A three-arm single blind randomised control trial of naïve medical students performing a shoulder joint clinical examination

BACKGROUND

Technological advances have previously been hailed as a new dawn in Higher Education, with the advent of 'massive open online courses' (MOOCs) and online learning. Virtual platforms have potential advantages such as accessibility and availability but simply transferring educational material to the online environment may not ensure high quality learning. Clinical examination is a fundamental principle of medical assessment, and this study aimed to assess the role of technology in teaching these skills.

AIMS/OBJECTIVES

To determine whether three teaching modalities were of equal efficacy in teaching examination of the shoulder joint to naïve medical students.

METHODS

Sixty-seven pre-clinical medical students naïve to large joint examination were recruited. Participants completed a learning style questionnaire and were then block randomised to three study: textbook study, face-to-face seminar, or video tutorial via online platform. The same examination technique was taught in all groups, with the intervention being the method of delivery All second year students were eligible for inclusion. The single exclusion criteria was previous exposure to clinical examination teaching. Students were assessed using a standardised scoring system at baseline (pre-intervention), and days 5 and 19 post-intervention (maximum score 30). Assessors were blinded to group allocation. The primary outcome was assessment score at day 5 post intervention.

RESULTS

There was no difference between the three groups at baseline assessment (mean scores 2.4 for textbook, 2.8 for face-to-face, and 3.1 for video; p = 0.267). Mean post-intervention scores were 16.5 textbook, 25.5 face-to-face, and 22.4 video (p < 0.001, η2 = .449). There was no change between day 5 and day 19 post-intervention assessment scores in any group (p = 0.373), Preferred learning style did not affect scores (p = 0.543).

CONCLUSION

Face-to-face teaching was the most effective method for teaching clinical examination of the shoulder. Technology can potentially increase accessibility and remove geographic barriers, but is not as effective if teaching techniques are simply mirrored in an online format. Online platforms allow in depth data analysis of how learners interact with educational material and this may have value in improving the design of online educational materials, and is a potential area for further research.

Surgical cognitive simulation improves real-world surgical performance: randomized study

BACKGROUND

Despite the acknowledgement of human factors, application of psychological methods by surgeons to improve surgical performance is sparse. This may reflect the paucity of evidence that would help surgeons to use psychological techniques effectively. There is a need for novel approaches to see how cognitive training might be used to address these challenges.

METHODS

Surgical trainees were divided into intervention and control groups. The intervention group received training in surgical cognitive simulation (SCS) and was asked to apply the techniques while working in operating theatres. Both groups underwent procedure-based assessment based on the UK and Ireland Intercollegiate Surgical Curriculum Programme (ISCP) before the training and 4 months afterwards. Subjective evaluations of SCS application were obtained from the intervention group participants.

RESULTS

Among 21 participants in the study, there was a statistically significant improvement in 11 of 16 procedure-based assessment domains (P < 0.050) as well as a statistically significant mean reduction in time to complete the procedure in the intervention group (-15.98 versus -1.14 min; P = 0.024). Subjectively, the intervention group experienced various benefits with SCS, especially in preoperative preparedness, intraoperative focus, and overall performance.

CONCLUSION

SCS training has a statistically significant impact in improving surgical performance. Subjective feedback suggests that surgeons are able to apply it in practice. SCS may prove a vital adjunct for skill acquisition in surgical training.

Patient-specific mental rehearsal with three-dimensional models before low anterior resection: randomized clinical trial

Background

It was hypothesized that preparing for a surgical procedure, taking into account individual patient characteristics, may facilitate the procedure and improve surgical quality. The aim of this study was to compare different case-specific, preoperative mental rehearsal methods before minimally invasive rectal cancer surgery.

Methods

In this RCT, patients were allocated in a 1 : 1 : 1 : 1 ratio to four groups: systematic mental rehearsal (SMR) using MRI scans; SMR and three-dimensional (3D) virtual models; SMR and synthetic 3D printed models; and routine practice (control group). Surgeons operating on all but the control group underwent mental rehearsal with the visual aids, including axial MRI scans of the pelvis, interactive 3D virtual models reconstructed from axial MRIs, and synthetic models, manufactured by 3D printing. Operations were video-recorded and assessed by two experts blinded to allocation using two validated scores, the Competency Assessment Tool (CAT) and Objective Clinical Human Reliability Analysis (OCHRA). The primary outcome of the study was surgical performance, measured by the CAT.

Results

Forty-nine patients were randomized and allocated to the four groups. There were 12 participants in each of the control, MRI and SMR, and virtual and SMR groups, whereas the SMR using physical models and simulation group included 13. No difference was observed between groups in median CAT scores (control 30.50, MRI 34.25, virtual 31.75, physical 34.00; P = 0.748, partial η² <0.001, where _pη² is indicative of effect size) or OCHRA scores (anterior, posterior, right and left lateral planes, transection P>0.200, _pη² =0.052–0.088). Time spent not performing dissection was significantly shorter for the SMR with MRI group than for the control (57.5 versus 42 respectively; P < 0.001, _pη² =0.212).

Conclusion

Mental rehearsal did not affect CAT and OCHRA scores of consultant surgeons. Reference number: ISRCTN 75603704 (https://www.isrctn.com).

Influence of Early Life Lead (Pb) Exposure on α-Synuclein, GSK-3β and Caspase-3 Mediated Tauopathy: Implications on Alzheimer's Disease

BACKGROUND

Previously we have shown that developmental exposure to the heavy metal lead (Pb) resulted in latent cognitive impairment, upregulation of biomarkers and pathology associated with both the tau and amyloid pathways, however, the impact on Alpha Synuclein (α-Syn) and its relationship to these pathways and their connection to cognitive performance warrant further elucidation.

OBJECTIVE

The present study determined the impact of developmental Pb exposure on the α-Syn pathways in a mouse model knock-out (KO) for murine tau gene and in differentiated human neuroblastoma SHSY5Y cell line exposed to a series of Pb concentrations.

METHODS

Western blot analysis and RT-PCR were used to assess the levels of intermediates in the tau and α-Syn pathways following postnatal Pb exposure on aged mice lacking tau gene and in differentiated SHSY5Y cells on day 3 and day 6 after the Pb exposure had ceased.

RESULT

Early life Pb exposure is accompanied by latent up-regulation in α-Syn in these mice. Furthermore, prior exposure to Pb in-vitro also resulted in an increase in α-Syn, its phosphorylated forms, as well as an increase in glycogen synthase kinase 3β (GSK-3β) and Caspase-3.

CONCLUSION

An environmental agent can act as a latent inducer of both α-Syn and associated kinases that are involved in tau hyperphosphorylation and may allude to the interactive nature of these two neurodegenerative pathways.

Tolfenamic Acid: A Modifier of the Tau Protein and its Role in Cognition and Tauopathy

BACKGROUND

Tangles are deposits of hyperphosphorylated tau, which are found in multiple neurodegenerative disorders that are referred to as tauopathies, of which Alzheimer's disease (AD) is the most common. Tauopathies are clinically characterized by dementia and share common cortical lesions composed of aggregates of the protein tau.

OBJECTIVE

In this study, we explored the therapeutic potential of tolfenamic acid (TA), in modifying disease processes in a transgenic animal model that carries the human tau gene (hTau).

METHODS

Behavioral tests, Western blotting and Immunohistochemical analysis were used to demonstrate the efficacy of TA.

RESULTS

Treatment of TA improved improving spatial learning deficits and memory impairments in young and aged hTau mice. Western blot analysis of the hTau protein revealed reductions in total tau as well as in sitespecific hyperphosphorylation of tau in response to TA administration. Immunohistochemical analysis for phosphorylated tau protein revealed reduced staining in the frontal cortex, hippocampus, and striatum in animals treated with TA.

CONCLUSION

TA holds the potential as a disease-modifying agent for the treatment of tauopathies including AD.

Operating list composition and surgical performance

BACKGROUND

Recent reviews suggest that the way in which surgeons prepare for a procedure (warm up) can affect performance. Operating lists present a natural experiment to explore this phenomenon. The aim was to use a routinely collected large data set on surgical procedures to understand the relationship between case list order and operative performance.

METHOD

Theatre lists involving the 35 procedures performed most frequently by senior surgeons across 38 private hospitals in the UK over 26 months were examined. A linear mixed-effects model and matched analysis were used to estimate the impact of list order and the cost of switching between procedures on a list while controlling for key prognosticators. The influence of procedure method (open versus minimally invasive) and complexity was also explored.

RESULTS

The linear mixed-effects model included 255 757 procedures, and the matched analysis 48 632 pairs of procedures. Repeating the same procedure in a list resulted in an overall time saving of 0·98 per cent for each increase in list position. Switching between procedures increased the duration by an average of 6·48 per cent. The overall reduction in operating time from completing the second procedure straight after the first was 6·18 per cent. This pattern of results was consistent across procedure method and complexity.

CONCLUSION

There is a robust relationship between operating list composition and surgical performance (indexed by duration of operation). An evidence-based approach to structuring a theatre list could reduce the total operating time.

Contributory factors in surgical incidents as delineated by a confidential reporting system

Background Confidential reporting systems play a key role in capturing information about adverse surgical events. However, the value of these systems is limited if the reports that are generated are not subjected to systematic analysis. The aim of this study was to provide the first systematic analysis of data from a novel surgical confidential reporting system to delineate contributory factors in surgical incidents and document lessons that can be learned. Methods One-hundred and forty-five patient safety incidents submitted to the UK Confidential Reporting System for Surgery over a 10-year period were analysed using an adapted version of the empirically-grounded Yorkshire Contributory Factors Framework. Results The most common factors identified as contributing to reported surgical incidents were cognitive limitations (30.09%), communication failures (16.11%) and a lack of adherence to established policies and procedures (8.81%). The analysis also revealed that adverse events were only rarely related to an isolated, single factor (20.71%) - with the majority of cases involving multiple contributory factors (79.29% of all cases had more than one contributory factor). Examination of active failures - those closest in time and space to the adverse event - pointed to frequent coupling with latent, systems-related contributory factors. Conclusions Specific patterns of errors often underlie surgical adverse events and may therefore be amenable to targeted intervention, including particular forms of training. The findings in this paper confirm the view that surgical errors tend to be multi-factorial in nature, which also necessitates a multi-disciplinary and system-wide approach to bringing about improvements.

Should prospective dental students be screened for colour vision deficits?

A perennial question in dental education is: what skills and aptitudes should be assessed in prospective dental students? Intellectual capacity and manual dexterity understandably rank highly, but are there minimum thresholds for visual perception that applicants need be able to demonstrate before they enter the profession? We have recently flagged this issue with regard to the thresholds of stereoscopic acuity required for a dentist when operating on teeth. In the present article, we highlight the issue of identifying a minimum acceptable level of colour vision.

Capturing differences in dental training using a virtual reality simulator

Virtual reality simulators are becoming increasingly popular in dental schools across the world. But to what extent do these systems reflect actual dental ability? Addressing this question of construct validity is a fundamental step that is necessary before these systems can be fully integrated into a dental school's curriculum. In this study, we examined the sensitivity of the Simodont (a haptic virtual reality dental simulator) to differences in dental training experience. Two hundred and eighty-nine participants, with 1 (n = 92), 3 (n = 79), 4 (n = 57) and 5 (n = 61) years of dental training, performed a series of tasks upon their first exposure to the simulator. We found statistically significant differences between novice (Year 1) and experienced dental trainees (operationalised as 3 or more years of training), but no differences between performance of experienced trainees with varying levels of experience. This work represents a crucial first step in understanding the value of haptic virtual reality simulators in dental education.

Importance of tau in cognitive decline as revealed by developmental exposure to lead

Previous reports by us have determined that developmental exposure to the heavy metal lead (Pb) resulted in cognitive impairment in aging wildtype mice, and a latent induction in biomarkers associated with both the tau and amyloid pathways. However, the relationship between these two pathways and their correlation to cognitive performance needs to be scrutinized. Here, we investigated the impact of developmental Pb (0.2%) exposure on the amyloid and tau pathways in a transgenic mouse model lacking the tau gene. Cognitive function, and levels of intermediates in the amyloid and tau pathways following postnatal Pb exposure were assessed on young adult and mature transgenic mice. No significant difference in behavioral performance, amyloid precursor protein (APP), or amyloid beta (Aβ) levels was observed in transgenic mice exposed to Pb. Regulators of the tau pathway were impacted by the absence of tau, but no additional change was imparted by Pb exposure. These results revealed that developmental Pb exposure does not cause cognitive decline or change the expression of the amyloid pathway in the absence of tau. The essentiality of tau to mediate cognitive decline by environmental perturbations needs further investigation.

Feedback and motor skill acquisition using a haptic dental simulator

AIM

To investigate the effect of qualitatively different types of pedagogical feedback (FB) on the training, transfer and retention of basic manual dexterity dental skills using a virtual reality (VR) haptic dental simulator.

METHODS

Sixty-three participants (M = 22.7 years; SD = 3.4 years), with no previous dental training, were randomly allocated to one of three groups (n = 21 each). Group 1 received device-only feedback during the training phase, that is the visual display of the simulator (DFB); Group 2 received verbal feedback from a qualified dental instructor (IFB); and Group 3 received a combination of instructor and device feedback (IDFB). Participants completed four tasks during which feedback was given according to group allocation as well as two skills transfer tests. Skill retention was examined immediately after training, at 1 week and at 1 month post-test.

RESULTS

Statistically significant differences were found between the groups in overall performance (P < 0.001) and error (P = 0.006). Post hoc comparisons revealed the IDFB group produced substantially better performance and fewer errors in comparison with DFB and IFB training. This difference translated to improved performance in skill retention and generalisation of knowledge to novel tasks.

CONCLUSION

These data indicate that the acquisition and retention of basic dental motor skills in novice trainees is best optimised through a combination of instructor and visual display (VR)-driven feedback. The results have implications for the utility and implementation of VR haptic technology in dental education.

A smart multifunctional drug delivery nanoplatform for targeting cancer cells

Wirelessly guided magnetic nanomachines are promising vectors for targeted drug delivery, which have the potential to minimize the interaction between anticancer agents and healthy tissues. In this work, we propose a smart multifunctional drug delivery nanomachine for targeted drug delivery that incorporates a stimuli-responsive building block. The nanomachine consists of a magnetic nickel (Ni) nanotube that contains a pH-responsive chitosan hydrogel in its inner cavity. The chitosan inside the nanotube serves as a matrix that can selectively release drugs in acidic environments, such as the extracellular space of most tumors. Approximately a 2.5 times higher drug release from Ni nanotubes at pH = 6 is achieved compared to that at pH = 7.4. The outside of the Ni tube is coated with gold. A fluorescein isothiocyanate (FITC) labeled thiol-ssDNA, a biological marker, was conjugated on its surface by thiol-gold click chemistry, which enables traceability. The Ni nanotube allows the propulsion of the device by means of external magnetic fields. As the proposed nanoarchitecture integrates different functional building blocks, our drug delivery nanoplatform can be employed for carrying molecular drug conjugates and for performing targeted combinatorial therapies, which can provide an alternative and supplementary solution to current drug delivery technologies.

Inconsistent reporting of minimally invasive surgery errors

INTRODUCTION

Minimally invasive surgery (MIS) is a complex task requiring dexterity and high level cognitive function. Unlike surgical 'never events', potentially important (and frequent) manual or cognitive slips ('technical errors') are underresearched. Little is known about the occurrence of routine errors in MIS, their relationship to patient outcome, and whether they are reported accurately and/or consistently.

METHODS

An electronic survey was sent to all members of the Association of Surgeons of Great Britain and Ireland, gathering demographic information, experience and reporting of MIS errors, and a rating of factors affecting error prevalence.

RESULTS

Of 249 responses, 203 completed more than 80% of the questions regarding the surgery they had performed in the preceding 12 months. Of these, 47% reported a significant error in their own performance and 75% were aware of a colleague experiencing error. Technical skill, knowledge, situational awareness and decision making were all identified as particularly important for avoiding errors in MIS. Reporting of errors was variable: 15% did not necessarily report an intraoperative error to a patient while 50% did not consistently report at an institutional level. Critically, 12% of surgeons were unaware of the procedure for reporting a technical error and 59% felt guidance is needed. Overall, 40% believed a confidential reporting system would increase their likelihood of reporting an error.

CONCLUSION

These data indicate inconsistent reporting of operative errors, and highlight the need to better understand how and why technical errors occur in MIS. A confidential 'no blame' reporting system might help improve patient outcomes and avoid a closed culture that can undermine public confidence.

MERS CoV infection in two renal transplant recipients: case report

Middle East Respiratory Syndrome Coronavirus (MERS CoV) infection has recently emerged as a cause of severe potentially fatal pneumonia. The clinical presentation ranges from asymptomatic infection to severe pneumonia and acute renal failure. Data on the clinical presentation in solid organ transplant recipients are lacking. We report two cases of MERS CoV infections in two renal transplant recipients with variable clinical presentations and outcomes. The first patient presented with progressive respiratory symptoms, acute renal failure and died. While the second patient presented with respiratory tract symptoms, remained stable and had an excellent clinical recovery despite recent reception of thymoglobulin induction. This is a rare report of MERS CoV infection in renal transplant recipients. Further data are needed to gain better understanding of the impact of anti-rejection immunosuppressive therapy on the clinical presentation, severity and outcome of MERS CoV infections in solid organ transplant recipients.

Acupuncture-induced pneumothorax: the hidden complication

Acupuncture can be associated with potentially life-threatening complications. Although rare, we feel that potential complications are not being conveyed to patients. We present a case of acupuncture-induced pneumothorax and describe some changes to acupuncture practice that we would like to see implemented.

Dose-dependent effects of tryptophan on learning and memory

The concentration of 5-hydroxytryptamine (5-HT, Serotonin) varies as a result of physiological changes in the availability of its precursor tryptophan to the serotonergic neurons in the brain. Increase in brain tryptophan occurs following an increase in plasma tryptophan concentration. Tryptophan intake increases brain serotonin metabolism and enhances memory. The Present study was designed to investigate the effects of oral administration of tryptophan (TRP) at different doses (100, 300 and 500mg/kg) for two weeks on learning and memory functions and Neurochemical changes in rats. Control rats were given drinking water. Assessment of memory in rats was done by using the water Maze. on the 14th day trail training of water Maze was given to rats and after 1h of this 2nd trial of these rats were done. On the next day (After 24h of trail) long-term memories of these rats were monitored. After 1 hour of this all rats were killed by decapitation using guillotine. Brain and blood was collected and stored at -70°C. Neurochemical estimations of Plasma and brain tryptophan, 5-HT and 5-HIAA in brain were made by HPLC-EC. Result showed that administration of tryptophan enhanced performance on water Maze test. Tryptophan treated animals exhibited higher level of Plasma as well as brain tryptophan. 5-HT and 5-HIAA levels were also increased in tryptophan treated rats. Findings are discussed in context with the role of 5-HT metabolism in learning and memory process in rats. Results may help to understand the 5-HT changes following long term TRP administration in a dose dependent manner and will help to suggest the use of TRP in serotonin related illnesses.

Pattern of glomerular disease in the Saudi population: a single-center, five-year retrospective study

Glomerular diseases continue to be the leading cause of end-stage renal disease (ESRD) globally. Hence, it is important to recognize the pattern of glomerular diseases in different geographical areas in order to understand the patho-biology, incidence and progression of the disorder. Published studies from different centers in Saudi Arabia have reported contradicting results. In this retrospective study, we report our experience at the Armed Forces Hospital, Riyadh, Saudi Arabia. A total of 348 native renal biopsies performed at our center on patients with proteinuria >1 g, hematuria and/or renal impairment during a period of 5 years (between January 2005 and December 2009) were studied by a histopathologist using light microscopy, immunofluorescence and electron microscopy, and were categorized. Results showed that primary glomerular disease accounted for 55.1% of all renal biopsies. The most common histological lesion was focal and segmental glomerulosclerosis (FSGS) (27.6%), followed by minimal change disease (MCD) (17.7%) and membrano-proliferative glomerulonephritis (MPGN) (13.0%). Secondary glomerular disease accounted for 37.9% of the glomerular diseases, with lupus nephritis (LN) being the most common lesion (54.5%), followed by hypertensive nephrosclerosis (22%), post-infectious glomerulonephritis (7.5%), diabetic nephropathy (DN) (6.8%) and vasculitides (4.5%). Four percent of all biopsies turned out to be ESRD while biopsy was inadequate in 2.8% of the cases. In conclusion, our study showed that FSGS was the most common primary GN encountered, while LN was the most common secondary GN. We encountered 14 cases of crescentic glomerulonephritis. Also, the prevalence of MPGN, MCD, IgA nephropathy and membranous GN was many folds higher in males when compared with the Western data. We believe that it is mandatory to maintain a Saudi Arabian Renal Biopsy Registry to understand better the pattern of glomerular disease in the Saudi population and to follow any change in trend.

Microperimetric changes in neovascular age-related macular degeneration treated with ranibizumab

PURPOSE

To assess the value of microperimetry in eyes with neovascular age-related macular degeneration previously treated with ranibizumab and now in the maintenance phase of therapy.

METHODS

A total of 21 eyes (14 patients) were included. Microperimetry was performed using the Macular Integrity Assessment Device on at least three occasions for each eye. Intravitreal ranibizumab was administered if visual acuity (VA) or optical coherence tomography (OCT) showed signs of active disease.

RESULTS

Five eyes showed no change in VA or OCT findings, and required no intravitreal injections. In these eyes, mean threshold sensitivity (TS) decreased by 13% (paired t-test, P=0.05) during the study period, but fixation stability (FS) was unchanged. In all, 16 eyes showed signs of disease activity, and therefore required ranibizumab injections during the study. In these eyes, VA, central retinal thickness (CRT), FS, and TS remained unchanged during follow-up. Peak TS was noted when CRT was 210 μm; above or below 210 μm, there was a gradual reduction in TS.

CONCLUSION

This study has provided novel information on the relationship between macular sensitivity, CRT, and VA in the maintenance phase of ranibizumab therapy. Patients with stable VA and CRT may still have deteriorating retinal sensitivity. This is usually a late manifestation and may indicate subclinical CNV activity.

Rare case of spot diagnosis of nephrotic syndrome in a Saudi male

A 26- year- old Saudi male school teacher presented with clinical features of nephrotic syndrome. Physical examination revealed loss of subcutaneous fat over the face and upper arms (partial lipodystrophy) and drusen in both eyes. The serum level of complement C3 was low, with normal C4. Renal biopsy revealed features consistent with membranoproliferative glomerulo- nephritis (MPGN) type II [Dense Deposit Disease (DDD)]. He was treated with prednisolone and mycophenolate mofetil with partial remission. He also received lipitor and lisinopril. The occurrence of partial lipo- dystrophy and drusen in a patient with nephrotic syndrome provides a rare clinical opportunity of making a bedside diagnosis of type II MPGN even before kidney biopsy.

Do we know what people die of in the emergency department?

OBJECTIVE

To establish the discrepancy rate between the predicted cause of death and the actual cause of death as determined by postmortem examination result, for all deaths in the emergency department reported to the Scottish Procurator Fiscal and subsequently undergoing postmortem examination.

METHODS

A prospective study of all patients who were dead on arrival or died in the emergency department of a busy Glasgow hospital over a 12 month period. The most senior emergency physician present at the time of death predicted the cause of death. This was then compared to the actual postmortem examination determined cause of death and was considered either to be correct or incorrect.

RESULTS

During the study period, 146 patients were pronounced dead in the department. Of these, 81 patients (age range 39-99 years, median 71; male:female 2.5:1) had death certificates issued, 63 patients (age range 26 days to 99 years, median 48; male:female 2.4:1) had a postmortem performed by the forensic pathologist, and two patients underwent a "view and grant". Of the 63 deaths reported to the Procurator Fiscal, the emergency physician attributed 51 (80.1%) to non-trauma, 9 (14.2%) to trauma, and in 3 (4.7%) cases were uncertain. Of the 63 (39.7%) deaths, 25 were inaccurately predicted (99% confidence interval 24.3% to 56.6%; p<0.0)1. Cardiovascular related and drugs poisoning deaths occurred most commonly. They were also the most accurately predicted cause of deaths. Intracranial events, pulmonary thromboembolism, and airway obstruction were also frequently predicted, but were often wrong.

CONCLUSIONS

This study highlights the difficulties in accurately identifying cause of death for patients who die suddenly. This could have implications for the accuracy of health service statistics.