Determination of required anatomical knowledge for clinical practice in emergency medicine: national curriculum planning using a modified Delphi technique

OBJECTIVES

To identify the content of the postgraduate anatomy curriculum for trainees in emergency medicine (EM) in the UK.

METHODS

Modified Delphi technique involving 160 randomly sampled consultants in EM. The outcome measure was percentage agreement, based upon a three round iterated Delphi process, of participants to items derived from a standard anatomy text being core knowledge for postgraduate clinical practice in the specialty. A national curriculum document was derived as a result of the data obtained.

RESULTS

Response rates ranged from 61% to 70% after three Delphi rounds. From an initial overall questionnaire content of 808 discrete items, 64% was retained as core required knowledge following iteration. This formed the basis of a national consensus anatomy curriculum both to inform question development in postgraduate EM examinations and to benchmark anatomical knowledge requirements for safe clinical practice.

CONCLUSIONS

Application of a national consensus methodology allows for determination of curricular content in anatomy. The principles can be applied to all aspects of training and curricular policy at national collegiate level to guide the development of robust documentation.

Exposure or expert? Setting standards for postgraduate education through a Delphi technique

OBJECTIVES

The aim of this study was to determine if a syllabus of upper limb anatomy for emergency clinicians composed by an expert panel reflected clinical practice as experienced by those at whom the syllabus would be directed.

METHODS

A three round Delphi study was performed using an expert group. We compared this with a measure of the exposure to anatomical concepts in the day to day practice of trainees in emergency medicine.

RESULTS

In total, 404 separate anatomical facts relating to the upper limb were reviewed by both groups. There was poor agreement (kappa = 0.348) between the expert group and the trainees.

CONCLUSION

We have shown disparity between what an expert group believes trainees should know and what trainees are actually exposed to in clinical practice. We believe this demonstrates that curriculum development must strike a balance between important (expert) and common (exposure) information. We have shown how an expert:exposure matrix may be used to inform curriculum development.

The European Trauma Course--from concept to course

The Advanced Trauma Life Support (ATLS) course, developed by the American College of Surgeons, has revolutionised in-hospital management of major trauma patients and is now accepted as a standard of care in many countries worldwide. However, within Europe, there are significant differences in both the aetiology of trauma and the specialties involved in its initial management compared to the American model. Over the past 4 years, there have been a number of initiatives aimed at producing a trauma management course that was evidence based, practical and flexible enough to meet regional European needs and team oriented. Initial attempts tried to incorporate both pre- and in-hospital trauma care. This was eventually rationalised to the production of an in-hospital course and the first pilot course was run in Malta in November 2006. This article describes the evolution of the course, its current structure and plans for the future following the feedback received from candidates and instructors who participated in the first course.

Peptide selection by class I molecules of the major histocompatibility complex

Class I molecules of the major histocompatibility complex (MHC) bind peptides derived from cytoplasmic proteins. Comparison of over 100 such peptides reveals the importance of the carboxy-terminal residue in selective binding. Recent evidence implicates the proteases and transporters of the processing pathway in providing peptides with the correct residues at the carboxyl terminus.

Inter-individual vs line/strain differences in psychogenetically selected Roman High-(RHA) and Low-(RLA) Avoidance rats: neuroendocrine and behavioural aspects

Inter-individual differences in neuroendocrine and behavioural responses to environmental challenges will be considered within the context of psychogenetic selection, using the Roman High-(RHA) and Low-(RLA) Avoidance rat lines as an example. We assume that the selected genotypes, by interacting with environmental factors, determine specific 'biobehavioural profiles'. Practical and theoretical problems regarding the measurement of inter-individual vs line/strain differences, the definition of 'traits' vs experimental variables, and possible correlations between physiological and behavioural parameters will be discussed. We will argue that environmental influences are the main cause of inter-individual variability, and that the genotype only constitutes a 'blueprint' from which typical biobehavioural profiles are established, notably under the influence of early environmental factors. These biobehavioural profiles may correspond in part to human categories known as 'types', 'temperaments' or 'personality traits'. Within each category (including those which can be obtained by psychogenetic selection), more individual personality traits can evolve, notably as a result of social interactions and particular life events.

The psychogenetically selected Roman rat lines differ in the susceptibility to develop amphetamine sensitization

The mesolimbic dopamine system is considered to play a pivotal role in the locomotor activation produced by psychostimulants and in the augmentation of this effect observed upon repeated drug administration, a process denominated behavioral sensitization. The selective breeding of Roman high- (RHA) and low-avoidance (RLA) rats, respectively, for rapid versus poor active avoidance acquisition has resulted in two phenotypes that differ in the functional properties of the mesolimbic dopamine system and in their behavioral and neurochemical responses to addictive drugs, including psychostimulants and opiates. Hence, the present study was designed to compare the ability of these lines to develop behavioral sensitization to psychostimulants. To this aim, the acute effects of amphetamine (0.125 or 0.25 mg/kg, s.c.) on locomotion were assessed in RHA and RLA rats prior to and subsequent to 10 daily doses of either amphetamine (1 mg/kg, s.c.) or saline (1 ml/kg, s.c.). In the RHA line, the locomotor activation produced by either challenge dose of amphetamine was more pronounced in rats that had been repeatedly treated with amphetamine versus the respective saline treated controls. In contrast, no significant change in locomotor activity was observed in RLA rats. Likewise, repeated amphetamine caused an increased frequency of sniffing, rearing, licking/gnawing, and grooming versus the control, repeated saline, group only in the RHA line. The results show that the repeated treatment regimen used in this study induced behavioral sensitization to amphetamine in RHA rats, but not in their RLA counterparts, and underscore the utility of these lines for studying the influence of neural substrates and genetic make up on the individual vulnerability to addiction.

A differential activation of dopamine output in the shell and core of the nucleus accumbens is associated with the motor responses to addictive drugs: a brain dialysis study in Roman high- and low-avoidance rats

Addictive substances like morphine and psychostimulants induce a preferential increase in dopamine (DA) output in the nucleus accumbens (NAC), a major terminal field of the mesolimbic dopaminergic projection. Two subregions of the NAC, the dorsolateral core and the ventromedial shell, are thought to subserve different functions related to the reinforcing properties of natural and drug rewards. The selective breeding of Roman high- (RHA) and low-avoidance (RLA) rats, respectively, for rapid vs. extremely poor active avoidance acquisition in a shuttle-box has resulted in two phenotypes that differ in their behavioural and neurochemical responses to addictive drugs. We used brain dialysis to assess whether such differences in the responsiveness to drugs of abuse are related to differences in mesolimbic DA neuron function. In RHA rats, morphine, cocaine, and amphetamine caused a larger increase in DA efflux in the NAC shell vs. the NAC core, whereas the profile for the drug-induced increases in DA output was almost completely superimposable in the NAC shell and NAC core of RLA rats. Moreover, morphine, cocaine, and amphetamine caused a larger increment in basal DA output in the NAC shell of RHA rats vs. the NAC shell of RLA rats. These drugs also elicited a more robust increase in locomotion, rearing, sniffing, and grooming in RHA than in RLA rats. These results demonstrate that genetically determined differences in the functional properties of DA neurons projecting to the NAC shell may critically influence the behavioural response patterns to addictive drugs that distinguish the Roman lines.

A confidential study of deaths after emergency medical admission: issues relating to quality of care

In this retrospective pilot study we examine the feasibility of establishing a confidential enquiry into why some patients die after emergency admission to hospital. After excluding those who died in the first hour or who were admitted for palliative care, pairs of physicians were able to collect quantitative and qualitative data on 200 consecutive deaths. Both physicians reported shortfalls of care in 14 patients and one of the pair in 25 patients whose deaths would not have been the expected outcome. In 25, the shortfalls of care may have contributed to their deaths. Major problems were delays in seeing doctors, inaccurate diagnoses, delays in investigations and initiation of treatment. They occurred mostly in those admitted at night. It is possible that establishing the correct diagnosis and starting appropriate treatment may have been delayed in 64% of the 200 patients. The headline figures appear worse than some previous external assessment studies but this study did concentrate on those in whom problems were more likely. Nevertheless, the frequency is too high to be overlooked. In this feasibility study we have demonstrated that it is practicable for local staff to collect and assess data in hospitals and that the types of problems identified are relevant to anyone planning how to organise emergency care. A larger definitive study should be performed.

Differential neurochemical properties of central serotonergic transmission in Roman high- and low-avoidance rats

The selective breeding of Roman high- (RHA/Verh) and low-avoidance (RLA/Verh) rats for rapid versus poor acquisition of active avoidant behaviour has produced two behavioural phenotypes with different performances in a variety of animal models of anxiety, in which RLA/Verh rats are consistently more fearful than RHA/Verh rats. In addition, these two lines display different functional properties of brain neurotransmitters like serotonin (5-HT), known to be involved in the expression of anxiety- and depression-related behaviours. Therefore, we used brain microdialysis and [3H]-citalopram binding autoradiography to characterize further the neurochemical properties of 5-HTergic transmission in the two lines. No significant line-related differences were detected in the basal 5-HT output in the frontoparietal cortex (FPCx). In contrast, the increase in the cortical 5-HT output elicited by the systemic administration or the local application, via reverse dialysis, of chlorimipramine and fluoxetine was more robust in RHA/Verh than in RLA/Verh rats. Moreover, the binding signal of [3H]-citalopram to 5-HT re-uptake sites was more intense in the FPCx of RHA/Verh rats than in their RLA/Verh counterparts. These findings suggest that the functional tone of the 5-HTergic projection to the FPCx is stronger in the RHA/Verh line relative to the RLA/Verh line. It is proposed that RLA/Verh rats may be used as a model with heuristic value for studying the role of 5-HTergic transmission in anxiety and in the anxiolytic effects of monoamine re-uptake inhibitors.

Effect of cellular telephone conversations and other potential interference on reaction time in a braking response

This experiment studied the effect of phone conversations and other potential interference on reaction time (RT) in a braking response. Using a laboratory station which simulated the foot activity in driving, 22 research participants were requested to release the accelerator pedal and depress the brake pedal as quickly as possible following the activation of a red brake lamp. Mean reaction time was determined for five conditions: (a) control, (b) listening to a radio, (c) conversing with a passenger, (d) conversing using a hand-held phone, and (e) conversing using a hands-free phone. Results indicated that conversation, whether conducted in-person or via a cellular phone caused RT to slow, whereas listening to music on the radio did not.

Dissociation between mesocortical dopamine release and fear-related behaviours in two psychogenetically selected lines of rats that differ in coping strategies to aversive conditions

The mesocortical and mesolimbic dopaminergic (DAergic) pathways are activated by either aversive or rewarding stimuli. The functional tone of these DAergic neurons also increases during the execution of cognitive tasks. The present study was designed to examine the relationship between mesocortical and mesolimbic DAergic function and the expression of fear-related behaviours as compared with attention- and cognition-related mechanisms (e.g. coping strategies), in response to aversive conditions. To this aim, we used two psychogenetically selected rat lines, Roman high-avoidance (RHA/Verh) and Roman low-avoidance (RLA/Verh), which display drastically different emotion- and coping-related behaviours in response to stressors: RLA/Verh rats are 'reactive copers' and more fearful than RHA/Verh rats, which are 'proactive copers'. Brain dialysis experiments demonstrated that tail-pinch (TP) and the anxiogenic compounds pentylenetetrazol (PTZ) and ZK 93426 increased DA output in the medial prefrontal cortex (PFCX) of RHA/Verh but not RLA/Verh, rats. In contrast, in the shell compartment of the nucleus accumbens (NAC shell), TP caused a small increase in DA output only in RLA/Verh rats, whereas PTZ and ZK 93426 had no significant effect on either line. RHA/Verh rats displayed more robust and longer lasting coping activity and less frequent freezing and self-grooming episodes than did RLA/Verh rats after TP, PTZ or ZK 93426. This dissociation between fear-related behaviour and cortical DAergic activation argues against the view that the latter may be involved in the control of fear-like responses. We therefore propose that the activation of mesocortical DAergic projections by aversive stimuli underlies the cognitive mechanisms that are triggered in an attempt to gain control over the stressor.

Divergent stress responses and coping styles in psychogenetically selected Roman high-(RHA) and low-(RLA) avoidance rats: behavioural, neuroendocrine and developmental aspects

The Swiss sublines of Roman high-(RHA/Verh) and low-(RLA/Verh) avoidance rats have been genetically selected for good vs. poor performance in two-way active avoidance since 1972. RLA/Verh rats show increased stress responses (e.g. freezing behaviour, ACTH, corticosterone and prolactin secretion) and adopt a more passive (or reactive) coping style when confronted with a novel environment. In the open field, elevated plus-maze, black/white box test, and in a new light/dark open field test, RLA/Verh rats appear to be more anxious than their RHA/Verh counterparts. Anxiety may result from their particular psychophysiological profile, i.e. increased emotionality combined with a passive coping style. In contrast, RHA/Verh rats are less responsive to stress, they show little anxiety in novel situations and tend to be impulsive and novelty (sensation) seekers. Some behavioural differences are already noticeable shortly after birth, but the full pattern appears to stabilize only after puberty. Gene-environment interactions are critical in establishing this pattern. The data reviewed indicate that the differences between RHA/Verh and RLA/Verh rats probably result from a complex interaction among divergent anxiety/emotionality characteristics, differences in locomotor activity and novelty/reward seeking, as well as active vs. passive coping styles. It is proposed further that these divergent personality types are to be found not only in other selective breeding programs but in the form of individual differences in most populations of rats used for this type of research.

Fearfulness and sex in F2 Roman rats: males display more fear though both sexes share the same fearfulness traits

The pattern of sex differences in a large sample (about 400 for each sex) of F2-generation rats, derived from inbred Roman high- and low-avoidance strains differing in fearfulness and brain functioning, was investigated. We obtained measures from responses to a battery of novel/threatening tests [open field (OF), plus maze (PM), hole board (HB), activity (A), and acoustic startle reflex (ASR)] as well as learned fear paradigms [classical fear conditioning (CFC) and shuttlebox avoidance conditioning (SAC)]. The results showed that almost all behaviors assessed fit with a pattern of unidirectional sex effects characterized by male rats as being more fearful than females: males defecated more than females in the OF, PM, HB, ASR, and CFC; ambulated less in the OF, PM, A, and SAC; showed more self-grooming in PM and HB; explored the open arms of the PM and the holes of the HB less; displayed enhanced ASR; and showed poorer performance in the SAC task. We applied two factor analyses to each sex showing that, in general, they shared a common three-factor structure: a Learned Fear Factor comprising SAC and CFC responding, a Fear of Heights/Open Spaces Factor with the highest loadings for open arm behavior in the PM, and an Emotional Reactivity Factor, mainly grouping defecations, ambulation, and self-grooming. These results indicate that the essential components of fearful behavior are similar for both sexes in an inbred but genetically heterogeneous population.