Undergraduate exposure to patient presentations on the acute medical placement: a prospective study in a London teaching hospital.

OBJECTIVES: To identify the availability and variability of learning opportunities through patient presentations on an acute medical placement at a teaching hospital. DESIGN: A prospective study evaluating all acute admissions to the Acute Medical Unit over 14 days (336 hours). Clinical presentations and the day and time of admission were recorded and compared with the learning outcomes specified in the medical school curriculum. SETTING: An Acute Medical Unit at a London teaching hospital. OUTCOMES: (1) Number of clinical presentations to the Acute Medical Unit over 14 days and (2) differences between the availability and variation of admissions and presentations between in-hours and out-of-hours. RESULTS: There were 359 admissions, representing 1318 presentations. Of those presentations, 76.6% were admitted out-of-hours and 23.4% in-hours. Gastrointestinal bleeding, tachycardia, oedema and raised inflammatory markers were over three times more common per hour out-of-hours than in-hours. Hypoxia was only seen out-of-hours. Important clinical presentations in the curriculum such as chest pain and hemiparesis were not commonly seen. CONCLUSIONS: There is greater availability of presentations seen out-of-hours and a changing landscape of presentations seen in-hours. The out-of-hours presentation profile may be due to expanded community and specialist services. Medical schools need to carefully consider the timing and location of their clinical placements to maximise undergraduate learning opportunities.

FEEDBK: a novel approach for providing feedback.

BACKGROUND: High-quality feedback is fundamental to students' learning. We describe and evaluate FEEDBK, a novel feedback tool that encompasses the focus of learning, student self-evaluation (reflection), the encounter with the patient (professionalism), one task that the student should continue to do (reinforcement), one task that they could do better (improvement) and a key take-home message for self-directed learning. METHODS: Medical students received regular bedside teaching and feedback during a 9-week clinical placement at a teaching hospital. Teaching fellows gave feedback in their usual style during weeks 1-3 and then used the FEEDBK tool during weeks 4-9. Questionnaires and focus groups were used to evaluate the students' experience of feedback before and after the introduction of FEEDBK. RESULTS: FEEDBK significantly enhanced the feedback experience across six domains: identifying learning objectives, chance to reflect, feedback on communication skills/professionalism, specific suggestions for improvement, clear take-home message and personalised feedback. The analysis of the feedback from focus groups yielded four categories: (i) FEEDBK influenced the feedback process (delivering timely feedback); (ii) the nature of the feedback (enhancing both the quantity and the quality of the feedback received); (iii) the structure of the feedback; and (iv) the evolution of teaching and learning. DISCUSSION: FEEDBK may enhance both the quantity and the quality of feedback and has the potential to improve the quality of teaching. It provides teachers with a quick and easy-to-follow framework to signpost curriculum-aligned feedback.

Very Short Answer Questions: A Novel Approach To Summative Assessments In Pathology.

BACKGROUND: A solid understanding of the science underpinning treatment is essential for all doctors. Pathology teaching and assessment are fundamental components of the undergraduate medicine curriculum. Assessment drives learning and the choice of assessments influences students' learning behaviours. The use of multiple-choice questions is common but is associated with significant cueing and may promote "rote learning". Essay-type questions and Objective Structured Clinical Examinations (OSCEs) are resource-intensive in terms of delivery and marking and do not allow adequate sampling of the curriculum. To address these limitations, we used a novel online tool to administer Very Short Answer questions (VSAQs) and evaluated the utility of the VSAQs in an undergraduate summative pathology assessment. METHODS: A group of 285 medical students took the summative assessment, comprising 50 VSAQs, 50 single best answer questions (SBAQs), and 75 extended matching questions (EMQs). The VSAQs were machine-marked against pre-approved responses and subsequently reviewed by a panel of pathologists, with the software remembering all new marking judgements. RESULTS: The total time taken to mark all 50 VSAQs for all 285 students was 5 hours, compared to 70 hours required to manually mark an equivalent number of questions in a paper-based pathology exam. The median percentage score for the VSAQs test (72%) was significantly lower than that of the SBAQs (80%) and EMQs (84%), p <0.0001. VSAQs had a higher Cronbach alpha (0.86) than SBAQs (0.76), and EMQs (0.77). VSAQs, SBAQs and EMQs had a mean point-biserial of 0.35, 0.30 and 0.28, respectively. CONCLUSION: VSAQs are an acceptable, reliable and discriminatory method for assessing pathology, and may enhance students' understanding of how pathology supports clinical decision-making and clinical care by changing learning behaviour.

Using prescribing very short answer questions to identify sources of medication errors: a prospective study in two UK medical schools.

OBJECTIVE: To assess the utility and ability of the novel prescribing very short answer (VSA) question format to identify the sources of undergraduate prescribing errors when compared with the conventional single best answer (SBA) question format and assess the acceptability of machine marking prescribing VSAs. DESIGN: A prospective study involving analysis of data generated from a pilot two-part prescribing assessment. SETTING: Two UK medical schools. PARTICIPANTS: 364 final year medical students took part. Participation was voluntary. There were no other inclusion or exclusion criteria. OUTCOMES: (1) Time taken to mark and verify VSA questions (acceptability), (2) differences between VSA and SBA scores, (3) performance in VSA and (4) SBA format across different subject areas and types of prescribing error made in the VSA format. RESULTS: 18 200 prescribing VSA questions were marked and verified in 91 min. The median percentage score for the VSA test was significantly lower than the SBA test (28% vs 64%, p<0.0001). Significantly more prescribing errors were detected in the VSA format than the SBA format across all domains, notably in prescribing insulin (96.4% vs 50.3%, p<0.0001), fluids (95.6% vs 55%, p<0.0001) and analgesia (85.7% vs 51%, p<0.0001). Of the incorrect VSA responses, 33.1% were due to the medication prescribed, 6.0% due to the dose, 1.4% due to the route and 4.8% due to the frequency. CONCLUSIONS: Prescribing VSA questions represent an efficient tool for providing detailed insight into the sources of significant prescribing errors, which are not identified by SBA questions. This makes the prescribing VSA a valuable formative assessment tool to enhance students' skills in safe prescribing and to potentially reduce prescribing errors.

Management of skin cancer in recipients of solid organ transplants.

Recent improvements in post-transplant care have led to an increased life expectancy for recipients of organ transplants. These patients require lifelong immunosuppression, which is associated with an increased incidence of malignant disease. Skin cancers are the most common malignancies seen in recipients of organ transplants and are associated with significant morbidity and mortality. This review describes factors pertaining to the development and prognosis of skin cancers in recipients of organ transplants, as well as outlining prevention and management strategies in this cohort.

Platinum-induced ototoxicity: a review of prevailing ototoxicity criteria.

The antineoplastic agent's cisplatin and carboplatin are widely used as they are highly effective. Unfortunately, ototoxicity is a frequently encountered side effect of platinum-based chemotherapy. Clinically, patients generally develop a progressive, bilateral, and irreversible sensorineural hearing loss. With rising cancer survival rates, a greater proportion of patients are living with the side effects of their chemotherapy treatments. Consequently, the quality of life of cancer survivors has now become a major concern for clinicians. Various classification systems are currently available to grade side effects and provide a guideline for subsequent treatments. An extensive review of the literature revealed that a variety of criteria are used worldwide for grading platinum-induced hearing loss in children and adults, including the National Cancer Institute criteria, Brock's grading system, the American Speech-Hearing-Language Association criteria, the World Health Organization criteria, the Pediatric Oncology Group criteria, and the Muenster classification. Less commonly used criteria include the Chang classification, the Functional Hearing Loss scale, the HIT system (German Hirntumor study grading system), and most recently, the International Society of Pediatric Oncology Boston ototoxicity grading scale. The objective of this review is to evaluate the commonly used ototoxicity criteria and discuss their benefits and limitations.

Hearing loss in a pediatric patient following cisplatin chemotherapy and subsequent exposure to excessive noise.

Cisplatin is a commonly-used chemotherapeutic agent that is highly-effective against a variety of pediatric cancers. Unfortunately, it may lead to ototoxicity, with serious consequences on the quality of life of survivors. Patients remain at risk of progression of ototoxicity even after completion of treatment. We report the case of a medulloblastoma survivor with previously documented normal hearing, who developed significant hearing loss and tinnitus following exposure to excessive noise at a nightclub three years after completion of treatment. We highlight the importance of long-term audiological follow up and education about the increased risk of hearing loss in this population.

Incidence of platinum-induced ototoxicity in pediatric patients in Quebec.

BACKGROUND: The antineoplastic agents cisplatin and carboplatin are widely-used and highly-effective against a variety of pediatric cancers. Unfortunately, ototoxicity is a frequently encountered side effect of platinum-based chemotherapy. There is currently no treatment or prevention for platinum-induced ototoxicity and development of hearing loss may lead to devastating consequences on the quality of life of pediatric cancer survivors. The objective of this study is to determine the incidence of platinum-induced ototoxicity in a large series of pediatric patients and to evaluate the incidence of progression of ototoxicity after completion of treatment. PROCEDURES: A retrospective chart review of pediatric patients treated with cisplatin or carboplatin between 2000 and 2012 was conducted. The incidence of ototoxicity was determined based on the American-Speech-Language-Hearing Association (ASHA) criteria and severity was based on the Chang classification. RESULTS: Four hundred and sixty-six patients received platinum-based chemotherapy. Patients were excluded due to congenital hearing loss (n = 1) and insufficient data for calculating the platinum dose (n = 24) or for assessing ototoxicity (n = 135). Three hundred and six patients were included in the analysis. Post-chemotherapy ototoxicity was detected in 148 (48%) patients, and clinically-significant ototoxicity was present in 91 (30%). In addition, based on the ASHA criteria, 48% of patients (97/204) with long-term follow-up had further deterioration of their hearing after completion of treatment. CONCLUSIONS: Ototoxicity following chemotherapy with cisplatin or carboplatin is common and can frequently progress after the completion of treatment. Long-term follow-up is strongly recommended.

Attenuation of cisplatin ototoxicity by otoprotective effects of nanoencapsulated curcumin and dexamethasone in a guinea pig model.

OBJECTIVES: Cisplatin, one of the most effective and widely used chemotherapeutic agents in the treatment of head and neck malignancies, has severe dose-limiting side effects including ototoxicity. This study evaluates the effectiveness of nanoencapsulated curcumin and dexamethasone in preventing degenerative changes in inner ear cells caused by cisplatin. STUDY DESIGN: Prospective study, animal experiment. METHODS: Cultured auditory cells [House Ear Institute Organ of Corti-1 (HEI-OC1)] and a guinea pig model were used for in vitro and in vivo experiments, respectively. Cell viability assays were conducted to compare the direct toxicity of cisplatin against auditory cells in the presence or absence of pretreatment with nanoencapsulated curcumin and dexamethasone. To recapitulate these effects in vivo, 68 guinea pigs received cisplatin either alone, or along with dexamethasone, nanoencapsulated curcumin, or the combination of both products. Outcome measures included auditory brainstem response, cochlear morphology under both light and scanning electron microscopy, and antioxidant enzyme assays. RESULTS: Pretreatment of auditory cells with naonoencapsulated curcumin and dexamethasone resulted in significant attenuation of cisplatin toxicity. Similarly, in the corresponding animal model (guinea pig), cisplatin caused an average hearing loss of 50 dB, which was attenuated by nanoencapsulated curcumin and dexamethasone across all of the hearing frequencies. There was also greater preservation of histologic structures in this group. Superoxide dismutase and catalase activities were increased in cisplatin-treated animals, whereas the nanoencapsulated curcumin with dexamethasone led to a diminution of this effect. CONCLUSION: Nanoencapsulated curcumin administered in combination with dexamethasone provides a partial but marked protection against cisplatin-induced hearing loss, likely because of reduced toxic damage to auditory cells.

Otoacoustic emissions in newborn hearing screening: a systematic review of the effects of different protocols on test outcomes.

BACKGROUND AND OBJECTIVES: Otoacoustic emission (OAE) tests are currently used to screen newborns for congenital hearing loss in many Universal Newborn Hearing Screening programs. However, there are concerns about high referral and false-positive rates. Various protocols have been used to address this problem. The main objective of this review is to determine the effects of different screening protocols on the referral rates and positive predictive values (PPV) of the OAE newborn screening test. METHODS: Eligible studies published in English from January 1990 until August 2012 were identified through searches of MEDLINE, Medline In-Process, Embase, PubMed (NCBI), ISI Web of Science, and the Cochrane Central Register of clinical controlled trials. Two reviewers independently screened the data sources, using pre-defined inclusion criteria to generate a list of eligible articles. Data extracted included the number of newborns screened, age at screening, OAE pass criteria, frequencies screened, number of retests, referral rates, and the number of newborns identified with permanent congenital hearing loss. RESULTS: Ten articles met the inclusion criteria, with a total of 119,714 newborn participants. The pooled referral rate was 5.5%. Individual referral rates ranged from 1.3% to 39%; the PPV from 2 to 40%. Increasing the age at initial screening and performing retests reduced the referral rate. Likewise, screenings involving higher frequencies had lower referral rates. CONCLUSION: Delaying newborn hearing screening improves test results but may not be practical in all contexts. The use of higher frequencies and more sophisticated OAE devices may be useful approaches to ensure better performance of the OAE test in newborn hearing screening.

Assessment of the ototoxicity of almond oil in a chinchilla animal model.

OBJECTIVES/HYPOTHESIS: Almond oil is frequently prescribed as a ceruminolytic, to soften ear wax or relieve ventilation tube occlusion. Ceruminolytics could lead to ototoxicity in the presence of a tympanic perforation. Reports on the safety of almond oil as a ceruminolytic is limited. The present study aimed to assess the effect of ototopic almond oil on hearing. STUDY DESIGN: Prospective, randomized, controlled trial in a chinchilla animal model. METHODS: Bilateral myringotomies were performed in 19 female chinchilla. One randomly selected ear received almond oil, whereas the other ear received saline applied transtympanically. Auditory Brainstem Response (ABR) testing was performed prior to application and at 14 and 30 days following application. Postmortem Scanning Electron Microscopy (SEM) images were obtained to assess cochlear hair cell status. RESULTS: At 30 days following application, there was no significant change in ABR thresholds at 16, 20, or 25 kHz. No cochlear hair cell loss was observed with SEM. CONCLUSIONS: In the chinchilla, when a tympanic perforation is present, almond oil does not seem to cause ototoxicity. Further studies are needed to better assess the effect of almond oil on hearing in humans.