Postgraduate medical education: see one, do one, teach one…and what else?

Postgraduate medical education (PGME) faces many challenges and must evolve. Three principles can guide this evolution. First, PGME apprenticeship, a form of situated learning, is guided by the four dimensions of the Cognitive Apprenticeship Model: content, method, sequence, and sociology. Second, situated learning involves experiential learning and inquiry processes; it is most effective for learners practicing self-directed learning. The promotion of self-directed learning requires consideration of its three dimensions: process, person, and context. Finally, the need for competency-based PGME can be accomplished through holistic models, such as situated learning. The implementation of this evolution should be informed by the characteristics of the new paradigm, inner and outer settings of the organisations, and individuals involved. Implementation encompasses communication to engage stakeholders, training process redesign in accordance with the new paradigm, faculty development to empower and engage involved individuals, and research to enhance the understanding of PGME.

Effect of Home-Based Self-Management Intervention for Community-Dwelling Patients with Early Parkinson's Disease: A Feasibility Study

PURPOSE

This study aimed to evaluate the effect of a home-based self-management intervention in community-dwelling patients with early Parkinson's diseases (PD).

DESIGN

A randomized-controlled design.

METHODS

Thirty-two patients participated (15=intervention, 17=control), and the intervention group received 16 weeks of the intervention.

FINDINGS

Physical activity and non-motor symptoms improved more in the intervention group than in the control group.

CONCLUSION

Home-based self-management intervention was effective in improving physical activity and non-motor symptoms for them.

CLINICAL EVIDENCE

Home-based intervention - comprising education, telephone counseling, smartphone-based message and information, and smart wearable devices - was feasible for patients with early PD.

Automatic Patient Fall Outcome Extraction Using Narrative Incident Reports

Patient outcome is one of the key information categories in incident reporting. Being able to extract meaningful patient fall outcomes would allow better analysis of the consequences and possible mitigating actions for in-hospital fall incidents. This study aims to automate the extraction of patient outcomes from narrative fall incident reports by decomposing this into three classification subtasks: injured or not, injury types, and the number of injuries. Implementing an existing incident report classification (IRC) framework, the experimental results demonstrated that oversampling and structured features were effective to achieve better overall performances across all three subtasks. The study further validated the application of an IRC framework to deal with imbalanced classification problems found in fall patient outcome classification and advanced the science of automatic patient outcomes extraction.

Evaluating resampling methods and structured features to improve fall incident report identification by the severity level

OBJECTIVE

This study aims to improve the classification of the fall incident severity level by considering data imbalance issues and structured features through machine learning.

MATERIALS AND METHODS

We present an incident report classification (IRC) framework to classify the in-hospital fall incident severity level by addressing the imbalanced class problem and incorporating structured attributes. After text preprocessing, bag-of-words features, structured text features, and structured clinical features were extracted from the reports. Next, resampling techniques were incorporated into the training process. Machine learning algorithms were used to build classification models. IRC systems were trained, validated, and tested using a repeated and randomly stratified shuffle-split cross-validation method. Finally, we evaluated the system performance using the F1-measure, precision, and recall over 15 stratified test sets.

RESULTS

The experimental results demonstrated that the classification system setting considering both data imbalance issues and structured features outperformed the other system settings (with a mean macro-averaged F1-measure of 0.733). Considering the structured features and resampling techniques, this classification system setting significantly improved the mean F1-measure for the rare class by 30.88% (P value < .001) and the mean macro-averaged F1-measure by 8.26% from the baseline system setting (P value < .001). In general, the classification system employing the random forest algorithm and random oversampling method outperformed the others.

CONCLUSIONS

Structured features provide essential information for categorizing the fall incident severity level. Resampling methods help rebalance the class distribution of the original incident report data, which improves the performance of machine learning models. The IRC framework presented in this study effectively automates the identification of fall incident reports by the severity level.

Factors Associated with Medication Beliefs in Patients with Parkinson's Disease: A Cross-Sectional Study

OBJECTIVE

Medication beliefs are a significant determinant of medication adherence in chronic illness. This study aimed to identify demographic, clinical, and medication-related factors associated with medication beliefs in patients with Parkinson's disease (PD).

METHODS

We used a descriptive cross-sectional design with a convenience sample of 173 PD patients who had been taking antiparkinson drugs for more than one year.

RESULTS

The subjects who believed PD medication was more necessary had more severe illness, younger age of onset, longer illness duration, and longer duration of levodopa therapy. They had higher levels of non-motor symptoms and depression, number of medication uses, number of drugs, and levodopa equivalent dose, and they reported fluctuation of motor symptoms and dyskinesia. The subjects who used catechol-O-methyltransferase (COMT) inhibitors, dopamine agonists, amantadine, and monoamine oxidase-B (MAO-B) inhibitors had significantly higher necessity scores than those who did not use them. The subjects who had higher concerns about PD medications had higher levels of non-motor symptoms and depression. The subjects using amantadine and anticholinergics had significantly higher concern scores than those who did not use them. Positive necessity-concerns differentials were associated with severe illness, the presence of motor fluctuation and dyskinesia, and the use of COMT inhibitors. Based on stepwise multiple regression, the most significant factors influencing necessity beliefs were severe illness, followed by depression and motor fluctuation.

CONCLUSION

Severe illness, higher levels of depression, and motor fluctuation are independent factors influencing patients' beliefs regarding medication necessity. Therefore, these characteristics should be considered in medication belief assessment and interventions for PD patients.

Medication-rights detection using incident reports: A natural language processing and deep neural network approach

Medication errors often occurred due to the breach of medication rights that are the right patient, the right drug, the right time, the right dose and the right route. The aim of this study was to develop a medication-rights detection system using natural language processing and deep neural networks to automate medication-incident identification using free-text incident reports. We assessed the performance of deep neural network models in classifying the Advanced Incident Reporting System reports and compared the models' performance with that of other common classification methods (including logistic regression, support vector machines and the decision-tree method). We also evaluated the effects on prediction outcomes of several deep neural network model settings, including number of layers, number of neurons and activation regularisation functions. The accuracy of the models was measured at 0.9 or above across model settings and algorithms. The average values obtained for accuracy and area under the curve were 0.940 (standard deviation: 0.011) and 0.911 (standard deviation: 0.019), respectively. It is shown that deep neural network models were more accurate than the other classifiers across all of the tested class labels (including wrong patient, wrong drug, wrong time, wrong dose and wrong route). The deep neural network method outperformed other binary classifiers and our default base case model, and parameter arguments setting generally performed well for the five medication-rights datasets. The medication-rights detection system developed in this study successfully uses a natural language processing and deep-learning approach to classify patient-safety incidents using the Advanced Incident Reporting System reports, which may be transferable to other mandatory and voluntary incident reporting systems worldwide.

Utilisation and outcome of renal replacement therapy in an Asian tertiary intensive care unit

OBJECTIVES

To determine the period prevalence, demographic characteristics, cost of treatment, and outcomes of patients admitted to the intensive care unit for continuous renal replacement therapy.

DESIGN

Descriptive case series.

SETTING

Intensive Care Unit in a Hong Kong tertiary referral, teaching hospital.

PATIENTS

All patients admitted to the Intensive Care Unit from January to December 2007 who underwent continuous renal replacement therapy.

MAIN OUTCOME MEASURES

Period prevalence of continuous renal replacement therapy, patient demographic data, referral sources by specialty and hospital location, diagnosis, daily cost of disposable items, duration of renal replacement therapy, intensive care unit length of stay, and hospital mortality.

RESULTS

Of 1652 patients admitted to the intensive care unit over a 12-month period, 131 (8%) underwent continuous renal replacement therapy, of whom 56% were admitted from general wards (the department of medicine being the source of 59% of referrals). The median age of these continuous renal replacement therapy patients was 67 (interquartile range, 55-76) years, with a slight male predominance (66%). The mean APACHE II score of the patients was 29 (standard deviation, 7). Chronic renal failure requiring either haemodialysis or peritoneal dialysis was present in 20/131 (15%) patients. Sepsis was the diagnosis most commonly associated with renal failure deemed to warrant continuous renal replacement therapy (43%). The median duration of such continuous therapy was 55 (interquartile range, 25-93) hours and the median intensive care unit length of stay was 120 (interquartile range, 51-289) hours. The mean daily cost of disposables for the provision of continuous renal replacement therapy was HK$3510. The overall intensive care unit mortality of patients having continuous renal replacement therapy was 38% and the hospital mortality was 53%. The corresponding rates for patients with acute renal failure were 45% and 56%, respectively. Patients undergoing continuous renal replacement therapy had prolonged intensive care unit stays (120 vs 24 hours; P<0.05) and higher corresponding hospital mortality rates (53% vs 20%; P<0.001) compared to those not having such therapy.

CONCLUSION

The 8% period prevalence of patients admitted to the intensive care unit undergoing continuous renal replacement therapy was somewhat higher than in recently published reports in the international literature. However intensive care unit and hospital mortality rates for such patients were lower than previously reported. The corresponding total daily cost of relevant disposables was similar to costs reported internationally, whilst the length of intensive care unit stays for our cohort were relatively short.

Hong Kong Chinese teachers' attitudes towards life-sustaining treatment in the dying patients

OBJECTIVE

To evaluate the attitudes of Hong Kong Chinese teachers towards life-sustaining treatment in the dying patients.

DESIGN

Prospective structured questionnaire survey.

SETTING

Hong Kong Institute of Education.

SUBJECTS AND METHODS

All teaching staff at the Hong Kong Institute of Education were sent the survey questionnaire. The questionnaire gathered demographic data, information on experience of 'life and death' decision-making, and views on life-sustaining treatment decisions. Respondents were also requested to respond to statements on life-sustaining treatment using a 5-point Likert Scale (1 representing strong disagreement and 5 representing strong agreement).

RESULTS

A total of 436 questionnaires were sent to teaching staff at the Hong Kong Institute of Education. The response rate was 27.8%. More than half (65.8%) of the respondents were aged between 30 and 49 years. There was an equal proportion of men and women among respondents. The respondents agreed with statements supporting end-of-life decisions (mean aggregate score, 3.13; standard deviation, 1.24; P<0.0001), and disagreed with statements against such decisions (mean aggregate score, 2.81; standard deviation, 1.22; P<0.0001). If the patient is competent, half of the respondents agreed that the patient alone should make the decision, while 27.2% believed that it should be a joint decision made by the patient, the family, and the doctor. Conversely, if the patient is incompetent, 52.6% agreed that it should be a joint decision made by the family and the doctor. There was strong support for advanced directives, whereby decisions in relation to life-sustaining treatment were legally recorded in advance (mean score, 3.62; P=0.0001).

CONCLUSION

The teachers in this survey appear to support the practice of withdrawing and withholding life-sustaining treatment in the dying patients when medical treatment is considered futile. Although patient autonomy in decision-making was supported by the greatest number of respondents, joint decision-making by the patient, family members, and doctors was also favoured by a substantial group. There was strong support for the use of advanced directives with respect to life-sustaining treatment.

Recall of preoperative anaesthesia information in Hong Kong Chinese patients

OBJECTIVE

To evaluate the ability of patients to recall information provided during a preoperative visit.

DESIGN

Qualitative study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Sixty patients scheduled for elective surgery under general anaesthesia or central neuro-axial block.

MAIN OUTCOME MEASURES

Satisfactory recall of preoperative information, defined as the ability to remember at least 75% of adverse effects described.

RESULTS

Fifty-nine (98.3%) patients were satisfied with the preoperative information. Forty-two (70%) patients rated anaesthetic complications as important. At the interview on the day of the operation, 57 (95%) patients had satisfactory recall of the information provided. Eighty-five percent of patients remembered that the information was provided by an anaesthesiologist. After the operation, of those who experienced adverse effects, 48 (96%) patients remembered being told to anticipate the adverse anaesthetic event. Univariate analysis found that age, sex, education level, occupation, and the modality of anaesthesia did not affect patient recall of preoperative information on the day of surgery or 1 day postsurgery. CONCLUSION. There was satisfactory recall of preoperative information by the majority of patients in the study. Most patients expressed satisfaction with the information provided.

Anaesthetic clinical indicators in public hospitals providing anaesthetic care in Hong Kong: prospective study

OBJECTIVES

To assess the quality of anaesthetic services as defined in the six anaesthetic clinical indicators against preset standards and to identify risk factors for adverse events in the recovery room.

DESIGN

Prospective study.

SETTING

All public hospitals providing anaesthetic care in Hong Kong.

PATIENTS

Eighteen thousand, seven hundred and fifty-nine patients receiving elective or emergency anaesthesia administered by anaesthetists from June 1998 to July 1998.

MAIN OUTCOME MEASURES

Patient demographics, American Society of Anesthesiologists status, category and nature of operation, presence of preoperative anaesthetic visit in ward, type of anaesthesia, reasons for a recovery room stay of more than a 2-hour duration, intubation to relieve respiratory distress in the recovery room, presence of hypothermia in the recovery room for operations lasting more than 2 hours, and dental or ocular injuries attributable to anaesthesia.

RESULTS

There are two major findings from this study. Firstly, a high incidence of hypothermia in the recovery room was reported. Secondly, a greater risk of prolonged stay in the recovery room was identified for patients older than 65 years, major operations, and anaesthetic techniques using combined general and regional anaesthesia.

CONCLUSION

The six anaesthetic clinical indicators reflected the provision of anaesthetic care in public hospitals in Hong Kong. Good compliance to the preset standard of the anaesthetic clinical indicators was achieved during the study period.

Distribution characteristics of PCBs in the sediments of the lower Nakdong River, Korea

The objective of this study is to investigate the distribution characteristics of polychlorinated biphenyl (PCB) congeners in sediments of the lower Nakdong River of Korea. The sediments were collected using a grab sampler in May 1999. PCBs were extracted in the Soxhlet extractor and cleaned by using adsorption chromatographic techniques and concentrated sulfuric acid. A HP6890 gas chromatograph equipped with an electron capture detector was used for quantification. The results of congener specific analysis showed that the total concentration is ranged over 1.1-141 ng/g dry weight. The levels of PCB congeners are significantly correlated with the total organic carbons (TOC) in the sediments. The major fractions of PCBs in these sediments are congeners containing 4, 5 or 6 chlorine atoms per biphenyl molecule.

Factors affecting outcome following cardiopulmonary resuscitation

Many patients who receive cardiopulmonary resuscitation (CPR) for cardiac arrest do not survive to leave hospital. Factors associated with adverse outcomes include unwitnessed cardiac arrest in general wards, particularly at night, prolonged resuscitation, asystole, associated disorders (e.g. sepsis, malignancy, renal failure, and left ventricular dysfunction), absent pupillary responses, hypoxaemia, low PetCO2 during resuscitation, and severe acid base imbalance. Outside hospitals, cardiac arrests result in more favourable outcomes if they occur at work, and bystander CPR and early defibrillation are initiated. On admission to ICU, likely predictors of death or severe neurological disability include prolonged coma, impaired brainstem reflexes, and persistent convulsions. Experience with cerebrospinal fluid enzymes and electrophysiological measurements is limited. Multivariate scoring systems are not sufficiently reliable. The importance of hyperglycaemia, the required level of CPR training, and the appropriateness of responding to some cases, remain debatable.

One hundred and sixty-three consecutive video thoracoscopic procedures: the Hong Kong experience

Video-assisted thoracoscopy (VAT) offers a new approach to the diagnosis and treatment of many thoracic conditions. From September 1992 to August 1993, a total of 163 VAT procedures were successfully performed on 108 patients (87 male, 21 female; age range from 12 to 77) which consisted of 42 bleb eliminations and 64 mechanical pleurodesis for spontaneous pneumothorax, 11 wedge resections for pulmonary nodules, three wedge biopsies for diffuse pulmonary infiltrate, four thoracic sympathectomies, resections of two mediastinal masses, three pericardial windows, 10 guided pleural biopsies for undiagnosed effusions, six guided drainage of empyema and haemothorax, 16 staging of intrathoracic tumours and two explorations for penetrating thoracic trauma. There was no procedure-related mortality. Complications included one recurrence for spontaneous pneumothorax, one re-exploration for bleeding (also by VAT approach), one wound infection, and six persistent air leaks for more than 10 days. The median duration of postoperative chest tube drainage was 2 days and the median hospital stay was 4 days. It was concluded that VAT is a safe and effective approach in thoracic surgery and with further refinement in instrumentation even more procedures will be technically feasible. The long-term results of VAT are being awaited in order to define its true merits in thoracic surgery.

Gastric pH and volume after oral fluids in the postpartum patient

The aim of this study was to investigate the relationship between preoperative oral fluids and gastric pH and volume in women undergoing sterilization between one and five days postpartum. Fifty postpartum patients received 150 ml water approximately two to three hours before surgery while 50 postpartum and 50 non-pregnant women were fasted from midnight. After induction of anaesthesia, gastric contents were aspirated using a Salem sump tube and the gastric pH and volume were measured. There were no differences in intragastric pH and volume, median (range), among the postpartum fasted group, 1.19 (0.74-4.57), 22 (1-78) ml, postpartum water group 1.18 (0.70-6.4), 25.5 (3-66) ml and the non-pregnant group 1.27 (0.51-6.63), 25 (3-69) ml. There was no correlation between postpartum interval, 60 (12-120) hr, and intragastric pH or volume. It is concluded that oral water may be given safely two to three hours preoperatively to patients more than one day postpartum. Intragastric volume and acidity were not increased and the findings in postpartum patients were similar to those found in non-pregnant patients.

[Effect of lateral position and chest percussion on pulmonary gas exchange in patients with decreased level of consciousness]

The purpose of this study is to verify the effect of lateral position and chest percussion on gas exchange in the decreased level of conscious patients. The Subjects for this study were 21 patients 'admitted in ICU of CNUH from Dec 18th, 1989 to Aug 4th, 1990. The Data was analyzed by paired t-test. The results of this study as follows: 1) In comparison of supine position, good-lung dependent position and good-lung dependent with chest percussion, the difference of PaO. was statistically significant (P less than 0.05). 2) In comparison of supine position, good-lung dependent position and good-lung dependent with chest percussion, the difference of A-a Do. was statistically significant (p less than 0.05). In conclusion, the use of good-lung dependent position and chest percussion was effective nursing intervention on decreased level of conscious patients in ICU.

Tubeless anaesthesia for microlaryngeal surgery

An anaesthetic technique for laryngeal microsurgery is described and evaluated using intravenous propofol infusion and topical lignocaine with the patient breathing spontaneously without an endotracheal tube. Eighty adult patients divided into two groups according to their ASA status (Group A; 58 ASA I and II; Group B; 22 ASA III and IV) were analysed. Operating conditions were good in all but one case. Good anaesthesia was achieved in about 70% of patients. The requirement for propofol was less in Group B. Blood pressures decreased significantly following induction (P less than 0.001) but returned towards the preoperative values after ten minutes in Group A patients whereas the recovery was slower in Group B. Apnoea occurred on induction in about 40% of patients overall. PaCO2 showed a similar small increase in both groups. Oxygenation was adequate. The results show that propofol as an infusion in this simple tubeless technique is satisfactory. As the technique was considered potentially hazardous in those patients with upper airway obstruction, such patients were not included in this study.