51 The Impact of Disability on Performance in the Intercollegiate Membership of the Royal College of Surgeons examination (MRCS)

Aim

The number of clinicians with disabilities is increasing, however there is no data on the performance of doctors with registered disabilities in the postgraduate environment. If we are to ensure diversity and equality within the workforce, we must first identify whether attainment differences exist in markers of performance. To address this, we assessed the impact of disabilities on performance in the MRCS.

Method

All UK medical graduates who had attempted MRCS Part A (n = 9,597) and Part B (n = 4,562) between 2007-2017 with linked disability data in the UK Medical Education Database (https://www.ukmed.ac.uk) were included. Univariate analysis identified associations with MRCS performance and logistic regression models identified independent predictors of success.

Results

Candidates with registered disabilities (n = 635) had lower MRCS Part A pass rates (46.3% vs 59.8% (p < 0.001)) but similar Part B pass rates (68.2% vs 70.9% (p = 0.339)). They were nearly twice as likely to fail Part A (odds ratio 0.55 [95% Confidence Interval 0.46-0.64]). When prior academic attainment (A-Levels and medical school performance) was accounted for, there was no statistically significant difference in the likelihood of MRCS success (p>0.05). Pass rates were similar for candidates with specific learning difficulties and those with other registered disabilities (p>0.05).

Conclusions

This is the first study to assess the impact of disability status and type on performance at a postgraduate medical examination. It appears that candidates with registered disabilities performed less well in formal, written examinations generally. Although our data indicate that current MRCS testing accommodations are fair, enabling performance unrestricted by disability.

Factors influencing the effective management of diabetes during humanitarian crises in low- and middle-income countries: a systematic review

OBJECTIVES

The management of non-communicable chronic diseases such as diabetes mellitus is often poor in humanitarian crisis settings. Poor disease management can have serious long-term consequences. This review sought to identify studies that explored the effectiveness of interventions and the determinants that may improve the management of diabetes in the humanitarian context.

STUDY DESIGN

A systematic review was conducted of all types of studies that implemented diabetes programmes in humanitarian settings.

METHODS

MEDLINE, Embase, CINAHL and Web of Science were searched for relevant articles using multiple search terms for relevant studies published in English between 2000 and June 2020. Quality assessments using valid tools, were conducted. A narrative synthesis of the findings was then performed.

RESULTS

The search yielded 550 citations. After de-duplicating and screening, 19 studies were eligible for inclusion. Most studies were conducted in the Middle East (74%), Asia (16%) and Africa (10%). The interventions reported to improved diabetes care included the mHealth tool, intensive lifestyle intervention, task-shifting, psychosocial support, distribution of glucometers and comprehensive care. Insufficient drug supply, out-of-pocket cost, the complexity of insulin therapy and low adherence to guidelines were identified as barriers.

CONCLUSION

There is a paucity of evidence on optimal diabetes care in acute crisis and natural disaster settings. The review was constrained by the low quality of the studies included. Nevertheless, it is likely that mHealth can be feasibly utilised, as educational SMS messages are cost-effective and electronic medical records can enhance disease monitoring. In addition, a multidisciplinary approach to care improves glycaemic control and is desirable due to the multifaceted nature of the disease and management required. Several key barriers have been identified that need to be tackled. Overall, the evidence base for diabetes care in humanitarian settings remains sparse, and further research is needed.

Universal use of surgical masks is tolerated and prevents respiratory viral infection in stem cell transplant recipients

Prevention of respiratory viral infection in stem cell transplant patients is important due to its high risk of adverse outcome. This single-centre, mixed methods study, conducted before the severe acute respiratory syndrome coronavirus-2 pandemic, explored the barriers and facilitators to a policy of universal mask use by visitors and healthcare workers, and examined the impact of the first year of introduction of the policy on respiratory viral infection rates compared with preceding years, adjusted for overall incidence. Education around universal mask use was highlighted as being particularly important in policy implementation. A significant decrease in respiratory viral infection was observed following introduction.

N95 respirator decontamination: a study in reusability

The coronavirus disease 2019 (COVID-19) pandemic had caused a severe depletion of the worldwide supply of N95 respirators. The development of methods to effectively decontaminate N95 respirators while maintaining their integrity is crucial for respirator regeneration and reuse. In this study, we systematically evaluated five respirator decontamination methods using vaporized hydrogen peroxide (VHP) or ultraviolet (254 nm wavelength, UVC) radiation. Through testing the bioburden, filtration, fluid resistance, and fit (shape) of the decontaminated respirators, we found that the decontamination methods using BioQuell VHP, custom VHP container, Steris VHP, and Sterrad VHP effectively inactivated Cardiovirus (3-log10 reduction) and bacteria (6-log10 reduction) without compromising the respirator integrity after 2-15 cycles. Hope UVC system was capable of inactivating Cardiovirus (3-log10 reduction) but exhibited relatively poorer bactericidal activity. These methods are capable of decontaminating 10-1000 respirators per batch with varied decontamination times (10-200 min). Our findings show that N95 respirators treated by the previously mentioned decontamination methods are safe and effective for reuse by industry, laboratories, and hospitals.

Hospital outbreak of New Delhi metallo-β-lactamase type-1 (NDM-1) in Salmonella enterica with inter-species plasmid transmission

New Delhi metallo-β-lactamase (NDM) gene confers high-level resistance to an array of β-lactams including carbapenems. Short- and long-read sequencing was used to investigate outbreaks of NDM-positive Enterobacterales including a potential horizontal gene transfer (HGT) event of an NDM-positive plasmid between Salmonella enterica and Klebsiella pneumoniae. Genomic analysis demonstrated a high degree of similarity between NDM-carrying plasmids from patient 1 in K. pneumoniae and patient 2 with S. enterica, K. pneumoniae and Klebsiella oxytoca, confirming an inter-species HGT event. The utility of whole-genome sequencing was demonstrated for in-hospital outbreaks, previously undetected using traditional infection-control surveillance.

The effect of Candida famata and Lactobacillus plantarum on the number of coliforms and the antibiotic resistance and virulence of Escherichia coli in the gut of broilers

This study was undertaken to determine the effect of a yeast (Candida famata) and a bacterium (Lactobacillus plantarum), administered alone or in combination in the drinking water, on the population of yeast, Lactobacillus sp. and coliforms, and the prevalence of antimicrobial resistance (AMR) and virulence genes in Escherichia coli (E. coli) isolated from digesta samples taken throughout the life of broiler chickens. Male (Ross 308) day-old chicks (220) were used. C. famata (isolated from a chicken) and L. plantarum (isolated from a pig) were administered via the drinking water. Water was provided either untreated or with C. famata (CF; 10⁸/ml), L. plantarum (LP; 10⁵-10⁸/ml), or a combination of CF and LP (10⁶-10⁸/ml) in water hoppers on 2 days each week for 35 days. Administering probiotics did not affect the growth performance in broiler chickens. No significant interactions were observed between main effects, and neither CF nor LP had any effect on the population size of Lactobacillus sp. or coliforms. The administration of C. famata increased the population density of yeasts in the small intestine at these ages. The population density of coliforms, Lactobacillus sp. and yeast decreased with age (P < 0.001). There was no significant effect of probiotics on the prevalence of phenotypic AMR and virulence genes in these studies. The prevalence of E. coli that was resistant to ampicillin and tetracycline, as well as carrying ≥3 virulence-associated genes, was greatest at the end of the starter phase (around 8 days old), before declining through the grower and finisher phases. There was only limited evidence that administering either CF or LP affected either the AMR or the virulence of E. coli in the bird. However, tetracycline resistance in E. coli was associated (P < 0.001, P < 0.01, P < 0.05, and P < 0.05) with the carriage of the iron uptake systems of E. coli D, iron-repressible protein, increased serum survival and temperature-sensitive haemagglutinin genes respectively, suggesting that the accumulation of iron and the genetic element conferring tetracycline resistance may be intertwined.

p62 overexpression induces TDP-43 cytoplasmic mislocalisation, aggregation and cleavage and neuronal death

Amyotrophic lateral sclerosis (ALS) and frontotemporal lobar degeneration (FTLD) that exist on a spectrum of neurodegenerative disease. A hallmark of pathology is cytoplasmic TDP-43 aggregates within neurons, observed in 97% of ALS cases and ~ 50% of FTLD cases. This mislocalisation from the nucleus into the cytoplasm and TDP-43 cleavage are associated with pathology, however, the drivers of these changes are unknown. p62 is invariably also present within these aggregates. We show that p62 overexpression causes TDP-43 mislocalisation into cytoplasmic aggregates, and aberrant TDP-43 cleavage that was dependent on both the PB1 and ubiquitin-associated (UBA) domains of p62. We further show that p62 overexpression induces neuron death. We found that stressors (proteasome inhibition and arsenic) increased p62 expression and that this shifted the nuclear:cytoplasmic TDP-43 ratio. Overall, our study suggests that environmental factors that increase p62 may thereby contribute to TDP-43 pathology in ALS and FTLD.

191 Performance at Medical School and Foundation Programme Selection Can Predict Success in The MRCS Examination

Background

Identifying factors that predict success in the Membership of the Royal College of Surgeons (MRCS) examination can aid trainees’ exam preparation and help deaneries identify candidates likely to require additional support. We assessed whether performance at Medical School and UK Foundation Programme selection (Educational Performance Measurement (EPM) and Situational Judgement Test (SJT)) predicted MRCS success.

Method

We analysed data from the UKMED Database for UK graduates who had attempted MRCS Part A (n = 1,975) and Part B (n = 630) between 2013-2017. Univariate analysis examined the relationship between performance and the likelihood of passing MRCS at first attempt. Logistic regression identified independent predictors of MRCS success.

Results

Each additional EPM decile increased the chances of passing MRCS by 52% for Part A (odds ratio 1.52 [95% confidence interval 1.46-1.60]) and 27% for Part B (1.27 [1.18-1.38]). Each EPM point awarded for degrees increased the likelihood of passing Part A by 29% (1.29 [1.12-1.48]). SJT score was not a statistically significant independent predictor of MRCS success (P&gt;0.05).

Conclusions

This is the first study to investigate the relationship between UK medical school performance and postgraduate surgical exam success. Higher ranked students are more likely to succeed in the MRCS compared to their lower ranked peers.

327 Rare Synchronous Volvulus of Sigmoid Colon and Caecum, Management of Two Cases

Colonic volvulus accounts for approximately 5% of cases of large bowel obstruction. Sigmoid volvulus is commonest (75%), followed caecal volvulus (15%). Synchronous volvulus of the caecum and sigmoid is rare, with five reported cases in the literature. We report two cases in a London teaching hospital managed within 6 months. Both male patients (aged 72 and 79 years) had presented to the emergency department on multiple occasions (2-5 times in the preceding 1-8 months), with obstructive symptoms including tender abdominal distension and constipation. On all occasions, sigmoid volvulus was diagnosed based on plain abdominal films and flatus tubes were inserted, with initial clinical resolution. On their final presentation, both patients were admitted for definitive surgery. CT scans of the abdomen and pelvis were consistently reported as showing only sigmoid volvulus. Only intra-operatively was the diagnosis of synchronous caecal and sigmoid volvulus appreciated. Complete symptom resolution was achieved with subtotal colectomy and ileostomy formation. The key learning points from these cases are: 1) synchronous large bowel volvulus is a rare and easily missed diagnosis, 2) conservative management is unlikely to be successful, 3) radiological appearances may only suggest one type of large bowel volvulus and 4) definitive diagnosis is made intra-operatively.

71 Electronic Prescribing Promotes Antimicrobial Stewardship In Surgery: A Closed-Loop Audit

Introduction

Antimicrobial resistance is increasing globally. Surgical inpatients are more likely to receive inappropriately broad-spectrum and prolonged antimicrobial treatment, against local policy. Electronic prescribing (e-prescribing) has the potential to promote antimicrobial stewardship. We conducted a closed-loop audit to assess the impact of e-prescribing on surgical inpatient prescriptions.

Method

Audit standards (from Public Health England) included: (1) documentation of allergy status, prescriber contact information, antimicrobial indication and review/stop dates; and (2) prescription of appropriate antimicrobials for appropriate durations (IV and total). Prospective data collection occurred over 1-week. The interventions included an educational session, a once weekly microbiology round of surgical inpatients and the introduction of e-prescribing (Cerner©).

Results

Compliance improved significantly between cycle 1 (n = 54 prescriptions) and 2 (n = 59 prescriptions), for: documentation of prescriber contact details (69 vs 100%) and appropriate antimicrobial review/stop dates (17 vs 100%), indications (78 vs 96%), selection (76 vs 90%) and IV and total antibiotic duration (63 vs 93% and 87 vs 100%, respectively); p &lt; 0.05 throughout.

Conclusions

Audit compliance improved significantly, partly because Cerner© prompts clinicians to input contact details, review dates and indications before prescribing. E-prescribing in combination with appropriate education is likely to promote antimicrobial stewardship and should be considered by other Trusts using paper prescriptions.

220 Choice of UK Medical School Predicts Success in The Intercollegiate Membership of The Royal College of Surgeons (MRCS) Examination

Background

UK medical schools vary in terms of factors such as mission, specific curricula and pedagogy. As relatively little is understood about the impact of these differences at a post-graduate level, we examined the relationship between medical school and MRCS success.

Method

Using the UKMED database we analysed data on UK medical graduates who attempted MRCS Part A (n = 9729) and MRCS Part B (n = 4644) between 2007-2017. Univariate analysis characterised the relationship between medical school and first attempt MRCS success. Logistic regression modelling identified independent predictors of MRCS success.

Results

MRCS pass rates differed significantly between medical schools (P &lt; 0.001). Trainees from standard-entry 5-year programmes were more likely to pass MRCS at first attempt compared to those from extended (Gateway) courses ((Part A (Odds Ratio (OR) 3.72 [95% Confidence Interval (CI) 2.69-5.15]); Part B (OR 1.67 [1.02-2.76])). Non-graduates were more likely to pass Part A (OR 1.40 [1.19-1.64]) and Part B (OR 1.66 [1.24-2.24]). Russell Group graduates were more likely to pass MRCS Part A (OR 1.79 [1.56-2.05]) and Part B (OR 1.24 [1.03-1.49])).

Conclusions

Medical programme and medical school are associated with MRCS success. Further research is needed to tease out the relationship between individual factors, medical school and MRCS performance.