SIM-STEPS: a structured trainee educator programme in simulation – an innovative, blended learning approach for simulation faculty development

At present there are limited resources for simulation faculty development and educators are unable to access face-to-face courses uniformly across the region. Currently available online resources lack interactive reflective activity and recorded faculty videos which leads to a less engaging and effective learner experience. We aimed to create a structured and accredited simulation faculty development course on the Bridge online platform for educators who are novice in simulation-based education using a blended learning approach by incorporating recorded faculty videos and current available resources on eLearning For Healthcare (eLFH), Scottish Simulation framework and provide a platform with links to online resources.

A scoping review was conducted to review current available online resources and face to face courses across the East of England region. Faculty across the region were contacted to understand the learning objectives, outcomes, and content of their courses. A survey was sent out to Bridge users across the region to determine how best to deliver the simulation faculty development course and whether they would find a Bridge course useful. We received 158 responses of which 94% respondents were keen to develop their simulation education skills, 74% had not received any formal training, and nearly 90% wanted a blended learning course.

SIMSTEPS has been developed following a detailed gap analysis and scoping review. The course has been designed incorporating the eLFH learning modules, the Scottish framework for Simulation Faculty development. It does not replace face to face teaching but gives a starting point to develop the learners’ knowledge and skills about simulation-based education which can be enhanced further in face-to-face courses or workshops. Modules have been developed on key topics relevant to simulation-based education [1] with links to videos, recorded Faculty sessions, and online educational resources. Learners are encouraged for continuing reflective practice [2] and prompted to reflect after modules. The course would be accessible to all Bridge users (Interprofessional educators) in the East of England at no cost and can be completed by them at their own pace and time. We planned meticulously to ensure the course content meets learning objectives and ensured quality assurance by independent review of the course by established and experienced faculty.

Post-course evaluation by learners will be done on course completion.

A blended learning course like SIM-STEPS can potentially provide an effective resource on Simulation faculty development and improve learner experience and engagement.

Virtual reality wraparound learning modules: an innovative approach to self-debriefing to augment learner experience

Virtual Reality (VR) simulation has opened to a lot of trainees an ability to experience various clinical scenarios in a virtual space at a time and place that suits them [1]. It also gives an opportunity for deliberate practice as one can repeat the scenario as many times as one likes till proficiency is reached. Research over the years has shown most of the learning occurs during the debriefing [2] and the VR scenario gives a unique opportunity for self-debriefing or peer-peer debriefing in small groups [3]. However, in the current VR scenarios available to trainees, there is no provision of any link at the end of the scenario to access current best practice guidelines on the topic/scenario which the learner could use as part of their self-debriefing. The project aims to create wraparound learning module around the Virtual Reality clinical scenario to include a patient journey through the hospital, current guidelines, and teaching videos so that learners could conceptualize and consolidate their learning from the VR experience

VR scenarios available to Foundation doctors were chosen and a review of the topic and related standard best practice guidelines were reviewed on NICE, BTS, and similar resources. We also searched for real patient stories and easy to access procedural videos related to the topic and incorporated them on the module. Wraparound learning modules were created using a blended learning approach on Bridge online platform on topics like pneumothorax and infective exacerbation of Chronic Obstructive Pulmonary Disease. More modules are being created for the benefit of the Foundation doctors across East of England. Throughout the module reflection is encouraged and the topic is aligned to the Foundation curriculum and reviewed for quality assurance. A Likert scale survey would be sent out to the trainees who have completed the modules to assess the increase in their confidence in managing a clinical case after finishing the wraparound module.

The results of the pre-course and post-course levels of knowledge, skills and confidence are being analysed.

Wraparound learning modules could potentially improve learners’ experience of the VR scenario and improve learning and confidence in the clinical setting.

1. Cheng A, Kolbe M, Grant V, Eller S, Hales R, Symon B, Griswold S, Eppich W. A practical guide to virtual debriefings: communities of inquiry perspective. Advances in Simulation. 2020;5(1):1–9.

2. Rudolph JW, Simon R, Dufresne RL, Raemer DB. There’s no such thing as ‘non-judgmental’ debriefing: a theory and method for debriefing with good judgment. Simul Healthcare. 2006;1(1):49–55.

3. Pottle J. Virtual reality and the transformation of medical education. Future healthcare journal. 2019;6(3):181–185.

Acyclovir-induced acute renal failure and the importance of an expanding waist line

A 23-year-old gentleman with no significant medical history other than obesity was admitted with a history of balance problems, double vision and strange behaviour following a fall from bed. Systems examination was unremarkable. The patient was given intravenous acyclovir and intravenous ceftriaxone given the suspicion of encephalitis/meningitis. Investigations including routine bloods, CT/MRI Head and lumbar puncture were unremarkable. Within 48 h of commencing intravenous acyclovir, there was a marked deterioration in renal function. On stopping acyclovir therapy, renal function improved back to baseline. No other cause for deterioration in renal function was identified. The most likely cause for acute renal failure was secondary to acyclovir therapy. This has been well documented and is due to intratubular crystal precipitation. Moreover, in this case nephrotoxicity is likely secondary to the large boluses of intravenous acyclovir that had been given as prescribed according to the total body weight.

Apparent renal disease due to elevated creatinine levels associated with the use of boldenone

The widespread use of reporting estimated glomerular filtration rate (eGFR) alongside serum creatinine has led to a heightened appreciation of renal disease. However, creatinine is recognized as an insensitive marker of true GFR and therefore can lead to misdiagnosis of renal dysfunction in the absence of true pathology. We report the case of a 37-year-old male referred due to abnormal eGFR and creatinine in the absence of clinical signs, symptoms or other biochemical abnormalities of renal disease. Subsequent investigations based on a high index of suspicion for exogenous substance abuse led to a novel observation of significantly raised creatinine due to the presence of boldenone, an equine anabolic steroid commonly abused in body building.

Successful outcome of accidental ethylene glycol poisoning despite delayed presentation

A 69-year-old man presented to the emergency department after being found unconscious by his son. He had experienced headache the previous day but had been otherwise well. Investigations revealed a severe metabolic acidosis, raised lactate and acute kidney injury. The calculated anion and osmolar gap were both elevated at 37.7 and 39.3, respectively. Due to his reduced Glasgow coma score (GCS) he was intubated and a CT scan performed: only a small, mature pontine infarct was found of uncertain significance. Further questioning of the family revealed accidental ingestion of 150 ml of a 'blue liquid' 24 h earlier (later identified as car screenwash). With ethylene glycol (EG) poisoning suspected, he was given intravenous ethanol, fomepizole (a competitive inhibitor of alcohol dehydrogenase) and haemofiltration. Despite the delayed presentation, prompt recognition and treatment of EG poisoning led to a successful discharge in this case.

Trisodium citrate 46.7% selectively and safely reduces staphylococcal catheter-related bacteraemia

BACKGROUND

Trisodium citrate (TSC) 30% has been shown in a randomized control trial to be an effective antimicrobial catheter locking solution, able to significantly reduce catheter-related bacteraemia (CRB) in haemodialysis patients. Since that report, the formulation in Europe has been changed to 46.7% TSC without confirmatory data on efficacy. We report a 55 915 patient-day at risk experience in tunnelled lines of 46.7% TSC, emphasizing efficacy and changes in microbiology seen.

METHODS

On 1 July 2006, inter-dialytic catheter locking solution was changed from 5000 IU/ml heparin to Citra-lock(TM) (46.7% TSC) in all haemodialysis patients at Barts and the London Renal Unit dialysing through an incident or prevalent tunnelled catheter. Prospectively collected blood culture data for the 6 months prior to the switch and 3 months at the end of the first year of TSC use were analysed. TSC tolerability was excellent with only a single withdrawal for intolerance of the agent. No major adverse events were reported.

RESULTS

A major fall in CRB rates was noticed with a change from heparin (2.13/1000 catheter-days) in 2006 to TSC (0.81/1000 catheter-days) in 2007. This was due to significant reductions in staphylococcal CRB, true for sensitive, methicillin-resistant and coagulase-negative staphylococci. No increase in catheter malfunction was observed.

CONCLUSIONS

We found that 46.7% TSC is a safe, convenient and highly effective catheter locking solution, leading to significant reduction in CRB largely by preventing staphylococcal bloodstream infections. Given that Staphylococcus aureus in particular is associated with serious and often disseminated infection, TSC seems to be a powerful tool for dialysis units.

Aromatase inhibition by 15-deoxy-prostaglandin J(2) (15-dPGJ(2)) and N-(4-hydroxyphenyl)-retinamide (4HPR) is associated with enhanced ceramide production

Inhibition of aromatase activity is an established endocrine therapy in the treatment of hormone-dependent breast cancer. Recent studies on aromatase inhibition by the synthetic retinoid 4HPR, also known as fenretinide, and the PPARgamma agonist 15-dPGJ(2) have implicated a direct receptor-independent, redox-sensitive mechanism of action. The signalling molecule ceramide has also been previously implicated as a negative regulator of aromatase activity. In the present study, we have investigated a potential mediatory role for this sphingolipid during aromatase inhibition by fenretinide and 15-dPGJ(2) in the breast cancer cell line MDA MB 231 and JEG-3 choriocarcinoma cells. 4HPR and 15-dPGJ(2) caused a dose-dependent inhibition of aromatase activity associated with an increase in ceramide production. Both these actions were redox-sensitive as demonstrated by their abrogation in the presence of the anti-oxidant N-acetylcysteine. Exogenous ceramide analogue mimicked these inhibitory actions on aromatase, but in a redox-independent manner. Blockade of the de novo ceramide production pathway by fumonisin B(1) or myriocin inhibited the ceramide responses, but did not prevent aromatase inhibition by 15-dPGJ(2) or 4HPR. This study highlights a potential role for aromatase inhibition and the stress-response signal ceramide during the therapeutic actions of 15-dPGJ(2) and 4HPR in breast cancer treatment. However, these data do not support a mediatory role for this sphingolipid during aromatase inhibition by these agents.

Prostaglandin J2 metabolites inhibit aromatase activity by redox-sensitive mechanisms: potential implications for breast cancer therapy

The mechanisms by which prostaglandin (PG)J(2) metabolites inhibit tumorigenicity are poorly understood but may involve thiol reactivity or peroxisome proliferator-activated receptor (PPAR)-dependent pathways. Because aromatase is an important therapeutic target in breast cancer treatment, we have investigated the effect of PGJ(2) metabolites on aromatase activity and evaluated a potential role for redox status during PGJ(2) metabolite action. 15-deoxy-Delta(12,14)PGJ(2) (15d-PGJ(2)) and 9-deoxy-Delta(9,12)13,14-dihydroPGD(2) (Delta(12)PGJ(2)) caused dose-dependent inhibition of both pre-induced aromatase activity in human breast fibroblasts and MDA MB 231 breast cancer cells and of constitutive aromatase activity in JEG-3 choriocarcinoma cells. Structure-activity studies showed that this inhibition was mimicked by 4-cyclopentene-1,3-dione but not by the PPARgamma agonist troglitazone nor the eicosanoids PGE(2) or arachidonic acid. The thiol oxidants diamide and H(2)O(2) simulated the inhibitory action of 15d-PGJ(2) on aromatase activity, whereas the glutathione (GSH) repletor and antioxidant N-acetyl-cysteine (NAC) reversed these actions of 15d-PGJ(2) and H(2)O(2) on aromatase. 15d-PGJ(2) also caused a direct dose-dependent inhibition of aromatase activity in JEG-3 cell sonicates, which was also reversed in the presence of GSH. Kinetic analysis of this 15d-PGJ(2)-induced inhibition of cell-free aromatase indicated the involvement of a non-competitive mechanism possibly resulting from direct thiol-targeted alkylation of the enzyme. These redox-sensitive, PPARgamma-independent actions of 15d-PGJ(2) on aromatase activity demonstrate a novel therapeutic potential for such cyclopentenone PGs in breast cancer treatment.

Gas chromatographic determination of fenvalerate insecticide residues in processed tomato products and by-products

The results of a 5-laboratory collaborative determination of residues of the synthetic pyrethroid insecticide fenvalerate in tomato products are presented. Tomatoes from plants treated in the field at 2-4 day intervals (13 foliar applications) were processed into chopped fresh tomatoes, canned quarters, juice, paste, and the by-product skins plus seeds. Gas chromatographic analysis of the commodities for fenvalerate showed the fresh produce to contain 0.26 ppm, and the skins plus seeds contained 1.9 ppm. Residues were barely detectable in canned peeled quarters and juice, but averaged 0.12 ppm for paste, the concentration product of juice. High residues were associated with the skin content of the product. Five laboratories using modifications of the same analytical technique obtained good collaborative agreement.

Gas-liquid chromatographic determination of fenvalerate insecticide residues in processed apple products and by-products

Apples from trees treated in the field at 2-week intervals (9 foliar applications) with the synthetic pyrethroid insecticide fenvalerate (cyano(3-phenoxyphenyl) methyl 4-chloro-alpha-(1-methylethyl)-benzeneacetate) were processed into apple sauce, juice, pomace, and peels plus cores. Gas-liquid chromatographic analysis of the commodities for fenvalerate showed the sauce and juice to be essentially residue-free, the whole apples to contain about 0.4 ppm, and the pomace and peels plus cores to contain about 2 and 1.5 ppm, respectively. Agreement among 5 laboratories using modifications of the same basic method was good.

A hair sampling tube for the detection of small and medium-sized mammals

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