This article introduces the concept of a key feature and describes its function as the cornerstone of key-feature problems, a new problem format for the written assessment of clinical decision-making skills of medical trainees and practitioners. The rationale for using this problem format and the steps in problem and examination development--including issues of scoring and standard setting--are described. A key feature is defined as a critical step in the resolution of a clinical problem, and a key-feature problem consists of a clinical case scenario followed by questions that focus on only those critical steps. The questions can be presented to require examinees either to write in their responses or to select them from a list of options. For each question, examines can be instructed to supply or select whatever number of responses is appropriate to the clinical task being tested, and answer keys can comprise one or several responses. This problem format, with its focus on only the critical steps in problem resolution, and with its flexibility in question format and scoring keys, effectively addresses the psychometric considerations of content validity and test score reliability, and accommodates the complexity and configurations of actions often required in the resolution of clinical problems.

Background While aberrant fibrinolysis and plasminogen activator inhibitor-1 (PAI-1) are implicated in ALI, the role of this serpin in the pathogenesis of wood bark smoke (WBS) induced acute lung injury (SIALI) and its regulation in resident lung cells after exposure to smoke is unclear. Methods A total of 22 mechanically ventilated pigs were included in this study. Immunohistochemical analyses were used to assess fibrin and PAI-1 in the lungs of pigs with SIALI in situ. PAI-1 was measured in bronchoalveolar lavage fluids by Western blotting. Induction of PAI-1 was determined at the protein and mRNA levels by Western and PCR analyses in primary porcine alveolar type II (ATII) cells, fibroblasts and pleural mesothelial cells (PMCs). PAI-1 mRNA stability was determined by transcription chase studies. Gel shift analyses were used to characterize the mechanism regulating PAI-1 mRNA stability. Results SIALI induced PAI-1, with prominent extravascular fibrin deposition in large and small airways as well as alveolar and subpleural compartments. In PMCs, lung fibroblasts and ATIIs, PAI-1 mRNA was stabilized by WBS extract and contributed to induction of PAI-1. The mechanism involves dissociation of a novel 6-Phospho-D-Gluconate-NADP oxidoreductase -like PAI-1 mRNA binding protein from PAI-1 mRNA. Conclusions Exposure to WBS induces prominent airway and mesothelial expression of PAI-1, associated with florid distribution of fibrin in SIALI in vivo. WBS components induce PAI-1 in vitro in part by stabilization of PAI-1 mRNA, a newly recognized pathway that may promote extravascular fibrin deposition and lung dysfunction in SIALI.

BackgroundWith Canada’s senior population increasing, there is greater demand for family physicians with enhanced skills in Care of the Elderly (COE). The College of Family Physicians Canada (CFPC) has introduced Certificates of Added Competence (CACs), one being in COE. Our objective is to summarize the process used to determine the Priority Topics for the assessment of competence in COE.MethodsA modified Delphi technique was used, with online surveys and face-to-face meetings. The Working Group (WG) of six physicians acted as the nominal group, and a larger group of randomly selected practitioners from across Canada acted as the Validation Group (VG). The WG, and then the VG, completed electronic write-in surveys that asked them to identify the Priority Topics. Responses were compiled, coded, and tabulated to identify the topics and to calculate the frequencies of their selection. The WG used face-to-face meetings and iterative discussion to decide on the final topic names.ResultsThe correlation between the initial Priority Topic list identified by the VG and that identified by the WG is 0.6793. The final list has 18 Priority Topics.ConclusionDefining the required competencies is a first step to establishing national standards in COE.

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