Student advanced trauma management and skills (SATMAS): a validation study.

INTRODUCTION: Despite trauma accounting 9% of global mortality, it has been demonstrated that undergraduate trauma teaching is inadequate nationally and worldwide. With COVID-19 exacerbating this situation, a scalable, accessible, and cost-effective undergraduate trauma teaching is required. METHODS: Our Continual Professional Development United Kingdom (CPUDK)-accredited University Hospitals Birmingham (UHB) Major Trauma Service (MTS) affiliated programme consisted of seven biweekly pre-recorded sessions that were delivered online through the Moodle educational platform to University of Birmingham students. Pre- and post-randomised session-specific multiple-choice questions (MCQs) and anonymous feedback forms were administered. RESULTS: There were 489 student responses, with 63 students completing all seven sessions. On an 8-point scale, students' objective knowledge scores increased by a mean of 1.2 (p < 0.001). Using a 5-point Likert scale, students also showed improvement in subjective outcomes including their confidence in assessing trauma patient (absolute difference (AD) 1.38, p < 0.001), advising initial investigations and formulating initial management plans (AD 1.78, p < 0.001) and thereby their confidence to manage a trauma patient overall (AD 1.98, p < 0.001). A total of 410 student responses endorsed the online delivery of SATMAS through Moodle and recommended SATMAS to future medical students. CONCLUSION: SATMAS has demonstrated positive student feedback and extensive recruitment from only one centre, demonstrating that our programme can be an indispensable low-cost learning resource that prepares undergraduate medical students for their trauma exams and informs the implementation of clinical skills required by all doctors. We publish our pilot study findings to encourage similar teaching programmes to be adopted at other universities nationally and internationally, to synergistically benefit students, tutors, and ultimately patients, on a larger scale.

Evaluation of National Anaesthetics Teaching in Undergraduate Medicine (ENATUM).

BACKGROUND: During a global pandemic where anaesthetists play a pertinent role in treating coronavirus 2019 (COVID-19), it is crucial to inspire medical students to consider a career in anaesthetics and perioperative care. Where anaesthetic skills are vital for all surgical foundation doctors, regardless of whether they have a rotation in anaesthetics, this study seeks to establish the current level of exposure to anaesthetics in the UK medical schools' curriculum and evaluate if the current anaesthetic undergraduate curriculum is sufficient to prepare students to pass their exams and perform the duties expected of them as future junior doctors. METHODS: A 35-item structured questionnaire, registered at University College London Hospital Research & Development (R&D), was distributed amongst foundation doctors who had graduated from UK universities within the previous 3 years between August and October 2020. RESULTS: In total, 239 participants completed the questionnaire from 34 UK medical schools. Despite 90.0% of participants being allocated an 'anaesthesia' placement, 54.0% spent <15 hours shadowing an anaesthetist throughout their medical school. Of participants, 38.5% agreed that their anaesthetic teaching was sufficient compared to teaching of other specialities, with 48.6% of students not satisfied with the teaching provided to meet anaesthetic learning outcomes set by The Royal College of Surgeons of England; 72.4% said they would have benefited from additional anaesthetic teaching, with 80.7% stating it would have increased understanding into the speciality; and 71.5% stated a short course in anaesthetics alongside undergraduate training would have been beneficial. CONCLUSIONS: Our results demonstrate that there is a lack of standardization in undergraduate anaesthetics teaching nationally and an additional undergraduate anaesthetic teaching programme is required to increase understanding and provide further insight into anaesthetics. Key messages:  The emergence of the coronavirus 2019 (COVID-19) pandemic has halted undergraduate medical education, in particular perioperative medicine and surgery.Exposure to anaesthesia is already limited in the medical undergraduate curriculum, with a limited number of anaesthesia-themed foundation rotations available for junior doctors.Recent UK graduates feel that undergraduate anaesthetics education is inadequate at medical school, reporting a lack of confidence in applying undergraduate anaesthesia learning outcomes.Additional anaesthetic teaching and online teaching methods are suggested ways of improving the delivery of undergraduate anaesthetic education.Can a national, standardized anaesthetics teaching curriculum improve the undergraduate knowledge base of anaesthesia?

Improved outcome in penile cancer with radiologically enhanced stratification protocol for lymph node staging procedures: a study in 316 inguinal basins with a mean follow-up of 5 years.

BACKGROUND: Lymph node metastasis is the main determinant of survival in penile cancer patients. Conventionally clinical palpability is used to stratify patients to Inguinal Lymph node dissection (ILND) if clinically node positive (cN +) or Dynamic sentinel node biopsy (DSNB) if clinically node negative (cN0). Studies suggest a false negative rate (FNR) of around 10% (5-13%) for DSNB. To our knowledge there are no studies reporting harder end point of survival and outcomes of all clinically node positive (cN +) patients. We present our outcome data of all patients with penile cancer including false negative rates and survival in both DSNB and ILND groups. METHODS: One hundred fifty-eight consecutive patients (316 inguinal basins), who had lymph node surgery for penile cancer in a tertiary referral centre from Jan 2008 to 2018, were included in the study. All patients underwent ultrasound (US) ± fine needle aspiration cytology (FNAC) and then MRI/ CT, if needed, to stage their disease. We used combined clinical and radiological criteria (node size, architecture loss, irregular margins) to stratify patients to DSNB vs ILND as opposed to clinical palpability alone. RESULTS: 11.2% i.e., 27/241 inguinal basins had lymph node positive disease by DSNB. 54.9% i.e., 39/71 inguinal basins (IBs) had lymph node-positive disease by ILND. 4 inguinal basins with no tracer uptake in sentinel node scans are being monitored at patient's request and have not had any recurrences to date. With a mean follow-up of 65 months (range 24-150), the false-negative rate (FNR) for DSNB is 0%. Judicious uses of cross-sectional imaging necessitated ILND in 2 inguinal basins with non-palpable nodes and negative US with false positive rate of 6.3% (2/32) for ILND. The same cohort of DSNB patients might have had 11.1% (3/27) FNR if only palpability criteria was used. 43 (28%) patients who did require cross sectional imaging as per our criteria had a low node positive rate of 4.7% (p = 0.03). Mean cancer specific survival of all node-positive patients was 105 months. CONCLUSION: The performance of DSNB improved with enhanced radiological stratification of patients to either DSNB or ILND. We for the first time report the comprehensive outcome of all lymph node staging procedures in penile cancer.

Anaesthetic National Teaching Programme for Students (ANTPS).

The COVID-19 pandemic has significantly undermined undergraduate anaesthetic teaching in spite of the vital role of the specialty against the pandemic. Anaesthetic National Teaching Programme for Students (ANTPS) was designed to meet the evolving needs of undergraduates and tomorrow's doctor by standardising anaesthetic training, preparing for final exams and equipping competencies vital for doctors of all grades and specialties. Our Royal College of Surgeons England-accredited University-College-Hospital-affiliated programme consisted of six-biweekly sessions were delivered online by anaesthetic trainees. Prerandomised and postrandomised session-specific multiple-choice questions (MCQs) assessed students' improvement in knowledge. Anonymous feedback forms were provided to students after each session and 2 months following the programme. 3743 student feedback forms (92.2% of attendees) across 35 medical-schools were recorded. There was a mean improvement in test score (0.94±1.27, p<0.001). 313 students completed all six sessions. Based on 5-point Likert scale, students who completed the programme showed an improvement in their confidence in knowledge and skills to face common foundation challenges (1.59±1.12, p<0.001) and thus felt better prepared for life as junior doctors (1.60±1.14, p<0.001). With an increase in confidence in students to pass their MCQs, Observed Structured Clinical Examinations and case-based discussion assessments, 3525 students stated they would recommend ANTPS to other students. Unprecedented COVID-19 factors impacting training, positive student feedback and extensive recruitment, demonstrate that our programme is an indispensable learning resource which standardises anaesthetic undergraduate education nationally, prepares undergraduates for their anaesthetic and perioperative exams and lays strong foundations for implementation of clinical skills required by all doctors, to optimise training and patient care.

National evaluation of trauma teaching for students (NETTS).

Despite the shift towards consultant-led care, many patients with trauma are still seen by junior doctors. Previous research has demonstrated that junior doctors feel unprepared to work in acute care but there is a paucity of recent research in trauma specifically. Thus, a national study is required to investigate the current state of undergraduate trauma teaching and identify specific areas for improvement. Between August and September 2020, a 35-item structured questionnaire was distributed among doctors who graduated from UK medical schools within the last 4 years. The questionnaire retrospectively assessed their experience of trauma teaching at medical school and their confidence to diagnose and manage patients with trauma. 398 responses were recorded from graduates of 39 UK medical schools. With 79.6% reporting only 0-5 hours of bedside trauma teaching and 51.8% reporting less than 20 hours in Accident and Emergency, graduates reported that trauma teaching was deficient compared with other specialties (78.1%). The majority of graduates were not confident in the initial assessment (72.9%) of a patient with trauma and almost all felt that a short course in trauma would be useful (93.7%). 77.4% of students felt that online learning would be beneficial and 92.9% felt that simulation would be useful. There is lack of standardised undergraduate trauma teaching nationally; a formal undergraduate teaching to ensure that new graduates are competent in the management of trauma would be supported by students. It is likely that a blended learning approach, incorporating e-learning with traditional teaching and clinical experience would be well received.

PGC-1α induced mitochondrial biogenesis in stromal cells underpins mitochondrial transfer to melanoma.

INTRODUCTION: Progress in the knowledge of metabolic interactions between cancer and its microenvironment is ongoing and may lead to novel therapeutic approaches. Until recently, melanoma was considered a glycolytic tumour due to mutations in mitochondrial-DNA, however, these malignant cells can regain OXPHOS capacity via the transfer of mitochondrial-DNA, a process that supports their proliferation in-vitro and in-vivo. Here we study how melanoma cells acquire mitochondria and how this process is facilitated from the tumour microenvironment. METHODS: Primary melanoma cells, and MSCs derived from patients were obtained. Genes' expression and DNA quantification was analysed using Real-time PCR. MSC migration, melanoma proliferation and tumour volume, in a xenograft subcutaneous mouse model, were monitored through bioluminescent live animal imaging. RESULTS: Human melanoma cells attract bone marrow-derived stromal cells (MSCs) to the primary tumour site where they stimulate mitochondrial biogenesis in the MSCs through upregulation of PGC1a. Mitochondria are transferred to the melanoma cells via direct contact with the MSCs. Moreover, inhibition of MSC-derived PGC1a was able to prevent mitochondrial transfer and improve NSG melanoma mouse tumour burden. CONCLUSION: MSC mitochondrial biogenesis stimulated by melanoma cells is prerequisite for mitochondrial transfer and subsequent tumour growth, where targeting this pathway may provide an effective novel therapeutic approach in melanoma.

F1-taught orthopaedic teaching programme for students (FOTS).

INTRODUCTION: The COVID-19 pandemic has impacted students learning, with the time off resulting in students 'de-skilling', increasing concerns for upcoming observed structured clinical examinations. Foundation Year 1 (F1) doctors (F1s), despite being expected to teach, rarely receive formal preparation, with COVID-19 exacerbating opportunities to practice. As such, a national orthopaedic teaching programme was designed to provide F1s with opportunities to develop their teaching skills and to synergistically teach medical students how to perform clinical orthopaedic examinations. METHODS: Six weekly sessions, each delivered by two newly qualified F1 tutors, on each joint examination were delivered online via Zoom Video Communications (USA). Presession and postsession multiple choice questions (MCQs) were provided to students to assess improvement in knowledge. Anonymous feedback forms were provided to both students and tutors. RESULTS: Of the 341 students that attended, 87.1% provided feedback. 86.2% felt that they had de-skilled due to time off, with a mean 15 weeks off from placement. Based on a 5-point Likert scale, students displayed a mean improvement in confidence (1.9±1.1, p<0.001) and MCQ scores (1.4±1.3, p<0.001) before and after the sessions. 91.6% and 95.3% agreed that the use of online teaching increased attendance and laid the foundation for practice. Of the six tutors, all reported improvement in confidence to teach and teaching skills. CONCLUSION: We demonstrate that online delivery of clinical orthopaedic examinations is effective, increasing the knowledge and confidence of students, while providing opportunities for F1s to teach. We present our findings to encourage similar teaching programmes to be adopted at other locations and specialties, to synergistically benefit students, doctors and ultimately, patients.

Higher Component Malposition Rates with Patient-Specific Cruciate Retaining TKA than Contemporary Posterior Stabilized TKA.

Customized individually manufactured total knee arthroplasty (CIM-TKA) was developed to improve kinematic total knee arthroplasty (TKA) performance. Component placement accuracy may influence the success of CIM-TKA designs. We performed this study to compare radiographic component alignment and revision rates of a cruciate retaining (CR) CIM-TKA and a contemporary posterior stabilized TKA (PS-TKA). After obtaining Institutional Review Board approval, we identified 94 CR CIM-TKAs (76 patients) and 91 PS-TKAs (82 patients) performed between July 1, 2013 and December 31, 2014 with a minimum 2-year follow-up (mean 41.1 months, range 24-59 months). We performed a retrospective electronic medical record review to identify patient demographic characteristics and revision procedures performed. Postoperative plain radiographs were reviewed to assess component alignment including cruciate ligament imbalance, femoral overhang, and femoral notching. Demographic characteristics, component malalignment, and revision surgery rates were assessed using a student's t-test or two-tailed Fisher's exact test, with a p-value < 0.05 designating significance. Technical errors were more commonly identified with CR CIM-TKA (29.8 vs. 9.9%, p < 0.001), including higher rates of tibiofemoral instability (13.8 vs. 1.1%, p < 0.01), femoral notching (12.8 vs. 3.3%, p = 0.03), and patellofemoral malalignment (20.2 vs. 7.7%, p = 0.02). CR CIM-TKA had more frequent coronal plane malposition (26.6 vs. 9.9%, p < 0.01) or sagittal plane reconstruction > 3 degrees outside of an optimized range (20.2 vs. 9.9%, p = 0.06). Aseptic revisions occurred more frequently with the CR CIM-TKA design (9.6 vs. 3.3%, p = 0.13). Demographic characteristics were not significantly different between the treatment groups. CR CIM-TKA may improve kinematic performance for patients undergoing knee replacement surgery. However, our study observations suggest that careful attention to surgical technique is important for optimizing implant survivorship with the CR CIM-TKA design. Additional study is needed to determine whether higher revision rates identified during this study are related to patient selection, surgical technique, or implant design.

Clinical Audit Platform for Students (CAPS): a pilot study.

BACKGROUND: A clinical audit measures specific clinical outcomes or processes against a predefined standard. However, many clinicians are unable to carry out audits given their time constraints. Alternatively, medical students may often wish to complete audits early in their career to strengthen their portfolios. As such, the student clinical audit platform was designed to connect willing supervisors and these medical students. METHODS: Project supervisors were members of a regional trainee-led network. Interested students were familiarised with the various aspects of an audit and allocated to supervisors with similar interests. There was regular communication to track progress and anonymised feedback forms were distributed to all students and supervisors after a year. RESULTS: A total of 17 responses were received from the 19 students who were involved in a project. Based on a 5-point Likert scale, students displayed a mean improvement in their understanding of a clinical audit (1.18±1.07, p<0.001), the confidence to approach a supervisor (1.29±1.21, p<0.001) and the ability to conduct an audit by themselves in the future (1.77±1.15, p<0.001). Of the seven affiliated supervisors, five provided feedback with 80% indicating they had projects which remained inactive and all happy with the quality of work produced by their students. CONCLUSION: Despite limitations to this programme, the platform produced projects which were disseminated both locally and nationally, demonstrating positive collaboration between medical students and clinicians. We present our findings and evaluations to encourage similar audit platforms to be adopted at other locations.

Clinical Orthopaedic Teaching programme for Students (COTS).

INTRODUCTION: There is a huge variation in the depth and breadth of content taught regarding orthopaedic examinations. Undergraduate students are often confused by the variability in examination teaching, therefore increasing concerns for upcoming objectively structured clinical examinations (OSCEs). Doctors, despite being expected to teach, rarely receive formal preparation, with only a handful of institutions providing necessary training. The Clinical Orthopaedic Teaching programme for Students (COTS) was designed to equip medical students with the knowledge to perform orthopaedic examinations and to synergistically provide senior students with the necessary experience for the future teaching required of them. METHODS: Six fortnightly sessions were delivered, each focusing on a specific joint examination. Student and tutor recruitment were voluntary. Pre-session and post-session multiple-choice questions (MCQs) were provided to students to assess improvement in knowledge. Anonymous feedback forms were provided to both students and tutors. RESULTS: From 61 student responses, 98.4% of students stated that COTS met the learning outcomes, with content relevant for their medical curriculum. 96.7% supported COTS' near-peer teaching (NPT) style for OSCE preparation. Based on a five-point Likert scale, students displayed a mean improvement in confidence (1.7±1.2, p<0.001) and MCQ scores (1.3±1.2, p<0.001). All 10 tutors perceived an improvement of their teaching skills and confidence to teach (1.0±0.9, p=0.016). CONCLUSION: COTS shows that an NPT style can be used to effectively teach orthopaedic examinations, with benefits for students and tutors. With our aim to refine and upscale this programme, we publish our pilot study findings to encourage similar teaching programmes to be adopted at other universities.

Mitochondrial oxidative phosphorylation in cutaneous melanoma.

The Warburg effect in tumour cells is associated with the upregulation of glycolysis to generate ATP, even under normoxic conditions and the presence of fully functioning mitochondria. However, scientific advances made over the past 15 years have reformed this perspective, demonstrating the importance of oxidative phosphorylation (OXPHOS) as well as glycolysis in malignant cells. The metabolic phenotypes in melanoma display heterogeneic dynamism (metabolic plasticity) between glycolysis and OXPHOS, conferring a survival advantage to adapt to harsh conditions and pathways of chemoresistance. Furthermore, the simultaneous upregulation of both OXPHOS and glycolysis (metabolic symbiosis) has been shown to be vital for melanoma progression. The tumour microenvironment (TME) has an essential supporting role in promoting progression, invasion and metastasis of melanoma. Mesenchymal stromal cells (MSCs) in the TME show a symbiotic relationship with melanoma, protecting tumour cells from apoptosis and conferring chemoresistance. With the significant role of OXPHOS in metabolic plasticity and symbiosis, our review outlines how mitochondrial transfer from MSCs to melanoma tumour cells plays a key role in melanoma progression and is the mechanism by which melanoma cells regain OXPHOS capacity even in the presence of mitochondrial mutations. The studies outlined in this review indicate that targeting mitochondrial trafficking is a potential novel therapeutic approach for this highly refractory disease.