Impact of Simulated Patients on Physiotherapy Students' Skill Performance in Cardiorespiratory Practice Classes: A Pilot Study.

Purpose: To date, no evidence exists that high-fidelity simulation improves skill development among physiotherapy students in the university setting. With pressures to reduce costs and maintain or improve the quality of the learning experience, and with pressures on clinical placement, it is essential to investigate methods that might improve students' skill performance before they undertake clinical practice. Our study set out to investigate (1) the impact of using simulated patients (SPs) in a practical class on physiotherapy students' skill acquisition and (2) the students' reflections on the intervention. Method: We devised a pilot study using a single-centre randomized controlled trial. A total of 28 undergraduate physiotherapy students, matched using previous practical examination grades, undertook a 2-hour practical class in which they practised their core cardiorespiratory skills. Pre-session resources were identical. The control group practised on peers; the intervention group practised on SPs. The students' skill performance was assessed 2 weeks later using the Mini-Clinical Evaluation Exercise (MiniCEX), including gathering qualitative data from the students' reflections. Twenty-eight students undertook the practical class and subsequent MiniCEX assessment. Results: A statistically significant difference was found for all aspects of the MiniCEX except medical interview (p = 0.07) and physical interview (p = 0.69), and a large effect size was found for all areas except physical interview (0.154) and medical interview (0.378). The students' reflections focused on three key themes: behaviours and attitudes, teaching the active cycle of breathing technique, and feedback. Conclusions: Our findings suggest that interacting with SPs improves student skill performance, but further research using a larger sample size and an outcome measure validated for this population is required to confirm this.

Objectif : jusqu'à présent, aucune donnée probante n'indique que la simulation haute-fidélité améliore les compétences des étudiants universitaires en physiothérapie. Compte tenu des pressions pour réduire les coûts, maintenir ou améliorer la qualité de l'expérience d'apprentissage et participer à des stages, il est essentiel d'explorer des méthodes pour améliorer le rendement des compétences avant d'entreprendre la pratique clinique. Dans la présente étude, les chercheurs ont exploré 1) les répercussions du recours à des patients simulés (PS) dans un cours pratique d'acquisition des compétences des étudiants en physiothérapie et 2) les réflexions des étudiants à l'égard de l'intervention. Méthodologie : les chercheurs ont conçu un projet pilote dans le cadre d'un essai aléatoire et contrôlé monocentrique. Au total, 28 étudiants au premier cycle en physiothérapie, jumelés d'après leurs notes antérieures aux examens pratiques, ont suivi un cours pratique de deux heures pendant lequel ils ont exercé leurs compétences de base en santé cardiorespiratoire. Ils ont tous reçu les mêmes ressources avant le cours. Les membres du groupe témoin se sont exercés sur leurs homologues, et ceux du groupe d'intervention, sur des PS. Les chercheurs ont évalué le rendement des compétences des étudiants deux semaines plus tard à l'aide du mini-exercice d'évaluation clinique (MiniCEX), qui incluait une collecte de données qualitatives sur les réflexions des étudiants. Les 28 étudiants ont suivi le cours pratique et rempli l'évaluation MiniCEX subséquente. Résultats : les chercheurs ont constaté une différence statistiquement significative dans tous les aspects du MiniCEX, sauf l'entrevue médicale (p = 0,07) et l'entrevue physique (p = 0,69), et une taille d'effet importante dans tous les secteurs sauf l'entrevue physique (0,154) et l'entrevue médicale (0,378). Les réflexions des étudiants ont porté sur trois grands thèmes : comportements et attitudes, enseignement du cycle actif de la technique respiratoire et rétroaction. Conclusion : d'après les résultats, l'interaction avec des PS améliore le rendement des compétences des étudiants, mais il faudra réaliser d'autres recherches auprès d'un plus gros échantillon et valider les résultats dans cette population pour confirmer ces observations.

Lactate - Arterial and Venous Agreement in Sepsis: a prospective observational study.

BACKGROUND: Sepsis is a common condition in the emergency department (ED). Lactate measurement is an important part of management: arterial lactate (A-LACT) measurement is the gold standard. There is increasing use of peripheral venous lactate (PV-LACT); however, there is little research supporting the interchangeability of the two measures.If PV-LACT has good agreement with A-LACT, it would significantly reduce patient discomfort and the risks of arterial sampling for a large group of acutely unwell patients, while allowing faster and wider screening, with potential reduced costs to the healthcare system. OBJECTIVE: The aim of this study is to determine the agreement between PV-LACT and A-LACT in septic patients attending the ED. METHODS: We carried out a prospective observational cohort study of 304 consented patients presenting with sepsis to a single UK NHS ED (110 000 adult attendances annually) taking paired PV-LACT and A-LACT. Bland-Altman analysis was carried out to determine agreement. Receiver operating characteristic curves and 2×2 tables were constructed to explore the predictive value of PV-LACT for A-LACT. RESULTS: The mean difference (PV-LACT-A-LACT) is 0.4 mmol/l [95% confidence interval (CI): 0.37-0.45], with 95% limits of agreement from -0.4 (95% CI: -0.45 to -0.32) to 1.2 (95% CI: 1.14-1.27). A PV-LACT of at least 2 mmol/l predicts an A-LACT of at least 2 with 100% sensitivity (95% CI: 89-100%) and 83% specificity (95% CI: 77-87%). CONCLUSION: This study is the largest comparing the two measurements, and shows good clinical agreement. We recommend using PV-LACT in the routine screening of septic patients. A PV-LACT less than 2 mmol/l is predictive of an A-LACT less than 2 mmol/l.

Long-term impacts on macroinvertebrates downstream of reclaimed mountaintop mining valley fills in Central Appalachia.

Recent studies have documented adverse effects to biological communities downstream of mountaintop coal mining and valley fills (VF), but few data exist on the longevity of these impacts. We sampled 15 headwater streams with VFs reclaimed 11-33 years prior to 2011 and sampled seven local reference sites that had no VFs. We collected chemical, habitat, and benthic macroinvertebrate data in April 2011; additional chemical samples were collected in September 2011. To assess ecological condition, we compared VF and reference abiotic and biotic data using: (1) ordination to detect multivariate differences, (2) benthic indices (a multimetric index and an observed/expected predictive model) calibrated to state reference conditions to detect impairment, and (3) correlation and regression analysis to detect relationships between biotic and abiotic data. Although VF sites had good instream habitat, nearly 90 % of these streams exhibited biological impairment. VF sites with higher index scores were co-located near unaffected tributaries; we suggest that these tributaries were sources of sensitive taxa as drifting colonists. There were clear losses of expected taxa across most VF sites and two functional feeding groups (% scrapers and %shredders) were significantly altered. Percent VF and forested area were related to biological quality but varied more than individual ions and specific conductance. Within the subset of VF sites, other descriptors (e.g., VF age, site distance from VF, the presence of impoundments, % forest) had no detectable relationships with biological condition. Although these VFs were constructed pursuant to permits and regulatory programs that have as their stated goals that (1) mined land be reclaimed and restored to its original use or a use of higher value, and (2) mining does not cause or contribute to violations of water quality standards, we found sustained ecological damage in headwaters streams draining VFs long after reclamation was completed.

Early lactate clearance in septic patients with elevated lactate levels admitted from the emergency department to intensive care: time to aim higher?

PURPOSE: Septic patients with hyperlactatemia have increased mortality rates, irrespective of hemodynamic and oxygen-derived variables. The aims of the study are the following: (1) to ascertain whether lactate clearance (LC) (percentage change in lactate over unit time) predicts mortality in septic patients admitted to intensive care directly from the emergency department and (2) to calculate the optimal "cut-off" value for mortality prediction. METHODS: Three-year retrospective observational study of consecutive patients with severe sepsis and septic shock admitted to intensive care from the emergency department of a tertiary UK hospital. We calculated 6-hour LC, performed receiver operating characteristic analyses to calculate optimal cut-off values for initial lactate and LC, dichotomized patients according to the LC cut-off, and calculated hazard ratios using a Cox proportional hazards model. RESULTS: One hundred six patients were identified; 78, after exclusions. Lactate clearance was independently associated with 30-day mortality (P<.04); optimal cut-off, 36%. Mortality rates were 61.1% and 10.7% for patients with 6-hour LC 36% or less and greater than 36%, respectively. Hazard ratio for death with LC 36% or less was 7.33 (95% confidence interval, 2.17-24.73; P<.001). CONCLUSIONS: Six-hour LC was independently associated with mortality, and the optimal cut-off value was 36%, significantly higher than previously reported. We would support further research investigating this higher LC as a distinct resuscitation end point in patients with severe sepsis and septic shock.