Defining performance levels in undergraduate otolaryngology education.

OBJECTIVES: This study seeks the opinions of qualified doctors on what they feel medical students should learn about otolaryngology. It aims to identify both the content deemed relevant and the performance levels for medical students in otolaryngology. METHODS: A national survey developed from a content analysis of undergraduate otolaryngology curricula from the UK was undertaken, accompanied by a review of the literature and input from an expert group. Data were collected from a wide range of doctors. RESULTS: Participants felt that graduating students should be able to: recognise, assess and initiate management for common and life-threatening acute conditions; take an appropriate patient history; and perform an appropriate examination for the majority of otolaryngology clinical conditions but manage only a select few. CONCLUSION: This study reports performance levels for otolaryngology topics at an undergraduate level. Participating doctors felt that a higher level of performance should be expected of students treating life-threatening, acute and common otolaryngology conditions.

An undergraduate Otolaryngology curriculum comparison in the United Kingdom using a curriculum evaluation framework.

OBJECTIVE: To compare undergraduate otolaryngology curricula in the United Kingdom. To develop a tool which would allow undergraduate specialty curricula to be compared. DESIGN: Development of a curriculum evaluation framework (CEF) and survey. SETTING: UK medical schools. PARTICIPANTS: Otolaryngology curricula were requested from all 32 UK medical schools who award a primary medical qualification. Nineteen curricula were received and examined. MAIN OUTCOME MEASURES: Thematic and content analysis of curriculum documents were undertaken. Outcome measures include an examination of curriculum content and methods, type of assessment and alignment of curricula with the General Medical Council's Tomorrow's Doctors document. RESULTS: Learning objectives were listed by 18 of the 19 medical schools who responded. The most commonly included theme was clinical conditions (100%). Psychosocial aspects of otolaryngology was the least covered theme (37%). Examination skills was covered by the majority (74%). Outpatient clinics and theatre attendance were the most commonly utilised teaching methods (47%). Student checklists were the most common form of assessment (32%). Only four medical schools linked their curricula to the GMC's Tomorrow's Doctors document. CONCLUSIONS: The development of a CEF allowed for a systematic comparison of curricula. This study, evaluating otolaryngology curricula, has highlighted the variability of curricula from both a content and methods perspective in the UK. The study provides those involved with curriculum planning an overview of the main themes currently taught in the UK and offers examples of individual topics. It also offers an insight into the way in which otolaryngology is taught in the UK.

Educational benefits of student self-marking of short-answer questions.

A pilot study was undertaken to evaluate the feasibility and reliability of undergraduate medical student selfmarking of degree written examinations, and to survey student opinion regarding the process. The correlation between student and faculty staff scores for individual questions and the total examination was high (correlation coefficient ranged from 0.77 to 0.91: p < 0.001). There were no significant differences between the mean student and mean faculty staff scores for individual questions or the total examination: 98% (97199) of student scores fell within ± 15% of the faculty staff score, with 92% (91199) of students falling within ± 10%. Although the approach was demonstrated to be reliable, students generally failed to acknowledge the potential value of self-marking in terms of feedback and as a learning opponunity, and found the process stressful.

The development and validation of an algorithm for real-time computerised fetal heart rate monitoring in labour.

OBJECTIVE: To develop and validate a computerised algorithm for the interpretation of the characteristics of fetal heart rate monitoring in labour. DESIGN: Prospective observational study. SETTING: Labour ward in a tertiary hospital. SAMPLE: Intrapartum cardiotocograms from 24 pregnancies. METHODS: A computerised algorithm was developed to assess the fetal heart baseline rate, variability, the number of accelerations and the number of decelerations. Twenty five minute segments of cardiotocograms were interpreted by the algorithm and also by seven expert reviewers independently. The reviewers were unaware of the outcome of labour. The reliability of the characteristics of cardiotocography and the validity of the computerised algorithm were assessed using the intraclass correlation coefficient and weighted kappa statistic for continuous and ordinal variables respectively. RESULTS: The inter rater reliability of the baseline fetal heart rate and the number and type of decelerations was good (intraclass correlation coefficient 0.93, 0.93 and 0.79, respectively). The reliability of baseline variability (kappa = 0.27) and accelerations (intraclass correlation coefficient = 0.27) was poor. The computerised algorithm had good agreement with the reviewers for the baseline fetal heart rate (intraclass correlation coefficient 0.91 to 0.98) and the number of decelerations (intraclass correlation coefficient 0.82 to 0.91), but was less valid as regards the number of late decelerations (intraclass correlation coefficient 0.68 to 0.85) and the number of accelerations (intraclass correlation coefficient 0.06 to 0.80), and was invalid as regards baseline variability (kappa 0.00 to 0.34). CONCLUSIONS: The high level of validity of the computerised algorithm for the estimation of the baseline fetal heart rate and the number of decelerations justifies its further technical development.

A comparison of performance by medical and midwifery students in multiprofessional teaching.

AIM: At Dundee University, midwifery and medical students are taught obstetrics together in a 2-week intensive course. We set out to test the hypothesis that staff time and effort could be saved by using shared resources in teaching a multidisciplinary group of students to an acceptable level. METHOD: In order to measure the knowledge gain by two different groups of students, we tested the students before and after a timetabled computer-assisted learning (CAL) session focusing on how to interpret a cardiotocograph (CTG). Also, half of each student group was given extra CTG teaching before the CAL session. RESULTS: The medical students (n=38) increased their median score from 9 to 17 after the CAL (P<0.001) but the midwifery students (n=13) only increased their median score from 12 to 14 after the CAL (n.s.). However, when given a tutorial and CAL, the post-test scores for both medical and midwifery students were similar and significantly higher than pre-test scores (median score increase from 8.5 to 18 for medical students, P<0.001, n=34, and from 9 to 16 for midwifery students, P<0.01 n=11). There was no significant knowledge gain by the medical students who undertook the additional tutorial. CONCLUSION: We conclude that shared resources could be used by medical and midwifery students to reach equivalent levels of skill in CTG interpretation. However, in order to achieve equivalence, staff time and effort was wasted as medical students were given unnecessary tuition.

Use of a computerised maternity information system to improve clinical effectiveness: thromboprophylaxis at caesarean section.

An audit of the introduction of a protocol for thromboprophylaxis at caesarean section revealed over treatment of low risk women and the under treatment of high risk women. A routine computer generated risk assessment profile was introduced as part of a maternity information system. Reaudit showed a significant improvement in adherence to the thromboprophylaxis protocol in all risk groups.

Screening practices for gestational diabetes mellitus in UK obstetric units.

AIM: To identify current screening practices for gestational diabetes mellitus (GDM) in all maternity units. METHODS: A questionnaire was sent to the senior obstetrician of all obstetric units known to the UK Royal College of Obstetricians and Gynaecologists. RESULTS: A response rate of 84% was achieved. 89% of units reported that they screened for GDM with a wide variation in the screening methods used, both between and within units. The most commonly employed procedure (81% of units) was screening based on the presence of maternal risk factors. The 75 g oral glucose tolerance test (OGTT) was the commonest diagnostic test (79% of units). Sixty-six per cent of units operate a combined diabetic antenatal clinic and 58% of units have written guidelines for screening. Seventy-six per cent of units would welcome national guidelines. CONCLUSION: The majority of obstetric units in the UK screen for GDM but with little consensus on the appropriate screening methods. National guidelines would probably be welcomed.

The use of audit to improve clinical effectiveness in an infrequent obstetric therapy: magnesium sulphate in severe pre-eclampsia.

Magnesium sulphate has been established as the drug of choice in the management of eclampsia and even when used in cases of severe pre-eclampsia it is given infrequently. It is recognised to have potentially severe toxic effects but there is a need to achieve therapeutic levels quickly enough to prevent seizures. This paper reports an audit following the introduction of a protocol for the use of magnesium sulphate in eclampsia and severe pre-eclampsia at Ninewells hospital, Dundee. Problems were identified with both the time taken to reach therapeutic levels and clinical monitoring of magnesium levels despite the use of loading doses commonly recommended. Reaudit after changes to the protocol and the introduction of an administration/monitoring chart showed a significant improvement in both monitoring and the adequacy of prophylaxis. This demonstrates how audit of clinical practice has been used to improve clinical effectiveness in an area in which a potentially toxic drug is used infrequently but with potentially life saving benefits.

Assessment of uterine arterial notching as a screening test for adverse pregnancy outcome.

OBJECTIVE: The objective of the study was to evaluate the screening potential of routine uterine arterial Doppler ultrasonography as a predictor of adverse pregnancy outcome. STUDY DESIGN: All women (n = 6579) with singleton pregnancies undergoing a fetal anomaly scan at 18 to 20 weeks' gestation between January 1, 1994, and December 31, 1995, at Ninewells Hospital and Medical School were screened for the presence of uterine arterial notching. Women who had evidence of bilateral notching were rescanned at 22 to 24 weeks' gestation. Outcome measures included proteinuric hypertension, premature separation of the placenta, and birth weight z score. RESULTS: The sensitivity and positive predictive value of uterine arterial notching as a predictor of adverse pregnancy outcomes was low. For all types of notching and disease, outcome sensitivity was never higher than 44% and positive predictive value was never higher than 27%. In contrast, the relative risk of adverse pregnancy outcome in the presence of uterine arterial notching was uniformly high for all disease outcomes (range of relative risk 3.5-30.7). Significant obstetric morbidity was seen in 57% of women with bilateral notches at 18 to 20 weeks' gestation and 72% of women with persistent bilateral notches. CONCLUSIONS: As a screening test for adverse pregnancy outcomes, detection of uterine arterial notching is poor. Nevertheless, the presence of bilateral uterine arterial notching is associated with a significantly increased risk of adverse pregnancy outcome. In units performing routine anomaly screening, the addition of maternal uterine arterial Doppler ultrasonography may help to discriminate this small group of women at high risk.

Episiotomy and perineal tears in low-risk UK primigravidae.

BACKGROUND: The aim of the study was to determine the rates and to describe the risk factors for episiotomy and perineal tears in low-risk primigravidae. METHOD: A cross-sectional survey of 101 randomly selected NHS hospitals in the UK was carried out between February 1993 and January 1994. Subjects were 40 consecutive low-risk primigravidae in each hospital. The main outcome measures were number and reasons for episiotomy, and number and degree of perineal tears. RESULTS: A large proportion of women (83 per cent) experienced some form of perineal trauma. Forty per cent of the women had an episiotomy only, 6 per cent an episiotomy and perineal tear, and 37 per cent perineal or other tears without episiotomy. The main reasons for performing an episiotomy were foetal distress (27 per cent), impending tear (25 per cent) and delay of the second stage of labour (21 per cent). Fifty-nine per cent of women with a delayed second stage had a spontaneous vaginal delivery and 41 per cent required instrumental assistance. The likelihood of having an episiotomy increased with the duration of the second stage of labour, irrespective of type of delivery. Episiotomy rates varied appreciably throughout regions and hospitals in the United Kingdom, ranging from 26 to 67 per cent. There was also a large regional variation in the rates of perineal trauma; generally, high rates of one outcome were associated with low rates of the other. Compared with white women, women from the Indian sub-continent were almost twice as likely and those from the Orient almost five times as likely to have an episiotomy. CONCLUSIONS: The magnitude of the geographical variation suggests a lack of uniformity in indications for performing episiotomies and that guidelines for performing episiotomies may need to be reviewed. The rates of episiotomy in women from the Indian sub-continent and Orient were very high compared with those for white women, and this requires clarification and explanation, as they are contrary to rates experienced in these ethnic groups in other countries.

The reliability of the detection of an early diastolic notch with uterine artery Doppler velocimetry.

This study evaluates the ability of two reviewers to detect independently an early diastolic notch in 1371 uterine artery Doppler velocity waveform recordings. Agreement between the two reviewers for the detection of uterine artery notching was assessed by using the Kappa statistic. The inter-rater reliability for the detection of unilateral notching was 0.75 (95% CI 0.70-0.80), whereas that for the presence or absence of bilateral notching was 0.66 (95% CI 0.60-0.71). The results suggest that there was good reviewer agreement for the presence or absence of a notch on uterine artery Doppler velocimetry.

Foetal growth velocities in twin pregnancies.

A retrospective longitudinal study was performed to quantify foetal growth velocities in twin pregnancies and to determine the effect of variables specific to twin pregnancies on growth velocity. Foetal growth velocity standard deviation (Z) scores were calculated from serial ultrasound data using published singleton reference data for 131 consecutive sets of twins from 30 to 37 weeks' gestation. Compared with low-risk pregnancies, the twin foetal abdominal area growth velocity Z scores were significantly reduced from 30 to 37 weeks and biparietal diameter growth velocity Z scores were also significantly lower, from 30 to 33 weeks. Amongst the twin pairs there were no significant differences in Z scores with respect to chorionicity, foetal sex, birth order to whether delivery was premature or term. This retrospective study has demonstrated that twin foetal growth velocity is reduced when compared to singletons from at least as early as 30 weeks' gestation. Twin specific variables such as chorionicity, sex, birth order and subsequent premature birth do not need to be accounted for in the interpretation of growth velocities in twins. The clinical importance of determining foetal growth velocity in twin pregnancies awaits further prospective study.

Cerebral pathology in the pre-term infant and associated peripartum metabolic acidosis.

In a prospective study of 217 infants who were delivered before 37 weeks' gestation and in whom serial cranial ultrasound scans were performed to identify cerebral pathology, multivariate analysis, including a wide range of peripartum and neonatal variables, demonstrated that metabolic acidosis present at delivery and persisting during the early neonatal period was associated with the development of cerebral pathology in these infants. These findings support the hypothesis that the condition at birth of the preterm infant as assessed by acid/base balance, which reflects events occurring during labour and delivery, is an important factor in the subsequent development of cerebral pathology. In addition, the data support the view that obstetric policies aimed at avoiding metabolic acidosis at birth are likely to be of benefit to the pre-term infant.

A prospective evaluation of the value of intrapartum biophysical and Doppler parameters in identifying the potentially compromised fetus.

This study was designed to evaluate the use of the biophysical profile and umbilical arterial Doppler in early labour in identifying the potentially compromised fetus. Two hundred and forty-two women attending the labour suite in early labour were studied. One hundred and fifty-one were in spontaneous labour and the remaining 91 had labour induced. All women had intrapartum biophysical profile assessment and umbilical arterial Doppler performed. Umbilical arterial Doppler and fetal movements were variously identified as being independently and significantly associated with adverse perinatal outcomes. Positive predictive values for adverse outcomes were however poor. Umbilical arterial Doppler used individually or in combination with clinical risk, gave no advantage over the use of clinically assigned risk alone in identifying fetuses at risk of subsequent adverse outcome. The assignment of clinical risk on admission in labour remains the most predictive 'test' for identifying the fetus at risk of subsequent adverse outcome. The routine addition of intrapartum biophysical parameters and umbilical arterial Doppler as methods of assessment is not justified.

Improved intrapartum surveillance with PR interval analysis of the fetal electrocardiogram: a randomized trial showing a reduction in fetal blood sampling.

OBJECTIVE: Our goal was to test the hypothesis that the addition of fetal electrocardiogram time-interval analysis to conventional electronic fetal monitoring would significantly reduce the number of cases requiring fetal scalp blood sampling without an increase in adverse outcome. STUDY DESIGN: A randomized prospective trial was performed in 214 women with high-risk labor. RESULTS: There was a significant reduction in the number of cases that had fetal blood sampling performed in the fetal electrocardiogram plus electronic fetal monitoring group (risk ratio for electronic fetal monitoring alone 3.53; p < 0.01, 95% confidence interval 1.39 to 8.95). The fetal blood samplings performed in the electronic fetal monitoring alone group were less likely to be abnormal (pH < 7.25, base excess < -8.0) than those performed in the fetal electrocardiogram plus electronic fetal monitoring group (risk ratio for electronic fetal monitoring alone 0.62, p = 0.05, 95% confidence interval 0.35 to 1.10). There was a trend of more infants with an arterial umbilical pH < 7.15 and a base excess less than -8.0 mmol/L at birth being unsuspected and more instrumental deliveries for presumed fetal distress being performed in the electronic fetal monitoring alone than in the fetal electrocardiogram plus electronic fetal monitoring group. CONCLUSION: The addition of fetal electrocardiogram analysis to conventional electronic fetal monitoring during labor can reduce significantly the number of parturients undergoing fetal scalp blood sampling and can simultaneously increase its efficiency without an increase in adverse outcome.

Neonatal cerebral arterial flow velocity waveforms in term infants with and without metabolic acidosis at delivery.

To define the effects of acid base status at delivery on neonatal cerebral artery flow velocity waveform patterns obtained using Doppler ultrasound during the first week of life, a longitudinal comparative study of neonates born at term with and without evidence of metabolic acidosis in the umbilical artery was undertaken. Eighty-two appropriate for gestational age infants delivered after uncomplicated pregnancies with non-acidotic umbilical artery blood gases and in whom no neonatal complications were noted were studied to establish reference values of neonatal cerebral arterial vascular resistance index (RI) in normal term infants during the first week of life. A further 189 infants were grouped according to the presence and severity of metabolic acidosis at delivery, and also the presence of high risk features in the antenatal period. In the normal non-acidotic infants, over the first 24 h of life, there was a significant fall in the cerebral arterial resistance index (RI) in all the vessels examined, after which a steady state value was attained with no significant changes in vascular resistance index being noted during the remainder of the study period. The fall in RI between 12 and 24 h of age was consistent in all study groups. Infants with metabolic acidosis at delivery had blood flow patterns compatible with decreased resistance to flow in both anterior and middle cerebral arteries which persisted throughout the first week of life. This reduction in cerebral vascular resistance was most marked in those infants with severe metabolic acidosis. The majority of severely acidotic infants had a benign clinical outcome in the first week of life and all infants had normal cerebral ultrasound scans during the neonatal period. These findings suggest that metabolic acidosis at birth is associated with changes in neonatal cerebral arterial vascular resistance during the first week of life, and in the presence of benign clinical course the significance of this observation with regard to neurodevelopmental outcome requires evaluation.

Are 'notched' uterine arterial waveforms of prognostic value for hypertensive and growth disorders of pregnancy?

In a case-control controlled study of 86 women identified as having bilaterally 'notched' uterine arterial waveform patterns at 18 weeks, the presence of bilateral 'notched' uterine arterial waveforms at that time was associated with the subsequent development of hypertension and small-for-gestational-age infants, but the predictive value was poor. For those women in whom the bilateral uterine 'notches' were observed to persist to 24 weeks, the relative risk of developing proteinuric hypertension increased 14 times, and in these women the positive predictive value for the subsequent development of hypertension increased to 58.6% when compared with their matched controls. The identification of women with persistent bilateral uterine 'notches' provides a means of identifying women at significant risk of hypertensive and growth disorders at a stage when therapeutic intervention aimed at limiting the severity of the disease and its associated complications could be commenced.

Neonatal cerebral Doppler flow velocity waveforms in the pre-term infant with cerebral pathology.

In a longitudinal study of 217 infants delivering at < 37 completed weeks gestation, Doppler flow velocity waveforms were obtained, and resistance index (RI) values calculated from the middle (MCA) and anterior (ACA) cerebral arteries during the first 10 days of life. Sixty infants demonstrated ultrasound evidence of cerebral pathology, of which five cases were congenital, and an additional 13 cases were complicated by patent ductus arteriosus during the study period. The Doppler data obtained during the first week of life from the remaining 42 infants who developed cerebral pathology, and 15 infants who had evidence of metabolic acidosis at delivery without ultrasound evidence of cerebral pathology were compared with local reference data obtained from non-acidotic infants with normal cranial ultrasound from 24 h of age. In those infants who had evidence of minor periventricular haemorrhage alone (Grade I/II PVH), there was no significant difference between the ACA or MCA RI during the study period compared with the reference data. In those groups of infants who demonstrated major PVH (Grade III/IV) or persistent periventricular flares, the ACA and MCA RI was found to be consistently significantly higher than the reference group throughout the study period. In those infants who developed ultrasound evidence of periventricular cystic leukomalacia (PVCL), the MCA RI was significantly lower than the reference data between 48 and 72 h of age, there being no significant difference in the ACA RI. The Doppler findings in those infants with evidence of metabolic acidosis at delivery (umbilical arterial pH < 7.20; BD > 8 mmol/l) but with normal ultrasound findings were similar to those infants who developed PVCL, namely a significant fall in MCA RI between 48 and 72 h of life, with no significant difference in the ACA RI during the study period. These findings suggest that variable changes in cerebral vascular resistance occur with the evolution of, or as a consequence of the development of cerebral pathology in the pre-term infant, and these changes of increased and decreased vascular resistance are discussed. Further investigation of the changes occurring in the cerebral circulation in the early neonatal period of infants who develop PVCL is required to clarify the vascular changes taking place, but if the findings of this study are confirmed, this technique may provide a means of identifying infants at risk of developing ischaemic cerebral pathology at an early stage when it may be possible to initiate therapeutic intervention to limit the cerebral damage.