A managed care curriculum implemented across four academic departments using mandated evaluation instruments.
Explore the source record for details and available documents.
Curriculum↗
Biomedical subjects
B C Williams
Publications and source records attributed to B C Williams.
Teaching medical information retrieval skills to internal medicine residents at the terminal-side.
Explore the source record for details and available documents.
Humans↗
ZW10 helps recruit dynactin and dynein to the kinetochore.
Mutations in the Drosophila melanogaster zw10 gene, which encodes a conserved, essential kinetochore component, abolish the ability of dynein to localize to kinetochores. Several similarities between the behavior of ZW10 protein and dynein further support a role for ZW10 in the recruitment of dynein to the kinetochore: (a) in response to bipolar tension across the chromosomes, both proteins mostly leave the kinetochore at metaphase, when their association with the spindle becomes apparent; (b) ZW10 and dynein both bind to functional neocentromeres of structurally acentric minichromosomes; and (c) the localization of both ZW10 and dynein to the kinetochore is abolished in cells mutant for the gene rough deal. ZW10's role in the recruitment of dynein to the kinetochore is likely to be reasonably direct, because dynamitin, the p50 subunit of the dynactin complex, interacts with ZW10 in a yeast two-hybrid screen. Since in zw10 mutants no defects in chromosome behavior are observed before anaphase onset, our results suggest that dynein at the kinetochore is essential for neither microtubule capture nor congression to the metaphase plate. Instead, dynein's role at the kinetochore is more likely to be involved in the coordination of chromosome separation and/or poleward movement at anaphase onset.
Animals↗
Depletion of a Drosophila homolog of yeast Sup35p disrupts spindle assembly, chromosome segregation, and cytokinesis during male meiosis.
In the course of a genetic screen for male-sterile mutations in Drosophila affecting chromosome segregation during the meiotic divisions in spermatocytes, we identified the mutation dsup35(63D). Examination of mutant testes showed that chromosome misbehavior was a consequence of major disruptions in meiotic spindle assembly. These perturbations included problems in aster formation, separation, and migration around the nuclear envelope; aberrations in spindle organization and integrity; and disappearance of the ana/telophase central spindle, which in turn disrupts cytokinesis. The dsup35(63D) mutation is caused by a P element insertion that affects, specifically in the testis, the expression of a gene (dsup35) encoding the Drosophila homolog of the yeast Sup35p and Xenopus eRF3 proteins. These proteins are involved in the termination of polypeptide synthesis on ribosomes, but previous studies have suggested that Sup35p and closely related proteins of the same family also interact directly with microtubules. An affinity-purified antibody directed against the product of the dsup35 gene was prepared; interestingly, this antibody specifically labels primary spermatocytes in one or two discrete foci of unknown structure within the nucleoplasm. We discuss how depletion of the dsup35 gene product in spermatocytes might lead to the global disruptions in meiotic spindle assembly seen in mutant spermatocytes.
Amino Acid Sequence↗
Initial emergency department diagnosis and return visits: risk versus perception.
STUDY OBJECTIVES: To identify diagnostic predictors of return emergency department visits, and to compare actual and perceived associations between initial ED diagnosis and revisits to help identify target diagnoses for prevention strategies. METHODS: This 2-part study involved a retrospective observational study and a health professional survey. The study population consisted of all patients with 2 or more visits to the University of Michigan ED within a 3-day period between July 1995 and June 1996 ("early-return visitors"). Billing records identified the initial diagnoses of subsequent return visitors. The prevalence of each initial diagnosis was determined in the general ED population (n=52,553), early-return population (n=1,422), and early-return population admitted to the hospital ("return-admit," n=313). Surveys were distributed to all ED health professionals to assess their perception of the diagnoses most likely to return within 3 days. Relative risk (RR) ratios and 95% confidence intervals (CIs) were calculated. RESULTS: Dehydration was the most common diagnosis in the general, early-return, and return-admit populations (prevalence: 7%, 15%, 25%, respectively). Dehydration was also the diagnosis with the highest risk for both early return and subsequent admission on early return (RR [95% CI]: 2.3 [2.0-2.6], 1.8 [1.5-2.3], respectively). Nearly two thirds of health professionals, however, did not identify dehydration as a diagnosis at high risk for return, and almost half did not consider dehydration a high risk for admission. CONCLUSION: Initial ED diagnosis may be a useful predictor of early ED return and admission. Patients with an initial diagnosis of dehydration are at particularly high risk for early return and admission, yet providers underestimate the risk in this very common group. Screening a return ED population for high-frequency diagnoses may reveal underrecognized target groups for specific prevention strategies.
Adolescent↗
Neocentromere activity of structurally acentric mini-chromosomes in Drosophila.
Chromosome fragments that lack centromeric DNA (structurally acentric chromosomes) are usually not inherited in mitosis and meiosis. We previously described the isolation, after irradiation of a Drosophila melanogaster mini-chromosome, of structurally acentric mini-chromosomes that display efficient mitotic and meiotic transmission despite their small size (under 300 kb) and lack of centromeric DNA. Here we report that these acentric mini-chromosomes bind the centromere-specific protein ZW10 and associate with the spindle poles in anaphase. The sequences in these acentric mini-chromosomes were derived from the tip of the X chromosome, which does not display centromere activity or localize ZW10, even when separated from the rest of the X. We conclude that the normally non-centromeric DNAs present in these acentric mini-chromosomes have acquired centromere function, and suggest that this example of 'neocentromere' formation involves appropriation of a self-propagating centromeric chromatin structure. The potential relevance of these observations to the identity, propagation and function of normal centromeres is discussed.
Animals↗
Preservation of vascular function in rat mesenteric resistance arteries following cold storage, studied by small vessel myography.
1. The use of isolated blood vessels to investigate the physiological and pharmacological control of the vasculature is limited by the requirement to use freshly isolated vessels. Hence, the aim of this study was to determine whether vascular smooth muscle and endothelial cell function could be preserved in resistance arteries by storing them in physiological salt solution (PSS) at 4 degrees C. 2. Third order mesenteric resistance arteries (mean internal diameter 237+/-6 microm) were dissected from the mesenteric bed of male Cob-Wistar rats. The vessel segments were mounted in a small vessel myograph for measurement of isometric tension, and equilibrated at their optimum resting force. Contractile responses to noradrenaline (NA; 1 x 10(-9) - 3 x 10(-5) M), phenylephrine (PE, 1 x 10(-9)-3 x 10(-5) M), potassium chloride (KCI; 2.5-140 mM) and endothelin (ET-1, 1 x 10(-11)-3 x 10(-7) M) and relaxant responses to acetylcholine (ACh; 1 x 10(-9) - 3 x 10(-5) M) and 3-morpholinosydnonimine (SIN-1; 1 x 10(-9) - 1 x 10(-4) M) were obtained in arteries, immediately after dissection (day 0) and following one to four days storage (day 1-day 4). 3. All arteries produced concentration-dependent contractions in response to each of the vasoconstrictors. There were no significant differences in the magnitude or sensitivity (pD2) of the vasoconstrictor responses between fresh and stored vessels. 4. Arteries precontracted with NA to approximately 80% of the maximum response, relaxed in a concentration-dependent manner in response to ACh and SIN-1. Vessel storage for up to three days resulted in no change in response to ACh or SIN-1. 5. Vessels analysed after four days of storage demonstrated a significant increase in sensitivity to ACh and SIN-1 (-logIC50 (M) values; ACh; day 0, 7.46+/-0.13 vs day 4, 7.97+/-0.11, P<0.01 and SIN-1; day 0, 4.87+/-0.10 vs day 4, 5.52+/-0.08, P<0.01). There was also a significant increase in the maximum relaxant response to ACh after four days of storage (% relaxation; day 0, 92.65+/-2.84 vs day 4, 100.36+/-0.36, P<0.05). 6. These results demonstrate that small resistance arteries remain viable if stored in PSS at 4 degrees C for up to four days, with no loss in endothelial cell function. The altered sensitivity to the vasodilators on day 4 suggests that vessels should only be stored for up to three days following dissection for analysis of functional responses.
Animals↗
Validating a global measure of faculty teaching performance.
Explore the source record for details and available documents.
Faculty, Medical↗
Population-based assessment of childhood blindness in southern India.
Explore the source record for details and available documents.
Adolescent↗
Contractile response of isolated human hepatic arteries to alpha-adrenoceptor agonists is not impaired in patients with cirrhosis.
1. Impaired vasoconstriction in animals with cirrhosis is maintained in isolated vessels in vitro, indicating an intrinsic alteration in function or structure of the cells in the vascular wall. This may be due to receptor down-regulation, a defect in post-receptor signal transduction or overproduction of vasodilator compounds. This investigation examined the role of these mechanisms in modulating alpha-adrenoceptor-mediated contraction in hepatic arteries from patients with advanced cirrhosis. 2. Hepatic arteries were obtained from subjects with and without cirrhosis for functional investigation in vitro. Endothelial cell function was assessed using endothelium-dependent (acetylcholine) and independent (3'-morpholinosydnonimine) vasodilators. alpha-Adrenoceptor-mediated contraction was assessed by constructing cumulative concentration-response curves to the alpha1-selective agonist phenylephrine, the non-selective adrenoceptor agonist noradrenaline and the receptor-independent vasoconstrictor potassium chloride. 3. None of the vessels used in this study had an intact endothelium but endothelium-independent relaxation was not different in arteries from subject with (79.5+/-10.16%; n=23) and without (84.45+/-18%; n=20) cirrhosis. Phenylephrine, noradrenaline and potassium chloride produced contractions that were of similar size (P>0.05) in arteries from subjects with (10.10+/-0.97 g, 8.85+/-1.03 g and 8.56+/-0.65 g respectively) and without (10.42+/-1.23 g, 9.58+/-1.39 g and 8. 62+/-0.98 g respectively) cirrhosis. The sensitivities (pD2) of the responses to these agonists were also similar (P<0.05) in arteries from patients with cirrhosis (5.45+/-0.10, 5.60+/-0.12 and 1.57+/-0. 03 respectively) and those from non-cirrhotic donors (5.58+/-0.11, 5. 67+/-0.11 and 1.54+/-0.05 respectively).4. Contraction of the denuded hepatic artery was unaffected by cirrhosis indicating that vascular abnormalities in this condition in man are not due to an intrinsic alteration of smooth muscle cell function in hepatic conduit arteries.
Adrenergic alpha-Agonists↗
Conservation of the centromere/kinetochore protein ZW10.
Mutations in the essential Drosophila melanogaster gene zw10 disrupt chromosome segregation, producing chromosomes that lag at the metaphase plate during anaphase of mitosis and both meiotic divisions. Recent evidence suggests that the product of this gene, DmZW10, acts at the kinetochore as part of a tension-sensing checkpoint at anaphase onset. DmZW10 displays an intriguing cell cycle-dependent intracellular distribution, apparently moving from the centromere/kinetochore at prometaphase to kinetochore microtubules at metaphase, and back to the centromere/kinetochore at anaphase (Williams, B.C., M. Gatti, and M.L. Goldberg. 1996. J. Cell Biol. 134:1127-1140). We have identified ZW10-related proteins from widely diverse species with divergent centromere structures, including several Drosophilids, Caenorhabditis elegans, Arabidopsis thaliana, Mus musculus, and humans. Antibodies against the human ZW10 protein display a cell cycle-dependent staining pattern in HeLa cells strikingly similar to that previously observed for DmZW10 in dividing Drosophila cells. Injections of C. elegans ZW10 antisense RNA phenocopies important aspects of the mutant phenotype in Drosophila: these include a strong decrease in brood size, suggesting defects in meiosis or germline mitosis, a high percentage of lethality among the embryos that are produced, and the appearance of chromatin bridges at anaphase. These results indicate that at least some aspects of the functional role of the ZW10 protein in ensuring proper chromosome segregation are conserved across large evolutionary distances.
Animals↗
Predicting patient scores between the functional independence measure and the minimum data set: development and performance of a FIM-MDS "crosswalk".
OBJECTIVE: The functional status of rehabilitation patients is often measured using the Functional Independence Measure (FIM) in acute rehabilitation settings or the Minimum Data Set (MDS) in nursing homes. Because the relationship between the two instruments is unknown, preventing comparison of rehabilitation patients in different types of settings, a translation formula ("crosswalk") between items and subscales from the FIM and the MDS was developed and tested. DESIGN AND OUTCOME MEASURES: Using definitions recommended by an expert panel, MDS items were chosen and rescaled (termed "Pseudo-FIM(E)" items) to correspond to FIM items. The empiric relationships between Pseudo-FIM(E) and FIM scores were then measured using paired FIM-MDS assessments. SETTING AND PATIENTS: 173 rehabilitation patients admitted to six nursing homes. RESULTS: Pseudo-FIM(E) items could be defined for 12 of the 18 FIM items (8 motor and 4 cognitive items). Mean FIM and Pseudo-FIM(E) scores were not significantly different (p > .30) for 5 of the 12 items. Mean scores for the remaining 7 items and for motor and cognitive subscales were similar but statistically significantly different (p < .05). Intraclass correlation coefficients between the FIM and Pseudo-FIM(E) motor and cognitive subscales were both .81. CONCLUSIONS: FIM and MDS items can be used to predict item and subscale scores between the two instruments with reasonable accuracy. This capability will enhance efforts to compare case-mix between acute rehabilitation and nursing home rehabilitation patients, thus making feasible comparisons of the effectiveness (degree of improvement among similar patients) and efficiency (cost of care to obtain a given degree of improvement) of rehabilitation care in different types of settings.
Activities of Daily Living↗
The correction of autonomic dysfunction in cirrhosis by captopril.
BACKGROUND/AIMS: Vagal dysfunction is reported in about 70% of patients with cirrhosis, irrespective of aetiology, as detected by cardiovascular reflex tests. We have previously shown that RR-variability on 24-h ECG is a more sensitive marker of vagal dysfunction in cirrhosis. Angiotensin II inhibits vagal function in animals, and it is elevated in cirrhosis and may be the cause of the vagal dysfunction. Our aim was to observe the effect of captopril on vagal dysfunction in cirrhosis. METHODS: Eight patients with cirrhosis (biopsy proven, male two, female six, mean age 54.25) had 24-h ECG RR-variability performed. They then received captopril 25 mg t.d.s. for 48 h. The 24-h ECG was repeated on therapy. RESULTS: Mean blood pressure remained unchanged: baseline 89.8 +/- 4.8 mmHg (mean +/- sem) versus 91.8 +/- 5.9 mmHg, p = not significant. Median baseline RR-variability was 791 (range 18-5344) counts/24 h and increased in all but one patient, with captopril, to 1548 (56-4824) p = 0.008. Three increased into the normal range. CONCLUSION: The vagal dysfunction of cirrhosis is caused by neuromodulation by angiotensin II and is not due to a neuropathy.
Adult↗
In vivo and in vitro evidence of altered nitric oxide metabolism in the spontaneously diabetic, insulin-dependent BB/Edinburgh rat.
1. Altered vasoreactivity may contribute significantly to the pathogenesis of diabetic vascular complications. This study investigated the effect of (a) insulin-related diabetes, and (b) chronic in vivo administration of N(omega)-nitro-L-arginine ester (L-NAME), a nitric oxide (NO) synthase inhibitor, on mean arterial pressure and in vitro vascular reactivity to noradrenaline in mesenteric arterial bed preparations from spontaneously diabetic, insulin-dependent and treated BB rats, the best animal model of insulin-dependent mellitus (IDDM) currently available. Four groups of animals from the Edinburgh colony (BB/E) of spontaneous diabetic BB rats were studied: age-matched (mean +/- s.e. mean = 156 +/- 2d) non-diabetic (glycated haemoglobin = 3.8 +/- 0.1%) and insulin-treated diabetic (glycated haemoglobin = 6.2 +/- 0.5%; duration of diabetes = 56 +/- 4 d) groups were either L-NAME treated (oral dose = 27 +/- 1 mg kg-1 d-1; duration of treatment from 30 until 153 days of age) or untreated. Although our diabetic BB/E rats do not achieve overall normoglycaemia, individual adjustment of the daily insulin dose administered to every diabetic rat achieves better glycaemic control than previous groups studying altered vascular reactivity and endothelial dysfunction in this animal model of diabetes. 2. Mean arterial pressure (measured directly via indwelling carotid arterial cannulae) was not significantly different between non-diabetic (116 +/- 3 mmHg; n = 10) and diabetic (122 +/- 2 mmHg; n = 12) BB/E rats. L-NAME treatment significantly (P < 0.001) increased mean arterial pressure in both groups (165 +/- 6 mmHg; n = 9 and 142 +/- 4 mmHg; n = 6 respectively) but the degree of hypertension observed in L-NAME-treated diabetic rats was significantly (P < 0.01) attenuated compared to non-diabetic rats treated with L-NAME. 3. Mesenteric arterial bed preparations were cannulated under anesthesia, excised and intralumenally perfused ex vivo with noradrenaline (0.2-20 microM). Basal perfusion pressures were not significantly different in mesentery preparations from non-diabetic (27.0 +/- 2.6 mmHg) and diabetic (27.1 +/- 3.2 mmHg) BB/E rats. There was no significant difference in maximal response above basal perfusion pressure (MAX) or pEC50, defined as the negative log of the agonist concentration required to give 50% of the maximal response above basal perfusion pressure, to noradrenaline in untreated non-diabetic (166 +/- 7 mmHg and 5.74 +/- 0.05 respectively) and diabetic (170 +/- 11 mmHg and 5.59 +/- 0.05) BB/E rats. 4. In vivo treatment of non-diabetic and diabetic BB/E rats with L-NAME had no significant effect on basal perfusion pressure (25.9 +/- 4.3 mmHg and 28.5 +/- 3.9 mmHg respectively). L-NAME treatment in vivo increased (P < 0.001) MAX to noradrenaline of non-diabetic rats (224 +/- 8 mmHg) but did not affect the value for diabetic rats (178 +/- 14 mmHg). L-NAME treatment did not alter after the pEC50 values in either group (5.71 +/- 0.05 and 5.65 +/- 0.05). 5. Consistent with previous studies using vascular preparations from spontaneously diabetic BB rats, mesentery preparations from diabetic BB/E rats (n = 12) exhibited a significantly reduced vasodilator response to acetylcholine (F value = 4.4, P < 0.05) across the concentration range studied compared to non-diabetic BB/E rats (n = 12) although there was no significant difference in maximal relaxation (diabetic 53.1 +/- 4.3% vs non-diabetic 55.7 +/- 5.5%) or pEC50, (diabetic 6.92 +/- 0.25 vs non-diabetic 7.49 +/- 0.22). There was no significant (F value = 0.8, P > 0.1) difference in the response to GTN between preparations from non-diabetic and diabetic rats (maximal relaxation: 49.6 +/- 3.7% vs 48.5 +/- 4.3%; pEC50: 7.84 +/- 0.12 vs 7.89 +/- 0.22 respectively). 6. In conclusion, vascular responsiveness to noradrenaline is not impaired in spontaneously diabetic BB/E rats with significantly better glycaemic control than those used in previous studies. However, following chronic L-NAME treatment, diabetic BB/E rats exhibit attenuated hypertension and an absence of enhanced vascular responsiveness to noradrenaline in vitro compared to similarly treated non-diabetic rats. These results, together with the significantly impaired endothelium-dependent vasodilatation and unchanged endothelium-independent vasodilatation in vitro of preparations from diabetic BB/E rats, are consistent with the hypothesis that functional changes in the synthesis and metabolism of NO (rather than altered vascular responsiveness to NO) occur in diabetes. Our results indicate that good glycaemic control alone is insufficient to prevent these abnormalities in NO availability and further studies to characterize the origin of these changes are necessary.
Animals↗
Direct stimulation of cortisol secretion from the human NCI H295 adrenocortical cell line by vasoactive intestinal polypeptide.
OBJECTIVE: To investigate a possible direct action of vasoactive intestinal polypeptide (VIP) on adrenal cortisol secretion and to define its mechanism of action. DESIGN: The human adrenocortical carcinoma cell line NCI H295, which is not contaminated by medullary chromaffin cells, was used to aid distinction between a direct action of VIP on adrenocortical cells and an indirect mechanism involving VIP-stimulated release of catecholamines. METHODS: NCI H295 cells were challenged with 10(-11)-10(-7) mol/l VIP for 4 h, with or without prior exposure for 72 h to 10 micromol/l forskolin. Cortisol and cyclic AMP contents of the overlying media were measured using in-house radioimmunoassays. Cells were treated with 10(-8)-10(-6) mol/l adrenaline or 3.3 x 10(-8) mol/l VIP with and without 10(-8)-10(-6) mol/l propranolol to exclude the possibility that an indirect mechanism of action involving beta-adrenoceptors was operating. RESULTS: VIP treatment produced an increase in cortisol secretion without pre-incubation, but this was markedly enhanced by prior exposure of cells to forskolin. VIP was potent, with a threshold of 10(-11) mol/l (n = 4), reaching a maximum 3.9+/-0.9-fold increase in effect on cells pre-exposed to forskolin (n = 4) by 3.3 x 10(-8) mol/l. This increase matched the 4 h response to 10 micromol/l forskolin. Cortisol secretion was accompanied by a parallel, dose-dependent increase in accumulation of cAMP. CONCLUSIONS: VIP potently and directly stimulates secretion of cortisol from these adrenocortical cells of human origin via an adenylate cyclase-coupled VIP receptor. These findings raise the possibility of a significant and direct effect of VIP in the control of steroid secretion from the adrenal cortex in humans.
Adrenal Cortex Neoplasms↗
Neuromuscular activity and upper airway collapsibility. Mechanisms of action in the decerebrate cat.
We have shown that tracheal and tongue displacement represent two basic mechanisms by which upper airway collapsibility can be altered. In this study, we investigated whether hypercapnia, which activates upper airway muscles, alters upper airway collapsibility by a mechanism similar to tracheal or tongue displacement. To answer this question, we utilized a feline isolated upper airway preparation in which maximal inspiratory airflow (Vimax), the pharyngeal critical pressure (Pcrit) and the nasal resistance (Rn) upstream to the flow-limiting site (FLS) were measured. In protocol #1, upper airway airflow dynamics were studied at two levels of trachea displacement under either hypo- or hypercapnic conditions. We found that the increase in Vimax with 1 cm of caudal tracheal displacement was attenuated by hypercapnia (44 +/- 12 ml/s versus 81 +/- 7 ml/s during hypocapnia, p = 0.048), as was the decrease in Pcrit (-2.4 +/- 1.1 cm H2O versus -5.2 +/- 1.1 cm H2O, p = 0.001). In protocol #2, we investigated the effect of transecting the cervical strap muscles and hypoglossal nerves on airflow dynamics during hypercapnia. Vimax, Pcrit, and Rn did not change after transecting either the strap muscles or the hypoglossal nerves. We conclude that the primary mechanism for changes in Pcrit during hypercapnia is similar to trachea displacement and is mediated by muscles other than the straps or tongue.
Airway Obstruction↗
Predicting discharge outcomes of VA nursing home residents.
This article's purpose was to identify predictors of discharge outcomes of VA nursing home stays. Using data tapes, diagnostic and assessment data were assembled on elderly individuals admitted to VA nursing homes nationwide during Fiscal Year 1987. Six-month outcomes for 3 groups were considered: all residents (n = 5,895), and those remaining in care after 6 (n = 2,815) and 12 months (n = 1,812), respectively. Logistic regression was used to evaluate predictors of death and community discharge. Limited activities of daily living (ADL) dependency, younger age, and receipt of rehabilitation services most consistently predicted community discharge. ADL dependency, older age, oxygen use, terminally ill prognosis, malignancy, and congestive heart failure most consistently predicted mortality. For both dependent variables, predictive ability declined as stay length increased. Predicting death and community discharge become increasingly problematic as stay lengthens. Comparing observed versus expected discharge outcomes has limited usefulness as a quality-improvement tool.
Activities of Daily Living↗
Exploratory study of residents' conceptual framework for critical appraisal of the literature.
BACKGROUND: Limited success of efforts to improve residents' critical appraisal skills may be due to poor understanding of their preintervention conceptual framework. DESCRIPTION: To describe internal medicine residents' a priori conceptual approach to critical appraisal of intervention trials, we performed an exploratory content analysis of 41 residents' unprompted descriptions of strengths and weaknesses of a randomized trial of spa therapy for back pain. EVALUATION: Eighty-eight percent of responses were assigned independently by 2 reviewers to 23 categories ( kappa .65). Residents agreed on some important characteristics (e.g., blinding), disagreed on others (e.g., similarity of treatment and control groups), frequently mentioned some irrelevant characteristics (e.g., "objective" vs. "subjective" outcomes), and rarely mentioned some important criteria (e.g., intention to treat). CONCLUSIONS: An open-ended questionnaire reliably revealed both expected and unexpected conceptions and misconceptions among residents who had received minimal or no formal instruction in critical appraisal. We propose a classification model for residents' critical appraisal concepts that can be tested in future studies and used to identify areas for focusing interventions to improve resident physicians' critical appraisal skills.
Journal Article↗