E-learning vs lecture: which is the best approach to surgical teaching?

AIM

Most medical teaching is still delivered by traditional face-to-face interaction. E-learning has the potential benefit of instilling deeper learning of topics by virtue of repeated and convenient access to content presented in a range of media. We aimed to evaluate objectively the benefit of educating medical students on a common surgical topic (haemorrhoids), through a website and podcast package vs a traditional lecture.

METHOD

Baseline knowledge was established by a questionnaire given to two different groups of third-year medical students starting their first clinical attachment. Group A (n = 73) was given a lecture and group B (n = 75) was asked to use a website containing text and pictures augmented by a podcast. Students were reassessed using the same preintervention questionnaire, and satisfaction was acquired from details given in a feedback form.

RESULTS

There was no difference in knowledge between the two groups at baseline. Both groups demonstrated significant gains in knowledge after intervention (P < 0.0001). Group B (Web/podcast) showed a significantly greater increase in knowledge (P < 0.05) than group A (lecture). Preintervention subjective assessment of knowledge rated by the students showed no difference between the groups. Both groups of students were equally satisfied with the educational method.

CONCLUSION

E-learning supplemented with a podcast results in greater knowledge acquisition when compared with a traditional lecture, without a loss of satisfaction with teaching. Using augmented Web-based educational tools reduces demands on teaching time with no decrease in quality for selected parts of the curriculum.

Continuous adductor-canal-blockade for adjuvant post-operative analgesia after major knee surgery: preliminary results

Because both the saphenous nerve and in part the obturator nerve are traversing the adductor canal of the thigh, we hypothesised that repeated administration of a local anaesthetic (LA) into this aponeurotic space could be a useful option for post-operative analgesia after knee replacement surgery. A systematic search of the literature pertinent to the blockade of the saphenous and/or obturator nerves for pain relief after knee surgery was conducted. Further, pain and opioid requirements were evaluated in eight patients receiving a continuous blockade of the saphenous and obturator nerve (adductor-canal-blockade) after total knee arthroplasty (TKA). Finally, we performed cross-sectional MR scans of the adductor canal after injection of ropivacaine 30ml in one patient. The systematic literature search revealed only one controlled study, where selective blockade of the saphenous nerve was investigated for the purpose of clinical pain relief after knee arthroscopy. We located no studies reporting on saphenous and/or obturator nerve block for pain relief after TKA. Preliminary findings in eight patients demonstrated that a continuous adductor-canal-blockade for 48h after TKA was associated with low mean pain scores at rest and low mean requirements for supplemental morphine. MR scans in one patient demonstrated that 30ml of LA filled the adductor canal, including the distal part, where the posterior branch of the obturator nerve joins the vessels and the saphenous nerve. Continuous adductor-canal-blockade may be a valuable adjunct for post-operative analgesia after major knee surgery. These preliminary results should be confirmed in randomised, controlled trials.

A systematic review of studies measuring health-related quality of life of general injury populations

Background

It is important to obtain greater insight into health-related quality of life (HRQL) of injury patients in order to document people's pathways to recovery and to quantify the impact of injury on population health over time. We performed a systematic review of studies measuring HRQL in general injury populations with a generic health state measure to summarize existing knowledge.

Methods

Injury studies (1995-2009) were identified with main inclusion criteria being the use of a generic health status measure and not being restricted to one specific type of injury. Articles were collated by study design, HRQL instrument used, timing of assessment(s), predictive variables and ability to detect change over time.

Results

Forty one studies met inclusion criteria, using 24 different generic HRQL and functional status measures (most used were SF-36, FIM, GOS, EQ-5D). The majority of the studies used a longitudinal design, but with different lengths and timings of follow-up (mostly 6, 12, and 24 months). Different generic health measures were able to discriminate between the health status of subgroups and picked up changes in health status between discharge and 12 month follow-up. Most studies reported high prevalences of health problems within the first year after injury. The twelve studies that reported HRQL utility scores showed considerable but incomplete recovery in the first year after discharge.

Conclusion

This systematic review demonstrates large variation in use of HRQL instruments, study populations, and assessment time points used in studies measuring HRQL of general injury populations. This variability impedes comparison of HRQL summary scores between studies and prevented formal meta-analyses aiming to quantify and improve precision of the impact of injury on population health over time.

Balancing the role of the dental school in teaching, research and patient care; including care for underserved areas

Inequalities within dentistry are common and are reflected in wide differences in the levels of oral health and the standard of care available both within and between countries and communities. Furthermore there are patients, particularly those with special treatment needs, who do not have the same access to dental services as the general public. The dental school should aim to recruit students from varied backgrounds into all areas covered by the oral healthcare team and to train students to treat the full spectrum of patients including those with special needs. It is essential, however, that the dental student achieves a high standard of clinical competence and this cannot be gained by treating only those patients with low expectations for care. Balancing these aspects of clinical education is difficult. Research is an important stimulus to better teaching and better clinical care. It is recognized that dental school staff should be active in research, teaching, clinical work and frequently administration. Maintaining a balance between the commitments to clinical care, teaching and research while also taking account of underserved areas in each of these categories is a difficult challenge but one that has to be met to a high degree in a successful, modern dental school.

Validation of the PHEEM instrument in a Danish hospital setting

The Postgraduate Hospital Educational Environment Measure (PHEEM) has been translated into Danish and then validated with good internal consistency by 342 Danish junior and senior hospital doctors. Four of the 40 items are culturally dependent in the Danish hospital setting. Factor analysis demonstrated that seven items are interconnected. This information can be used to shorten the instrument by perhaps another three items.

Expression of genes involved in oxidative stress responses in airway epithelial cells of smokers with chronic obstructive pulmonary disease

RATIONALE

The molecular mechanisms involved in airway oxidative stress responses reported in healthy smokers and in those with chronic obstructive pulmonary disease (COPD) are poorly understood.

OBJECTIVES

To assess the expression of genes involved in oxidative stress responses in the bronchial epithelium of smokers with or without COPD and in relation to disease severity.

METHODS

Global gene expression was assessed in bronchial brushings in 38 subjects with COPD, 14 healthy nonsmokers, and 18 healthy smokers.

RESULTS

Gene expression analysis using Affymetrix arrays revealed mRNAs representing 341 out of 642 oxidative stress genes from two predefined gene sets to be differentially expressed in healthy nonsmokers when compared with healthy smokers, and 200 differentially expressed oxidative genes in subjects with COPD when compared with healthy smokers. Gene set enrichment analysis showed that pathways involved in oxidant/antioxidant responses were among the most differentially expressed gene pathways in smoking individuals, with further differences seen in COPD. Distinct, nonlinear gene expression patterns were identified across the severity spectrum of COPD, which correlated with the presence of certain transcription factor binding sites in their promoters. Significant changes in oxidant response genes observed in vivo were reproduced in vitro using primary bronchial epithelial cells from the same donors cultured at an air-liquid interface and exposed to cigarette smoke extract.

CONCLUSIONS

Cigarette smoke induces significant changes in oxidant defense responses; some of these are further amplified, but not in a linear fashion, in individuals who develop COPD.

Long-term effects of community-based injury prevention on the island of Vaerøy in Norway: a 20-year follow up

AIM

A multifactorial injury prevention programme started in 1981 and ran for about 10 years in an island community in Norway with a population of about 1,000. A study was undertaken to evaluate effects of the programme over a period of 20 years.

METHODS

Injuries were recorded by the one medical doctor on the island for several years during the period 1970-2001. The programme was carried out very intensively from 1981 to 1987. The intensity gradually decreased to a medium level that lasted until about 1994, when it was further reduced to a low level.

RESULTS

The injury incidence rate was reduced from 17.7% in 1980 (n = 188) to 9.7% in 1987 (n = 97) with relative risk reduced to 0.55 (95% CI 0.44-0.70, p < 0.0001). In 2001, an incidence rate of 9.6% was observed (n = 91). An even higher reduction was observed for serious injuries. The age groups 15-24 and 65+ showed the most distinct reductions from 1980 to 2001 while minor reduction was observed in children (0-14 years). The incidence rate of traffic injuries was reduced by 77% in spite of an increase in the number of motor vehicles. Occupational, home, and other injuries were reduced by 38%, 35%, and 49% respectively. The incidence rates were 2.6-3.0 times higher for men than for women through the 20-year observation period.

CONCLUSION

This study indicates that a long-lasting multifactorial community-based intervention in a small community with defined aims may lead to a considerable and long-lasting reduction in injuries.

[Risk factors for accidental injuries in the construction industry]

BACKGROUND

The construction industry is prone to accidents. In Norway there is little research-based knowledge on accident pattern and risk factors. The main objective of the study was to examine whether in-depth studies of accidents in this industry, leading to injuries registered by the health services, could identify preventable risk factors and preventive measures.

MATERIAL AND METHODS

50 accidents in the construction industry were thoroughly investigated. All had led to serious personal injury. Patients were interviewed after treatment in emergency wards and hospitals in Oslo, and inspections of the accident sites were performed. An interdisciplinary expert group discussed the accidents in order to identify risk factors and suggest preventive measures. The accident reports in the study were compared to reports from the Labour Inspectorate on the same accidents.

RESULTS

The investigation identified several risk factors, and a number of detailed preventive measures were proposed. We submitted these proposals to the authorities and organisations involved. Accidents because of time pressure and electricity were two main groups. More than one third of the respondents said that time pressure had contributed to the accident. Accident risk caused by time pressure can be reduced by avoiding piecework contracts, unrealistic time limits, and the use of day penalties for breach of contract. Possible preventive measures for electric injuries imply modification of the reporting system and of the work organisation so that workers can comply with the regulations more easily. The study reports generally contained more information of relevance for prevention than the routine reports from the Labour Inspectorate did. For accidents reported by the Inspectorate to the police, their reports were more informative than the study reports.

INTERPRETATION

By the method presented, we obtained detailed information about accidents and preventable risk factors, so that preventive measures could be proposed. The method can also be used for other types of accidents.

Improved early risk stratification and diagnosis of myocardial infarction, using a novel troponin I assay concept

BACKGROUND

We evaluated the clinical performance of a novel cardiac troponin I (cTnI) assay specifically designed to improve the very early risk stratification in acute coronary syndromes.

SUBJECTS AND METHODS

Serum and plasma samples (taken 0, 6-12 h and 24 h after admission) from 531 patients with suspected acute coronary syndrome were studied using a novel investigational cTnI assay, reference cTnI assay and myoglobin. The lowest cTnI concentration giving a total assay imprecision of 10% was used as the positive myocardial infarction (MI) cut-off value.

RESULTS

At the time of admission, the investigational assay was positive in 27.9% of the patients, the reference cTnI assay was positive in only 17.5% (P < 0.001) and myoglobin in 24.1% (P = 0.067). Receiver operating characteristic (ROC) curve analysis for the detection of myocardial injury on admission gave area-under-curve (AUC) values of 0.937, 0.775 and 0.762, respectively (P < 0.001). Of those MI patients who presented within 3 h of symptom onset, 50.0% were identified by the investigational assay at the time of presentation, compared with 44.2% by myoglobin (P = 0.791) but only 11.5% by the reference assay (P < 0.001).

CONCLUSIONS

The novel cTnI assay considerably improves the performance of cTnI as an early rule-in biomarker for MI.

A two-step medically based injury surveillance system--experiences from the Oslo injury register

This paper presents a two-step injury surveillance system. In the first step, limited data (a minimum data set) on all (or a representative sample of all) injuries to residents and non-residents within a defined geographical area were obtained using routine collection procedures within the medical care system. The second step involved periodically sampling of specific injuries, injured persons, or places for in-depth investigations from the database established by the first step, or selecting relevant injured persons seeking treatment in the medical care system, to collect many data (an expanded data set) on a limited number of injuries. This system was implemented in Oslo. Data from about 48,000 injuries were collected annually. Two in-depth investigations of serious occupational injuries were carried out. The first involved 223 cases and the second, 50 cases. Some in-site studies were included. Experiences from the implementation in Oslo suggest that this system can function in the medical care system and provide data required for making estimates of injury incidence rates, establishing trends, and on contributing factors to injuries. A crucial factor in the success of the first part of such a system is to have enough resources for continuous quality control and feedback to personnel involved in the registration of data. Combining the registered data from general practitioners, accident and emergency departments, hospitals and notifications of fatalities in Oslo, and on assessments of the number of injuries treated by private clinics and occupational health centres in Oslo, and in the health care system outside of Oslo, leads to the conclusion that 11.9% of the residents of Oslo will annually be treated for an injury.

Relationship between peripheral airway dysfunction, airway obstruction, and neutrophilic inflammation in COPD

BACKGROUND

Considerable research has been conducted into the nature of airway inflammation in chronic obstructive pulmonary disease (COPD) but the relationship between proximal airways inflammation and both dynamic collapse of the peripheral airways and HRCT determined emphysema severity remains unknown. A number of research tools have been combined to study smokers with a range of COPD severities classified according to the GOLD criteria.

METHODS

Sixty five subjects (11 healthy smokers, 44 smokers with stage 0-IV COPD, and 10 healthy non-smokers) were assessed using lung function testing and HRCT scanning to quantify emphysema and peripheral airway dysfunction and sputum induction to measure airway inflammation.

RESULTS

Expiratory HRCT measurements and the expiratory/inspiratory mean lung density ratio (both indicators of peripheral airway dysfunction) correlated more closely in smokers with the severity of airflow obstruction (r = -0.64, p<0.001) than did inspiratory HRCT measurements (which reflect emphysema severity; r = -0.45, p<0.01). Raised sputum neutrophil counts also correlated strongly in smokers with HRCT indicators of peripheral airway dysfunction (r = 0.55, p<0.001) but did not correlate with HRCT indicators of the severity of emphysema.

CONCLUSIONS

This study suggests that peripheral airway dysfunction, assessed by expiratory HRCT measurements, is a determinant of COPD severity. Airway neutrophilia, a central feature of COPD, is closely associated with the severity of peripheral airway dysfunction in COPD but is not related to the overall severity of emphysema as measured by HRCT.