gained. The cost-effectiveness acceptability curve shows that urodynamics has a 34% probability of being cost-effective at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year gained. This probability reduced further when the results were extrapolated over the patient's lifetime. Limitations include: only short-term outcomes were available, and as most participants underwent botulinum toxin injection-A treatment, pre-planned secondary analyses for some outcomes such as sacral neuromodulation were not possible. Participant-reported success in the urodynamics arm was not superior to the comprehensive clinical assessment only arm at 15-months follow-up. Urodynamics is not cost-effective at athreshold of £20,000 per quality-adjusted life-year gained. Longer-term follow-up is required to explore need for further interventions and treatments and their effect on the clinical and cost-effectiveness analyses. This trial is registered as ISRCTN63268739. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 15/150/05) and is published in full in Health Technology Assessment Vol. 29, No. 27. See the NIHR Funding and Awards website for further award information.

Introduction Residential care has been the mainstay of long-term care delivery systems in industrialized countries for decades. However, changes in acute care financing; individuals' preferences for remaining in the community; and the ageing of the elderly population mean that individuals with increasing frailty and impairments occupy these long-term care facilities. Most long-term care systems have evolved idiosyncratically as countries have faced different demographic imperatives and responded to different regulatory and medical-care systems. The need to characterize the needs of the population of long-term care users and the types and quality of services they receive has come to the forefront as the acuity of long-term care facilities has increased and as countries attempt to rebalance these budgets in order to provide more community support. This chapter describes the development of a comprehensive clinical and functional assessment instrument – the nursing home Resident Assessment Instrument (RAI), more commonly known as the Minimum Data Set (MDS). This was designed in the United States on the basis that the proper provision of the complex care needed by frail older persons is predicated upon a comprehensive clinical assessment and it is the absence of such that underlies deficient quality of care. Originally intended as a clinical care planning tool, this minimum set of clinical and demographic data on all nursing home residents has been adapted as a vehicle for determining payment levels and to monitor the quality of care.

Objectives To describe the comprehensive clinical paediatric assessment of a representative sample of children and adolescents (young people) sentenced to detention in Western Australia (WA) and participating in the first Fetal Alcohol Spectrum Disorder (FASD) prevalence study. Settings Individuals with FASD have lifelong difficulties with memory, attention, communication, emotional regulation and social skills with associated risk of engagement with juvenile justice. We found prevalence of FASD in 36% of young people sentenced to juvenile detention in WA. This paper describes the comprehensive clinical paediatric assessment of all young people participating in this study. Participants All young people aged 10–17 years 11 months and sentenced to detention in WA were eligible. All assessments were completed by a multidisciplinary team comprising a speech and language pathologist, occupational therapist, neuropsychologist and a paediatrician. Results In all, 103 young people completed the comprehensive clinical paediatric assessment, with maximum number of males (93%) and Aboriginal Australians (73%). One in two participants reported someone close to them, or themselves, having experienced a frightening event with associated symptoms of post-traumatic stress. One-third (36%) of participants had experienced suicide of a family member. Half of the young people had one or no parent (53%), an incarcerated sibling (44%) or an incarcerated family member (57%). One-fifth of participants talked about experiences of emotional neglect (20%), physical neglect (19%), physical abuse (21%) and suicidal ideation (18%). More than half (60%) of participants were 1 year or more behind their school-year grade according to their chronological age, and 73% reported waking tired. Polysubstance use was common, including cigarettes (82%), marijuana (76%), alcohol (66%) and methamphetamine (36%). Almost two-thirds (64%) had abnormal neuromotor findings, 47% reported head injury without hospitalisation, 38% had prior musculoskeletal injuries, 29% had impaired motor skills and 15% had abnormal visual fields. Conclusion Comprehensive clinical paediatric assessment of young people sentenced to detention in WA found significant psychosocial and physical difficulties. The findings of multiple and serious impairments and health issues, through completion of comprehensive clinical paediatric and multidisciplinary health and neuro-developmental assessments for this study, support their routine provision to all young people on entry to systems of juvenile justice.

Overactive bladder is a common problem affecting women worldwide, with a negative effect on their social and professional lives. Before considering invasive treatments, guidelines recommend urodynamics to identify detrusor overactivity. However, the clinical-effectiveness and cost-effectiveness of urodynamics has never been robustly assessed in this cohort of women. We aimed to compare the clinical-effectiveness and cost-effectiveness of urodynamics plus comprehensive clinical assessment (CCA) versus CCA only in the management of women with refractory overactive bladder symptoms. We did a multicentre, superiority, parallel, open-label, randomised controlled trial in 63 UK hospitals. Women aged 18 years or older with refractory overactive bladder or urgency predominant mixed urinary incontinence, with failed conservative management and being considered for invasive treatment, were randomly assigned (1:1) to urodynamics plus CCA versus CCA only. Assignment used an internet-based application with stratified random permuted blocks and site and baseline diagnosis as stratum. Primary outcome was participant-reported success at the last follow-up timepoint, measured by the Patient Global Impression of Improvement at 15 months after randomisation. Primary economic outcome was incremental cost per quality-adjusted life-year (QALY) gained modelled over the participants lifetime. Analysis was based on the intention-to-treat principle. This study is registered with ISRCTN registry (ISRCTN63268739). Between Nov 6, 2017, and March 1, 2021, 1099 participants were randomly assigned to urodynamics plus CCA (n=550) or CCA only (n=549). At the final follow-up timepoint, participant-reported success rates of "very much improved" and "much improved" were not superior in the urodynamics plus CCA group (117 [23·6%] of 496) versus the CCA-only group (114 [22·7%] of 503; adjusted odds ratio 1·12 [95% CI 0·73-1·74]; p=0·60). Serious adverse events were low and similar between groups. Incremental cost-effectiveness ratio was £42 643 per QALY gained. The cost-effectiveness acceptability curve showed urodynamics had a 34% probability of being cost-effective at a willingness-to-pay threshold of £20 000 per QALY gained, which reduced further when extrapolated over the patient's lifetime. In women with refractory overactive bladder or urgency predominant mixed urinary incontinence, the participant-reported success in the urodynamics plus CCA group was not superior to the CCA-only group, and urodynamics was not cost-effective at the £20 000 per QALY gained threshold. UK National Institute for Health and Care Research Health Technology Assessment Programme.

Assessing and monitoring treatment quality within graduate courses are vital for maintaining high standards and addressing areas needing improvement. In this study, we evaluated the treatment quality delivered by measuring the total scores obtained from the comprehensive clinical assessment (CCA) index and the objective grading system (OGS) index. This study aimed to evaluate the quality of orthodontic treatments administered by graduate students by using the CCA index and OGS index. The research was carried out at the Orthodontic Department of Mashhad School of Dentistry, focusing on a cross-sectional analysis of orthodontic treatments administered by graduate students. The study randomly selected 36 cases from the department's archives and evaluated them through pre- and post-treatment analyses, including radiographs, photographs, and dental casts. The evaluation employed the CCA and the OGS indices. Data analysis was performed using the Spearman and Mann-Whitney tests. The CCA correlated with the patient's age and gender and was statistically significant (P = 0.007 and P = 0.010, respectively). The CCA index was substantially associated with treatment duration (P = 0.032 a). There was no significant relationship between OGS and CCA (P = 0.223). The mean of post-treatment OGS was 18.97. All criteria of OGS and the overall score were improved significantly (P < 0.001). The results of this study suggested that orthodontic treatment results provided by the investigated program have high scores and meet high standards of the CCA and OGS indices.

Treatment outcomes in a graduate orthodontic clinic for cases defined by the American Board of Orthodontics malocclusion categories

University of Michigan Medical School

This investigation compares the treatment outcome of early treatment (in the mixed dentition) with that of late treatment (early permanent dentition) using objective evaluation criteria. Pretreatment and post-treatment records of all patients (n = 512) completed from 1998 to 2000 in the graduate orthodontics clinic at the Indiana University School of Dentistry (IUSD) were evaluated by the American Board of Orthodontics Objective Grading System (ABO OGS) and Comprehensive Clinical Assessment (CCA) method developed at IUSD. Two definitions of early treatment were used in this study: (1) all patients started in the mixed dentition with early-treatment objectives and (2) female individuals were <10 years and male individuals were <10.5 years of age when treatment began. Comparison of the final results between early- vs late-treatment groups showed that the early-treatment group had significantly longer treatment time and worse CCA scores than the late-treatment group, regardless of the definition of the early-treatment group or whether the early-debond (premature treatment termination) cases were included or not. There was no significant difference between early- and late-treatment groups regarding the ABO OGS score, which indicated that the CCA method is more sensitive in detecting compromised outcomes for patients with long treatment times. Prematurely terminated treatment was more prevalent in the early-treatment group than in the late-treatment group. In this large sample of consecutive patients (n = 512), the disadvantages of early treatment was prolonged treatment time, worse CCA score, and a higher incidence of premature termination of treatment, which was attributed to patient/parent "burn-out."

Background/Objective: The most effective strategy for addressing users’ prosthetic needs is a comprehensive clinical assessment that provides a holistic understanding of the individual’s symptoms, health, function, and environmental barriers and facilitators. A standardized evaluation form would provide guidance for a structured approach to comprehensive clinical assessments of people with LLA. The objective of this study was to determine a list of relevant elements to be included in prosthetic evaluation for adults with lower limb amputation. Methods: Three independent focus group discussions were conducted with prosthetists (n = 15), prosthesis users (n = 11), and decision makers (n = 4) to identify all relevant elements that should be included in the clinical assessment of prosthetic services. The final content was then determined using the Delphi technique, with 35 panelists (18 prosthetists and decision makers, and 17 prosthesis users) voting in each round. Results: A total of 91 elements were identified through the focus group, of which 78 were included through the Delphi process. The identified elements are mostly related to the physical health of the prosthesis user (e.g., mobility, pain, and medical information), while others address personal or psychosocial aspects (e.g., activities of daily living, goals, and motivation) or technical aspects (prosthesis-related). Conclusions: Through a Delphi consensus, a list of relevant elements to be included in a prosthetic evaluation was generated. These results will inform the development of a standardized clinical prosthetic assessment form. This form has the potential to improve the quality of clinical evaluations, guide interventions, and enhance the well-being of prosthetic users.

Poor performance on a medical school comprehensive clinical skills assessment after core clerkships requires remediation. Little is known about techniques used to remedy students' skills deficits and their effectiveness. The authors identified remediation strategies used at U.S. medical schools and determined instructors' confidence in remediation. In the fall of 2007, the authors surveyed persons responsible for remediation at U.S. medical schools that conduct comprehensive clinical assessments and remediation. Respondents reported their use of four types of remediation strategies: (1) clinical activities, (2) independent study, (3) precepted video review of exam recording, and (4) organized group activities for deficits in history-taking, physical examination, knowledge, clinical reasoning, professionalism, and communication. The authors assessed confidence in remediation for the six skill areas and analyzed these measures using repeated-measures analysis of variance. Fifty-three of 71 (74.6%) participants responded. Educators most commonly employ the precepted video review remediation activity across the six skill areas, and they use the clinical activities least commonly. Confidence in remediating the six skill areas was below the "agree" level. Confidence was highest for remediating history-taking and physical examination problems and lowest for professionalism. Educators express modest confidence in remediating fourth-year students' clinical skills deficiencies. The finding that schools employ primarily video review for remediation suggests a potential need to augment opportunities for mentored skills practice to address deficits more effectively. The remediation literature similarly stresses the importance of multiple approaches tailored to particular deficits.

Clinical assessment of orthodontic outcomes with the peer assessment rating, discrepancy index, objective grading system, and comprehensive clinical assessment

To estimate the cost-effectiveness of using invasive urodynamic studies (UDS) in the management of women with refractory overactive bladder (OAB) symptoms using the results of the FUTURE trial. The FUTURE study is the largest randomised controlled trial evaluating the clinical effectiveness of UDS with comprehensive clinical assessment (CCA) in this patient population compared to CCA only. We developed an economic model that replicates the 24-month results of FUTURE, then models the lifetime costs and quality-adjusted life-years (QALYs) using long-term studies of treatment outcomes. Over the patient cohort's lifetime the UDS plus CCA group is £1380 more costly and is associated with 0.002 fewer QALYs than the CCA only group, with only a 23.4% chance of being cost-effective at £20 000 per QALY gained. The sensitivity analysis shows that the results are robust to all changes except for the use of parameters based on the complete case analysis of the FUTURE trial. For the subgroup of patients with an initial diagnosis of mixed urinary incontinence, the UDS group gains more QALYs than the CCA group, albeit at a higher cost. The incremental cost-effectiveness ratio for UDS is £26 462, with a probability of being cost-effective of 45.3% at £20 000 per QALY gained and 53.8% at £30 000 per QALY gained. The use of UDS in women with a diagnosis of OAB and whose condition is refractory to initial medical and conservative treatments is unlikely to be cost-effective when examined from a UK perspective and with a lifetime horizon. Despite having access to the FUTURE study data, the parameterisation of the model is limited by the current evidence base. An ongoing long-term follow-up study will help reduce these uncertainties.

Universal developmental screening is recommen-ded at 9, 18, 24 and 36 months. The Government of India Mother and Child Protection (MCP) card is an immunization record that is used to monitor child development, and identify children requiring further evaluation. To determine the diagnostic accuracy of the MCP card for developmental screening, and perform its item analysis. Mixed-method study (prospective study of diag-nostic accuracy and qualitative study). Mother-child dyads of children between 2-36 months of age were recruited from the outpatient department or wards of a tertiary level children's hospital from November, 2019 to October, 2021. Children with confirmed neurodevelopmental disorders/disability, and mothers with less than 6th standard education were excluded. Each mother was given a MCP card, and taught how to mark the items. This was followed by the researcher's evaluation (index tool). The reference tool was a comprehensive clinical assessment (CCA) by the researcher and an expert. The CCA included clinical examination of hearing, vision, and neuro-development; and psychometric assessment of development and adaptive function. Each mother underwent an in-depth inter-view. Overall and group wise psychometric properties of diagnostic accuracy were computed. The interview transcripts were analyzed thematically. The proportion of children with 'fail' and 'delay' by the evaluation of the researcher with the MCP card and the expert by the CCA, respectively. The study population included 213 children (40.4% females). Fifty-two (24.4%) children were identified as 'Fail' by the MCP card and 43 (20.2%) as 'delay' by the expert's CCA. The overall sensitivity and specificity was 83.7% (95% CI 69.3-93.2) and 90.6% (95% CI 85.2-94.5), respectively. Acceptable diagnostic accuracy was found in the age-group 7-9 months, 13-18 months, and 25-36 months. The MCP card may be used for developmental screening at 9, 18, and 36 months.

Dear Editor, Low back pain (LBP) is not a disease itself, but it can be a sign of number of a number of conditions, such as pain near the midline, which can occasionally be localized sometimes, and occur between the inferior gluteal folds and costal margin, with or without referred leg pain [1,2]. The prevalence of LBP has been rising globally; According to recent studies Bangladesh, India, Nepal, Pakistan and Sri Lanka have rates of 64.8%, 19.8%, 69.5%, 40.6% and 36.2% respectively [3]. LBP can be categorised as either non-specific or specific. Non-specific means that the experience of pain cannot be confidently accounted for by another diagnosis such as an underlying disease, pathology or tissue damage. It is non-specific in about 90% of cases [4]. Study conducted in a Pakistani Tertiary Care Hospital showed that most of the LBP patients are the ones in the 21–40 years old age group. The study highlighted that the most frequent risk factors associated with LBP are hypertension, dyslipidaemia, history of lower back trauma, history of prolonged unsupported sitting, office workers using desks and healthcare environment. Additionally, LBP was also identified in women at home. In Pakistan, a woman is expected to do tiring house chores which involves hand washing clothes and dishes, cooking and cleaning all the house without any care given to posture or comfort. Physical inactivity, soft foam mattresses, smoking, drinking, heavy lifting, sleep disorders and anxiety were also found in association with LBP [5]. Nowadays, LBP has gained a significantly high attention in the Pakistani adult population, particularly among some occupations involving farmers, rickshaw drivers, office workers, teachers and textile workers. Effective management of LBP requires a comprehensive approach tailored to whether the pain is specific or non-specific. For non-specific LBP, combining physical therapy, psychological support, lifestyle changes, and careful use of medications can significantly improve outcomes. Comprehensive clinical assessment and a biopsychosocial approach are crucial, especially for chronic cases. Prioritizing non-pharmacological interventions and focusing on rehabilitation can help maintain independence and quality of life. Dear Editor, Low back pain (LBP) is not a disease itself, but it can be a sign of number of a number of conditions, such as pain near the midline, which can occasionally be localized sometimes, and occur between the inferior gluteal folds and costal margin, with or without referred leg pain [1,2]. The prevalence of LBP has been rising globally; According to recent studies Bangladesh, India, Nepal, Pakistan and Sri Lanka have rates of 64.8%, 19.8%, 69.5%, 40.6% and 36.2% respectively [3]. LBP can be categorised as either non-specific or specific. Non-specific means that the experience of pain cannot be confidently accounted for by another diagnosis such as an underlying disease, pathology or tissue damage. It is non-specific in about 90% of cases [4]. Study conducted in a Pakistani Tertiary Care Hospital showed that most of the LBP patients are the ones in the 21–40 years old age group. The study highlighted that the most frequent risk factors associated with LBP are hypertension, dyslipidaemia, history of lower back trauma, history of prolonged unsupported sitting, office workers using desks and healthcare environment. Additionally, LBP was also identified in women at home. In Pakistan, a woman is expected to do tiring house chores which involves hand washing clothes and dishes, cooking and cleaning all the house without any care given to posture or comfort. Physical inactivity, soft foam mattresses, smoking, drinking, heavy lifting, sleep disorders and anxiety were also found in association with LBP [5]. Nowadays, LBP has gained a significantly high attention in the Pakistani adult population, particularly among some occupations involving farmers, rickshaw drivers, office workers, teachers and textile workers. Effective management of LBP requires a comprehensive approach tailored to whether the pain is specific or non-specific. For non-specific LBP, combining physical therapy, psychological support, lifestyle changes, and careful use of medications can significantly improve outcomes. Comprehensive clinical assessment and a biopsychosocial approach are crucial, especially for chronic cases. Prioritizing non-pharmacological interventions and focusing on rehabilitation can help maintain independence and quality of life.