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The purpose of this mixed-method study was to examine racial differences in parental beliefs and concern about autism spectrum disorder (ASD) versus clinical judgment. The sample included 489 children with ASD undergoing their first ASD evaluation. Parent belief that their child had ASD was highest among parents of White children. White children whose parents believed the child had ASD had lower ASD severity. Parents of Black/African American and Hispanic children were more likely to report communication concerns than parents of White children. Parental concern about social communication was related to higher ASD severity for Hispanic children. Implications for diagnostic processes are discussed. Lay abstract The goal of this study was to examine if there were differences between races in parental concern and belief about autism spectrum disorder (ASD) and the perspectives of clinicians. We studied 489 children with ASD who were having their first evaluation at an ASD clinic. Parents of White children most often believed that their child had ASD. However, White children whose parents believed the child had ASD were less severe in their symptoms. Parents of Black/African American or Hispanic children were more likely to have concerns about communication than parents of White children. In Hispanic families, parental concern about social communication was related to more severe symptoms in children. We discuss the implications of our findings for diagnosis.

Background. Clinical learning activities in a pre-licensure nursing program are challenging to rapidly convert to an online format due to their objectives to provide hands-on practice. Previously, students spent their final day of pharmacology participating in low-fidelity lab-based, simulated pharmacology activities. Due to a public health crisis, the instructional team had to quickly change course to create an equally engaging virtual activity that provided opportunities for clinical judgment. Aim. In this article, we discuss a virtual pharmacology escape room created using Google forms for pre-licensure nursing students prior to their final pharmacology course exam. The learning objectives were to review difficult course concepts by making clinical decisions and to practice using medication protocols. Methods. The design and evaluation of a virtual pharmacology escape room are presented to reflect a learner centered approach. Key considerations when designing the escape room were to best use the students’ time, to focus on content frequently missed on exams by the student cohort, and to include medication protocols commonly encountered during the clinical part of their program. Results. Surveys provided positive feedback from learners along with suggestions for strengthening future escape room activities. Most students reported the activity provided opportunities for clinical judgment and was helpful for learning. Conclusion. Benefits of virtual escape rooms are they can be created at no cost to educators of learners and easily accessed using personal electronic devices. Future applications include designing additional escape rooms to aid student learning in challenging nursing coursework, such as pharmacology and clinical courses.

The World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF) provides an appropriate framework for conceptualizing cases within vocational rehabilitation (VR) programs. VR counselors can improve service delivery by using the framework and tools of the ICF, including the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), the ICF Checklist 2.1, and the ICF Core Sets. VR counselors can more readily begin the initial step of evidence-based practice (i.e., formulating well-defined, answerable questions) by using the ICF framework and its tools to identify and categorize common barriers and facilitators among VR consumers. The ICF framework and its tools are described in relation to their potential utilization in VR practice. In addition, specific case examples are given, describing how VR counselors can incorporate ICF perspectives and tools into their practice. The authors briefly describe training resources, future directions, and other considerations for the use of the ICF in VR settings.

Clinical judgment, one’s ability to think like a nurse, is an essential skill for safe nursing practice. With the rise of simulation to replace clinical experiences, there is limited evidence regarding the effectiveness of simulation on the development of clinical judgment. This study explored differences in clinical judgment in maternal–newborn courses between undergraduate nursing students participating exclusively in simulation and those participating in hospital-based clinical experiences. Following completion of the clinical rotation, students participated in an evaluative maternal–newborn high-fidelity simulation experience that was recorded and evaluated using the Lasater’s Clinical Judgment Rubric (2007). Lasater’s Clinical Judgment Rubric scores between the simulation and clinical practice groups were compared using an independent sample t-test. There was no statistical difference in clinical judgment scores between the simulation and hospital-based clinical groups ( t = −1.056, P = .295). Our findings suggest that simulation may be a comparable alternative to clinical experience in nursing education.

The design of digital information management systems for healthcare presents developers with several formidable engineering challenges. These systems must manage huge amounts of data and support communications across disparate platforms and divisions within a healthcare organization. They must ensure that data is kept private, secure, and available to the right people at the right time. However, as shown in other complex systems (e.g., nuclear power), simply making data available may be insufficient. The goals in designing digital healthcare as a ‘cognitive system’ are to present patient information in more meaningful ways, to help healthcare professionals become more productive, and to support healthcare professionals with clinical decision making. This paper describes how principles of cognitive systems engineering (CSE) and user experience (UX) design were applied to Cardiac Consultant, an interactive cardiovascular risk calculator, with those goals in mind.

The development of clinical judgment and decision-making skills is complex, requiring clinicians—whether students, novices, or experienced practitioners—to correlate information from their own experience; from discussions with colleagues; from attending professional meetings, conferences and congresses; and from studying the current literature. Feedback from treated cases will consolidate retention in memory of the complexities and management of past cases, and the conversion of this knowledge base into daily clinical practice. The purpose of this narrative review is to discuss factors related to clinical judgment and decision-making in clinical dentistry and how both narrative, intuitive, evidence-based data-driven information and statistical approaches contribute to the global process of gaining clinical expertise.

Objective: This study examined the incremental clinical utility of parent and teacher reports of ADHD symptomatology and functional impairment in Latino youth, as well as parent and teacher agreement with the final clinical judgment on a diagnostic structured interview. Method: Participants included 70 Latino youth (47 males, 23 females; M age = 8.13 years, SD = 2.51 years) and their parents and teachers; 60 participants were diagnosed with ADHD. Correlations, percent agreement, kappas, and regressions were utilized. Results: Results demonstrated that teachers agreed with the final clinical judgment more often than did parents. Results additionally demonstrated that functional impairment did not statistically significantly improve diagnostic models already including ADHD symptoms; follow-up analyses were run and are discussed. Finally, results demonstrated that teacher reports statistically significantly improved diagnostic models already including parent reports. Conclusion: The current findings suggest the importance of including both parent and teacher reports of both ADHD symptomatology and functional impairment when assessing ADHD in Latino youth.

Home care nurses complete many activities as part of the admission process. A pilot study of the home care admission process indicated that a nurse distributes data entry tasks between the patient’s home and a post-documentation period later in the day. We found evidence of a strategy to document information that requires direct observation (either from the patient or through viewing the home environment) in the home. We found evidence of a strategy to document outside of the home for data elements based on clinical judgment or assessments as well as information supported by clinical decision support in the Electronic Health Record (EHR). These finding inform recommendations for data entry and navigation design guidelines for home care admission EHR systems.

Social work assessments, and in turn clinical judgment and intervention practices, are increasingly framed by standardised tools and technologies that are digitised. These tools and technologies mediate social workers’ relationships with services users, while also privileging, and in turn reiterating, particular identities and particular forms of knowledge. In this article, I am interested in how standardised tools and technologies, like computers, operate to mediate the relationship between social workers and services users. I work with an autoethnographic narrative in order to examine standardised social work practice. Methodologically, autoethnography rests within a reflexive frame of qualitative research, allowing us to excavate our experiences in order to understand how our lives are ordered and knowledge is socially constitutive. In mining this narrative, I am interested in the body, and in particular, the corporeal dimension of standardised practices. I historically locate these practices, and use the work of Michel de Certeau and Michel Foucault to examine how tools and technologies function in relation to the body, even when there is no direct physical, bodily contact. Ultimately I argue that there is a scientific discourse underpinning current clinical practice and I use the framings of Donna Haraway to understand the implications of this for social workers.

This study aimed to assess physicians' susceptibility to framing effects in clinical judgment and decision making. A survey was administered online to 159 general internists in the United States. Participants were randomized into two groups, in which clinical scenarios varied in their framings: frequency vs percentage, with cost information vs without, female patient vs male patient, and mortality vs survival. Results showed that physicians' recommendations for patients in hypothetical scenarios were significantly different when the predicted probability of the outcomes was presented in frequency versus percentage form and when it was presented in mortality rate vs survival rate of the same magnitude. Physicians' recommendations were not different for other framing effects.

Since the advent of endovascular repair of aortic aneurysms (EVAR), clinical focus has been on preventing loss of sealing at the level of the infrarenal neck, which leads to type I endoleak and repressurization of the aneurysm sac. Enhanced mechanisms for central fixation and seal have consequently lowered the incidence of migration and endoleaks. However, endograft limb thrombosis and its causal mechanisms have not been addressed adequately in the literature. This article reviews the pathophysiological mechanisms associated with limb thrombosis in order to facilitate better clinical judgment to prevent iliac adverse effects.

Since Kraeplin and Kretschmer, the clarification of the limits between ordinary sadness and clinical depression has been a major concern. Much of the controversy has focused on whether and on which bases can be fixed a boundary in the continuum from the experience of sadness to major depressive episode. The new emphasis on the role of clinical judgment introduced by DSM-5 can be regarded as a way to address these issues, though leaving several questions open. After examining the implications of the main topics raised by this still ongoing discussion, we will argue that in a clinical reality both mobility and intensity of emotional states may account for the discontinuity between ordinary sadness and clinical depression.

Newly graduated nurses show lacking skills and competences regarding the ability to make appropriate clinical assessment of acute, complex care situations. There is also a lack of translated, qualitative relevance-evaluated and reliability-tested rubrics in the Swedish language. The purpose of this method article was to translate, and conduct a relevance evaluation and reliability test of the identified Lasater Clinical Judgment Rubric (LCJR). In this article, the Swedish translation LCJR (S) is presented. The results showed that the LCJR (S) was both qualitatively relevant and quantitatively reliable. We claim that there are several advantages to systematic use LCJR (S) for assessment of nursing students’ clinical judgement in laboratory simulation environments with acute patient situations.

Research to date in mainland China has mainly focused on children with autistic disorder rather than Autism Spectrum Conditions and the diagnosis largely depended on clinical judgment without the use of diagnostic instruments. Whether children who have been diagnosed in China before meet the diagnostic criteria of Autism Spectrum Conditions is not known nor how many such children would meet these criteria. The aim of this study was to evaluate children with a known diagnosis of autism in mainland China using the Autism Diagnostic Observation Schedule and the Autism Diagnostic Interview–Revised to verify that children who were given a diagnosis of autism made by Chinese clinicians in China were mostly children with severe autism. Of 50 children with an existing diagnosis of autism made by Chinese clinicians, 47 children met the diagnosis of autism on the Autism Diagnostic Observation Schedule algorithm and 44 children met the diagnosis of autism on the Autism Diagnostic Interview–Revised algorithm. Using the Gwet’s alternative chance-corrected statistic, the agreement between the Chinese diagnosis and the Autism Diagnostic Observation Schedule diagnosis was very good (AC1 = 0.94, p

Modified grounded theory method was utilized to explore the process of how clinicians defined and chose to respond to challenging issues in systemic therapy. Defining an issue as challenging was determined by negotiating internal and external cues and “bringing it forward” and “slowing the pace” emerged as key themes in responding to challenging issues. Clinicians appeared to focus on in-session relational process over content, attending to internal aspects of themselves and their interaction with clients and then negotiating those aspects of awareness with their clients. Practice implications are focused on supervision and helping postgraduate clinicians move toward the developmental stage of experienced professionals.

Objective: This study examined the influence of oncology social workers’ expectations regarding aging (ERA) and ERA with cancer (ERAC) on their clinical judgment. Methods: Oncology social workers ( N = 322) were randomly assigned to one of four vignettes describing a patient with lung cancer. The vignettes were identical except for the patent’s age and gender. Structural equation modeling served as the primary tool for testing the study hypotheses. Results: Significant differences were found in clinical judgment based on patient’s age, and social workers’ ERA and ERAC which affected diagnostic and treatment judgment for all patients. Lack of congruence was also found between the diagnosis and treatment phases of care for older patients. Emotional reaction was more often reported for the younger patient. Conclusion: Results suggest a barrier to “whole patient” care for all cancer patients and a need for student and practitioner training to place greater emphasis on the treatment phase of patient care.

Growing reliance on complex constructed response items has generated considerable interest in automated scoring solutions. Many of these solutions are described in the literature; however, relatively few studies have been published that compare automated scoring strategies. Here, comparisons are made among five strategies for machine-scoring examinee performances of computer-based case simulations, a complex item format used to assess physicians’ patient-management skills as part of the Step 3 United States Medical Licensing Examination. These strategies utilize expert judgments to obtain various (a) case-specific or (b) generic scoring algorithms. The various compromises between efficiency, validity, and reliability that characterize each scoring approach are described and compared.

Nurses have a key role to play in therapeutic interventions for bereaved and grieving families. In this article, hermeneutic inquiry is used to uncover what families found helpful or useful with respect to therapeutic conversations with advanced practice registered nurses. The findings show that nursing expertise is important in family nursing practice. Expertise in the relationship allowed the family to find healing and hope by addressing core constraining beliefs. Clinical judgment, or sense, was significant in guiding the therapeutic conversation. Lastly, how problems are framed and how families are positioned have implications for outcomes and therapeutic change.

Aims: To explore the reluctance of, and examine the arguments given by Norwegian general practioners (GPs), regarding their unwillingness to recruit their patients for a study where sick leave would be based on randomization. Methods: A qualitative study presenting individual arguments from 50 Norwegian GPs, as written responses to a web-based, open-ended questionnaire. The responses, ranging from 3⊟145 words, were analysed with systematic text condensation. Results: The GPs did not want to participate in a study where sick leave was decided by randomization. First, the complexity of clinical judgment was addressed. Would it be ethically acceptable to set the professional and medical assessment aside, and if so, was there any better judge than the regular GP in making this important decision? Second, the arguments dealing with sick leave as a human and legal right were addressed. Will patients feel they have a legitimate right to sick leave and will they be open for discussion with their GP? Third, the risk of jeopardizing the relationship between patient and doctor was emphasized. Would the patients be able to trust their GP if he or she offered the patient entry into a trial where sick leave would be decided by randomization? Conclusions: Randomization of sick leave in general practice in Norway was not viewed as feasible by the GPs themselves because of the importance of clinical judgment, ethical obligations, and the belief that the patients would refuse participation, and thereby, that the doctor‐patient relationship would be disturbed.

Clinical judgment is foundational to psychological practice. Accurate judgment forms the basis for establishing reasonable goals and selecting appropriate treatments, which in turn are essential in achieving positive therapeutic outcomes. Therefore, Spengler and colleagues' meta-analytic finding—clinical judgment accuracy improves marginally with traditional education, training, and clinical experience—is disconcerting and should serve as a wake-up call. Now is the time to move with urgency. The authors urge the development of a comprehensive, standardized, and scientifically based metatheory to inform clinical judgment. A metatheory should describe the content of clinical judgment, the process of clinical judgment, and the self-reflection of clinicians. Without employment of such a metatheory and concomitant improvement in clinicians' judgment, professional psychologists are on soft footing in extolling their claim as scientist—practitioners and ethical professionals.

In this rejoinder, the authors respond to reactions by Ridley and Shaw-Ridley and by Lichtenberg to their meta-analysis on the effects of experience on clinical judgment decision making accuracy.

This article examines issues raised by the application of a generic actuarial juvenile risk instrument (the Model Risk Assessment Instrument) to New York City, a context different from the one in which it was developed. It describes practical challenges arising from the constraints of locally available data and local sensibilities and highlights important differences between locally relevant recidivism predictors and generic tool predictors. The analysis shows that the generic tool is less predictive than a locally developed risk-assessment tool and also performs less well than unassisted clinical judgment. This is true even after the generic tool has been validated and optimized on local data. This is because the tool does not include key demographic variables relevant to the New York City context.

Breakthrough pain has been described differently in various countries, and not surprisingly, recommendations for its management vary according to the institution. Usually when breakthrough pain occurs, the patient's pain has already been managed according to the World Health Organization 3-step ladder for cancer pain. After this point, the treatment choice is usually based on clinical judgment, the physician's personal experience with interventional procedures, and local resources available. Opioids remain the mainstay of the management of breakthrough cancer pain. However, the combination of radio-oncology, adjuvant drugs, and interventional pain procedures can improve pain relief. This review addresses those questions and proposes a multimodal approach to manage breakthrough cancer pain.

The purpose of the present article is to discuss approaches to the development of cognitive process models of misdiagnosis of African Americans, with particular emphasis on structured clinical interviews. Two basic approaches to cognitive process models are discussed. The first is cognitive bias based on prototype models of information processing. The second approach involves using the structured clinical interview to see how and when the decision-making process may be flawed, or where cognitive shifts are made in considering one diagnosis over another. Although routine training in structured clinical interviews may nullify cognitive biases associated with clinician judgment, it does not address cultural biases in the diagnostic system. It is concluded that a comprehensive approach to training in clinical decision making for mental health professionals is needed which include courses in the administration of the Structured Clinical Interview for DSM-IV, sociocultural case formulation, and cross-cultural sensitivity in making psychodiagnostic judgments.

This paper is the fourth in a series that heralds a study that examines paramedic accounts and constructs of judgment and decision-making (JDM) of mental health and mental illness. This paper will provide the results of one stage of this study in which a discourse-historical case study of paramedic JDM of mental health and mental illness using ethnographic and ethnomethodological research methods was conducted. Preliminary themes describing the ways in which paramedics officially account for their judgments of mental illness will be presented.

Clinical predictions made by mental health practitioners are compared with those using statistical approaches. Sixty-seven studies were identified from a comprehensive search of 56 years of research; 92 effect sizes were derived from these studies. The overall effect of clinical versus statistical prediction showed a somewhat greater accuracy for statistical methods. The most stringent sample of studies, from which 48 effect sizes were extracted, indicated a 13% increase in accuracy using statistical versus clinical methods. Several variables influenced this overall effect. Clinical and statistical prediction accuracy varied by type of prediction, the setting in which predictor data were gathered, the type of statistical formula used, and the amount of information available to the clinicians and the formulas. Recommendations are provided about when and under what conditions counseling psychologists might use statistical formulas as well as when they can rely on clinical methods. Implications for clinical judgment research and training are discussed.

Recent clinical trials and critical reviews of Alzheimer's disease (AD) research discourage already relatively sparing clinical uses of cholinesterase inhibitors (ChEIs) considering the prevalence of AD. As evidence against use of this class of drugs, detractors cite critical reviews of ChEls and lack of long-term health benefits found in one long-term clinical trial. This paper describes the use of standard error of measurement to allow investigators to design clinical trials that address these issues. The new clinical trial procedures afford sufficient precision for two purposes. First, practitioners can assess individual patients with precision and certainty in their observations. Second, clinical trial researchers can study how short-term drug effects on individual patients predict long-term benefits from continued treatment. With these more clinically informative clinical trial designs, investigators would be able to avoid uncertainties currently raised by conflicts between short-and long-term AD clinical trials.

This paper provides a survey of the terrain of theories of human judgment and decision-making (JDM). It provides an introduction, overview, and some insight into the understanding of some conceptual theories, frameworks, and the literature of JDM. This paper is in no way an exhaustive meta-analysis of the literature on JDM, nor is it intended to be. It does not seek to categorise and compare existing theories of judgment and decision-making or critically evaluate each in terms of others, nor does it seek to reclassify existing categories. Indeed much of the debate in the literature is about that very issue—how researchers and theorists view, characterise, categorise and apply existing theory of JDM in existing philosophies, ‘schools-of-thought’, and professional domains. The problematic, controversial, and, in the view of some researchers, inappropriate attempts to do so are well-documented [1-4]. This paper will provide an overview of the competing accounts that various theories and philosophies place on judgment and decision-making.

What distinguishes a psychoanalyst from any other psychologically minded, empathic human being? This seemingly simple question goes to the heart of our profession, the way we see ourselves as competent clinicians. To understand a patient`s material beyond ordinary empathy—that is, to come to a clinical judgment—we need to step out of the dyadic, countertransference situation and reflect what we've experienced in reference to our clinical theories. An analytic vignette shows how a theoretical background can be used to understand and interpret to a patient in a way that is deeply meaningful.

This Web-based study investigated the effects of client race on the clinical judgment of practicing European American vocational rehabilitation counselors, specifically, whether participants demonstrated bias in their general evaluation, perceptions of psychopathology, and estimates of the educational and vocational potential of African American clients. Participants reviewed case materials depicting either an African American or a European American client and rendered judgments (a) once after minimal initial information was provided, when initial impressions could be more vulnerable to racial stereotypes, and (b) once after subsequent information was provided, facilitating more definitive judgments. African American clients were judged more negatively than European American clients, and these differences persisted after reviewing subsequent information. Implications for treatment planning are discussed.

Our objective was to study whether “compensatory” models provide better descriptions of clinical judgment than fast and frugal models, according to expertise and experience. Fifty practitioners appraised 60 vignettes describing a child with an exacerbation of asthma and rated their propensities to admit the child. Linear logistic (LL) models of their judgments were compared with a matching heuristic (MH) model that searched available cues in order of importance for a critical value indicating an admission decision. There was a small difference between the 2 models in the proportion of patients allocated correctly (admit or not-admit decisions), 91.2% and 87.8%, respectively. The proportion allocated correctly by the LL model was lower for consultants than juniors, whereas the MH model performed equally well for both. In this vignette study, neither model provided any better description of judgments made by consultants or by pediatricians compared to other grades and specialties.

This review addresses the epidemiology, historical reports, current issues, data and controversies involved in the management of brain metastases. The literature regarding surgery, whole brain radiation therapy, stereotactic radiosurgery or some combination of those treatments is discussed as well as issues of cost-effectiveness. Ongoing prospective randomized trials will further elucidate the optimal management for patients with brain metastases. Until those data are available, clinicians are encouraged to apply the existing data reviewed here in conjunction with best clinical judgment. A brief clinical guide is as follows. Patients with a solitary metastasis in an operable location and symptomatic mass effect should undergo surgery. Patients with poor performance status (KPS < 70) or more than three brain metastases should receive WBRT alone. Patients with 1-3 brain metastases and KPS ≥ 70, should receive WBRT + SRS. If the patient refuses WBRT or needs salvage after WBRT, then SRS alone is appropriate. Clinicians should not be too dogmatic and should always apply the best clinical judgment.

Two randomly assigned groups of African American undergraduate students in rehabilitation services were asked to review case materials of a client who was portrayed as African American to one group and as European American to the other. Participants rated the client in terms of their clinical impressions and estimates of future potential. In Rosenthal and Berven's (1999) similar study, European American students rated the European American client as having higher educational and employment potential than the African American client. In our study, African American students rated the African American client as having higher educational potential than the European American client. In addition, across all four of the other independent measures (general evaluation, psychopathology—conduct, psychopathology—substance abuse, and vocational potential), African American participants demonstrated no bias against the African American client or the European American client. The differential findings of these two studies and their implications for education and future research are discussed.

The ability of expert practitioners to make sound judgments when faced with non-routine situations calls on a form of tacit knowing that has been loosely branded as ‘intuition’, a ‘sixth sense’, or ‘gut feeling’. The development of tacit knowledge is associated with nonformal learning that occurs in the context of the workplace; however, the elusive nature of this phenomenon has served to hamper research efforts. The focus has therefore shifted away from tacit knowledge toward the more observable concept of ‘judgment’. Paramedics are called to make clinical judgments as part of their everyday practice, often unaware of the basis behind these judgments. This case study examines the source of knowledge drawn on by experienced paramedics when making judgments, especially when faced with situations they have not previously encountered, and proposes how new knowledge and meaning is constructed through such involvements. A better understanding of the relationship between knowing and judgment, and how they are developed, will have future implications for the provision of ongoing education and training programs for paramedics.

In recent years, antiphospholipid antibodies (aPL) and their associated clinical features have been recognized increasingly in various pediatric autoimmune and non-autoimmunediseases. Pathogenic mechanisms involved in pediatric antiphospholipid syndrome (APS) appear to be the same as inadults. However, since pediatric patients do not have prothrombotic risk factors present in adults, there clearly are differences in the spectrum of clinical findings. The frequency of aPL-related thrombotic events is generally low in pediatric populations. On the other hand, various commonly acquired infections are likely to be responsible for higher percentage of non-pathogenic and transient aPL in childhood. Such points have to be considered in clinical judgment of elevated aPL in children. In this review we summarize the recent data on the prevalence and clinical significance of aPL in neonates, children and adolescents.

Category: Hindfoot Introduction/Purpose: Assessment of hindfoot alignment in adult acquired flatfoot deformity (AAFD) can be challenging. Clinical judgment and radiograph studies while important may not represent the accurate valgus alignment of the affected patients. Weightbearing (WB) ConeBeam CT (CBCT) is an emerging imaging modality that may potentially better demonstrate the three-dimensional (3D) deformity, facilitating visualization of important soft-tissue and bony landmarks and helping in surgical planning. Based on the relative position of bone and soft-tissue axes, different measurements of hindfoot alignment can be obtained with CT images. Therefore, we compared clinical assessment of hindfoot valgus alignment in AAFD patients with different possible measurements performed on WB CBCT images. Methods: In this prospective, IRB-approved study, 20 patients (20 feet, 15 right and 5 left) with clinical diagnosis of flexible AAFD were included. There were 12 males and 8 females, with a mean age of 52.2 years (range, 20 – 88 years of age), and average BMI of 30.35 kg/m2 (range, 19.00 – 46.09 kg/m2). Patients underwent clinical assessment of hindfoot alignment as well as WB CBCT. Two independent and blinded foot and ankle board-certified surgeons performed different hindfoot alignment measurements on the WB CBCT images that included: 3D “clinical” alignment; Achilles tendon axis/calcaneal tuberosity angle; angles formed between the tibial axis and the calcaneal tuberosity, calcaneal axis and line connecting midpoint of subtalar joint and most inferior part of calcaneal tuberosity. Positive values were considered valgus alignment. Mean differences between the measurements modalities were compared by paired T-test. Intra- and Inter-observer reliability for the WB CBCT measurements were calculated using Pearson correlation. Results: The mean clinical hindfoot valgus measured was 15.15o (SD 7.7o). It was found to be significantly different from the mean values of all WB CBCT angles modalities: 3D “clinical” alignment (10.42o, p < 0.015); Achilles tendon/calcaneal tuberosity angle (2.96o, p < 0.0001); tibial axis/calcaneal tuberosity angle (5.42o, p < 0.0001); tibial axis/subtalar joint angle (7.52o, p < 0.0001) and tibial axis/calcaneal axis angle (20.39o, p < 0.017). We found an excellent intra-observer agreement for all WB CBCT 3D measurements (range, 0.8863 – 0.9713, p < 0.0001). There was also good to excellent inter-observer reliability, with the exception of the 3D “clinical” alignment (r=0.450, p < 0.04), that showed moderate correlation. Conclusion: The use of 3D WB CBCT imaging can help characterize the valgus hindfoot alignment in patients with adult acquired flatfoot deformity. We found the different CBCT measurements modalities to be reliable and repeatable, and to significantly differ from the clinical evaluation of hindfoot valgus alignment.

An exercise is presented, Rolling the Dice, that assists students in developing skill and clinical judgment in using interventive questions in counseling and therapy. Steps for using the exercise and different permutations of the exercise are presented, along with examples of its use with counselors in training at various experience levels.

Despite our intuition that representative expert judgments are highly nonlinear, previous studies have shown only little, if any, nonlinearity in such judgments. The current study presents a method for assessing nonlinearity in judgment that is based on estimating communal nonlinearity—the systematic nonlinearity shared by the community of judges. The article also examines the predictive accuracy of communal nonlinearity, and compares it with the corresponding linear accuracy.

Even with multislice computed tomography, it may be difficult to differentiate contained ruptured or leaking atherosclerotic aneurysm from a tender inflammatory aneurysm. The decision for early intervention is based on clinical judgment. We describe successful open graft repair of a tender inflammatory infrarenal abdominal aortic aneurysm simulating acute rupture in a 63-year-old man.

To evaluate three proposed models of the rehabilitation counselor judgment process, we asked a sample of master's level rehabilitation counselors selected from a random list provided by the Commission on Rehabilitation Counselor Certification to engage in a series of judgment tasks. Counselors made multiple judgments about a large number of clients whose information we systematically varied across three dimensions: severity of disability, degree of psychosocial adjustment, and IQ level. These data were then analyzed using path analytic techniques to determine which of the three models (complex, fully mediated, or simple) was the best description of the process rehabilitation counselors followed to make two predictive judgments (likelihood of progress in counseling and likelihood of obtaining employment) about clients with disabilities. In both instances, the fully mediated model was the most parsimonious yet most explanatory model of the process. Implications for theory, research, practice, and education are discussed.

The overall conclusion is that neither creatinine clearance nor urea clearance is the perfect index for predicting outcome in PD patients. In the absence of indices that are better validated and more convenient, creatinine and urea are what we have to use. They are best seen as two imperfect, but potentially complementary, measurements. On balance, creatinine clearance is the better of the two indices, in that it gives greater weight to residual renal function, and residual renal function is probably a stronger predictor of patient outcome than peritoneal clearance per se. However, creatinine clearance has a particular weakness in low transporters; values have to be interpreted with discretion in this group. Furthermore, both indices are flawed because of the manner in which they are conventionally normalized. Research into more appropriate methods of normalization, or into whether normalization is required at all, would be helpful. The complex relationship between these clearance indices, protein intake, and lean body mass also needs to be kept in mind. While this paper argues in favour of creatinine clearance as the better index, it still suggests that both indices be used, together with a large measure of clinical judgment.

A retrospective review was conducted of patients assigned ICD-9 codes for ectopic pregnancy between 1993 and 1996, to compare ultrasonographic assessment with surgically confirmed anatomic pathologic conditions. Demographic information, ultrasound findings, operative reports, and pathology reports were assessed. One hundred thirty of 154 patients (84%) who underwent surgery for treatment of ectopic pregnancy had preoperative ultrasound examinations. Ultrasound findings of an adnexal mass correctly predicted the presence of an ectopic pregnancy subsequently confirmed at surgery in 91 of 130 women, yielding a sensitivity of 70%. The sensitivity of sonographically predicting the location of an ectopic was 60%, and the presence of hemoperitoneum was 78%. Despite advances in technology, sonography should be used in an ancillary role to clinical judgment in the assessment algorithm of this common clinical condition.

There are always third elements intersecting the analytic pair. One such element is the analytic community. The analyst is therefore never in a dyadic relationship with the patient, but always in a triangle. In relation to the patient, the analyst will be concerned with useful practices. In relation to the analytic community, the analyst will be concerned with consensually approved principles. This tension is constant in analytic work and in the analytic literature.

The objective of the present study was to determine which of the established methods of estimating fetal weight in term and large fetuses is the most accurate. In a study population of 116 term gestations, an ultrasound examination was performed within 7 days of delivery. Each ultrasound measured abdominal and head circumference, biparietal diameter, and femur length using uniform measurement and scanning method criteria. Five different methods were used to calculate estimated fetal weights. Of the five current formulas used to estimate fetal weight in term and large fetuses, the four-parameter method of Hadlock provided the best estimate. The accuracy of estimating fetal weight by ultrasound in term and large fetuses can be improved by using multiple parameters, which in turn may influence clinical judgment in the timing and management of delivery.