Virtual ARCP assessment and trainee feedback meetings: facilitating the best experience and practice.

As a result of COVID-19, there has been an exponential increase in the use of remote technology for many local, regional and national meetings that would previously have been held on a face-to-face basis. Remote meetings have ensured that essential clinical, educational and strategic work can continue but it is not 'business as usual', although colleagues accept this form of communication as the new norm. In medical education and assessment, the Annual Review of Competence Progression (ARCP) meetings and other formative educational meetings are being conducted remotely. This form of communication has some advantages but may also present possible barriers for feedback and development particularly for 'trainees in difficulty' when there are concerns about progression, and when an unsatisfactory outcome has been awarded. It is also worth remembering that there may be generational differences with the ease of use of virtual meeting platforms. We present some of the important factors for optimising the panel of virtual ARCPs and discuss methods to improve feedback given remotely for trainees.

Health literacy and the perception of risk in a breast cancer family history clinic.

BACKGROUND: Informed consent is an essential component of medical practice, and especially so in procedural based specialties which entail varying degrees of risk. Breast cancer is one of the most common cancers in women, and as such is the focus of extensive research and significant media attention. Despite this, considerable misperception exists regarding the risk of developing breast cancer. AIMS: This study aims to examine the accuracy of risk perception of women attending a breast cancer family history clinic, and to explore the relationship between risk perception accuracy and health literacy. METHODS: A cross-sectional study of women attending a breast cancer family history clinic (n = 86) was carried out, consisting of a patient survey and a validated health literacy assessment. Patients' perception of personal and population breast cancer risk was compared to actual risk as calculated by a validated risk assessment tool. RESULTS: Significant discordance between real and perceived risks was observed. The majority (83.7%) of women overestimated their personal lifetime risk of developing breast cancer, as well as that of other women of the same age (89.5%). Health literacy was considered potentially inadequate in 37.2% of patients; there was a correlation between low health literacy and increased risk perception inaccuracy across both personal ten-year (rs = 0.224, p = 0.039) and general ten-year population estimations. (rs = 0.267, p = 0.013). CONCLUSION: Inaccuracy in risk perception is highly prevalent in women attending a breast cancer family history clinic. Health literacy inadequacy is significantly associated with this inaccuracy.

What happens to the heart in chronic kidney disease?

Cardiovascular disease is common in patients with chronic kidney disease. The increased risk of cardiovascular disease seen in this population is attributable to both traditional and novel vascular risk factors. Risk of sudden cardiac or arrhythmogenic death is greatly exaggerated in chronic kidney disease, particularly in patients with end stage renal disease where the risk is roughly 20 times that of the general population. The reasons for this increased risk are not entirely understood and while atherosclerosis is accelerated in the presence of chronic kidney disease, premature myocardial infarction does not solely account for the excess risk. Recent work demonstrates that the structure and function of the heart starts to alter early in chronic kidney disease, independent of other risk factors. The implications of cardiac remodelling and hypertrophy may predispose chronic kidney disease patients to heart failure, arrhythmia and myocardial ischaemia. Further research is needed to minimise cardiovascular risk associated with structural and functional heart disease associated with chronic kidney disease.

Can an educational application increase risk perception accuracy amongst patients attending a high-risk breast cancer clinic?

OBJECTIVES: To design, develop and test the effect of an educational initiative to improve risk perception amongst patients attending a high-risk breast cancer clinic. This was achieved through three objectives - 1. identifying an optimal method of presenting risk data, 2. designing and building a risk application, and 3. testing the ability of the application to successfully modify patients perceived risk of cancer. MATERIALS AND METHODS: A mobile application was developed for this project using best practice methods for displaying risk information. Patients (n = 84) were randomly allocated into two groups - 'Control' or 'Treatment'. Both groups underwent standard risk counseling while the application was employed in the 'Treatment' group. The patients were surveyed before their session, immediately after and six weeks later. RESULTS: Increases in accuracy were seen in both groups with larger increases demonstrated in the 'Treatment' group with 'Personal 10 Year Risk' statistically significant ('Control' group increase from 21% to 48% vs the 'Treatment' group increase from 33% to 71% - p = 0.003). CONCLUSION: This project demonstrated trends towards improved risk perception, however mixed logistic regression was unable to show a 30% difference between groups. Numerical literacy and understanding of risk were identified as issues amongst the general population. Overestimating risk remains high amongst attendees. Using mobile applications to convey risk information to patients is a new and evolving area with a corresponding paucity of data. We have demonstrated its potential and emphasised the importance of designing how this information is communicated to patients in order to make it understandable and meaningful.

Should warfarin or aspirin be stopped prior to prostate biopsy? An analysis of bleeding complications related to increasing sample number regimes.

AIM: To determine whether patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy with increased sampling numbers are more likely to experience bleeding complications and whether warfarin or low-dose aspirin are independent risk factors. MATERIALS AND METHODS: 930 consecutive patients with suspected prostatic cancer were followed up after biopsy. Warfarin/low-dose aspirin was not stopped prior to the procedure. An eight to 10 sample regime TRUS-guided prostate biopsy was performed and patients were offered a questionnaire to complete 10 days after the procedure, to determine any immediate or delayed bleeding complications. RESULTS: 902 patients returned completed questionnaires. 579 (64.2%) underwent eight core biopsies, 47 (5.2%) underwent nine, and 276 (30.6%) underwent 10. 68 were taking warfarin [mean international normalized ratio (INR) = 2.5], 216 were taking low-dose aspirin, one was taking both, and 617 were taking neither. 27.9% of those on warfarin and 33.8% of those on aspirin experienced haematuria. 37% of those on no blood-thinning medication experienced haematuria. 13.2% of those on warfarin and 14.4% of those on aspirin experienced rectal bleeding. 11.5% of those on no blood-thinning medication experienced rectal bleeding. 7.4% of those on warfarin and 12% of those on aspirin experienced haematospermia. 13.8% of those on neither experienced haematospermia. Regression analysis showed a significant association between increasing sampling number and occurrence of all bleeding complication types. There was no significant association between minor bleeding complications and warfarin use; however, there was a significant association between minor bleeding complications and low-dose aspirin use. There was no severe bleeding complication. CONCLUSION: There is an increased risk of bleeding complications following TRUS-guided prostate biopsy with increased sampling numbers but these are minor. There is also an increased risk with low-dose aspirin use; however, there is no increased risk of bleeding complications with warfarin use. These results suggest that up to 10 cores during prostate biopsy remains acceptable safe practice and cessation of warfarin and low-dose aspirin is usually not necessary.

A pain in the neck--imaging in neck sepsis.

Deep neck infection has a high morbidity and mortality and the extent of infection is often difficult to estimate clinically. The complex anatomy and the communication between neck spaces means that infection can spread along fascial planes leading to life-threatening complications such as airway compromise, vascular erosion/thrombosis, neural dysfunction, and ultimately descending necrotizing mediastinitis. Imaging has an important role to play in identifying the extent of infection and the presence of complications.

Ultrasound findings of masses of the paratesticular space.

Ultrasound is a routine investigation for the assessment of scrotal masses. Many of the detected lesions involve the paratesticular structures. The most common paratesticular masses in clinical practice are epididymal cysts and spermatoceles, but there are a large number of other pathologies that can be encountered and may result in diagnostic uncertainty. This review covers a wide range of the common and the rare, but important, causes of paratesticular masses. The ultrasound findings (both typical and atypical) of these lesions are clarified, and emphasis is given to the features that help to differentiate between them.

Immediate and long-term CT appearances following radiofrequency ablation of renal tumours.

The incidence of renal cell carcinoma is increasing and image-guided radiofrequency ablation (RFA) is emerging as a safe and effective primary treatment. Therefore, it is essential for radiologists to appreciate the varied computed tomography (CT) imaging features following RFA. Prompt recognition of residual or recurrent tumour is crucial in facilitating timely re-treatment where necessary. Conversely, involuting, completely ablated lesions may be mistaken for residual disease. Using examples from experience of treating 105 renal tumours over a 5-year period, the spectrum of post-RFA CT appearances will be illustrated.

Late relapse of metastatic non-seminomatous testicular germ cell tumours.

Although the majority of men presenting with non-seminomatous germ cell tumours (NSGCT) are cured, late relapse (occurring more than 2 years after obtaining a complete response to treatment) is increasingly recognized. The typical patterns of disease spread have been well-documented, but the findings at late relapse are more variable and less well-described. We discuss the phenomenon of late relapse, the characteristics of teratoma differentiated (TD), and the issue of long-term imaging surveillance of patients with NSGCT. The potential sites of late relapse of NSGCT and the associated spectrum of imaging appearances are illustrated.

The measurement of liver resection margins.

BACKGROUND: All tissue shrinks to some degree when placed in formalin fixative solution. The degree of shrinkage of liver tissue has particular relevance to the measurement of resection margins, as the current recommendation is that the surgeon should aim to achieve a resection margin of at least 1 cm. We were unable to find any published data concerning shrinkage of liver tissue in formalin. The aim of this study was therefore to quantify the shrinkage of liver specimens in the fixation process. METHODS: Distances of 10, 30 and 50 mm were measured and marked on 18 fresh liver specimens. The specimens were then fixed in 10% formalin solution for 24 h, and the distances were re-measured to assess shrinkage. RESULTS: The observed shrinkage at all three distances was <10% after 24 h in formalin. The degree of shrinkage was statistically significant. CONCLUSION: Although the degree of shrinkage is small, it may be important when considering resection margins of the order of 1 cm and should therefore be taken into account.

Stapled versus sutured gastrointestinal anastomoses in the trauma patient: a multicenter trial.

BACKGROUND: Construction of gastrointestinal anastomoses utilizing stapling devices has become a familiar procedure. In elective surgery, studies have shown no significant differences in complications between stapled and sutured anastomoses. Controversy has recently arisen regarding the accurate incidence of complications associated with anastomoses in the trauma patient. The objective of this multi-institutional study was to determine whether the incidence of postoperative complications differs between stapled and sutured anastomoses following the emergent repair of traumatic bowel injuries. METHODS: Using a retrospective cohort design, all trauma registry records from five Level I trauma centers over a period of 4 years were reviewed. RESULTS: A total of 199 patients with 289 anastomoses were identified. A surgical stapling device was used to create 175 separate anastomoses, while a hand-sutured method was employed in 114 anastomoses. A complication was defined as an anastomotic leak verified at reoperation, an intra-abdominal abscess, or an enterocutaneous fistula. The mean abdominal Abbreviated Injury Scale score and Injury Severity Score were similar in the two cohort groups. Stapling and suturing techniques were evenly distributed in both small and large bowel repairs. Seven of the total 175 stapled anastomoses and none of the 114 hand-sewn anastomoses resulted in a clinically significant leak requiring reoperation (RR = undefined, 95% CI 1.08-infinity, p = 0.04). Each anastomotic leak occurred in a separate individual. Nineteen stapled anastomoses and four sutured anastomoses were associated with an intra-abdominal abscess (RR = 2.7, 95% CI 0.96-7.57, p = 0.04). Enterocutaneous fistula formation was not statistically associated with either type of anastomoses (stapled cohort = 3 of 175 and sutured cohort = 2 of 114). Overall, 22 (13%) stapled anastomoses and 6 (5%) sutured anastomoses were associated with an intra-abdominal complication (RR = 2.08, 95% CI 0.89-4.86, p = 0.076). CONCLUSION: Anastomotic leaks and intra-abdominal abscesses appear to be more likely with stapled bowel repairs compared with sutured anastomoses in the injured patient. Caution should be exercised in deciding to staple a bowel anastomosis in the trauma patient.

The role of dead space ventilation in predicting outcome of successful weaning from mechanical ventilation.

BACKGROUND: The exact mechanism by which tracheostomy results in clinical improvement in respiratory function and liberation from mechanical ventilation remains unknown. Physiologic dead space, which includes both normal and abnormal components of non-gas exchange tidal volume, is a clinical measure of the efficiency of ventilation. Theoretically, tracheostomy should reduce dead space ventilation and improve pulmonary mechanics, thereby facilitating weaning from mechanical ventilation. METHODS: This study compares arterial blood gases (ABG), pulmonary mechanics, including minute ventilation (VE) and dead space ventilation (Vd/Vt) within 24 hours before and after tracheostomy in 45 patients admitted to a surgical intensive care unit. RESULTS: There was no difference noted in patients' ABG or VE. Pre- and posttracheostomy change in Vd/Vt was negligible (50.7 and 10 vs. 51.9 and 11; p = NS). On subgroup analysis, those patients that were weaned from mechanical ventilation with 72 hours of tracheostomy (T3) were compared with those patients weaned from mechanical ventilation 5 days or more after tracheostomy (T+5). Again, no difference was found in pulmonary mechanics or Vd/Vt pre- and posttracheostomy. CONCLUSION: There is minimal improvement in pulmonary mechanics after tracheostomy. The change in physiologic dead space posttracheostomy does not predict the outcome of weaning from mechanical ventilation. Tracheostomy does allow better pulmonary toilet, and easier initiation and removal of mechanical ventilation and control of the upper airway.

Measuring mental health outcomes in a private psychiatric clinic: Health of the Nation Outcome Scales and Medical Outcomes Short Form SF-36.

OBJECTIVE: This study reports on data collected from the routine use of the Health of the Nation Outcome Scales (HoNOS) and the Medical Outcomes Short Form (SF-36). Three main aims were addressed in using these measures: (i) to establish patient disability levels; (ii) to determine the level of treatment effectiveness; and (iii) to explore the ability of these instruments to predict length of stay and mood change. METHOD: The clinician-rate HoNOS and the patient-rated SF-36 were included in the assessment battery, at admission and discharge, of consecutive inpatients (n = 754) at one private psychiatric facility over a 2-year period. RESULTS: The sample, on admission, was comparable in illness severity to levels reported at other Australian private psychiatric facilities. Treatment was shown to be effective, and the degree of changes in HoNOS ratings compared favourably with other private psychiatric facilities. Certain factors underlying the structure of the HoNOS and the SF-36 only weakly predicted length of stay and changes in depression and anxiety levels. CONCLUSION: The HoNOS and the SF-36 provided valid and reliable data on patient function, with the HoNOS being most sensitive to treatment change. However, neither instrument proved useful in predicting length of stay or levels of depression and anxiety at discharge.

Incompetent perforating veins are associated with recurrent varicose veins.

AIMS: we suspected incompetent perforating veins of having a role in the development of recurrent varicose veins in some patients. The aim was to look for an association between perforators and recurrent varicose veins. METHODS: a consecutive group of patients presenting with varicose veins were examined using colour duplex ultrasonography by an experienced vascular technologist. Pathological perforating veins were defined as those exhibiting bi-directional flow and a diameter of 4 mm or greater at the fascia. RESULTS: between September 1998 and July 1999, 204 patients were examined. Primary varicose veins were found in 198 legs (135 patients) and recurrent varicose veins in 91 legs (69 patients). In patients with primary varicose veins, 88 (44%) had incompetent perforators compared to 57 (63%) of those with recurrent varicose veins (Chi-squared, p <0.005). Also, for recurrent varicose veins, the percentage of patients with any given number of incompetent perforators was higher than for primary varicose veins. Overall, there was a higher number of incompetent perforators in those with recurrent veins compared to primary veins and this difference was significant at 95% confidence interval. CONCLUSION: patients with recurrent varicose veins have both a higher prevalence and a greater number of incompetent perforating veins than patients with primary varicose veins.

Needle thoracostomy may not be indicated in the trauma patient.

OBJECTIVE: The aim of this study was to evaluate the usefulness of needle thoracostomy catheter (NTC) placement in trauma. METHODS: A consecutive case series was conducted from November 1996 to September 1997. All patients admitted to a level I trauma centre who had NTCs placed prior to arrival in the Emergency Department were included. No patients were excluded or omitted. During the course of the study 2801 patients were admitted to our trauma centre. Nineteen patients (0.68%) had NTCs placed prior to arrival in the emergency department. RESULTS: Twenty-five needle thoracostomies were performed in 19 patients. This group represented 0.68% of the trauma admissions. Four patients were found to have evidence of a pneumothorax with an air leak (28%). The NTC failed to decompress the chest in one of two patients who had physiologic evidence of a tension pneumothorax. Eleven patients (58%) were endotracheally intubated prior to NTC. CONCLUSIONS: This study suggests that field NTC placements are often ineffective and may be over-used. Further study on the usefulness of NTC is required.

Phenotypic markers as risk factors in schizophrenia: neurocognitive functions.

OBJECTIVE: To review the literature on neurocognitive measures as risk markers for schizophrenia and to present data from the Perth family study of schizophrenia. Of all the risk markers that have been identified, the most promising are deficits in sustained attention. METHOD: Inclusion in the review was determined by whether the research addressed a number of key questions: methods of assessing sustained attention; evidence of sustained attention deficits in patients and first-degree relatives including children; the importance of attentional dysfunction in the schizophrenic process and functional outcome; and the biological basis of sustained attention deficits. RESULTS: Sustained attention deficits are evident in both patients and a proportion of their first-degree relatives, a finding replicated in preliminary data from the Perth family study. The literature suggests that the attention deficit is a stable enduring trait that is independent of clinical state. The neural basis of the deficit may be a functional disconnection between prefrontal and parietal cortex. Attention impairment is an important predictor of functional outcome in patients and the development of social dysfunction in adulthood in the at-risk offspring of patients. However, sustained attention deficits that are measured in childhood results in an unacceptable high false-positive rate (21%) when predicting which at-risk offspring of parents with schizophrenia will develop a schizophrenia spectrum disorder, although the overall classification accuracy (78%) is impressive. CONCLUSIONS: The main findings are that sustained attention deficits are important risk markers for schizophrenia but need to be supplemented by other neurocognitive risk markers to improve predictive accuracy.