How to… support others in developing a career in clinical education research

The Incubator for Clinical Education Research (ClinEdR) is a UK-wide network, established with support from the National Institute for Health Research, to lead initiatives to build capacity in the field. A key barrier identified by this group is that many experienced educators, clinicians, and researchers, who may be committed to supporting others, have little guidance on how best to do this. In this "How to …" paper, we draw on relevant literature and our individual and collective experiences as members of the National Institute for Health Research ClinEdR incubator to offer suggestions on how educators can support others to develop successful careers involving ClinEdR. This article offers guidance and inspiration for all professionals whose role involves research and scholarship and who encounter aspiring or developing clinical education researchers in the course of their work. It will also be of interest to researchers who are starting out and progressing in the field.

Editorial: Clinical Education Research and Dental Public Health

The central premise of Dental Public Health (DPH) is striving to change the oral health of the nation for the better and as Leo Buscaglia, the 19th century historian, elegantly stated; 'Change is the end result of all true learning'. The two primary goals of DPH; promoting oral health and preventing oral disease, have at their very heart the education of the general public and patients. Similarly, in seeking to recruit, train and retain an effective dental workforce, with a focus on oral health-related quality of life improvements, close attention to the education of those practitioners is imperative.

Interprofessional simulation as an enhancement of psychological fidelity: A focus group study of medical and nursing students

Background and Aims

Interprofessional simulation has the potential to enhance the perceived realism of clinical simulation in the education of different healthcare professionals. This study considers how the inclusion of more than one profession in clinical simulation contributes to this psychological fidelity, defined as the subjective perception of the realism of a simulation, and the cues identified by medical and nursing students.

Methods

Eight focus groups were carried out with 27 medical and 18 nursing students in Newcastle and Oxford, UK. These were carried out immediately after students' participation in simulation sessions consisting of three acute scenarios. Focus group discussions encompassed perceptions of the realism of the simulation and of participants' own and other professional groups. Thematic analysis was carried out on transcripts.

Results

The analysis identified features of psychological fidelity that were influenced by the interprofessional element of the simulation. These included overall impressions of realism, and the perceived roles and expectations of doctors and nurses within the simulation. In particular, the presence of the other professional group afforded a more authentic response. Other features varied with the viewpoint of the student groups, in particular the realism of the patient manikin, which held lower psychological fidelity for the nursing students, because it did not allow them to fulfill their perceived role of delivering holistic, relational care.

Conclusion

Recognizing "psychological fidelity" as a subjective response to simulation allows greater consideration of the limitations of fidelity as a designed or engineered property of a simulation. While interprofessional involvement directly enhances psychological fidelity in some ways, potential differences in the views of students from different professional groups should be considered when implementing interprofessional simulation.

P78 MedEd Collaborative: a new research collaborative to promote medical education research

Introduction

In response to the disruption to medical education caused by COVID-19, there is a need for wide-scale robust medical education research and the generation of research capacity for the future. Trainee research collaboratives have demonstrated they can nurture the research skills of students and trainees while delivering high quality research outputs. However, we have been unable to identify a permanent medical education research collaborative for trainees and students.

Methods

We started the MedEd Collaborative in September 2020 to fill this gap, consisting of a trainee- and student-led medical education research collaborative supported by senior medical education experts and clinicians.

Results

Our vision is to increase engagement of students and trainees in high-quality medical education research that informs practice. The MedEd Collaborative will engage students and trainees in medical education research by completing at least one national multicentre study per year, the first being the COVID Ready 2 study. This is a national cross-sectional survey of the educational impact of medical student volunteering during the COVID-19 pandemic.

Conclusions

We anticipate the MedEd collaborative will: increase exposure to medical education research, thereby increasing the number of medical students and trainees aiming to pursue an academic medical education career; provide training in medical education research methodologies, such as qualitative analysis; improve the quality of medical education research outputs from students and trainees; encourage collaboration between medical schools and deaneries; and provide support to other trainee research collaboratives that aim to explore education research in their own specialties.

Effects of a single interprofessional simulation session on medical and nursing students' attitudes toward interprofessional learning and professional identity: a questionnaire study

BACKGROUND

Participation in simulation-based interprofessional education (sim-IPE) may affect students' attitudes towards interprofessional learning (through gaining experience with others) and their professional identity (by increasing the 'fit' of group membership). We examined this in two questionnaire studies involving students from four universities in two areas of the UK.

METHOD

Questionnaire data were collected before and after students took part in a sim-IPE session consisting of three acute scenarios. Questionnaires included the Readiness for Interprofessional Learning Scale (RIPLS) and measures of professional identity derived from the social identity theory literature. In Study 1, only identification with Professional Group (doctor or nurse) was measured, while in Study 2 identification with Student Group (medical or nursing student) and the immediate interprofessional Team worked with in the simulation were also measured. Linear mixed effects regression analysis examined the effect of the simulation session, and differences between medical and nursing students, sites and identity measures.

RESULTS

A total of 194 medical and 266 nursing students completed questionnaires. A five-item subset of RIPLS (RIPLSCore) was used in analysis. In both studies RIPLSCore increased for all groups following participation in sim-IPE, although this was larger for nursing students in Study 1. Nursing students had consistently higher RIPLSCore scores than medical students at one site. Effects of the session on identity varied between sites, and dimensions of identity. Notably, while positive emotions associated with group membership (Ingroup Affect) increased for Student Group, Professional Group and Team, the sense of belonging (Ingroup Ties) and importance (Centrality) of the group increased only for Team. Nursing students had consistently higher identification scores than medical students.

CONCLUSIONS

Participation in a sim-IPE session can improve attitudes towards interprofessional learning. It can also enhance professional identity, particularly as related to emotional aspects of group membership, with possible benefits for wellbeing. Changes in identification with the immediate Team suggest positive psychological consequences of ad hoc Team formation in the workplace. Differences between medical and nursing students suggest their differing opportunities to work with other professions during training may change baseline attitudes and identity. However, a single sim-IPE session can still have an additive effect.

Evidence That Rhesus Macaques Self-Cure from a Schistosoma japonicum Infection by Disrupting Worm Esophageal Function: A New Route to an Effective Vaccine?

Background

Rhesus macaques are unusual among schistosome hosts, self-curing from an established infection and thereafter manifesting solid immunity against a challenge, an ideal model for vaccine development. Previously, the immunological basis of self-cure was confirmed; surviving worms had ceased feeding but how immunological pressure achieved this was unclear. The schistosome esophagus is not simply a conduit for blood but plays a central role in its processing. Secretions from the anterior and posterior esophageal glands mix with incoming blood causing erythrocyte lysis and tethering and killing of leucocytes.

Methodology/Principal Findings

We have analysed the self-cure process in rhesus macaques infected with Schistosoma japonicum. Faecal egg output and circulating antigen levels were used to chart the establishment of a mature worm population and its subsequent demise. The physiological stress of surviving females at perfusion was especially evident from their pale, shrunken appearance, while changes in the structure and function of the esophagus were observed in both sexes. In the anterior region electron microscopy revealed that the vesicle secretory process was disrupted, the tips of lining corrugations being swollen by greatly enlarged vesicles and the putative sites of vesicle release obscured by intense deposits of IgG. The lumen of the posterior esophagus in starving worms was occluded by cellular debris and the lining cytoplasmic plates were closely adherent, also potentially preventing secretion. Seven proteins secreted by the posterior gland were identified and IgG responses were detected to some or all of them. Intrinsic rhesus IgG colocalized with secreted SjMEGs 4.1, 8.2, 9, 11 and VAL-7 on cryosections, suggesting they are potential targets for disruption of function.

Conclusions/Significance

Our data suggest that rhesus macaques self-cure by blocking esophagus function with antibody; the protein products of the glands provide a new class of potential vaccine targets.

Rhesus macaques can self-cure from a schistosome infection. Antibody is crucial to drive this process and adult worm elimination is preceded by cessation of blood feeding. Recently we have shown that the schistosome esophagus plays a central role in blood processing. We first confirm the self-cure process in rhesus macaques infected with Schistosoma japonicum and provide evidence that the self-cure mechanism involves blocking the worm esophagus function with antibody. In the anterior region, secretion of light vesicles is disrupted hence their contents are not released into the lumen to interact with blood components to fulfil their tasks. The plates in the posterior lining stick together whilst the lumen is occluded, hampering blood processing. Furthermore, rhesus IgG binds strongly to the worm esophageal lumen and co-localizes completely with five esophageal secreted proteins, SjMEGs 4.1, 8.2, 9, 11 and VAL-7. Our results indicate that rhesus macaques eliminate their adult worms by disrupting esophageal function making blood difficult to ingest; feeding stops eventually causing their demise because nutrient uptake across the body surface cannot fully compensate.

The use of adrenaline autoinjectors by children and teenagers

BACKGROUND

Although adrenaline is recommended as first line treatment for anaphylaxis, it is often not utilized. There has been a debate about when adrenaline autoinjectors should be prescribed and how many should be dispensed.

OBJECTIVES

To see how many adrenaline autoinjectors were used during anaphylactic reactions and to determine why they were not used in situations where they were clinically indicated.

METHODS

Patients were recruited prospectively at 14 paediatric allergy clinics throughout UK. Participants completed a questionnaire covering demographic data, atopic status and details of allergic reactions in the previous year and reasons for using more than one device.

RESULTS

A total of 969 patients were recruited of whom 466 (48.1%, 95% CI: 37.9-58.2) had had at least one reaction in the previous year; 245 (25.3%, 95% CI: 16.2-34.4) of these reactions were anaphylaxis. An adrenaline autoinjector was used by 41 (16.7%, 95% CI: 11.7-21.3) participants experiencing anaphylaxis. Thirteen participants received more than one dose of adrenaline, for nine of these a health professional gave at least one. The commonest reasons for using more than one were severe breathing difficulties (40%), lack of improvement with first dose (20%) and miss-firing (13.3%). The commonest reasons for not using adrenaline in anaphylaxis were 'thought adrenaline unnecessary' (54.4%) and 'unsure adrenaline necessary' (19.1%). Many with wheeze did not use their autoinjector.

CONCLUSIONS AND CLINICAL RELEVANCE

Adrenaline is used by only a minority of patients experiencing anaphylaxis in the community. Thirteen of the 41 patients with anaphylaxis who used their autoinjector needed another dose of adrenaline. Further research is needed to consider how to best encourage the usage of adrenaline when clinically indicated in anaphylaxis.

Potential role of hematopoietic stem cell transplantation in children with secondary acute lymphocytic leukemia

Secondary acute lymphocytic leukemias (ALL) are uncommon events in the pediatric patient population. There are few detailed reports on the laboratory characteristics and clinical course of patients with secondary lymphocytic leukemia. Historically, these patients have had a poor outcome. We report two patients treated at one institution who developed treatment-related secondary ALL. Both patients underwent hematopoietic stem cell transplantation, one with a compatible unrelated donor cord blood unit and one with an HLA-matched sibling donor bone marrow. One of the two patients survives disease-free 3 years after transplantation.

Modification of T-cell receptor Vbeta repertoire in response to allergen stimulation in peanut allergy

BACKGROUND

Peanut is one of the most common foods causing allergic reactions and is the most common cause of fatal and near-fatal food-related anaphylaxis. Little is known of the immunologic mechanisms that underlie peanut allergy.

OBJECTIVES

In this study we examined clonality of the T-cell response (TCR) to peanut in MHC class II identical, peanut allergy-discordant sibling pairs.

METHODS

Four sibling pairs were investigated. The TCR repertoire was analyzed before and after in vitro stimulation of PBMCs with crude peanut or PHA, as control for general/nonspecific reactivity. Eighteen TCR-Vbeta families were examined by flow cytometry. Where significant differences in incidence of particular TCR-Vbeta families were observed, PCR familyspecific cDNA amplification and gene scanning were performed.

RESULTS

After stimulation with peanut, no selective expansion of any TCR-Vbeta subpopulation was observed with flow cytometry, in either the peanut-allergic or nonallergic siblings, with the exception of 1 peanut-allergic subject who demonstrated a significant increase of TCR-Vbeta11(+) cells (0.3%-5.9% of the total CD3(+) cells). However, gene scanning revealed predominant single-size PCR products for TCRBV11 in all peanut-allergic subjects after peanut stimulation. TCRBV11 polyclo-nality was observed in allergic and nonallergic subjects before peanut stimulation and in nonallergic subjects after peanut stimulation. In comparison, all subjects, before and after stimulation with peanut, showed polyclonality for TCRBV2.

CONCLUSIONS

Our results argue for clonal or oligoclonal TCRs to crude peanut and indicate that changes in the TCRBV11 subpopulation are restricted to peanut-allergic subjects after stimulation with crude peanut allergen.

Toward quality assurance for metaphase FISH: a multicenter experience

Although fluorescent in situ hybridization (FISH) is rapidly becoming a part of clinical cytogenetics, no organization sponsors multicenter determinations of the efficacy of probes. We report on 23 laboratories that volunteered to provide slides and to use a probe for small nuclear ribonucleoprotein polypeptide N (SNRPN) and a control locus. Experiences with FISH for these laboratories during 1994 ranged from 0 to 645 utilizations (median = 84) involving blood, amniotic fluid, and bone marrow. In an initial study of hybridization efficiency, the median percentage of metaphases from normal individuals showing two SNRPN and two control signals for slides prepared at each site was 97.0 (range = 74-100); for slides prepared by a central laboratory, it was 97.8 (range = 81.6-100). In a subsequent blind study, each laboratory attempted to score 5 metaphases from each of 23 specimens [8 with del(15)(q11.2-->q12) and 15 with normal #15 chromosomes]. Of 529 challenges, the correct SNRPN pattern was found in 5 of 5 metaphases in 457 (86%) and in 4 of 5 in 33 (6%). Ambiguous, incomplete, or no results were reported for 32 (6%) challenges. Seven (1%) diagnostic errors were made, including 6 false positives and 1 false negative: 1 laboratory made 3 errors, 1 made 2, and 2 made 1 each. Most errors and inconsistencies seemed due to inexperience with FISH. The working time to process and analyze slides singly averaged 49.5 min; slides processed in batches of 4 and analyzed singly required 36.9 min. We conclude that proficiency testing for FISH by using an extensive array of challenges is possible and that multiple centers can collaborate to test probes and to evaluate costs.

Toward quality assurance for metaphase FISH: a multi-center experience

Although fluorescent in situ hybridization (FISH) is rapidly becoming a part of clinical cytogenetics, no organization sponsors multi-center determinations of the efficacy of probes. We report on 23 laboratories that volunteered to provide slides and to use a probe for SNRPN and a control locus. Experiences with FISH for these laboratories during 1994 ranged from 0 to 645 utilizations (median = 84) involving blood, amniotic fluid and bone marrow. In an initial study of hybridization efficiency, the median percentage of metaphases from normal individuals showing two SNRPN and 2 control signals for slides prepared at each site was 97.0 (range = 74-100); for slides prepared by a central laboratory, it was 97.8 (range = 81.6-100). In a subsequent blind study, each laboratory attempted to score 5 metaphases from each of 23 specimens [8 with del(15) (q11.2-->q12) and 15 with normal 15 chromosomes]. Of 529 challenges, the correct SNRPN pattern was found in 5 of 5 metaphases in 457 (86%) and in 4 of 5 in 33 (6%). Ambiguous, incomplete or no results were reported for 32 (6%) challenges. Seven (1%) diagnostic errors were made including 6 false positives and 1 false negative: 1 laboratory made 3 errors, 1 made 2, and 2 made 1 each. Most errors and inconsistencies seemed due to inexperience with FISH. The working time to process and analyze slides singly averaged 49.5 minutes; slides processed in batches of 4 and analyzed singly required 36.9 minutes. We conclude that proficiency testing for FISH using an extensive array of challenges is possible and that multiple centers can collaborate to test probes and to evaluate costs.

The human A1 adenosine receptor: ligand binding properties, sites of somatic expression and chromosomal localization

The A1 adenosine receptor (A1AR) exerts important biological effects in the mammalian biology. To provide insights into the role A1AR action in human physiology, we characterized the pharmacologic properties of the human A1AR, examined somatic sites of A1AR gene expression, and identified the chromosomal location of the human A1AR gene. Using stably transfected CHO cells, the ligand binding properties of human and rat A1ARs were directly compared. Saturation studies showed that the human and rat A1ARs had similar high affinity for the A1 agonist [(3)H]CCPA (human, K(d)=517±64 pM; B(max) 438±29 fmol/mg of protein; rat, K(d)=429±69 pM; B(max) 358±76 fmol/mg of protein). Competition studies performed using seven adenosine agonists and four adenosine antagonists also did not detect differences in the ligand binding properties among the rat and human A1ARs. Northern analysis of 16 human tissues revealed the presence of a single hybridizing transcript of 2.5 kb. Human A1AR receptor mRNA expression was greatest in brain and testis; lower levels of A1AR mRNA were present in heart, pancreas, kidney and spleen. Southern blotting and PCR analysis of human-rodent somatic cell hybrids showed that the A1AR gene is on human chromosome 1. Using fluorescence in situ hybridization, the human A1AR gene was further localized to the 1q32.1 region. These observations show that the human A1AR is a high affinity receptor that has ligand binding properties similar to the rat A1AR, human A1AR mRNA is heavily expressed in brain and testis, and the gene encoding the human A1AR is present on the long arm of chromosome 1.

Ocular manifestations of Hansen's disease

A detailed ophthalmic evaluation including slitlamp biomicroscopy, measurement of corneal sensitivity using Cochet and Bonnet aesthesiometer, Schirmer's test and Goldmann applanation tonometry was carried out in 89 patients of Hansen's disease attending the leprosy clinic with or without ocular symptoms and willing to undergo eye evaluation. Thirty-one patients had lepromatous leprosy (8 with erythema nodosum leprosum), 56 patients had borderline disease (13 with reversal reactions) and 2 had tuberculoid disease. In addition to the well documented changes of lagophthalmos (6.7%), uveitis (7.3%) and cataracts (19%), we noted prominent corneal nerves in 133 eyes (74.7%), beaded corneal nerves in 19 eyes (10.7%), corneal scarring in 10 eyes (5.6%), corneal hypoaesthesia in 51 eyes (28%) and dry eye in 18 eyes (13%). Beaded corneal nerves and/or stomal infiltrates occurred mainly in the lepromatous group (75%). Ocular hypotony (IOP less than 12 mm Hg) was not seen more frequently in Hansen's as compared to age and sex matched controls with refractive errors or cataracts (33.7%, vs. 37.8%, p = 0.33). Our study highlights the primary corneal involvement with corneal neuropathy as the predominant feature of Hansen's disease.

Some reflections on the phylogeny and function of the pineal

The pineal gland is a universal feature of vertebrate organization and has been implicated in the control of rhythmic adaptations to daily and seasonal cycles. This paper considers three aspects of pineal function; the generation of a rhythmical endocrine signal (the nocturnal synthesis of melatonin) and the use of the signal in the regulation of circadian and photoperiodic functions. The shape of the nocturnal signal is determined by an interaction of afferent neural control and biochemical processes intrinsic to the pinealocyte. The nature of the effect of the signal upon circadian systems is unclear, and in adult mammals may not be a specific, direct influence upon the entrainment pathways of the oscillator. In the foetus, strong evidence exists for a physiological role of the maternal melatonin signal as a true internal zeitgeber, remnants of which may persist in the adult. Photoperiodic time measurement in adult and foetal mammals is critically dependent upon the melatonin signal. Indirect evidence indicates that several neural systems may be involved in the response to melatonin and consistent with this, a variety of central melatonin binding sites have been identified in the brain and pituitary. The intra-cellular actions of melatonin and the properties of melatonin responsive neural systems have yet to be identified, but in the context of photoperiodic time measurement, it is clear that the neural responses to melatonin are not dependent upon the circadian clock. The two central effects of melatonin; photoperiodic time measurement and circadian entrainment are probably mediated through completely separate mechanisms.

Spinocerebellar ataxia: localization of an autosomal dominant locus between two markers on human chromosome 6

Inherited spinocerebellar ataxias (SCA) are progressively degenerative neurological diseases. The primary site of degeneration is the cerebellar cortex--in particular, the Purkinje cells. In the present report, the SCA locus, inherited as an autosomal dominant trait in a large kindred, is localized to a region approximately 15 centimorgans telomeric of HLA-A on the short arm of chromosome 6.

Coping with aversive stimulation in the neonatal period: quiet sleep and plasma cortisol levels during recovery from circumcision

Measures of behavioral state and plasma cortisol were obtained on 80 healthy, full-term, 2-3-day-old, male newborns who were scheduled to be circumcised. To establish baseline or precircumcision levels, the newborns were observed, and behavioral state was recorded for the half hour prior to circumcision. Blood was sampled via heelstick for plasma cortisol determination at the end of this observation period. The newborns were then circumcised and assigned randomly to one of 4 postcircumcision, blood-sampling time-point groups. The time points were 30, 90, 120, and 240 min following the beginning of circumcision. Behavioral state was observed during circumcision and for the half hour prior to taking the second blood sample. The results showed a return to baseline cortisol levels sometime prior to 240 min, with data from an additional group of 10 newborns indicating that the return occurred by 150 min. Behavioral distress during circumcision was associated with elevations in plasma cortisol at 30 and 90 min. Quiet sleep was correlated negatively with plasma cortisol prior to circumcision, and significant increases in quiet sleep followed circumcision, with the greatest increase corresponding to the period of most rapid reductions in cortisol.