Impact of student choice on academic performance: cross-sectional and longitudinal observations of a student cohort.

BACKGROUND: Student choice plays a prominent role in the undergraduate curriculum in many contemporary medical schools. A key unanswered question relates to its impact on academic performance. METHODS: We studied 301 students who were in years 2 and 3 of their medical studies in 2005/06. We investigated the relationship between SSC grade and allocated preference. Separately, we examined the impact of 'self-proposing' (students designing and completing their own SSC) on academic performance in other, standard-set, summative assessments throughout the curriculum. The chi-squared test was used to compare academic performance in SSC according to allocated preference. Generalised estimating equations were used to investigate the effect of self-proposing on performance in standard-set examinations. RESULTS: (1) Performance in staff-designed SSC was not related to allocated preference. (2) Performance in year 1 main examination was one of the key predictors of performance in written and OSCE examinations in years 2, 3 and 4 (p<0.001). (3) The higher the score in the year 1 examination, the more likely a student was to self-propose in subsequent years (OR [CI] 1.07 [1.03-1.11], p<0.001). (4) Academic performance of students who self-proposed at least once in years 2 and/or 3 varied according to gender and year of course. CONCLUSION: In this study, no association was observed between allocated preference and SSC grade. The effect of self-proposing on academic performance in standard-set examinations was small. Our findings suggest instead that academically brighter students are more likely to design their own modules. Although student choice may have educational benefits, this report does not provide convincing evidence that it improves academic performance.

Thyroid testing in pregnant women with thyroid dysfunction in Tayside, Scotland: the thyroid epidemiology, audit and research study (TEARS).

OBJECTIVE: To investigate the rate of thyroid testing during pregnancy. DESIGN: Population-based, retrospective record-linkage study. SETTING: Health care data on pregnant women in Tayside, Scotland. PARTICIPANTS: All pregnant women who were 18 years and above and who delivered between 1 January 1993 and 31 March 2011 in Tayside were identified. Patients were included in the study if they have had at least three thyroxine prescriptions prior to pregnancy of which at least one prescription was within 6 months prior to pregnancy. MAIN OUTCOME MEASURES: Number of thyroid-stimulating hormone (TSH) assays performed during pregnancy and the changes in dosage of thyroxine prescribed during pregnancy. RESULTS: We identified 950 pregnancies that had thyroxine prescribed prior to pregnancy. Overall, 96.9% (95% CI: 96-98) of these pregnancies had at least one TSH assay performed during or just prior to pregnancy, with 81.2% (95% CI: 79-84) in the first trimester. The prescription of thyroxine was increased in 60.0% (95% CI: 57-63) at any time during pregnancy and in 34.0% (95% CI: 31-37) of pregnancies during the first trimester. Overall, 60% (95% CI: 57-63) of pregnancies had at least one elevated serum TSH during pregnancy with 55% (95% CI: 51-58) in the first trimester. CONCLUSION: The TSH concentration is raised in many pregnancies in women taking long-term thyroxine.

The role of modifiable pre-pregnancy risk factors in preventing adverse fetal outcomes among women with type 1 and type 2 diabetes.

We investigated the fetal outcomes of pregnancy in women with pre-existing diabetes in relation to pre-pregnancy risk factors using a community-based cohort of women in Tayside, Scotland. There were 211 pregnancies in 132 women with insulin-requiring type 1 and 2 diabetes between January 1993 and December 2005. Adverse fetal outcome was classified as spontaneous miscarriage, termination for medical reasons, stillbirth, neonatal death, or congenital malformation and occurred in 61 (29%) pregnancies. Mothers with poor glycemic control pre-conceptually and at booking (HbA(1c)=7.5%) had almost a three-fold increase in adverse fetal outcome compared with mothers having fair control, odds ratio (OR) 2.59 (95% CI 1.11-6.03), and 2.71 (95% CI 1.39-5.28), respectively. Mothers who were still smoking at the booking visit had a two-fold increase in adverse fetal outcome (OR 2.12, 95% CI 1.09-4.10). Further improvement in the management of diabetes and pregnancy is needed through enhanced preconception services addressing the full spectrum of modifiable risk factors.

Evidence for multiple circulating factors in preeclampsia.

OBJECTIVE: The purpose of this study was to enrich vasoactive factors that are present in the plasma of women with preeclampsia by the application of sequential fractionation and determination of the activity of each fraction in a bioassay. STUDY DESIGN: Pooled plasma from women with preeclampsia (n = 23) and matched control subjects (n = 23) was subjected to fractionation with ultrafiltration, targeted immunodepletion, or size exclusion chromatography. Myometrial arteries that were isolated from healthy cesarean section biopsy specimens (n = 28) were incubated with plasma fractions (2%, volume/volume), and their endothelial function was assessed by wire myography. RESULTS: Incubation of arteries with preeclampsia plasma or immunodepleted preeclampsia plasma had a deleterious effect on endothelial-dependent relaxation. Bioactivity of the plasma factors was absent in all fractions after either plasma ultrafiltration or separation with the use of size exclusion chromatography; however, activity was restored after recombination of these fractions. CONCLUSION: This study provides the first conclusive evidence that multiple synergistic factors, with a combined vasoactive effect, are present in the plasma of women with preeclampsia.

Poor glycated haemoglobin control and adverse pregnancy outcomes in type 1 and type 2 diabetes mellitus: systematic review of observational studies.

BACKGROUND: Glycaemic control in women with diabetes is critical to satisfactory pregnancy outcome. A systematic review of two randomised trials concluded that there was no clear evidence of benefit from very tight versus tight glycaemic control for pregnant women with diabetes. METHODS: A systematic review of observational studies addressing miscarriage, congenital malformations and perinatal mortality among pregnant women with type 1 and type 2 diabetes was carried out. Literature searches were performed in MEDLINE, EMBASE, CINAHL and Cochrane Library. Observational studies with data on glycated haemoglobin (HbA1c) levels categorised into poor and optimal control (as defined by the study investigators) were selected. Relative risks and odds ratios were calculated for HbA1c and pregnancy outcomes. Adjusted relative risk estimates per 1-percent decrease in HbA1c were calculated for studies which contained information on mean and standard deviations of HbA1c. RESULTS: The review identified thirteen studies which compared poor versus optimal glycaemic control in relation to maternal, fetal and neonatal outcomes. Twelve of these studies reported the outcome of congenital malformations and showed an increased risk with poor glycaemic control, pooled odds ratio 3.44 (95%CI, 2.30 to 5.15). For four of the twelve studies, it was also possible to calculate a relative risk reduction of congenital malformation for each 1-percent decrease in HbA1c, these varied from 0.39 to 0.59. The risk of miscarriage was reported in four studies and was associated with poor glycaemic control, pooled odds ratio 3.23 (95%CI, 1.64 to 6.36). Increased perinatal mortality was also associated with poor glycaemic control, pooled odds ratio 3.03 (95%CI, 1.87 to 4.92) from four studies. CONCLUSION: This analysis quantifies the increase in adverse pregnancy outcomes in women with diabetes who have poor glycaemic control. Relating percentage risk reduction in HbA1c to relative risk of adverse pregnancy events may be useful in motivating women to achieve optimal control prior to conception.

MMP-2 levels are elevated in the plasma of women who subsequently develop preeclampsia.

OBJECTIVE: To determine levels of matrix metalloproteinase (MMP)-2 and MMP-9, and the tissue inhibitors of metalloproteinases (TIMP)-1 and TIMP-2 in the plasma of women destined to develop preeclampsia prior to the onset of clinical disease. STUDY DESIGN: Plasma samples were taken from women whose pregnancies were subsequently complicated by preeclampsia and from normal pregnant women at 22 and 26 weeks and at delivery or diagnosis. Following equal protein loading, MMP-2 and 9 and TIMP-1 and 2 were quantified using zymography and Western blot analysis, respectively. RESULTS: Plasma MMP-2 levels were significantly elevated at 22 weeks (p = 0.02) and at diagnosis (p = 0.003) in the preeclampsia group, but there was no difference at 26 weeks. TIMP-1 levels were significantly reduced in the preeclampsia group at 26 weeks (p = 0.0002), but TIMP-2 levels were not quantifiable. CONCLUSION: At all three gestational time points an imbalance in the MMP-2:TIMP-1 ratio was found in patients who subsequently developed preeclampsia. We speculate that increased net MMP-2 activity may contribute to the endothelial dysfunction that is central to the pathophysiology of preeclampsia.

Transient hypothyroxinemia in preterm infants: the role of cord sera thyroid hormone levels adjusted for prenatal and intrapartum factors.

CONTEXT: Transient hypothyroxinemia is common in infants less than 30 wk gestation and is associated with neurodevelopmental deficits; it has no consensus definition. We previously suggested that appropriate ranges for postnatal serum T4 values are at least cord levels corrected to an equivalent gestational age if the fetuses had remained in utero. OBJECTIVE: The study objective is to investigate the contribution of prenatal and intrapartum factors (n = 27) to the variations in cord levels of iodothyronines, T4-binding globulin, and TSH, and to provide an appropriate definition of transient hypothyroxinemia. DESIGN: The study design is a cohort study (n = 620) in 11 Scottish neonatal intensive care units. PATIENTS: Infants were delivered at 23- to 42-wk gestation and recruited between January 1998 and September 2001. RESULTS: Using -2 SD of adjusted T4 cord levels applied to postnatal d-7 values of equivalent gestational age, 14% of the 23- to 27-wk group, 1% of the 28- to 30-wk group, and 3% of the 31- to 34-wk group are hypothyroxinemic; using -1 SD, the respective figures are 41, 23, and 12%. CONCLUSIONS: In the absence of neurodevelopmental follow-up studies to quantify transient hypothyroxinemia, a pragmatic criterion is necessary for selection of extreme preterm infants into clinical trials of T4 supplementation. We suggest the use of serum T4 levels on postnatal d 7 that are below -1 SD of adjusted cord T4 levels of equivalent gestational age. This criterion avoids over-recruitment of the more mature infants in whom universal T4 supplementation is detrimental to neurodevelopmental outcome, but still allows selection of the least mature entrants on whom universal T4 supplementation is beneficial.

Characteristics of doctors and nurses as perceived by students entering medical school: implications for shared teaching.

INTRODUCTION: Debate continues with respect to when to introduce interprofessional education for maximal potential benefit. One perspective is that interprofessional education should be introduced early in the undergraduate curriculum before students develop stereotyped impressions of other professional groups. However, it may be that students at entry to medical school have already developed these stereotypical impressions. This study examines perceived professional characteristics of doctors and nurses by students entering medical school. METHODOLOGY: Year 1 medical students in 4 consecutive years completed a questionnaire on their perceptions of the characteristics and backgrounds of nurses and doctors and on their attitudes to shared teaching. RESULTS: Year 1 medical students were found to perceive the characteristics of doctors and nurses differently. They considered nurses to be more caring and doctors to be more arrogant. They considered nurses to have lower academic ability, competence and status, although comparable life experience. They were generally very positive about beginning shared learning at an early stage of training. DISCUSSION: Whilst it is encouraging that medical students are positive about shared teaching, it is of concern that they have a poor perception of the academic ability, status in society and professional competence of the nurse at entry to medical school. These perceived impressions, which may reflect societal misconceptions regarding the roles and responsibilities of nurses within a modern health care system, may have an impact on the success of early interprofessional teaching initiatives in undergraduate curricula.

Triploid pregnancy detected incidentally by Down's syndrome screening.

Maternal serum screening for Down's syndrome and trisomy 18 identifies pregnancies with a greater risk of these abnormalities, which are then followed-up by karyotyping of cells collected either by amniocentesis or by chorionic villus sampling. These techniques complement ultrasonography, which gives accurate gestational dating as well as identifying structural abnormalities. Other chromosomal abnormalities are sometimes detected by virtue of atypical maternal screening results. This report illustrates a case of triploidy, a lethal abnormality, detected incidentally due to an exceptionally high human chorionic gonadotrophin result identified during Down's syndrome screening. This allowed appropriate counselling of the parents followed by a decision to terminate the pregnancy, avoiding the potential trauma of a spontaneous miscarriage or, if born live, death of the baby. Termination of the pregnancy also resolved associated maternal hyperthyroidism.