Tools for structured team communication in pre-registration health professions education: a Best Evidence Medical Education (BEME) review: BEME Guide No. 41

INTRODUCTION

Calls for the inclusion of standardized protocols for information exchange into pre-registration health professions curricula have accompanied their introduction into clinical practice. In order to help clinical educators respond to these calls, we have reviewed educational interventions for pre-registration students that incorporate one or more of these ?tools for structured communication?.

METHODS

Searches of 10 databases (1990?2014) were supplemented by hand searches and by citation searches (to January 2015). Studies evaluating an intervention for pre-registration students of any clinical profession and incorporating at least one tool were included. Quality of included studies was assessed using a checklist of 11 indicators and a narrative synthesis of findings undertaken.

RESULTS

Fifty studies met our inclusion criteria. Of these, 21 evaluated the specific effect of a tool on educational outcomes, and 27 met seven or more quality indicators.

CONCLUSIONS

Pre-registration students, particularly those in the US, are learning to use tools for structured communication either in specific sessions or integrated into more extensive courses or programmes; mostly 'Situation Background Assessment Recommendation' and its variants. There is some evidence that learning to use a tool can improve the clarity and comprehensiveness of student communication, their perceived self-confidence and their sense of preparedness for clinical practice. There is, as yet, little evidence for the transfer of these skills to the clinical setting or for any influence of teaching approach on learning outcomes. Educators will need to consider the positioning of such learning with other skills such as clinical reasoning and decision-making.

Preconditioning of Cardiosphere-Derived Cells With Hypoxia or Prolyl-4-Hydroxylase Inhibitors Increases Stemness and Decreases Reliance on Oxidative Metabolism

Cardiosphere-derived cells (CDCs), which can be isolated from heart explants, are a promising candidate cell source for infarcted myocardium regeneration. However, current protocols used to expand CDCs require at least 1 month in vitro to obtain sufficient cells for transplantation. We report that CDC culture can be optimized by preconditioning the cells under hypoxia (2% oxygen), which may reflect the physiological oxygen level of the stem cell niche. Under hypoxia, the CDC proliferation rate increased by 1.4-fold, generating 6 × 10(6) CDCs with higher expression of cardiac stem cell and pluripotency gene markers compared to normoxia. Furthermore, telomerase (TERT), cytokines/ligands involved in stem cell trafficking (SDF/CXCR-4), erythropoiesis (EPO), and angiogenesis (VEGF) were increased under hypoxia. Hypoxic preconditioning was mimicked by treatment with two types of hypoxia-inducible factor (HIF) prolyl-4-hydroxylase inhibitors (PHDIs): dimethyloxaloylglycine (DMOG) and 2-(1-chloro-4-hydroxyisoquinoline-3-carboxamido) acetic acid (BIC). Despite the difference in specificity, both PHDIs significantly increased c-Kit expression and activated HIF, EPO, and CXCR-4. Furthermore, treatment with PHDIs for 24 h increased cell proliferation. Notably, all hypoxic and PHDI-preconditioned CDCs had decreased oxygen consumption and increased glycolytic metabolism. In conclusion, cells cultured under hypoxia could have potentially enhanced therapeutic potential, which can be mimicked, in part, by PHDIs.

Differential gene expression of activating Fcγ receptor classifies active tuberculosis regardless of human immunodeficiency virus status or ethnicity

New diagnostics and vaccines for tuberculosis (TB) are urgently needed, but require an understanding of the requirements for protection from/susceptibility to TB. Previous studies have used unbiased approaches to determine gene signatures in single-site populations. The present study utilized a targeted approach, reverse transcriptase multiplex ligation-dependent probe amplification (RT-MLPA), to validate these genes in a multisite study. We analysed ex vivo whole blood RNA from a total of 523 participants across four sub-Saharan countries (Ethiopia, Malawi, South Africa, and The Gambia) with differences in TB and human immunodeficiency virus (HIV) status. We found a number of genes that were expressed at significantly lower levels in participants with active disease than in those with latent TB infection (LTBI), with restoration following successful TB treatment. The most consistent classifier of active disease was FCGR1A (high-affinity IgG Fc receptor 1 (CD64)), which was the only marker expressed at significantly higher levels in participants with active TB than in those with LTBI before treatment regardless of HIV status or genetic background. This is the first study to identify a biomarker for TB that is not affected by HIV status or geo-genetic differences. These data provide valuable clues for understanding TB pathogenesis, and also provide a proof-of-concept for the use of RT-MLPA in rapid and inexpensive validation of unbiased gene expression findings.

Population structure, mitochondrial polyphyly and the repeated loss of human biting ability in anopheline mosquitoes from the southwest Pacific

Australia and New Guinea contain high levels of endemism and biodiversity, yet there have been few evaluations of population-level genetic diversity in fauna occurring throughout the Australo-Papuan region. Using extensive geographical sampling, we examined and compared the phylogenetic relationships, phylogeography and population structure of Anopheles farauti, An. hinesorum and An. irenicus throughout their ranges in the southwest Pacific using mitochondrial (mtDNA COI) and nuclear (ribosomal protein S9 and ribosomal DNA ITS2) loci. Phylogenetic analyses suggest that the ability to utilize humans as hosts has been lost repeatedly, coincident with independent colonizations of the Solomon Islands. As some of the species under investigation transmit malaria in the region, this is a medically important finding. Maximum likelihood and Bayesian phylogenetic analyses of nuclear loci also showed that the three species are monophyletic. However, putative introgression of An. hinesorum mtDNA onto a nuclear background of An. farauti was evident in populations from Queensland, Torres Strait and southern New Guinea. Haplotype networks and pairwise F(ST) values show that there is significant genetic structure within New Guinea and Australia in both An. farauti and An. hinesorum, consistent with a long-term history of low gene flow among populations.

Abstract P027: Preconditioning Cardiosphere-Derived Cells by Hypoxia and Prolyl Hydroxylase Inhibitors to Induce HIF-Related Metabolic Changes and C-Kit Expression

Cardiosphere-derived cells (CDCs) decrease loss of cardiac function following infarction, but the potential of CDC therapy is limited due to the low retention rate and the time required to obtain sufficient cells for transplantation.

AIM: Here, we aimed to precondition CDCs by culturing under hypoxia, or with prolyl hydroxylase inhibitors (PHIs), to prepare the cells for the hypoxic environment within the infarcted heart.

METHODS: Rat heart explants were cultured under hypoxia (2% O2) or normoxia (21% O2) to generate explant-derived cells (EDC). EDCs were isolated, cultured to form cardiosphere and expanded into monolayer CDCs. At 80% confluency, normoxic CDCs were treated with dimethyloxalyl glycine (DMOG), Ethyl 2-(2,3-dihyroxybenzamido) (KKC226) and FG-2216 for 24 h.

RESULTS: Hypoxia, 1 mM DMOG, 0.5 mM KKC226 and 30 μM FG-2216 treated CDCs showed significantly increased HIF-1α protein expression (3.9-fold, 2.6-fold, 2.1-fold and 1.5-fold, respectively) and reduced oxygen consumption (81%, 32%, 47% and 35%, respectively), compared with normoxic CDCs. Hypoxia and PHI treatment increased protein levels of GLUT-1 (6.7-fold, 3.2-fold, 4.0-fold and 2.1-fold, respectively), resulting in significant increases in glucose uptake and lactate accumulation in the culture medium, compared with controls, commensurate with increased glycolytic metabolism after hypoxia or PHI treatment. Further, hypoxia and KKC226 increased c-Kit mRNA expression 5.1-fold and 1.5-fold, respectively. qRT-PCR confirmed increased CXCR-4 mRNA in all hypoxia and PHI-treated CDCs. EDC and CDC proliferation were 1.7-fold faster under hypoxia, compared with normoxia, but did not increase with PHI treatment.

CONCLUSION: Hypoxia and PHIs stabilized and activated HIF, which induced metabolic changes in CDCs, including GLUT-1 upregulation and a switch to anaerobic glycolytic metabolism. All preconditioned cells had reduced oxygen consumption and were better adapted to survive within an hypoxic infarct scar. HIF-induced upregulation of CXCR-4 may increase the homing of these cells to the infarcted myocardium. Finally, increased proliferation and expression of the cardiac stem cell marker, c-Kit, could decrease the time required for cell expansion prior to therapy by a week.

A training programme for refugee doctors

Apart from the difficulties of being refugees in a foreign land, refugee doctors face complex difficulties in re-entering their medical career in the UK. All must pass the International English Language Testing System with high scores as specified by the General Medical Council, and the vast majority must pass the Professional and Linguist Assessments Board (PLAB) test before they are permitted to practice.

A questionnaire study of GPs' and patients' beliefs about the different components of patient centredness

Much research has explored the interaction between doctor and patient in the consultation and patient centredness has generally emerged as the preferred mode of consultation style. The present study aimed to examine and compare general practitioners' (GPs) and patients' beliefs about the importance of the different aspects of patient centred behaviour in a consultation. Matched questionnaires were completed by 410 patients (response rate=76.5%) and 64 GPs (response rate=85.3%) from practices around London concerning aspects of patient centredness operationalized in terms of doctor receptiveness, patient involvement, the affective content of the relationship and information giving. The results showed that GPs and patients showed similar beliefs about involving the patient in decision making, aspects of doctor receptiveness and the importance of the patient's own feelings in the consultation. However, GPs believed that it was less important to focus only on the patient's main problem, and more important to acknowledge their own feelings and avoid medical language. Further, GPs rated doctor receptiveness and the affective content of the relationship overall as more important for a good consultation than the patients. The patients also consistently rated information giving as more important than the GPs. To conclude, GPs rated the doctor receptiveness and affective components of patient centredness as more important than patients whereas patients showed greater endorsement of information indicating that although patient centredness may currently be the preferred style of consultation, doctors and patients prefer different aspects of this behaviour.

Identification of a chromosomal Shigella flexneri multi-antibiotic resistance locus which shares sequence and organizational similarity with the resistance region of the plasmid NR1

The ampicillin resistance gene from Shigella flexneri 2a strain YSH6000 was cloned and shown by Southern hybridization analysis to be closely linked to the previously cloned streptomycin, chloramphenicol, and tetracycline resistance determinants, which are borne on a chromosomally integrated 99-kb element. Analysis of this chromosomal multi-antibiotic resistance locus revealed that it had a high level of sequence and organizational similarity to an equivalent region of the Shigella R-plasmid, NR1. However, the chromosomal locus exhibited several differences, including the presence of two stretches of sequence derived from IS elements, the precise insertion of a beta-lactamase encoding oxal cassette into the Tn21-borne integron In2, a possible 17.5-kb deletion, and the loss or inactivation of the mercury resistance determinant. Based on these data, it is proposed that the chromosomal locus arose following integration of an NR1-like plasmid.

Lunate-triquetral and midcarpal joint instability

Instability of the ulnar side of carpus centers around the triquetrum, which is suspended by the ulnar triquetral ligaments and supported proximally by the TFCC. The triquetrum guides the lunate by an interosseous membrane and stout palmar ligaments that provide a relatively rigid connection between the two bones. Disruption of the LT ligament is frequently associated with pathology in the ulnar carpal area and may progress to triquetral instability, VISI, and finally, degenerative arthritic changes on the ulnar side of the carpus. The diagnosis of LT injuries is made by stress radiographs, arthrography, video-fluoroscopy, and arthroscopy. Treatment is initially nonoperative, but if symptoms persist, surgery is warranted. Arthroscopic debridement and pinning the LT joint, ligament repair or reconstruction, and intercarpal arthrodesis have all been reported as successful treatments. For the chronic problem confined to the LT joint, a limited intercarpal arthrodesis of the joint is the most predictable procedure for relieving pain without causing any significant restrictions in wrist motions. When there is a dissociation pattern in addition to LT instability, a more extensive intercarpal arthrodesis is required. Midcarpal instability occurs at the triquetral-hamate joint and is characterized by a dynamic subluxation of the joint. During ulnar deviation, the joint undergoes an exaggerated shift from volar flexion to dorsiflexion. Supportive care is generally successful; although in chronic cases, a midcarpal joint arthrodesis is often required.

The effects of scaphoid intercarpal stabilizations on wrist mechanics: an experimental study

A fresh cadaver study of the effects of a variety of scaphoid stabilizations on wrist motions is reported. Scaphoid-trapezium-trapezoid stabilizations with the scaphoid in its normal anatomic position and the same stabilizations with the scaphoid in malposition, either vertical or horizontal in relation to the radius, were compared. Scaphoid-capitate stabilizations with the scaphoid in its normal position were also studied. With the scaphoid vertical, a scaphoid-trapezium-trapezoid stabilization resulted in greater loss of wrist flexion and ulnar deviation whereas, with the scaphoid horizontal, wrist extension and radial deviation were more severely affected than when the scaphoid was stabilized in its normal position. With the scaphoid in its anatomic position, both scaphoid-trapezium-trapezoid and scaphoid-capitate stabilizations resulted in similar patterns of wrist motion.

Malunited Colles' fractures: correction with a biplanar closing wedge osteotomy

A malunited Colles' fracture causes distortion of three anatomic features of the distal radius: length of the bone and the angles of its articular surface in both frontal and sagittal planes. The relative importance of each of these factors was studied in a series of 14 patients with malunited Colles' fractures and severe disabilities. Reversal of the normal palmar tilt of the distal radius in the sagittal plane was the most consistent and serious deformity of the bone, and in five patients it was associated with dorsal subluxation of the entire carpus. Correction of the malunion was achieved with a biplanar closing wedge osteotomy without a bone graft. Resection of the ulna head and decompression of the median nerve within the carpal tunnel were done to reduce the likelihood that additional surgery would be required in the future.

Excision of the distal ulna in rheumatoid arthritis

Resection of the ulna is an effective operation in the treatment of rheumatoid disorders of the distal radioulnar joint. Tenosynovectomies of the overlying extensor tendons and synovectomy of the joint are integral parts of the procedure. Following resection, the ulna usually remains in alignment with the radius, although some dorsal displacement is common. Restoring stability to the ulna as well as reconstructing a new sheath for the extensor carpi ulnaris can be accomplished in most cases by using the extensor retinaculum. In those cases where the retinaculum has been destroyed by the disease process or when the distal ulna is severely displaced, stability can be restored using the extensor carpi ulnaris for a tenodesis.

Boxer's knuckle--dorsal capsular rupture of the metacarpophalangeal joint of a finger

An injury to the dorsal aspect of the metacarpophalangeal joint of a finger usually damages the sagittal fibers of the extensor tendon mechanism. Rupture of the underlying joint capsule, a far more serious injury, has received scant attention in the medical literature. The problem is often unrecognized because the extensor tendon may remain in its normal midline position. Eight dorsal capsular ruptures are described in six patients who had closed direct trauma to either the knuckle of their index or long fingers. Most of the injuries occurred in professional boxers.

Intrinsic muscle advancement to treat chronic palmar instability of the metacarpophalangeal joint of the thumb

Chronic palmar instability of the metacarpophalangeal joint of the thumb can result in a significant disability. Grasp, particularly pinch, is painful and weak because the thumb goes into hyperextension. Stabilization of the metacarpophalangeal joint can be achieved by distal advancement of the conjoined tendon of the abductor pollicis brevis and lateral fibers of the flexor pollicis brevis.