Block learning: Evaluation of a new teaching approach for nursing and midwifery education

AIM

The aim is to present outcome and engagement data from the initial years of the implementation of a new teaching approach in entry to practice nursing and midwifery education.

BACKGROUND

The Block Model (TBM) is a teaching approach that involves studying one unit of study at a time over a four-week period, as opposed to the traditional semester model. This paper presents data revealing the impact of TBM on student engagement and overall experience in entry to practice Bachelor of Nursing and Midwifery programs.

DESIGN

The evaluation retrospectively compared key indicators pre- Block Model implementation with outcomes for nursing and midwifery students using TBM approach using standard data sets and external comparators such as the Student Experience Survey and National Employability Survey.

METHODS

The study presents a comparative analysis of key indicators and graduate outcomes for students. We use reportable data and two external comparators, the Student Experience Survey and the National Employability Survey, to gauge student learning and graduate employability. The evaluation was conducted in a tertiary institution in Australia with for nursing and midwifery students who completed their studies using TBM approach at the university.

RESULTS

The implementation of TBM in nursing and midwifery programs resulted in improvements in learner engagement, retention rates and pass rates. Improvements were also noted graduate outcomes, with an increase in full-time graduate employment.

CONCLUSIONS

The results suggest the Block Model is a promising new teaching approach in nursing and midwifery education, with potential benefits for learner engagement, retention and pass rates.

An Exploratory Study of Undergraduate Nursing Students' Experiences of Group Work in Block Model Teaching

ABSTRACT

The study's aim was to examine students' perceptions of group work taught in a block model in the first unit of an undergraduate nursing program. The study used a qualitative descriptive design with open-ended questions. Data from 27 students were analyzed using thematic analysis. Three main themes emerged from the data: 1) unmet expectations, 2) cognitive and metacognitive strategies (subtheme, reflection), and 3) engagement. The benefits and challenges associated with group work using the block model are highlighted, along with implications for education, practice, and further research.

The impact of motivational interviewing on behavioural change and health outcomes in cancer patients and survivors. A systematic review and meta-analysis

BACKGROUND

Cancer patients and survivors commonly have poorer health behaviours and subsequent outcomes, often as a result of negative impacts of diagnosis and treatment. Motivational interviewing is reported to be an effective psychological tool to produce a shift in one's behaviour resulting in improved outcomes. However, there is a lack of analyses investigating this tool's impact on healthy behaviours and health outcomes in cancer populations.

OBJECTIVE

To investigate the effect of motivational interviewing on behaviours and health outcomes in cancer populations.

METHODS

The studies were identified from four databases using variations of the terms "cancer" and "motivational interviewing". Randomised trials, non-randomised trials and quasi-experimental studies which contained control (or usual care) comparators were included. Risk of bias was assessed using the Cochrane Risk of Bias Version 5.1.0 and the Risk of Bias In Non-Randomised Studies of Interventions tools. The quality of evidence was assessed using the GRADE framework. Means difference and standardised mean differences and 95 % confidence intervals were used to report the pooled effects using a random effects model.

RESULTS

Twenty-one studies were included in the review and 17 studies were included in the meta-analysis. A total of 1752 cancer patients and survivors received MI as an intervention (or part thereof). Quality of life, anxiety, depression, functional tasks (6-minute walk test), body mass index and body weight (BMI/BW), physical activity (PA), self-efficacy and fatigue were outcomes measured in the selected studies. Effects were seen in functional tasks, physical activity, BMI/BW, depression and self-efficacy. All of these outcomes were from studies that were classed as very low-quality evidence except for BMI/BW and PA, which were from moderate-quality evidence.

CONCLUSION

Motivational interviewing had positive effects on functional tasks, PA, BMI/BW, depression and self-efficacy in people diagnosed with cancer. However, more higher-quality studies need to be conducted to further ascertain the effect of this intervention.

The role of digital technologies in supporting quality improvement in Australian early childhood education and care settings

This national study explored the role of digital technologies in early childhood education and care settings and whether they could contribute to quality improvement as reported by educators and assessors of quality in Australia. In this paper, data from Stage 2 of the Quality Improvement Research Project were used, which comprised 60 Quality Improvement Plans from educators linked with 60 Assessment and Rating reports from the assessors who visited early childhood centres as part of the administration of the National Quality Standards by each of Australia's State and Territory jurisdictions. Bronfenbrenner's ecological systems theory ( Bronfenbrenner, U. (1995). Developmental ecology through space and time: A future perspective. In P. Moen, G. H. Elder, Jr., & K. Lüscher (Eds.), Examining lives in context: Perspectives on the ecology of human development (pp. 619-647). American Psychological Association. 10.1037/10176-018; Bronfenbrenner & Ceci, Bronfenbrenner and Ceci, Psychological Review 101:568-586, 1994) was adopted to facilitate a systemic and dynamic view on the use of digital technologies in these 60 ECEC settings. References (e.g. comments/ suggestions/ examples) made by the educators about the implementation of digital technologies were counted and thematically analysed. Results revealed the strong role new technologies (e.g. documentation and management platforms, tablets, apps, etc.) play in the majority of ECEC settings and especially in relation to three of the seven Quality Areas: Educational programme and practice (Quality Area 1); Collaborative partnerships with families and communities (Quality Area 6) and Governance and leadership (Quality Area 7). Future directions for research are suggested and implications for embracing a more holistic, integrated and broad view on the use of digital technologies are discussed.

Structures and systems influencing quality improvement in Australian early childhood education and care centres

This study assessed the impact of structural characteristics on quality rating and improvement systems (QRIS) outcomes in an Australian national study. Data from the Australian Children's Education and Care Quality Authority (ACECQA) repository of National Quality Standard (NQS) ratings were used to identify long day care services that had improved from Working Towards NQS to Meeting or Exceeding NQS or had no change over two assessments. QRIS outcomes were examined for state/territory jurisdiction, urban-rural location, community socio-economic status, type and size of provider organisation, centre size and stability of centre owner/provider using multinomial logistic regression analyses. Controlling for jurisdiction, results showed that improvement to Meeting NQS was more likely for not-for-profit versus for-profit providers and for large multi-site provider organisations versus small, stand-alone providers. Improvement to Exceeding NQS was also associated with not-for-profit and larger provider organisations, as well as larger versus smaller centres, and centres that had stable ownership.

A Psychometric Appraisal of the Motivated Strategies for Learning Questionnaire (MSLQ) in Final Year Undergraduate Nursing Students

BACKGROUND

The purpose of this study was to evaluate the psychometric properties of the Motivated Strategies for Learning Questionnaire (MSLQ) in undergraduate nursing students.

METHOD

An exploratory factor analysis was conducted to assess the reliability and construct validity of the MSLQ, using principal axis factoring (PAF) and varimax rotation on the 81-items.

RESULTS

300 Students completed the MSLQ. The MSLQ with 81-items produced an 8-factor solution, eigenvalues greater than 1.0, with only three of the original MSLQ factors retained. Cronbach alpha ranged from .69 to .89; parallel analysis results ranged from 2.22 to 1.80 across the factors.

CONCLUSION

The difference in the empiric fit between the data and the theoretical model suggests the need for instrument revisions, at least for this learner population.

The self-regulated learner, entry characteristics and academic performance of undergraduate nursing students transitioning to University

BACKGROUND

Although the importance of fostering students self-regulated learning is well known, little is known about the relationship between student entry characteristics, particularly students from disadvantaged backgrounds, self-regulatory strategy use and academic performance. The study aim was to examine undergraduate nursing students' entry characteristics, motivational behaviours and learning strategies, and academic performance after transitioning into the first unit of an undergraduate nursing course.

DESIGN

A cross-sectional survey.

SETTING

A university in Australia.

PARTICIPANTS

First-year undergraduate nursing students.

METHODS

The Motivational Strategies for Learning Questionnaire, including demographic information, was distributed to students in the fourth week of commencing University, consent was obtained for the use of student unit grades.

RESULTS

For the 448 eligible students, n = 282 (62.9%) completed the survey. Students were categorised by age into three groups: 18 years, 19-22 years, and 23+ years. Entry characteristics, motivation and learning strategies scores and academic performance were related to the age category with the greatest difference between 18 and 23+ student groups. 23 years+ had higher scores for 11 MSLQ scales (mean difference 0.78-0.31, p < 0.05) highest grades (F = 4.694, p = 0.010). Students 23+ years had the highest motivational behaviours and learning strategies. The international students' academic grades in this study were lower than the domestic student's grades (t = -2.212, p = 0.028).

CONCLUSION

This study highlights the need to address the tensions that exist between attracting quality students, the requirement to assess their quality efficiently and allowing students from disadvantaged groups the opportunity to enter nursing undergraduate degree courses. This study contributes new knowledge to the impact students' entry characteristics have on motivational behaviours, learning strategy use and academic performance. Knowing this would allow faculty to identify students at risk of failure early in the course and offer instructional support.

Undergraduate nursing student and preceptors' experiences of clinical placement through an innovative clinical school supervision model

This study explores final year undergraduate nursing and midwifery students and their preceptors' experiences of a newly introduced Clinical School Supervision (CSS) model, which was implemented to reduce a perceived disconnect between theory and practice. A descriptive design was used with qualitative data collected through open-ended survey questions. Respondents included 43 undergraduate nursing and midwifery students involved in the final year and 13 clinical preceptors from a large metropolitan tertiary health service in Victoria, Australia. Qualitative data were analysed using thematic analysis. Students described the CSS as a favoured supervision model with students being able to take advantage of support from both the academic supervisor and nursing staff in the clinical setting, a model which also supported student's sense of belonging. Students experiences indicated the CSS model facilitated consolidation of knowledge, reflective practice and transition to graduate nursing. The preceptors described a commitment to and preparedness for the role, although they found they had little break from teaching and their rosters did not always align with their students'. Preceptors also shared experiences of unfulfilled expectations, lack of recognition and incentives for supervising students. Further studies are needed to identify effective ways to support preceptors in their roles.

Queensland’s multi-year Wet and Dry periods: implications for grazing enterprises and pasture resources

Year-to-year variability in rainfall has long been recognised as a major issue in managing livestock enterprises across Australia’s grazing lands. Extension products documenting rainfall variability have been developed over the last 30 years and have been keenly sought by producers and their advisors. This paper describes multi-year rainfall variability from 1889 to 2020 and provides the basis for classifying the 131 years of rainfall into 18 discrete Wet (7), Average (2) and Dry (9) periods as presented in the ‘Queensland’s Extended Wet and Dry Periods’ poster. The classification was consistent with: analysis of fluctuations and trends in the long-term time series of reported livestock numbers; drought declarations for government assistance; and documented periods of pasture resource degradation and recovery. Rainfall during the nine Wet and Average periods was +18% above the long-term average annual rainfall (LTAAR), in contrast to the Dry periods with −17% below LTAAR. Wet periods (including Average) were on average 7 years in duration, ranging from 5 to 9 years. Dry periods were on average 8 years in duration and ranged from 5 to 13 years. Detailed analysis of the effects of the El Niño Southern Oscillation (ENSO) phenomenon indicated that: (a) the Wet/Dry periods were dominated by different frequencies and amounts of rainfall in La Niña/El Niño years; (b) rainfall in ENSO neutral years was generally above and below average rainfall for the Wet or Dry periods respectively; (c) the frequency of ENSO year-types was less important than the overall rainfall surplus (or deficit) in La Niña (or El Niño) years within the Wet (or Dry) periods respectively; and (d) the timing of Wet and Dry periods was correlated with indices of quasi-decadal and inter-decadal variability in components (sea surface temperatures and atmospheric pressures) of the global climate system. Climatic risk assessment systems for grazing management at multi-year timescales are yet to be developed.

An online system for calculating and delivering long-term carrying capacity information for Queensland grazing properties. Part 2: modelling and outputs

A combination of field data and models have been used to estimate long-term carrying capacity (LTCC) of domestic livestock in Queensland grazing lands. These methods have been synthesised and coupled with recent developments in science and information technology to provide a fully-automated approach of modelling LTCC through the FORAGE online system. In this study, the GRASP model was used to simulate pasture growth with parameter sets and safe pasture utilisation rates defined for 225 land types across Queensland. Distance to water points was used to assess the accessibility of pastures to livestock. Spatial analysis classified the property into unique areas based on paddock, land type and distance to water points, which estimated pasture growth, pasture utilisation and accessibility at a sub-paddock scale. Thirteen foliage projective cover (FPC) classes were used in modelling the pasture system to deal with the non-linear relationship between tree and grass interactions. As ‘proof of concept’, remotely-sensed individual-date green ground cover data were used to optimise the GRASP model parameters to improve the model performance, and a Monte Carlo analysis provided uncertainty estimates for model outcomes. The framework provides an efficient and standardised method for estimating LTCC. To test the system, LTCCs from 43 ‘benchmark’ properties were compared with simulated LTCCs, and 65% of the modelled LTCCs were within ± 25% of the benchmark LTCCs. Due to uncertainties in model inputs at the property scale and in model simulation, the modelled LTCC should be used as a starting point for further refinement of actual property LTCC.

Observed compliance with safe sleeping guidelines in licensed childcare services

OBJECTIVE

To independently assess compliance with safe sleeping guidelines for infants <12 months in licensed childcare services.

DESIGN

Full-day, in-situ observations of childcare practices (including sleep and non-sleep periods) conducted in 2016-2017.

SETTING

Australian home-based and centre-based licensed childcare services. All subject to national regulation and legislation to comply with safe sleeping guidelines.

PARTICIPANTS

The sample was 18 licensed childcare settings (15 centre-based, 3 home-based) that had infants <12 months (n=49) attending at the time of observation. 31 educators completed self-report surveys.

MAIN OUTCOMES AND MEASURES

Standard observations of childcare practices, including a 20-item infant Safe Sleeping Guideline checklist. Educator characteristics, including each individual's knowledge, beliefs and attitudes regarding safe sleeping practices.

RESULTS

83% of childcare services were observed to be non-compliant on at least 1 of 20 target guidelines (median 2.5, max=7); 44% were observed placing infants prone/side and 67% used loose bedding, quilts, doonas/duvets, pillows, sheepskins or soft toys in cots. 71% of the childcare settings had a copy of current safe sleeping guidelines displayed either in or at entry to the infant sleep room.

CONCLUSION

Despite 25 years of public health messaging, non-compliance with safe sleeping guidelines was observed to be high in childcare services. Understanding of the reasons underlying non-compliance, particularly in contexts were legislative mandate and access to information regarding safe sleeping is high, is critical to informing ongoing public health messaging and should be the focus of future studies.

TRIAL REGISTRATION NUMBER

ANZCTR 12618001056280-pre-results.

Factors affecting patient flow in a neurosurgery department

INTRODUCTION

Patient flow is the process by which movement of patients and clinical productivity is achieved. The objectives of this study were to implement and evaluate the NHS Improvement SAFER patient flow bundle, evaluate the impact of the Red2Green initiative, and assess the impact of frailty on patient flow.

MATERIALS AND METHODS

All patients admitted to a neurosurgery unit from 1 September to 30 November 2017 were included. Using guidance set out by NHS, data were prospectively collected from daily ward lists and patient notes, including demographics, admission and discharge details, length of stay, anticipated discharge date, red days with reasons and frailty (Rockwood Clinical Frailty Scale). NHS reference costs were used for cost analyses.

RESULTS

A total of 420 patients (55% elective) were included, totalling 3909 bed days. All patients received daily senior reviews before midday, and anticipated discharge dates were set at daily multidisciplinary team meetings. Ten per cent of patients were discharged before midday. There were 21% (837) red days, significantly more (76%) for emergency patients (639 vs 198 elective; P < 0.001); 63% red days were attributed to awaiting a bed in a local hospital; 25% (106) patients were classed as frail (50 elective), which was associated with a significantly longer length of stay (17.3 vs 6; P < 0.01), and more red days (615 vs 222; p<0.01). Considering excess bed charges and lost revenue (with penalties), red days cost over £1 million per year.

CONCLUSIONS

SAFER has identified areas for improvement in patient flow, with obvious cost implications. It has created a platform for discussion within the referral network and identified a role for a geriatric liaison service.

FP1-4 Factors affecting patient flow in a neurosurgery department

Objectives

The objectives of this study were to audit the NHS Improvement SAFER patient flow bundle, evaluate the impact of the Red2Green initiative, and assess the impact of frailty on patient flow.

Design

A prospective review over a 3 month period.

Subjects

All patients admitted to a Neurosurgery Unit from 01/09/2017 to 30/11/2017 were included.

Methods

Data were prospectively collected from daily ward lists and patient notes, including demographics, admission/discharge details, length of stay (LOS), expected discharge date, red days with reasons, and frailty (Rockwood Clinical Frailty Scale). NHS Improvement Reference Costs were used for cost analyses.

Results

420 patients (55% elective) were included, total 3909 bed days. All patients received a daily senior review before midday, and EDDs were set at daily MDT meetings. 10% patients were discharged before midday. There were 21% (837) red days, significantly more (76%) for emergency patients (639 vs 198 elective; p<0.001). 63% red days were attributed to awaiting a bed in a local hospital. 25% (106) patients were classed as frail (50 elective), which was associated with a significantly longer LOS (17.3 vs 6; p<0.01), and more red days (615 vs 222; p<0.01). Considering bed costs and lost revenue (with penalties), red days cost is estimated at over £1M per year.

Conclusions

SAFER has identified areas for improvement in patient flow, with obvious cost implications. It has created a platform for discussion within the referral network, and identified a role for a geriatric liaison service.

Near-peer teaching in undergraduate nurse education: An integrative review

INTRODUCTION/BACKGROUND

Studies in peer learning and teaching reported in the nursing literature are mainly descriptive, summarising positive aspects using survey and interviews. Application of pedagogical approaches to near-peer teaching in undergraduate nursing, using educational psychology frameworks to explain the outcomes, is relatively unknown.

OBJECTIVES

The objective of this integrative review was to ascertain outcomes of near-peer teaching in undergraduate nurse education and theoretical frameworks used to explain outcomes of near-peer teaching.

DESIGN

Included qualitative and quantitative studies.

METHOD

The review was conducted in accordance with the PRISMA protocol and Joanna Briggs Institute processes and included studies published between the years 1990 and 2017. Quality appraisal involved two independent reviewers analysing the data, and narrative synthesis was used to report results.

RESULTS

Two hundred and twenty-one abstracts were assessed independently by two reviewers for relevance to near-peer teaching in undergraduate nurse education, 29 articles selected for further review with 10 meeting the inclusion criteria. Benefits of near-peer teaching were reported as creating a safe supportive learning environment, learners viewing near-peer teachers as effective role models and increased confidence experienced by learner and teacher. Studies focused mainly on cognition in relation to performance with little emphasis on metacognition or affective behaviours, highlighting the need for more studies to provide definitive evidence supporting this pedagogical approach and framing its implementation around theories, particularly from educational psychology.

CONCLUSION

Lack of training provided to near-peer teachers highlighted that it is imperative that faculty embed near-peer teaching into the curriculum. To develop this educational intervention, studies in near-peer teaching are required to assess affective behaviours and metacognitive qualities of near-peer teachers to determine how this educational intervention can impact learning and performance of both the learner and near-peer teacher.

Paradoxical upgrading reaction in extra-pulmonary tuberculosis: association with vitamin D therapy

SETTING:

Glasgow, Scotland, UK.

BACKGROUND:

Paradoxical reactions in tuberculosis (TB) are a notable example of our incomplete understanding of host-pathogen interactions during anti-tuberculosis treatment.

OBJECTIVES:

To determine risk factors for a TB paradoxical reaction, and specifically to assess for an independent association with vitamin D use.

DESIGN:

Consecutive human immunodeficiency virus (HIV) negative adult patients treated for extra-pulmonary TB were identified from an Extended Surveillance of Mycobacterial Infections database. In our setting, vitamin D was variably prescribed for newly diagnosed TB patients. A previously published definition of paradoxical TB reaction was retrospectively applied to, and data on all previously described risk factors were extracted from, centralised electronic patient records. The association with vitamin D use was assessed using multivariate logistic regression.

RESULTS:

Of the 249 patients included, most had TB adenopathy; 222/249 had microbiologically and/or histologically confirmed TB. Vitamin D was prescribed for 57/249 (23%) patients; 37/249 (15%) were classified as having paradoxical reactions. Younger age, acid-fast bacilli-positive invasive samples, multiple disease sites, lower lymphocyte count and vitamin D use were found to be independent risk factors.

CONCLUSION:

We speculate that vitamin D-mediated signalling of pro-inflammatory innate immune cells, along with high antigenic load, may mediate paradoxical reactions in anti-tuberculosis treatment.

How are we assessing near-peer teaching in undergraduate health professional education? A systematic review

BACKGROUND

Near Peer teaching (NPT) is reported as an effective pedagogical approach to student learning and performance. Studies in medicine, nursing and health sciences have relied mainly on self-reports to describe its benefits, focusing on psychomotor and cognitive aspects of learning. Despite increasing research reports on peer teaching internationally, little is known about the various domains of learning used in assessment of performance and objective learning outcomes of NPT.

OBJECTIVE

To determine the domains of learning and assessment outcomes used in NPT in undergraduate health professional education.

METHODS

Quantitative systematic review was conducted in accord with the PRISMA protocol and the Joanna Briggs Institute processes. A wide literature search was conducted for the period 1990-November 2015 of fourteen databases. Grey literature was undertaken from all key research articles. Studies meeting the inclusion criteria were eligible for consideration, including measured learning outcomes of near-peer teaching in undergraduate education in nursing, medicine and health sciences. Set limitations included publications after 1990 (2015 inclusive), English language and objective learning outcomes. A quality appraisal process involving two independent reviewers was used to analyse the data.

RESULTS

Of 212 selected articles, 26 were included in the review. Terminology was confusing and found to be a barrier to the review process. Although some studies demonstrated effective learning outcomes resulting from near-peer teaching, others were inconclusive. Studies focused on cognitive and psychomotor abilities of learners with none assessing metacognition, affective behaviours or learning outcomes from quality of understanding.

CONCLUSION

The studies reviewed focused on cognitive and psychomotor abilities of learners. Even though evidence clearly indicates that metacognition and affective behaviours have direct influence on learning and performance, indicating more research around this topic is warranted. Methodological quality of the studies and lack of theoretical frameworks underpinned by educational psychology may have contributed to inconsistencies in learning outcomes reported.

Peer-assisted learning: time for nomenclature clarification

BACKGROUND

Peer-assisted learning (PAL) is used throughout all levels of healthcare education. Lack of formalised agreement on different PAL programmes may confuse the literature. Given the increasing interest in PAL as an education philosophy, the terms need clarification. The aim of this review is to 1) describe different PAL programmes, 2) clarify the terminology surrounding PAL, and 3) propose a simple pragmatic way of defining PAL programmes based on their design.

METHODS

A review of current PAL programmes within the healthcare setting was conducted. Each programme was scrutinised based on two aspects: the relationship between student and teacher, and the student to teacher ratio. The studies were then shown to fit exclusively into the novel proposed classification.

RESULTS

The 34 programmes found, demonstrate a wide variety in terms used. We established six terms, which exclusively applied to the programmes. The relationship between student and teacher was categorised as peer-to-peer or near-peer. The student to teacher ratio suited three groupings, named intuitively 'Mentoring' (1:1 or 1:2), 'Tutoring' (1:3-10), and 'Didactic' (1:>10). From this, six novel terms - all under the heading of PAL - are suggested: 'Peer Mentoring', 'Peer Tutoring', 'Peer Didactic', 'Near-Peer Mentoring', 'Near-Peer Tutoring', and 'Near-Peer Didactic'.

CONCLUSIONS

We suggest herein a simple pragmatic terminology to overcome ambiguous terminology. Academically, clear terms will allow effective and efficient research, ensuring furthering of the educational philosophy.

Lenses and Lessons: Using three different research perspectives in early childhood education research

In contemporary Western research, collaboration is held in high esteem. This developing practice is chal¬lenging particularly for researchers who follow varying theoretical approaches. However although a challeng¬ing endeavour, when viewing the one data set with different lenses, there are various lessons that can be shared. A key aspect of this paper is involved researchers' different analytical perspectives in one data set to learn more about each other's research insights, rather than become instant expert in other's approaches. The interview data reported in this paper originates from a larger study researching parents' experience of using early child¬hood education and care (ECEC) in Australia. Here we analyse and report on two shared interview excerpts and use three different research lenses for analysis; phenomenographic study, conversational analysis and cul¬tural-historical theory. The finding of this paper demonstrates that applying different lenses provide different interpretations, including strengths, limitations and opportunities. In this paper we argue that collaborative research practices enhance our understanding of varying research approaches and the scope, quality, transla¬tion of research and the researchers' capacity are enhanced.

Bridging the gap: from simulation to clinical practice

BACKGROUND

There has been a shift from the initial learning of skills on patients in the clinical setting to initial learning in a simulated environment, using part-task models, with the risk of a task focus to the learning. We contend that quality learning in both the simulated and the clinical environment is crucial to enhance the transferability of skills to the clinical setting.

CONTEXT

We describe teaching strategies, with the sequencing of events and increasing complexity, for the simulated training of basic procedural skills. These teaching strategies can be readily implemented into basic skills training to 'bridge' the gap between the simulated environment and the clinical setting.

IMPLICATIONS

We suggest that our approach takes basic skills training beyond a task-focused approach to exemplify clinical scenarios encountered in real life. We argue that there is a need to broaden the focus of medical student training in basic procedural skills, and that the use of a preceptor model of supervision in the clinical setting better enables the transferability of the skills. Although our strategies are based on learning theory, well-designed research is required to test the efficacy in improving medical student learning.

Simple merging technique for improving resolution in qualitative single image phase contrast tomography

For dynamic samples and/or for simple ease-of-use experiments, single-image phase contrast tomography is a very effective method for the 3D visualization of materials which would otherwise be indiscernible in attenuation based x-ray imaging. With binary samples (e.g. air-material) and monochromatic wavefields a transport-of-intensity (TIE)-based phase retrieval algorithm is known to retrieve accurate quantitative maps of the phase distribution. For mixed material samples and/or white beam radiation the algorithm can still produce useful qualitative tomographic reconstructions with significantly improved area contrast. The stability of the algorithm comes with a recognized associated loss of spatial resolution due to its essential behaviour as a low-pass filter. One possible answer to this is an image fusion technique that merges the slices reconstructed from raw phase contrast images and those after phase retrieval, where the improved contrast may be acquired without the associated loss of high-frequency information. We present this technique as a simple few-parameter Fourier method, which is easily tunable and highly compatible with current reconstruction steps.

Risk of venous thromboembolism in patients treated for bacterial infection in the community with outpatient parenteral antimicrobial therapy

BACKGROUND

It is recommended that venous thromboembolism (VTE) prophylaxis be considered for patients receiving outpatient parenteral antimicrobial therapy (OPAT), but there is no published data to quantify VTE risk in this patient group.

AIM AND METHOD

The aim of this retrospective cohort study was to establish VTE incidence in patients managed through an OPAT service and assess utility of a common VTE prediction score normally used for inpatients. Consecutive episodes of OPAT between May 2009 and May 2012 were included. Patients on long-term anti-coagulants, those with an established indication for extended, outpatient VTE prophylaxis (i.e. patients referred to OPAT following hip or knee arthroplasty) were excluded. The Padua VTE Prediction Score was retrospectively applied to the cohort. The primary outcome was incidence of symptomatic VTE during or up to 90 days after completion of OPAT treatment.

RESULTS

There were 780 included patient episodes; 105 (13.5%) patients had a Padua VTE risk score >3; no patients received pharmacological VTE prophylaxis during OPAT treatment. During or up to 90 days following OPAT, two proximal lower limb DVTs were diagnosed, giving VTE incidence of 2/780 (0.26%, 95% CI: 0.03-0.92%), and there were eight deaths of which none were suspected to be related to VTE. There was one intracranial haemorrhage associated death.

CONCLUSION

This retrospective cohort study found a low incidence of VTE in OPAT patients, and does not support routine application of inpatient VTE prophylaxis algorithms to patients treated for infection in the community.

Unraveling wetting transition through surface textures with X-rays: liquid meniscus penetration phenomena

In this report we show that synchrotron X-ray radiography is a powerful method to study liquid-air interface penetration through opaque microtextured surface roughness, leading to wetting transition. We investigate this wetting phenomenon in the context of sessile drop evaporation, and establish that liquid interface sinking into the surface texture is indeed dictated by the balance of capillary and Laplace pressures, where the intrinsically three-dimensional nature of the meniscus must be accounted for. Air bubble entrapment in the texture underneath impacting water drops is also visualized and the mechanisms of post-impact drop evaporation are discussed.

Inhibition of neointimal hyperplasia in a rabbit vein graft model following non-viral transfection with human iNOS cDNA

Vein graft failure caused by neointimal hyperplasia (IH) after coronary artery bypass grafting with saphenous veins is a major clinical problem. The lack of safe and efficient vectors for vascular gene transfer has significantly hindered progress in this field. We have developed a Receptor-Targeted Nanocomplex (RTN) vector system for this purpose and assessed its therapeutic efficacy in a rabbit vein graft model of bypass grafting. Adventitial delivery of β-Galactosidase showed widespread transfection throughout the vein wall on day 7, estimated at about 10% of cells in the adventitia and media. Vein grafts were then transfected with a plasmid encoding inducible nitric oxide synthase (iNOS) and engrafted into the carotid artery. Fluorescent immunohistochemistry analysis of samples from rabbits killed at 7 days after surgery showed that mostly endothelial cells and macrophages were transfected. Morphometric analysis of vein graft samples from the 28-day groups showed approximately a 50% reduction of neointimal thickness and 64% reduction of neointimal area in the iNOS-treated group compared with the surgery control groups. This study demonstrates efficacy of iNOS gene delivery by the RTN formulation in reducing IH in the rabbit model of vein graft disease.

X-ray mosaic nanotomography of large microorganisms

Full-field X-ray microscopy is a valuable tool for 3D observation of biological systems. In the soft X-ray domain organelles can be visualized in individual cells while hard X-ray microscopes excel in imaging of larger complex biological tissue. The field of view of these instruments is typically 10(3) times the spatial resolution. We exploit the assets of the hard X-ray sub-micrometer imaging and extend the standard approach by widening the effective field of view to match the size of the sample. We show that global tomography of biological systems exceeding several times the field of view is feasible also at the nanoscale with moderate radiation dose. We address the performance issues and limitations of the TOMCAT full-field microscope and more generally for Zernike phase contrast imaging. Two biologically relevant systems were investigated. The first being the largest known bacteria (Thiomargarita namibiensis), the second is a small myriapod species (Pauropoda sp.). Both examples illustrate the capacity of the unique, structured condenser based broad-band full-field microscope to access the 3D structural details of biological systems at the nanoscale while avoiding complicated sample preparation, or even keeping the sample environment close to the natural state.

The 4th Annual Ontario Thoracic Cancer Conference at Niagara-on-the-Lake

The 4th annual Ontario Thoracic Cancer Conference at Niagara-on-the-Lake focused on the themes of innovations in the management of lung cancer, controversies in the management of esophageal cancer, and molecular targeted therapies in lung cancer. This conference summary highlights the presentations and provides clinicians with a referenced update on these topics.

The 4th Annual Ontario Thoracic Cancer Conference at Niagara-on-the-Lake

The 4th annual Ontario Thoracic Cancer Conference at Niagara-on-the-Lake focused on the themes of innovations in the management of lung cancer, controversies in the management of esophageal cancer, and molecular targeted therapies in lung cancer. This conference summary highlights the presentations and provides clinicians with a referenced update on these topics.

Time to pregnancy and semen parameters: a cross-sectional study among fertile couples from four European cities

BACKGROUND

In fertile populations, little is known about the association between semen parameters and time to pregnancy (TTP).

METHODS

Pregnant women from Copenhagen, Edinburgh, Paris and Turku who conceived without medical intervention were asked for their TTP (942 couples), and their partners provided a semen sample. The proportion of morphologically normal sperm and the multiple anomalies index (MAI, ratio of the total number of anomalies to the number of abnormal sperm) were centrally estimated. We estimated rate ratios for the occurrence of a pregnancy by a discrete survival model, adjusted for sexual activity and female factors affecting fecundity.

RESULTS

Increasing sperm concentration influenced TTP up to 55 x 10(6)/ml. The proportion of morphologically normal sperm influenced TTP up to 39% according to David's criteria, and this association held among the subjects with a sperm concentration >55 x 10(6)/ml. For strict criteria, the threshold value was 19% normal sperm. An increase of 0.5 in MAI was associated with an adjusted rate ratio for the occurrence of a pregnancy of 0.68 (95% confidence interval: 0.54-0.85).

CONCLUSIONS

These results highlight the importance of sperm morphology parameters and indicate that the effect of proportion of normal sperm on TTP may be independent of sperm concentration.

Regional differences in waiting time to pregnancy among fertile couples from four European cities

BACKGROUND

A previous European study found a longer time to pregnancy (TTP) among fertile women from Paris compared with women from other Western European countries. A co-ordinated, cross-sectional study of pregnant couples from Denmark (Copenhagen), France (Paris), Scotland (Edinburgh) and Finland (Turku) was therefore undertaken to assess differences in waiting TTP among couples from these cities.

METHODS

Pregnant women were invited to participate when they showed up for their first antenatal visit in one of the four centres. Inclusion criteria included that their partner was 20-45 years of age and born in the country in which he was currently living and that the pregnancy was achieved without fertility treatment. Both partners filled in a questionnaire and the man underwent a physical examination and delivered a semen sample (Turku: n = 237, Copenhagen: n = 302, Edinburgh: n = 212, Paris: n = 191).

RESULTS

French couples had a decreased probability of conception compared with couples from the other three countries, although only after adjustment for confounders. No significant differences between couples from the three other countries were found.

CONCLUSION

The observed geographical differences in TTP remain unexplained and were not due to differences in semen quality, but may be caused by varying exposures to environmental factors or psychological distress. In addition, selection bias due to the low participation rates cannot be ruled out. Future studies examining the causes for geographical differences in TTP are needed.

Incidence and Distribution of Raspberry bushy dwarf virus in Commercial Red Raspberry (Rubus idaeus) Crops in Scotland

A survey was done in 1998 to determine whether Raspberry bushy dwarf virus (RBDV) was established in raspberry fruiting plantations in Scotland. Raspberry-producing holdings were selected according to geographical area and size. Samples (201), each comprising 60 shoots per stock, were obtained from 77 holdings and tested by enzyme-linked immunosorbent assay (ELISA). ELISA-positive shoots from each infected stock were grafted onto cultivar Glen Clova, which is resistant to the Scottish-type isolate of RBDV (RBDV-S), to establish whether the virus is a resistance-breaking (RB) isolate. RBDV was detected in 22% of the stocks sampled, with 2 to 80% incidence of infection. No RBDV was in any of the 40 plantations containing cultivars resistant to RBDV-S or in Glen Clova plants, which were grafted successfully with samples from 15 infected plantations, indicating that no RB isolates were detected. The percentage of infected plantations increased with time from the planting date. In order to investigate possible sources of infection, ELISA for RBDV was made in 1999 on samples of stocks of raspberry cultivars entered for the lowest certified grade (Standard Grade) in Scotland and, in 1994 to 1997, on certified stocks planted with material originating from outside Scotland. No RBDV was detected in any of the samples. RBDV was found only rarely in samples of wild raspberry in Angus and Perthshire.

Chronic exercise reduces sympathetic nerve activity in rabbits with pacing-induced heart failure: A role for angiotensin II

BACKGROUND

Chronic exercise (EX) improves the quality of life and increases the survival of patients with chronic heart failure (CHF). Because sympathetic nerve activity is elevated in the CHF state, it is possible that EX is beneficial in this disease due to a decrease in sympathetic outflow.

METHODS AND RESULTS

We evaluated arterial baroreflex function and resting renal sympathetic nerve activity (RSNA) in EX normal and CHF rabbits before and after angiotensin II type 1 (AT(1)) receptor blockade. Four groups of rabbits were studied: a normal non-EX group, a normal EX group, a CHF non-EX group, and a CHF EX group. EX lowered resting RSNA in rabbits with CHF but not in normal rabbits. In addition, EX increased arterial baroreflex sensitivity in the CHF group (heart rate slope: CHF 1. 7+/-0.3 bpm/mm Hg, EX CHF 4.9+/-0.3 bpm/mm Hg; P:<0.01; RSNA slope: CHF 2.2+/-0.2%max/mm Hg, EX CHF 5.7+/-0.4%max/mm Hg; P:<0.01. AT(1) receptor blockade enhanced baroreflex sensitivity in the non-EX CHF rabbits but had no effect in EX CHF rabbits. Concomitant with this effect, EX lowered the elevated plasma angiotensin II concentration in the CHF group. A significant positive correlation was observed between sympathetic nerve activity and plasma angiotensin II.

CONCLUSIONS

These data strongly suggest that EX reduces the sympathoexcitatory state in the setting of CHF. Enhanced arterial baroreflex sensitivity may contribute to this reduction. In addition, EX lowers plasma angiotensin II concentration in CHF. These data further suggest that the lowering of angiotensin II may contribute to the decrease in sympathetic nerve activity after EX in the CHF state.

Early referral, diagnosis, and treatment of rheumatoid arthritis: evidence for changing medical practice

OBJECTIVES

To study the delay in starting disease modifying anti-rheumatic drugs (DMARDs) in patients with rheumatoid arthritis (RA), and any changes in medical practice between 1980 and 1997.

METHODS

198 consecutive RA patients attending the rheumatology clinics at a teaching hospital, for routine review, had their case sheet reviewed. The dates of symptom onset, general practitioner (GP) referral, first clinic appointment and first use of DMARD were recorded. Data were collected on the erythrocyte sedimentation rate, C reactive protein, rheumatoid factor, and the presence/absence of erosions at the first clinic assessment. Patients were split into four groups according to the date of their first clinic assessment-before 1986, 1987-9, 1990-3, and 1994-7.

RESULTS

There was a sharp drop in the delay between symptom onset and GP referral (before 1986, 21 months; 1987-89, 23 months; 1990-3, 7 months; 1994-7, 4 months, p<0.03), and in the delay between first assessment at the rheumatology clinic and the start of DMARD treatment (before 1986, 32 months; 1987-89, 21 months; 1990-1993, 8 months; 1994-7, 1 month, p<0.001). The number of patients given DMARD treatment within six months of symptom onset increased from 5% (before 1994) to 44% (1994-7). Seventy three per cent of patients waiting more than a year from symptom onset to first clinic appointment already had erosive change, compared with 34% of patients seen within a year.

CONCLUSIONS

Patients are being referred earlier in their disease, and DMARDs are prescribed sooner in the disease course. There has been a substantial increase in the proportion of patients treated with a DMARD within six months of symptom onset.

On the cellular mechanisms by which the bicarbonate ion mediates the extragenomic action of progesterone on human spermatozoa

Progesterone exerts an extragenomic action on human spermatozoa, inducing a rapid calcium transient in the acrosomal domain of these cells and enhancing their potential for fertilization. This response is known to exhibit an absolute dependence on the presence of extracellular bicarbonate, although the mechanisms underlying this interaction are not understood. In this study, bicarbonate was found to exert a dose-dependent impact on the ability of progesterone to promote sperm-oocyte fusion in the absence of any collateral effect on sperm motility. The loss of sperm function in bicarbonate-free medium was associated with a failure to produce reactive oxygen species, an impaired capacity to exhibit redox-associated changes in tyrosine phosphorylation, and an apparent incapacity to generate normal calcium transients on exposure to progesterone. These defects were not related to a cAMP deficiency but were associated with a significant fall in intracellular pH. If cytosolic pH was chemically buffered into the normal range, then the spermatozoa regained every element of their response to progesterone. These results emphasize the importance of an alkaline intracellular milieu for the extragenomic action of progesterone on human spermatozoa and stress the fundamental difference between intracellular and extracellular sources of bicarbonate in maintaining the proton balance within such cells.

Reactive oxygen species generation by human spermatozoa is induced by exogenous NADPH and inhibited by the flavoprotein inhibitors diphenylene iodonium and quinacrine

Human spermatozoa possess a specialized capacity to generate reactive oxygen species (ROS) that is thought to be of significance in the redox regulation of sperm capacitation (De Lamirande and Gagnon, 1993; Aitken et al., 1995). However, the mechanisms by which ROS are generated by these cells are not understood. In this study we have examined the possible significance of NADPH as a substrate for ROS production by human spermatozoa. Addition of NADPH to viable populations of motile spermatozoa induced a sudden dose-dependent increase in the rate of superoxide generation via mechanisms that could not be disrupted by inhibitors of the mitochondrial electron transport chain (antimycin A, rotenone, carbonyl cyanide m-chlorophenylhydrazone [CCCP], and sodium azide), diaphorase (dicoumarol) xanthine oxidase (allopurinol), or lactic acid dehydrogenase (sodium oxamate). However, NADPH-induced ROS generation could be stimulated by permeabilization and was negatively correlated with sperm function. Both NADH and NADPH were active electron donors in this system, while NAD+ and NADP+ exhibited little activity. Stereo-specificity was evident in the response in that only the beta-isomer of NADPH supported superoxide production. The involvement of a flavoprotein in the electron transfer process was indicated by the high sensitivity of the oxidase to inhibition by diphenylene iodonium and quinacrine. These results indicate that NAD(P)H can serve as an electron donor for superoxide generation by human spermatozoa and present a simple strategy for the production of motile populations of free radical generating cells with which to study the significance of these molecules in the control of normal and pathological sperm function.

Homeobox genes in the Ctenophora: identification of paired-type and Hox homologues in the atentaculate ctenophore, Beroë ovata

Homeobox-containing genes are a phylogenetically widespread family of transcription factors that can regulate cell fates during embryogenesis. Two distinct homeobox gene sequences are described for the atentaculate ctenophore Beroë, the first homeoboxes to be identified in this phylum. Beroë homeobox fragments were cloned in a survey of genomic DNA using polymerase chain reaction (PCR). Parsimony, neighbor-joining, and maximum likelihood methods were used to infer the orthology of the ctenophore sequences to specific homeoboxes from higher metazoans including Drosophila, Caenorhabditis elegans, and humans. Cteno-paired appears most closely related to paired-typed homeoboxes. This is the first evidence of a paired-type homeobox in one of the so-called diploblastic animals. Cteno-Hoxl appears most closely related to members of the Hox class, particularly Antennapedia.