Enhancing OSCE preparedness with video exemplars in undergraduate nursing students. A mixed method study

BACKGROUND

Objective structured clinical examinations (OSCEs) are designed to assess clinical skill performance and competency of students in preparation for 'real world' clinical responsibilities. OSCEs are commonly used in health professional education and are typically associated with high levels of student anxiety, which may present a significant barrier to performance. Students, including nursing students, have identified that flexible access to exemplar OSCEs might reduce their anxiety and enable them to better prepare for such examinations.

AIM

To implement and evaluate an innovative approach to preparing students for OSCEs in an undergraduate (registration) acute care nursing course.

METHOD

A set of digitized OSCE exemplars were prepared and embedded in the University-based course website as part of usual course learning activities. Use of the exemplars was monitored, pre and post OSCE surveys were conducted, and qualitative data were collected to evaluate the approach. OSCE grades were also examined.

FINDINGS

The online OSCE exemplars increased self-rated student confidence, knowledge, and capacity to prepare and provided clarity around assessment expectations. OSCE exemplars were accessed frequently and positively received; but did not impact on performance.

CONCLUSION

Video exemplars aid student preparation for OSCEs, providing a flexible, innovative and clear example of the assessment process. Video exemplars improved self-rated student confidence and understanding of performance expectations, leading to increased engagement and reduced anxiety when preparing for the OSCE, but not overall OSCE performance. Such OSCE exemplars could be used to increase staff capacity and improve the quality of the student learning experience.

Integrated microscopy techniques for comprehensive pathology evaluation of an implantable left atrial pressure sensor

The safety and efficacy of an implantable left atrial pressure (LAP) monitoring system is being evaluated in a clinical trial setting. Because the number of available specimens from the clinical trial for histopathology analysis is limited, it is beneficial to maximize the usage of each available specimen by relying on integrated microscopy techniques. The aim of this study is to demonstrate how a comprehensive pathology analysis of a single specimen may be reliably achieved using integrated microscopy techniques. Integrated microscopy techniques consisting of high-resolution gross digital photography followed by micro-computed tomography (micro-CT) scanning, low-vacuum scanning electron microscopy (LVSEM), and microground histology with special stains were applied to the same specimen. Integrated microscopy techniques were applied to eight human specimens. Micro-CT evaluation was beneficial for pinpointing the location and position of the device within the tissue, and for identifying any areas of interest or structural flaws that required additional examination. Usage of LVSEM was reliable in analyzing surface topography and cell type without destroying the integrity of the specimen. Following LVSEM, the specimen remained suitable for embedding in plastic and sectioning for light microscopy, using the positional data gathered from the micro-CT to intersect areas of interest in the slide. Finally, hematoxylin and eosin (H&E) and methylene blue staining was deployed on the slides with high-resolution results. The integration of multiple techniques on a single specimen maximized the usage of the limited number of available specimens from the clinical trial setting. Additionally, this integrated microscopic evaluation approach was found to have the added benefit of providing greater assurance of the derived conclusions because it was possible to cross-validate the results from multiple tests on the same specimen.

Inhibitory effects of omega-3 fatty acids on injury-induced epidermal growth factor receptor transactivation contribute to delayed wound healing

Epidermal growth factor receptor (EGFR)-mediated signaling is required for optimal intestinal wound healing. Since n-3 polyunsaturated fatty acids (PUFA), specifically docosahexaenoic acid (DHA), alter EGFR signaling and suppress downstream activation of key signaling pathways, we hypothesized that DHA would be detrimental to the process of intestinal wound healing. Using a mouse immortalized colonocyte model, DHA uniquely reduced EGFR ligand-induced receptor activation, whereas DHA and its metabolic precursor eicosapentaenoic acid (EPA) reduced wound-induced EGFR transactivation compared with control (no fatty acid or linoleic acid). Under wounding conditions, the suppression of EGFR activation was associated with a reduction in downstream activation of cytoskeletal remodeling proteins (PLCγ1, Rac1, and Cdc42). Subsequently, DHA and EPA reduced cell migration in response to wounding. Mice were fed a corn oil-, DHA-, or EPA-enriched diet prior to intestinal wounding (2.5% dextran sodium sulfate for 5 days followed by termination after 0, 3, or 6 days of recovery). Mortality was increased in EPA-fed mice and colonic histological injury scores were increased in EPA- and DHA-fed mice compared with corn oil-fed (control) mice. Although kinetics of colonic EGFR activation and downstream signaling (PLCγ1, Rac1, and Cdc42) were delayed by both n-3 PUFA, colonic repair was increased in EPA- relative to DHA-fed mice. These results indicate that, during the early response to intestinal wounding, DHA and EPA uniquely delay the activation of key wound-healing processes in the colon. This effect is mediated, at least in part, via suppression of EGFR-mediated signaling and downstream cytoskeletal remodeling.

Characterization of an arachidonic acid-deficient (Fads1 knockout) mouse model

Arachidonic acid (20:4(Δ5,8,11,14), AA)-derived eicosanoids regulate inflammation and promote cancer development. Previous studies have targeted prostaglandin enzymes in an attempt to modulate AA metabolism. However, due to safety concerns surrounding the use of pharmaceutical agents designed to target Ptgs2 (cyclooxygenase 2) and its downstream targets, it is important to identify new targets upstream of Ptgs2. Therefore, we determined the utility of antagonizing tissue AA levels as a novel approach to suppressing AA-derived eicosanoids. Systemic disruption of the Fads1 (Δ5 desaturase) gene reciprocally altered the levels of dihomo-γ-linolenic acid (20:3(Δ8,11,14), DGLA) and AA in mouse tissues, resulting in a profound increase in 1-series-derived and a concurrent decrease in 2-series-derived prostaglandins. The lack of AA-derived eicosanoids, e.g., PGE₂ was associated with perturbed intestinal crypt proliferation, immune cell homeostasis, and a heightened sensitivity to acute inflammatory challenge. In addition, null mice failed to thrive, dying off by 12 weeks of age. Dietary supplementation with AA extended the longevity of null mice to levels comparable to wild-type mice. We propose that this new mouse model will expand our understanding of how AA and its metabolites mediate inflammation and promote malignant transformation, with the eventual goal of identifying new drug targets upstream of Ptgs2.

Th17 cell accumulation is decreased during chronic experimental colitis by (n-3) PUFA in Fat-1 mice

During colon inflammation, Th17 cells and immunosuppressive regulatory T cells (Treg) are thought to play promotive and preventative roles, respectively. Dietary (n-3) PUFA favorably modulate intestinal inflammation in part by downregulating T-cell activation and functionality. We used the Fat-1 mouse, a genetic model that synthesizes long-chain (n-3) PUFA de novo, to test the hypothesis that (n-3) PUFA protect against colonic inflammation by modulating the polarization of Treg and Th17 cells during colitis. Male and female wild-type (WT) and Fat-1 mice were administered dextran sodium sulfate (DSS) in the drinking water (2.5%) to induce acute (5 d DSS) or chronic (3 cycles DSS) colitis and the percentage of Treg and Th17 cells residing locally [colonic lamina propria (cLP)] and systemically (spleen) was determined by flow cytometry. The percentage of Treg in either tissue site was unaffected by genotype (P > 0.05); however, during chronic colitis, the percentage of Th17 cells residing in both the spleen and cLP was lower in Fat-1 mice compared to WT mice (P < 0.05). Colonic mucosal mRNA expression of critical Th17 cell cytokines and chemokine receptors (IL-17F, IL-21, and CCR6) were lower, whereas expression of the Th17 cell suppressive cytokine, IL-27, was greater in Fat-1 mice compared to WT mice during chronic colitis (P < 0.05). Moreover, colon histological scores were improved in Fat-1 mice (P < 0.05). Collectively, these results demonstrate for the first time, to our knowledge, that (n-3) PUFA can modulate the colonic mucosal microenvironment to suppress Th17 cell accumulation and inflammatory damage following the induction of chronic colitis.

Immunomodulatory action of dietary fish oil and targeted deletion of intestinal epithelial cell PPARδ in inflammation-induced colon carcinogenesis

The ligand-activated transcription factor peroxisome proliferator-activated receptor (PPAR)-δ is highly expressed in colonic epithelial cells; however, the role of PPARδ ligands, such as fatty acids, in mucosal inflammation and malignant transformation has not been clarified. Recent evidence suggests that the anti-inflammatory/chemoprotective properties of fish oil (FO)-derived n-3 polyunsaturated fatty acids (PUFAs) may be partly mediated by PPARδ. Therefore, we assessed the role of PPARδ in modulating the effects of dietary n-3 PUFAs by targeted deletion of intestinal epithelial cell PPARδ (PPARδ(ΔIEpC)). Subsequently, we documented changes in colon tumorigenesis and the inflammatory microenvironment, i.e., local [mesenteric lymph node (MLN)] and systemic (spleen) T cell activation. Animals were fed chemopromotive [corn oil (CO)] or chemoprotective (FO) diets during the induction of chronic inflammation/carcinogenesis. Tumor incidence was similar in control and PPARδ(ΔIEpC) mice. FO reduced mucosal injury, tumor incidence, colonic STAT3 activation, and inflammatory cytokine gene expression, independent of PPARδ genotype. CD8(+) T cell recruitment into MLNs was suppressed in PPARδ(ΔIEpC) mice. Similarly, FO reduced CD8(+) T cell numbers in the MLN. Dietary FO independently modulated MLN CD4(+) T cell activation status by decreasing CD44 expression. CD11a expression by MLN CD4(+) T cells was downregulated in PPARδ(ΔIEpC) mice. Lastly, splenic CD62L expression was downregulated in PPARδ(ΔIEpC) CD4(+) and CD8(+) T cells. These data demonstrate that expression of intestinal epithelial cell PPARδ does not influence azoxymethane/dextran sodium sulfate-induced colon tumor incidence. Moreover, we provide new evidence that dietary n-3 PUFAs attenuate intestinal inflammation in an intestinal epithelial cell PPARδ-independent manner.

Small intestine large granular lymphoma in a horse

A 12-year-old Appaloosa gelding was referred to the Texas Veterinary Medical Center with a history of chronic diarrhea and weight loss. At necropsy, numerous oval, craterlike ulcers were observed throughout the small intestine. Histologically, these lesions were composed of a neoplastic proliferation of round cells with intracytoplasmic phosphotungstic acid-hematoxylin-positive granules. The tumor cells stained positively for the CD3 antigen and negatively for a B-cell marker. A diagnosis of large granular lymphoma was based on the morphologic and immunohistochemical characteristics of the neoplasm. The postmortem presentation of this case depicted unusual multifocal, ulcerative lymphomatous lesions throughout the small intestine without involvement of the regional lymph nodes. The histologic and ultrastructural morphology of the neoplastic lymphocytes was similar to that in previously reported cases of abdominal equine large granular lymphomas, but in this case the neoplasm was restricted to the small intestine.

Nociceptin, endomorphin-1 and -2 do not interact with invertebrate immune and neural mu 3 opiate receptor

AIM

To determine if endomorphin-1, -2 and nociceptin (orphanin FQ) bind to the mu 3 opiate receptor subtype or release nitric oxide as mu 3 selective ligands do.

METHODS

These opioid peptides were examined for their ability to displace [3H]dihydromorphine (DHM) binding from the invertebrate (immunocytes and pedal ganglia) mu 3 opiate receptor in membrane homogenates. The ligands were also tested for their ability to release nitric oxide from the same intact tissues utilizing an amperometric probe that measures nitric oxide in real-time.

RESULTS

Endomorphin-1, -2 and nociceptin do not displace [3H]DHM binding from immunocyte or pedal ganglia membrane homogenates nor do they release nitric oxide from these tissues.

CONCLUSION

Since these newly discovered opioid peptides do not interact with the mu 3 opiate receptor subtype, endogenous morphine's significance is enhanced because it appears to be the only naturally occurring opiate ligand for the receptor. Furthermore, since this study involves invertebrate tissues, this signal system had to evolve early during evolution.

Mapping regions of herpes simplex virus type 1 glycoprotein I required for formation of the viral Fc receptor for monomeric IgG

Glycoprotein E (gE) and glycoprotein I (gI) of herpes simplex virus type 1 (HSV-1) form a complex that binds the Fc domain of monomeric IgG. In this study, we used two approaches to map the regions of gI-1 required for formation of the HSV-1 Fc receptor for monomeric IgG. First, we constructed six plasmids encoding gD-1/gI-1 fusion proteins. Each fusion protein contains a large gI-1 peptide inserted into the ectodomain of gD-1. gD-1/gI-1 fusion proteins were coexpressed with gE-1 using a transfection-infection assay in which cells were transfected with individual fusion protein constructs and then infected with a gE+/gI- virus. Cells were then assayed for monomeric IgG binding using immunofluorescence microscopy. Transfection-infection with two of six fusion proteins conferred monomeric IgG binding activity to cells, whereas cells infected with gE+/gI- virus alone failed to bind IgG monomers. The smallest gI-1 peptide to confer monomeric IgG binding activity contained amino acids 43 to 192. To more precisely map the region of gI-1 required for monomeric IgG binding, we constructed a panel of 10 gI-1 linker insertion mutants. Transfection-infection studies identified two mutants containing linker insertions at gI-1 amino acids 128 and 145, which failed to bind monomeric IgG. The other eight mutants demonstrated wild-type IgG binding activity. Taken together, these results indicate that the region of gI-1 between amino acids 128 and 145 is required for formation of the HSV-1 Fc receptor for monomeric IgG.

Mapping regions of herpes simplex virus type 1 glycoprotein I required for formation of the viral Fc receptor for monomeric IgG

Glycoprotein E (gE) and glycoprotein I (gI) of herpes simplex virus type 1 (HSV-1) form a complex that binds the Fc domain of monomeric IgG. In this study, we used two approaches to map the regions of gI-1 required for formation of the HSV-1 Fc receptor for monomeric IgG. First, we constructed six plasmids encoding gD-1/gI-1 fusion proteins. Each fusion protein contains a large gI-1 peptide inserted into the ectodomain of gD-1. gD-1/gI-1 fusion proteins were coexpressed with gE-1 using a transfection-infection assay in which cells were transfected with individual fusion protein constructs and then infected with a gE+/gI- virus. Cells were then assayed for monomeric IgG binding using immunofluorescence microscopy. Transfection-infection with two of six fusion proteins conferred monomeric IgG binding activity to cells, whereas cells infected with gE+/gI- virus alone failed to bind IgG monomers. The smallest gI-1 peptide to confer monomeric IgG binding activity contained amino acids 43 to 192. To more precisely map the region of gI-1 required for monomeric IgG binding, we constructed a panel of 10 gI-1 linker insertion mutants. Transfection-infection studies identified two mutants containing linker insertions at gI-1 amino acids 128 and 145, which failed to bind monomeric IgG. The other eight mutants demonstrated wild-type IgG binding activity. Taken together, these results indicate that the region of gI-1 between amino acids 128 and 145 is required for formation of the HSV-1 Fc receptor for monomeric IgG.

A physical examination of health care's readiness for a total quality management program: a case study

Initiating a total quality management (TQM) effort can be a time-consuming and costly effort for a hospital. Perceptions of management and employees are important in initiating TQM because people function as if perceptions are fact. Assessing these perceptions and determining the levels of readiness or resistance to change are important steps in reducing costs, thus increasing organizational ability to address proactively challenges to the implementation and ultimate success of a TQM effort. Key assessment criteria are discussed including a comparison of management and employee perceptions in one hospital.

A synthetic peptide containing the IKVAV sequence from the A chain of laminin mediates cell attachment, migration, and neurite outgrowth

Laminin is a basement membrane glycoprotein which consists of A, B1, and B2 chains. Laminin has diverse biological activities including promoting cell adhesion, migration, differentiation, growth, and neurite extension. Synthetic peptides from the active region of the A chain were prepared and tested for their biological activity. A 19-mer peptide (designated PA22-2), from just above the carboxyl globule on the long arm of the A chain, was found to promote cell adhesion, spreading, migration, and neurite outgrowth. By testing smaller sequences within the 19-mer peptide, a constituent pentapeptide, IKVAV (Ile-Lys-Val-Ala-Val), was identified as the active site for cell adhesion and neurite outgrowth. These data suggest that this sequence is one of the principle sites in laminin which regulate cellular behavior.

Vectorcardiographic analysis of ventricular tachycardia

From a study of 69 patients with ventricular tachycardia using digitised vectorcardiograms, it is suggested that the following features are evidence of a ventricular origin. 1. Anterior QRS predominantly in the left anterior quadrant. 2. Slow initial tangential QRS velocity greater than or equal to 20 ms in the presence of an anterior QRS monophasic loop. 3. QRS totally in the right posterior quadrant. 4. In the presence of a QRS in the left posterior quadrant slow anterior QRS initial forces lasting greater than or equal 20 ms in the horizontal plane. The following features are suggestive of a ventricular origin. 1. Slow initial tangential QRS velocity greater than or equal to 20 ms in the presence of an anterior QRS loop resembling right bundle branch block (RBBB). 2. Anterior monophasic QRS loop with counterclockwise rotation. 3. Slow initial QRS forces posteriorly (TV of first 40 ms less than 10 mV . s-1) in the presence of a QRS loop in the left posterior quadrant. 4. A vertical right QRS axis greater than or equal to +60 degrees in the presence of a left bundle branch block (LBBB) loop in the horizontal plane and any axis greater than or equal to +90 degrees less than or equal to -160 degrees. The importance of three simultaneous perpendicular leads for recording or arrhythmias is stressed. In addition vectorcardiograms have clearly separated multifocal ventricular tachycardia from multiformity, fusion beats with and without aberration, and bundle branch ventricular tachycardia. It is suggested that further study of the QRS waveform at the initiation and termination of ventricular tachycardia will elucidate the mechanisms and types of tachycardias.

QRS waveform of ventricular extrasystoles and their differentiation from aberrant conduction

Horizontal and frontal plane QRS loops of patients in sinus rhythm with uniform ventricular extrasystoles were constructed from digitised Frank orthogonal electrocardiogram. In 4 patients ventricular extrasystoles were indistinguishable from right bundle-branch complexes, and in another 4 from left bundle-branch complexes. In 25 patients ventricular extrasystoles showed an initial delay (greater than or equal to 20 msec) of the QRS, followed by an R loop, which in 13 patients resembled LBBB complexes, and 12 patients resembled RBBB complexes with an anterior clockwise loop in the horizontal plane. However, the frontal plane loop was often atypical of either RBBB or LBBB. In 51 patients ventricular extraplane loop was often atypical of either RBBB or LBBB. In 51 patients ventricular extrasystoles and an initial delay which was prolonged into the efferent limb of the QRS loop with acceleration of the afferent limb and/or the QRS loop was directed anteriorly, inferiorly and to the left. Conventional recordings of these extrasystoles usually showed an initial slow upstroke (or downstroke) of the QRS resembling a delta wave. It is suggested that extrasystoles resembling bundle-branch complexes arise close to the main bundle branches but that the other extrasystoles arise at the Purkinje-myocardial junction. Identification and differentiation of ventricular extrasystoles from aberrant conduction is aided by vectorcardiography.

The electrocardiographic diagnosis of apical infarction

Dyskinetic areas of the left ventriculograms of 151 patients were related to electrocardiographic signs of infarction. Apical dyskinesia alone or in combination with anterior or inferior dyskinesia could be associated with inferior and/or anterior infarction patterns. Appreciation of this fact prevents over-estimation of the severity of coronary artery disease from a resting electrocardiogram, showing both ‘anterior and inferior infarction’.

Vectorcardiographic features of ventricular extrasystoles correlated with conventional scalar electrocardiographic interpretation

Horizontal and frontal plane QRS loops of patients in sinus rhythm with uniform ventricular extrasystoles were constructed from digitised Frank orthogonal electrocardiograms. In 4 patients ventricular extrasystoles were indistinguishable from right bundle-branch complexes, and in another they were indistinguishable from left bundle-branch complexes. In 25 patients ventricular extrasystoles showed an initial delay (greater than or equal to 20 ms) of the QRS, followed by an R loop, which in 13 patients resembled left bundle-branch block complexes, and in 12 patients resembled right bundle-branch block complexes, with an anterior clockwise loop in the horizontal plane. However, the frontal plane loop often did not resemble that of either right or left bundle-branch block. In 51 patients ventricular extrasystoles had an initial delay which was prolonged into the efferent limb of the QRS loop with acceleration of the afferent limb, and/or the QRS loop was directed anteriorly, inferiorly, and to the left. Conventional recordings of these extrasystoles usually showed an initial slow upstroke (or downstroke) of the QRS resembling a delta wave. Apparently uniform ventricular extrasystoles on scalar recordings were shown to be multiform vectorcardiographically though in all such cases the direction of the initial 40 ms forces was constant. It is suggested that the slow initial inscription of ventricular extrasystoles is the result of excitation of ventricular muscle directly and not through specialised His-Purkinje fibres, and that the direction of such initial forces may indicate the ventricular origin of ventricular extrasystoles.