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Title

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

Author(s)

Ali, F. M.

Year

2021

Abstract

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.

Subjects

Distance learning; Medical education; Physical examination; Teaching; Technology

Title

Optic perineuritis

Author(s)

Rai, Harminder. K.

Year

2021

Abstract

Optic perineuritis (OPN) is a rare inflammatory disorder in which the inflammation is confined to optic nerve sheath. It can be idiopathic or secondary to underlying systemic autoimmune disorder. It usually presents with unilateral progressive diminution of vision with pain on eye movements and optic disc oedema. Hence, clinically OPN mimics optic neuritis resulting in delayed diagnosis and suboptimal treatment. In contrast to optic neuritis, patients with OPN are usually of older age group and more likely show sparing of central vision. MRI is an important tool for diagnosis of OPN apart from optic nerve sheath biopsy. Perineural enhancement on MRI is diagnostic of OPN. Oral corticosteroid therapy gives dramatic and rapid improvement in signs and symptoms. Rapid tapering of steroids increases the risk of relapse. Overall, prognosis of OPN is generally good if adequate treatment is given timely.

Subjects

imaging; optic nerve; treatment medical

Title

Psychological distress and trauma during the COVID-19 pandemic: survey of doctors practising anaesthesia, intensive care medicine, and emergency medicine in the United Kingdom and Republic of Ireland

Author(s)

Tambe, N.

Year

2021

Abstract

No abstact available

Subjects

COVID-19; anaesthesia; emergency medicine; intensive care; mental health; psychological trauma.

Title

The low FODMAP diet for IBS; A multicentre UK study assessing long term follow up

Author(s)

Robinson, Kelly. Elphick, David.

Year

2021

Abstract

Background: The low FODMAP diet (LFD) is effective in managing irritable bowel syndrome (IBS) in the short term. This study assessed the long-term effect of the LFD on symptoms, nutritional composition and socialising.

Methods: Patients with IBS who received dietetic-led LFD advice were approached at long term follow up (>6 months post LFD advice) from six centres across the United Kingdom. Participants completed questionnaires assessing gastrointestinal symptoms, adherence, nutritional intake, dietary acceptability and food related quality of life (QOL).

Results: 205 participants completed the study, with a mean follow up of 44 months (3.7 years). Adequate symptom relief was noted in 60% of individuals at long term follow up, with 76% being on the personalisation phase of the LFD (pLFD). Mean nutritional intake did not differ between individuals on the pLFD versus habitual diet, with no difference in fructan intake (2.9 g/d vs 2.9 g/d, p = 0.96). The majority (80%) of individuals on the pLFD consumed specific 'free-from' products at the long term, with the purchase of gluten or wheat free products being the commonest (68%).

Conclusion: The majority of patients follow the pLFD in the long term, with a large proportion purchasing gluten or wheat free products to manage their symptoms.

Subjects

Dietary therapies; Irritable bowel syndrome; Low FODMAP diet

Title

Hydration Strategies for Physical Activity and Endurance Events at High (>2500 m) Altitude: A Practical Management Article

Author(s)

Windsor, Jeremy. S.

Year

2021

Abstract

A growing number of adventurous athletes are seeking new challenges through endurance events or physical activities held at high altitude (>2500 m). This coincides with a significant increase in the numbers of trekkers who ascend into the world's mountains. Altitude itself influences and complicates the athlete's effective and safe hydration. This article considers the physiology of adaptation to altitude and the effects on hydration at altitude compared with sea level, reviews the "ad libitum versus programmed hydration" controversy in conventional endurance event hydration, examines the evidence for extrapolation of sea level hydration strategies to the high-altitude environment, and synthesizes these disparate factors into a set of practical recommendations for hydration management during high-altitude physical activity. The guidelines will be relevant to participants of physical activity at altitude and health care staff who may care for them in the preparation or performance phases of their adventure.

Subjects

acclimatization; altitude training; athletes; hydration

Title

Does observational study on the effectiveness of the Twin Blocks overestimate or underestimate the results? A comparative analysis of retrospective samples versus randomized controlled trial

Author(s)

Sandler, Jonathan

Year

2021

Abstract

Background and objectives: Class II malocclusion is one of the most common orthodontic problems. The Twin Block appliance has proven to be the most popular appliance for the correction of these malocclusions. Although randomized controlled trials (RCTs) on the Twin Block appliance have reported the changes to be mainly dentoalveolar, several nonrandomized studies have reported a significant skeletal improvement in these patients. Hence, the aim of this study was to compare the effectiveness of Twin Block appliance evaluated using an RCT or retrospectively selected cases (RSC) for the treatment of Class II Division 1 malocclusion in an adolescent population.

Methods: This was a retrospective study. The results for an RCT were selected from a UK Class II multicenter study. Sixty-three patients from the trial were included. This group was matched with retrospectively selected Class II cases treated with a Twin Block functional appliance and their results submitted for Membership in Orthodontics examination in the United Kingdom, from four centers. The primary outcome was skeletal measurement ANB (A point, nasion, B point). Secondary outcomes included final peer assessment rating (PAR) scores and final overjet. Intrarater reliability of measurements was assessed. Independent samples t-test was carried out to look at the difference between the groups.

Results: The reliability assessment showed excellent agreement for all measurements. The data were normally distributed. There was a statistically significant difference favoring the RSC group for final overjet (mean difference [MD] = 1.068, 95% confidence interval [CI] -0.67 to 1.47, P = 0.000) and final PAR (MD = 4.0, 95% CI -0.79 to 5.5, P = 0.000). There was no significant difference in the scores for final ANB (MD = 0.34, 95% CI -0.39 to 1.07, P = 0.33).

Conclusion: The RSCs show significantly improved overjet and PAR scores at the end of treatment and no statistically significant difference for skeletal change. The study raises the question of a potential role of observational studies in evaluating the effect of an intervention in orthodontics

Subjects

Class II Division 1; Functional appliance; RCT; Retrospective study; Twin Block

Title

For four sixes, revisited

Author(s)

Sandler, Paul Jonathan

Year

2021

Abstract

Rarely is the extraction of the four first molars the ideal choice in the course of orthodontic treatment, particularly in older patients. Although this approach can offer distinct advantages in carefully selected patients, it is also associated with a number of well-recognized problems, including the extension of treatment times, anchorage management, and control of second molars during space closure. However, by careful use of contemporary materials and techniques, a high standard of treatment can be achieved, even in patients with complex malocclusions. This is illustrated in a report of a case that highlights both the challenges and some of the solutions this treatment modality can offer.

Subjects

Dentistry; Orthodontic Treatment

Title

Are Regulations Safe? Reflections From Developing a Digital Cancer Decision-Support Tool

Author(s)

Scott, Beverly C.

Year

2021

Abstract

Purpose: Informatics solutions to early diagnosis of cancer in primary care are increasingly prevalent, but it is not clear whether existing and planned standards and regulations sufficiently address patients' safety nor whether these standards are fit for purpose. We use a patient safety perspective to reflect on the development of a computerized cancer risk assessment tool embedded within a UK primary care electronic health record system.

Methods: We developed a computerized version of the CAncer Prevention in ExetER studies risk assessment tool, in compliance with the European Union's Medical Device Regulations. The process of building this tool afforded an opportunity to reflect on clinical concerns and whether current regulations for medical devices are fit for purpose. We identified concerns for patient safety and developed nine practical recommendations to mitigate these concerns.

Results: We noted that medical device regulations (1) were initially created for hardware devices rather than software, (2) offer one-shot approval rather than supporting iterative innovation and learning, (3) are biased toward loss-transfer approaches that attempt to manage the fallout of harm instead of mitigating hazards becoming harmful, and (4) are biased toward known hazards, despite unknown hazards being an expected consequence of health care as a complex adaptive system. Our nine recommendations focus on embedding less-reductionist and stronger system perspectives into regulations and standards.

Conclusion: Our intention is to share our experience to support research-led collaborative development of health informatics solutions in cancer. We argue that regulations in the European Union do not sufficiently address the complexity of healthcare information systems with consequences for patient safety. Future standards and regulations should continue to follow a system-based approach to risk, safety, and accident avoidance.

Subjects

Cancer; Diagnosis; Support Tool; Digital

Title

Dens invaginatus: a review and orthodontic implications

Author(s)

Sandler, Paul Jonathan

Year

2021

Abstract

Dens invaginatus (DI) is a developmental anomaly resulting in a deepening or invagination of the enamel organ into the dental papilla prior to calcification of the dental tissues. Presence of DI is considered to increase the risk of caries and pulpal pathology, but they are often missed in the initial orthodontic assessment as they present with no clinical signs of an anomaly. In absence of adequate oral hygiene and maintenance, bacterial contamination of these malformations can lead to the development of early caries and consequent pulpal death. Early diagnosis of these lesions is critical as they can negatively impact any planned orthodontic treatment and assessment of the prognosis of these lesions is therefore necessary prior to the commencement of orthodontic treatment. In this article, we aim to illustrate the need for appropriate diagnosis and multidisciplinary approach in the management of DI in patients undergoing orthodontic treatment.

Subjects

Anomaly; Dens Invaginatus; Treatment

Title

Development of clinical prediction models for outcomes of complicated intra-abdominal infection

Author(s)

Narula, Harjeet, S

Year

2021

Abstract

Background: Complicated intra-abdominal infections (cIAIs) are associated with significant morbidity and mortality. The aim of this study was to describe the clinical characteristics of patients with cIAI in a multicentre study and to develop clinical prediction models (CPMs) to help identify patients at risk of mortality or relapse.

Methods: A multicentre observational study was conducted from August 2016 to February 2017 in the UK. Adult patients diagnosed with cIAI were included. Multivariable logistic regression was performed to develop CPMs for mortality and cIAI relapse. The c-statistic was used to test model discrimination. Model calibration was tested using calibration slopes and calibration in the large (CITL). The CPMs were then presented as point scoring systems and validated further.

Results: Overall, 417 patients from 31 surgical centres were included in the analysis. At 90 days after diagnosis, 17.3 per cent had a cIAI relapse and the mortality rate was 11.3 per cent. Predictors in the mortality model were age, cIAI aetiology, presence of a perforated viscus and source control procedure. Predictors of cIAI relapse included the presence of collections, outcome of initial management, and duration of antibiotic treatment. The c-statistic adjusted for model optimism was 0.79 (95 per cent c.i. 0.75 to 0.87) and 0.74 (0.73 to 0.85) for mortality and cIAI relapse CPMs. Adjusted calibration slopes were 0.88 (95 per cent c.i. 0.76 to 0.90) for the mortality model and 0.91 (0.88 to 0.94) for the relapse model; CITL was -0.19 (95 per cent c.i. -0.39 to -0.12) and - 0.01 (- 0.17 to -0.03) respectively.

Conclusion: Relapse of infection and death after complicated intra-abdominal infections are common. Clinical prediction models were developed to identify patients at increased risk of relapse or death after treatment, although these require external validation.

Subjects

Intra-abdominal infection; Clinical Predictions

Title

Extensive bony sarcoidosis of the head and neck region: a rare presentation

Author(s)

Hosni, Iman Usama; Karbhari, Bhavesh; Orr, Robert; Opie, Neil.

Year

2021

Abstract

We present a rare case of sarcoidosis with extensive bony destruction of the maxillofacial and skull base bones. A 65-year-old woman was referred with an asymptomatic, non-healing dental socket. Examination revealed an oroantral fistula that was biopsied and repaired under general anaesthesia. Investigations included plain and cross-sectional imaging. Serological tests, in particular ACE, were normal. Histology showed benign florid granulomatous inflammation. At 6 months, the patient remained asymptomatic. She was re-referred 3 years later with further bony destruction of her maxilla and mandible. Repeat imaging showed intrathoracic lymphadenopathy and skull base involvement. Repeat biopsy confirmed granulomatous inflammation. Given the pulmonary, histological and radiological findings, a sarcoidosis diagnosis was made. Following multidisciplinary team meetings, the patient was treated with methotrexate and arrangements made for close monitoring. This case highlights the need for a consensus in identifying, treating and developing a follow-up protocol in such patients.

Subjects

Dentistry and oral medicine; lung function; oral and maxillofacial surgery; respiratory system; rheumatology.

Title

Use of procalcitonin for antibiotic stewardship in patients with COVID-19: A quality improvement project in a district general hospital

Author(s)

Peters, Christina; Williams, Kelly; Un, Elena A; Little, Louisa; Saad, Abeer; Lendrum, Katherine; Thompson, Naomi; Pegden, Amanda.

Year

2021

Abstract

Antibiotic stewardship during the COVID-19 pandemic is an important part of a comprehensive strategy to improve patient outcomes and reduce long-term adverse effects secondary to rising antibiotic resistance. This report describes a quality improvement project which incorporates the use of procalcitonin (PCT) testing to rationalise antibiotic prescribing in patients with suspected or confirmed COVID-19 at Chesterfield Royal Hospital. Data were collected from 118 patients with a total of 127 PCT levels checked over a period of 20 days. Each PCT level was correlated with the subsequent antibiotic outcome as well as the result of the COVID-19 PCR swab. Results indicate that antibiotics were either never started or were stopped within 48 hours in 72% of COVID-confirmed cases with a PCT less than 0.25 μg/L. Our findings suggest that procalcitonin testing, when used in combination with thorough clinical assessment, is a safe, simple and sustainable way of reducing antibiotic use in COVID-19.

Subjects

COVID-19; antibiotic stewardship; bacterial resistance; procalcitonin; quality improvement.