A non-randomised trial of video and written educational adjuncts in undergraduate ophthalmology.

BACKGROUND: Provision of relevant pre-learning materials has been shown to increase student engagement and improve outcomes in medical education. This non-randomised study attempts to quantify the educational gains, and relative efficacy of video and written pre-learning materials, in ophthalmology undergraduate teaching. METHODS: Ninety-eight final year medical students were contacted prior to their three-day ophthalmology placements at a British tertiary ophthalmology unit. All participants were sent welcome packs prior to arrival requesting they undertake 90 min of work focusing on a list of specified ophthalmic conditions. One cohort (N = 33) were sent written materials, another (N = 32) was provided with video materials and a third cohort (N = 33) were not sent any materials. On arrival participants completed a simple knowledge test, a questionnaire estimating the time they spent preparing for the placement and a self-reported knowledge score. The teaching on placement was the same for all cohorts. At the conclusion of each placement participants completed a challenging knowledge test, a clinical skills test and repeated self-reported knowledge scores. RESULTS: Eighty seven percent of students receiving specified materials claimed to complete pre-placement work compared to 70% of those receiving learning outcomes alone (p = 0.05). Students receiving learning materials scored higher in the post-placement tests of knowledge (p < 0.001), 74.8% (72.4-77.2%) vs 63.6% (95%CI 59.3-67.9%) and skills (p = 0.04), 86.9% (83.9-89.9%) vs 81.3% (77.2-85.4%). Students using video resources outperformed students using written materials in their visual acuity assessment test (p = 0.03), 90.4% (86.6-94.2%) vs 83.6% (80.1-87.1%) whilst those receiving written rather than video material performed better in the end of placement knowledge test (p = 0.03), 77.7% (74.3-81.1%) vs 72.0% (68.9-75.1%). CONCLUSION: This study showed that providing pre-placement learning materials improves undergraduates' commitment and achievement. Written materials better facilitate knowledge acquisition while video materials preferentially promote skill acquisition. This is a novel demonstration within ophthalmology and can help address the imbalance between the expectations placed on undergraduates and the resources committed to ensuring they are met.

The Next Generation: How medical students use new Social Media to support their learning.

This article was migrated. The article was marked as recommended. Background The rise of social media [SoMe] has changed medical education practice, possibly facilitating learning through conversational interaction, social feedback and relationships. Usage of newer SoMe tools like Instagram and Snapchat has not been scrutinised.This study aimed to understand how medical students may use newer SoMe tools, specifically Twitter, Instagram & Snapchat, in their learning, in the context of a parallel SoMe course. Methods An optional, parallel SoMe course was established at Newcastle University Medical School. 301 fourth-year medical students were invited to engage using Twitter, Snapchat and Instagram. Evaluation adopted a mixed methods approach, gathering SoMe analytics and survey data as well as qualitative, free-text responses from a questionnaire and focus-group discussion. Results Live-tweeting lectures featured 95 facilitator tweets, with five replies by students. 22 Instagram posts received no student responses, and three Snapchat stories were viewed 15,312 times, with 212 screenshots taken. Of questionnaire respondents, 75% [n=66] stated they engaged with content. Framework analysis of free-text responses and focus group discussion identified peer influence, fear of exposure, cognitive load and curiosity as drivers in new SoMe use. Discussion Medical students may engage with new SoMe for learning. This may manifest as yet another unilateral learning resource, rather than a tool for discussion or debate. Educators should be aware of external influences, such as peer influence, before assuming student interaction. Further research into medical student use of newer SoMe platforms is warranted, given their popularity, rapidly evolving nature and short lifespan.

Evaluation of an established learning portfolio.

BACKGROUND: The trainee-held learning portfolio is integral to the foundation programme in the UK. In the Northern Deanery, portfolio assessment is standardised through the Annual Review of Competence Progression (ARCP) process. In this study we aimed to establish how current trainees evaluate portfolio-based learning and ARCP, and how these attitudes may have changed since the foundation programme was first introduced. METHODS: Deanery-wide trainee attitudes were surveyed by an electronic questionnaire in 2009 and compared with perceptions recorded during the pilot phase (2004-2005). RESULTS: Many trainees continue to view the e-portfolio negatively. Indeed, significantly fewer trainees in 2009 thought that the e-portfolio was a 'good idea' or a 'worthwhile investment of time' than in 2005. Trainees remain unconvinced about the educational value of the e-portfolio: fewer trainees in 2009 regarded it as a tool that might help focus on training or recognise individual strengths and weaknesses. Issues around unnecessary bureaucracy persist. Current trainees tend to understand how to use the e-portfolio, but many did not know how much, or what evidence to collect. Few supervisors were reported to provide useful guidance on the portfolio. ARCP encouraged portfolio completion but did not give meaningful feedback to drive future learning. DISCUSSION: Continued support is needed for both trainees and supervisors in portfolio-building skills and in using the e-portfolio as an educational tool. Trainee-tailored feedback is needed to ensure that portfolio-based assessment promotes lifelong, self-directed and reflective learners.

Evidence-based algorithms and the management of falls and syncope presenting to acute medical services.

Falls and syncope are symptoms that commonly present to medical services. Detailed international guidelines for their management are available but tend to be aimed at specialists rather than generalists. Novel, evidence-based algorithms for the management of these symptoms when they present to acute medical services were formulated and their impact on patient care audited. The percentage of people admitted with falls and syncope was unexpectedly high (10.6% at baseline); this had decreased to 8.2% at repeat audit. Readmission rates decreased from 12% at baseline audit to 0% in repeat audit, while length of inpatient stay was unchanged. Mortality was strikingly high (12%) in both audits. Although inappropriate use of investigations decreased, the use of appropriate management strategies increased. Easy-to-use algorithms can help reduce the number of patients admitted to acute medical services with falls and syncope while optimising the care of those managed as inpatients. The algorithms are provided for use by interested parties.

Contribution of age, body size, and CYP2C9 genotype to anticoagulant response to warfarin.

OBJECTIVE: Our objective was to assess the contribution of CYP2C9 genotype, age, body size, and vitamin K and lipid status to warfarin dose requirements. METHODS: Patients with stable warfarin dose requirements and an international normalized ratio (INR) of the prothrombin time within the target range of 2.0 to 3.0 were recruited to the study. On arrival at the clinic in the morning, after an overnight fast, a blood sample was taken from each patient for CYP2C9 genotyping and for determination of venous INR and plasma vitamin K, R- and S-warfarin, and triglyceride concentrations. RESULTS: A total of 121 patients were recruited to the study. CYP2C9 genotyping showed that 74 patients were homozygous wild-type (*1/*1), 30 were heterozygous *1/*2, and 15 were heterozygous *1/*3 genotype. One patient was found to have the genotype *2/*3, and another was found to have the genotype *3/*3. The mean warfarin daily dose requirement in milligrams fell from 4.06 +/- 1.72 mg in homozygous wild-type patients to 3.63 +/- 1.78 mg for *1/*2-positive patients and 2.70 +/- 1.36 mg for *1/*3-positive patients. The multiple linear regression model for warfarin dose indicated significant contributions from age (r = 0.41, P <.001), genotype (r = 0.24, P <.005), and age and genotype together (r = 0.45, P <.005). Although there were significant linear correlations between warfarin dose and body surface area (r = 0.21, P =.02), body weight (r = 0.25, P =.005), and plasma vitamin K concentration (r = 0.18, P <.05), none of these variables made a significant contribution to the regression model for warfarin dose. CYP2C9 genotype had a significant effect on S-warfarin clearance (r = 0.34, P <.0001) but none on R-warfarin clearance. CONCLUSION: This study showed that age and CYP2C9 polymorphism affect warfarin dose requirements in patients receiving long-term therapy and having stable control of anticoagulation. It is anticipated that using dosing regimens modified to take into account the contribution of age and CYP2C9 genotype has the potential to improve the safety of warfarin therapy.

A prospective evaluation of bone mineral density measurement in females who have fallen.

BACKGROUND: The National Service Framework for Older Persons recognises the relationship between falls and osteoporosis; however, the best method for the evaluation of bone mineral density measurement in fallers is unclear. Dual energy X-ray absorptiometry of lumbar spine and hip is the gold standard for bone mineral density measurement, but is time consuming and may not be readily available. A cheaper, more portable alternative is peripheral dual energy X-ray absorptiometry of the heel. This predicts overall fracture risk as effectively as dual X-ray at the spine and hip, although site specific measurements provide the best estimate of fracture risk at a particular location. AIMS: 1. To validate peripheral dual energy X-ray in fallers by comparing heel bone mineral density measurement with measurements obtained at the lumbar spine and hip. 2. To determine the prevalence of osteoporosis in an unselected cohort of fallers. METHODS: 118 consecutive females over 50 attending for investigation of falls had heel bone mineral density measurement measured using peripheral dual energy X-ray (PIXI, Lunar). A representative sample of 52 (44%) also attended for bone mineral density measurement at the hip and lumbar spine using Hologic QDR 4500. Bone mineral density (g/cm(2)) measurements were compared with mean values for young adults and age-related normals giving T (number of standard deviation units above or below the mean for normal young adults) and Z (number of standard deviations above or below the age-related normal mean) scores. RESULTS: In the total group [n = 118 mean (SD) age 74 (11)] heel bone mineral density was 0.4 (0.1), T score--1.1 (1.6) and Z score--0.1 (1.5). The relationship between absolute bone mineral density measurements taken at heel, total hip and lumbar spine were compared and the correlation coefficients show a strong positive relationship between all measurements (all r values > 0.54, P < 0.0001) with a particularly strong relationship between hip and heel (r = 0.74). Those with two or more risk factors for falls were significantly more likely to have lower bone mineral density. DISCUSSION: This study has shown that peripheral dual energy X-ray is a reliable method of assessment, applicable to use within a Falls Unit. In addition, although the prevalence of osteoporosis is not increased in unselected fallers, those with two or more risk factors for falls are at increased risk of osteoporosis and limited resources may be more appropriately targeted toward this group.

Polymyalgia rheumatica and temporal arteritis: evidence and guidelines for diagnosis and management in older people.

Polymyalgia rheumatica and temporal arteritis commonly present for the first time in older people. Guidelines for diagnosis, investigation and management are available but have largely been developed by rheumatologists from studies where older people have been excluded. It is not clear whether geriatricians care for a group of patients with different clinical presentations compared to those under the care of other clinicians. There is a need for further prospective studies and randomised controlled trials to clarify a host of outstanding issues to improve the care of older people with polymyalgia rheumatica and temporal arteritis.

Prevalence of family history in vasovagal syncope and haemodynamic response to head up tilt in first degree relatives: preliminary data for the Newcastle cohort.

UNLABELLED: Vasovagal syncope is an exaggerated form of the common faint affecting all age groups. Aetiology is unknown but the tendency for the disease to run in families has previously been noted. AIM: To determine the true prevalence of family history in subjects with a definitive diagnosis of vasovagal syncope made by positive head up tilt with symptom reproduction. To determine the strength of the genetic effect in vasovagal syncope by calculation of sibling (lambdas) and offspring (lambdao) relative risk. Haemodynamic responses to head up tilt were also examined in a sample of first-degree relatives of those with vasovagal syncope. RESULTS: All subjects identified from the Cardiovascular Investigation Unit database with a definitive diagnosis of vasovagal syncope (n = 603) between 1993-2001 were asked to complete a questionnaire. 19% had positive family history for blackouts or faints. From these pedigrees and using a crude estimate of population prevalence, sibling and offspring relative risk was calculated: lambdas = 1080, lambdao = 1356. Eleven first-degree relatives from 6 families attended for head up tilt testing with glyceryl trinitrate (GTN) provocation (4 unaffected, 7 affected). All subjects had symptoms in response to tilt in association with a range of haemodynamic responses. CONCLUSIONS: Vasovagal syncope has a strong genetic component. Elucidating underlying genetic mechanisms may lead to more effective, specific treatments.