Diagnostic accuracy of intraoperative methods for margin assessment in breast cancer surgery: A systematic review & meta-analysis.

PURPOSE: There are a wide variety of intraoperative techniques available in breast surgery to achieve low rates for positive margins of excision. The objective of this systematic review was to determine the pooled diagnostic accuracy of intraoperative breast margin assessment techniques that have been evaluated in clinical practice. METHODS: This study was performed in accordance with PRISMA guidelines. A systematic search of the literature was conducted to identify studies assessing the diagnostic accuracy of intraoperative margin assessment techniques. Only clinical studies with raw diagnostic accuracy data as compared with final permanent section histopathology were included in the meta-analysis. A bivariate model for diagnostic meta-analysis was used to determine overall pooled sensitivity and specificity. RESULTS: Sixty-one studies were eligible for inclusion in this systematic review and meta-analysis. Cytology demonstrated the best diagnostic accuracy, with pooled sensitivity of 0.92 (95 % CI 0.77-0.98) and a pooled specificity of 0.95 (95 % CI 0.90-0.97). The findings also indicate good diagnostic accuracy for optical spectroscopy, with a pooled sensitivity of 0.86 (95 % CI 0.76-0.93) and a pooled specificity of 0.92 (95 % CI 0.82-0.97). CONCLUSION: Pooled data indicate that optical spectroscopy, cytology and frozen section have the greatest diagnostic accuracy of currently available intraoperative margin assessment techniques. However, long turnaround time for results and their resource intensive nature has prevented widespread adoption of these methods. The aim of emerging technologies is to compete with the diagnostic accuracy of these established techniques, while improving speed and usability.

Risky business: medical students' feedback-seeking behaviours: a mixed methods study.

There are differing views on how learners' feedback-seeking behaviours (FSB) develop during training. With globalisation has come medical student migration and programme internationalisation. Western-derived educational practices may prove challenging for diverse learner populations. Exploring undergraduate activity using a model of FSB may give insight into how FSB evolves and the influence of situational factors, such as nationality and site of study. Our findings seek to inform medical school processes that support feedback literacy. Using a mixed methods approach, we collected questionnaire and interview data from final-year medical students in Ireland, Bahrain, and Malaysia. A validated questionnaire investigated relationships with FSB and goal orientation, leadership style preference, and perceived costs and benefits. Interviews with the same student population explored their FSB experiences in clinical practice, qualitatively, enriching this data. The data were integrated using the 'following the thread' technique. Three hundred and twenty-five of a total of 514 completed questionnaires and 57 interviews were analysed. Learning goal orientation (LGO), instrumental leadership and supportive leadership related positively to perceived feedback benefits (0.23, 0.2, and 0.31, respectively, p < 0.05). Perceived feedback benefits are related positively to feedback monitoring and inquiry (0.13 and 0.38, respectively, p < 0.05). The personal cost of feedback is unsupported in quantitative data, but was a strong theme in interviews, as was feedback avoidance, peer feedback, and unsupportive learning environment. No differences were observed across sub-groups based on gender, study site, or student nationality. Integrated analysis describes FSB: avoiding 'unsafe' feedback (first, do no harm) and overcoming barriers (beat the system) and goal-centred curation (shop around) to optimise benefits. Diverse medical students across three continents undertake FSB with careful navigation, as a valued but risky business, that is highly contextualised. Promoting a constructive FSB is complex. Overcoming outdated theory and practices on the wards remains a challenge to psychologically safe, learner-centred feedback.

Performance in Irish Selection and Future Performance in Surgical Training.

Importance: Selection processes for surgical training should aim to identify candidates who will become competent independent practitioners and should aspire to high standards of reliability and validity. Objective: To determine the association between measured candidate factors at the time of an Irish selection and assessment outcomes in surgical training, examined via rate of progression to Higher Specialist Training (HST), attrition rates, and performance as assessed through a multimodal framework of workplace-based and simulation-based assessments. Design, Setting, and Participants: This retrospective observational cohort study included data from all successful applicants to the Royal College of Surgeons in Ireland (RCSI) national Core Surgical Training (CST) program. Participants included all trainees recruited to dedicated postgraduate surgical training from 2016 to 2020. These data were analyzed from July 11, 2016, through July 10, 2022. Exposures: Selection decisions were based on a composite score that was derived from technical aptitude assessments, undergraduate academic performance, and a 4-station multiple mini-interview. Main outcomes and measures: Assessment data, attrition rates, and rates of progression to HST were recorded for each trainee. CST performance was assessed using workplace-based and simulation-based technical and nontechnical skill assessments. Potential associations between selection and assessment measures were explored using Pearson correlation, logistic regression, and multiple linear-regression analyses. Results: Data were available for 303 trainees. Composite scores were positively associated with progression to HST (odds ratio [OR], 1.09; 95% CI, 1.05-1.13). There was a weak positive correlation, ranging from 0.23 to 0.34, between scores and performance across all CST assessments. Multivariable linear regression analysis showed technical aptitude scores at application were associated with future operative performance assessment scores, both in the workplace (ß = 0.31; 95% CI, 0.14-0.48) and simulated environments (ß = 0.57; 95% CI, 0.33-0.81). There was evidence that the interpersonal skills interview station was associated with future performance in simulated communication skill assessments (ß = 0.55; 95% CI, 0.22-0.87). Conclusions and Relevance: In this study, performance at the time of Irish national selection, measured across technical and nontechnical domains in a multimodal fashion, was associated with future performance in the workplace and in simulated environments. Future studies will be required to explore the consequential validity of selection, including potential unintended effects of selection and ranking on candidate performance.

The correlation between sub-epidermal moisture measurement and other early indicators of pressure ulcer development-A prospective cohort observational study. Part 1. The correlation between sub-epidermal moisture measurement and ultrasound.

The correlation between sub-epidermal moisture (SEM) and other early indicators of pressure ulcer (PU) development is yet to be determined. This three-part series aims to bridge this knowledge gap, through investigating SEM and its correlation with evidence-based technologies and assessments. This article focuses on the correlation between SEM and ultrasound. A prospective cohort observational study was undertaken between February and November 2021. Patients undergoing three surgery types were consecutively enrolled to the study following informed consent. Assessments were performed prior to and following surgery for 3 days at the sacrum, both heels and a control site, using a SEM scanner and high-frequency ultrasound scanner (5-15 MHz). Spearman's rank (rs ) explored the correlation between SEM and ultrasound. A total of 60 participants were included; 50% were male with a mean age of 58 years (±13.46). A statistically significant low to moderately positive correlation was observed between SEM and ultrasound across all anatomical sites (rs range = 0.39-0.54, p < 0.05). The only exception was a correlation between SEM and ultrasound on day 0 at the right heel (rs = 0.23, p = 0.09). These results indicate that SEM and ultrasound agreed in the presence of injury; however, SEM was able to identify abnormalities before ultrasound.

A comparative analysis of student, educator, and simulated parent ratings of video-recorded medical student consultations in pediatrics.

BACKGROUND: Simulation-based education (SBE) affords learners opportunities to develop communication skills, including those related to pediatrics. Feedback is an integral part of SBE, and while much research into feedback from multiple sources exists, the findings are mixed. The aim of this comparative study was to replicate some of this work in a novel area, pediatric medical education, to better understand how multisource feedback (self, educator, and simulated parent) may inform learning and curriculum design. METHODS: During their pediatric rotation, medical students participated in a consultation with a simulated parent, engaged in video-assisted self-reflection, and received feedback from both an educator and the simulated parent through an e-learning platform. The Pediatric Consultation Skills Assessment Tool (PCAT) was used for self-assessment and educator feedback, and the Consultation and Relational Empathy (CARE) measure was used for simulated parent feedback. RESULTS: Our results showed that high-performing students underrated their performance, and low-performing students overrated their performance. Feedback from multiple sources helps to identify both areas of weakness in student performance and areas of weakness in student self-appraisal. Overall, general areas of weakness identified for the learners related to making contingency plans and providing easy-to-understand explanations for simulated parents. Some simulated parent feedback did not align with educator and student ratings, highlighting the value of including the simulated parent perspective. Our findings question whether a third party can reliably judge the simulated parent's level of understanding. CONCLUSION: Multisource feedback allows students to develop layered insights into their performance and supports self-appraisal. Aggregating feedback through an e-learning platform allows educators to gain greater insights into the strengths and weakness of students and design a more tailored teaching plan to support student needs.

Meta-analysis: Impact of intragastric balloon therapy on NAFLD-related parameters in patients with obesity.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is a leading cause of chronic liver disease affecting approximately 25% of adults in the western world. Intragastric balloon (IGB) is an endoscopic bariatric therapy -a therapeutic endoscopic tool that has shown promise in inducing weight loss. Its role in the treatment of NAFLD is yet to be established. AIM: To evaluate the effect of IGB as a treatment option in NAFLD. METHODS: We searched MEDLINE (PubMed) and EMBASE from inception to September 2022. We included studies evaluating the impact of IGB on obesity with the assessment of one or more liver-related outcomes and studies primarily evaluating the impact of IGB on NAFLD. We included comparative and non-comparative studies; primary outcomes were liver-related NAFLD surrogates. RESULTS: We included 19 studies with 911 patients. IGB demonstrated an effect on NAFLD parameters including NAFLD activity score (NAS): mean difference (MD): -3.0 [95% CI: -2.41 to -3.59], ALT: MD: -10.40 U/L [95% CI: -7.31 to -13.49], liver volume: MD -397.9 [95% CI: -212.78 to 1008.58] and liver steatosis: MD: -37.76 dB/m [95% CI: -21.59 to -53.92]. There were significant reductions in non-liver-related outcomes of body weight, BMI, glycated haemoglobin and HOMA-IR. CONCLUSION: Intragastric balloons may play an important role in addressing the treatment gap in NAFLD management.

Professional Identity Formation, Professionalism, Leadership and Resilience (PILLAR) in Medical Students: Methodology and Early Results.

Objectives: The fundamental role of medical education is the transformation of students to doctors, through a process of education and professional identity formation (PIF), which can be informed by several educational, behavioural and emotional factors. PIF has been deemed to be of equal importance to the acquisition of clinical knowledge and skills and includes constructs such as professionalism, leadership and resilience. We aimed to assess professional identity formation, professionalism, leadership and resilience (PILLAR) in the junior years of medical school in the 2020/2021 academic year and illustrate the potential role of quantitative assessment to demonstrate progression in these areas. In this research, we provide the methods and baseline results for the PILLAR study. Methods: We implemented a compulsory assessment in pre-clinical years of graduate entry and direct entry medicine at the Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland. Validated scales were used to assess students' PILLAR. Descriptive and univariable statistical techniques were used to compare student scores between respective years. Results: A total of 1311 students (92% response rate) provided their consent for research. For the psychometric scales, there were no evident trends among the years on these assessment measures. Results indicated significant differences in all measures, however, these did not correspond to ascending years of seniority. Conclusion: The PILLAR methodology provides important information on the challenges of quantitatively assessing medical students in the four key areas of PIF, professionalism, leadership, and resilience. Our cross-sectional results point to cohort effects, without the expected progression per year in the cross-sectional data, or suggest that the chosen quantitative measures may be problematic for these constructs in pre-clinical students. Therefore, while we believe that PILLAR has potential as a progress test for these constructs, this will only truly be elucidated by repeated measures of each cohort over time.

Efficacy and Safety of Trastuzumab Deruxtecan in Breast Cancer: A Systematic Review and Meta-Analysis.

Trastuzumab deruxtecan (T-DXd) is a novel antibody-drug-conjugate (ADC), primarily used in the treatment of HER2-positive breast cancer. This study aimed to conduct a systematic review to evaluate the efficacy and safety of T-DXd in treating breast cancer, based on clinical trials. A systematic search of the literature was conducted to identify clinical trials investigating the efficacy and safety of T-DXd in breast cancer. Clinical trials of any phase were included. Outcome measures were any adverse events and survival. Meta-analysis was conducted where possible. Pooled prevalence for each adverse event of any grade and grade 3 or greater were estimated. Progression-free survival (PFS), overall survival (OS) and objective response rates (ORRs) were also reported to evaluate the efficacy of T-DXd in breast cancer. A total of 1593 patients from 6 clinical trials were included. Common adverse events of any grade were nausea, anemia, neutropenia, vomiting, fatigue, constipation and diarrhea, occurring in greater than 30% of cases. In terms of adverse events of grade 3 or more, only anemia and neutropenia occurred at a relatively high rate. Median PFS ranged from 11.1 to 22.1 months. There was evidence of a benefit of T-DXd compared to controls in terms of both PFS (OR: 0.38; 95% CI: 0.32, 0.45) and OS (OR: 0.61; 95% CI: 0.48, 0.78). ORRs ranged from 37% to 79.9%. The present systematic review shows evidence that T-DXd is a safe and effective agent in the treatment of breast cancer based on currently available data. The most common adverse events affected the blood, lymphatic and gastrointestinal systems. Interstitial lung disease (ILD) is a notable and potentially serious adverse event.

The effects of advanced factor analysis approaches on outcomes in randomised trials for depression: protocol for secondary analysis of individual participant data.

BACKGROUND: Modern psychometric methods make it possible to eliminate nonperforming items and reduce measurement error. Application of these methods to existing outcome measures can reduce variability in scores, and may increase treatment effect sizes in depression treatment trials. AIMS: We aim to determine whether using confirmatory factor analysis techniques can provide better estimates of the true effects of treatments, by conducting secondary analyses of individual patient data from randomised trials of antidepressant therapies. METHOD: We will access individual patient data from antidepressant treatment trials through Clinicalstudydatarequest.com and Vivli.org, specifically targeting studies that used the Hamilton Rating Scale for Depression (HRSD) as the outcome measure. Exploratory and confirmatory factor analytic approaches will be used to determine pre-treatment (baseline) and post-treatment models of depression, in terms of the number of factors and weighted scores of each item. Differences in the derived factor scores between baseline and outcome measurements will yield an effect size for factor-informed depression change. The difference between the factor-informed effect size and each original trial effect size, calculated with total HRSD-17 scores, will be determined, and the differences modelled with meta-analytic approaches. Risk differences for proportions of patients who achieved remission will also be evaluated. Furthermore, measurement invariance methods will be used to assess potential gender differences. CONCLUSIONS: Our approach will determine whether adopting advanced psychometric analyses can improve precision and better estimate effect sizes in antidepressant treatment trials. The proposed methods could have implications for future trials and other types of studies that use patient-reported outcome measures.

Why do children with unilateral cerebral palsy struggle with the single leg stance test? A kinematic and centre of pressure analysis.

BACKGROUND: Children with unilateral cerebral palsy often report difficulty with balance in everyday life. The single leg stance test is a challenging task, requiring rapid sensory input and precise motor adjustment. The purpose of this study was to examine how children with cerebral palsy perform this test, compared to typically developing children. METHODS: Three-dimensional kinematics of the trunk and lower limbs of 10 children with cerebral palsy and 15 children with typical development were captured as they performed a single leg stance test on their non-dominant leg on a force platform. Stance time, joint kinematics and centre of pressure sway were measured and examined. FINDINGS: There was evidence of shorter single leg stance performance and increased mediolateral centre of pressure sway in children with cerebral palsy. Coronal plane movement at the subtalar joint and foot was reduced (-6.0° (-10.9, -1.2°)), while proximally there was greater trunk movement in the coronal (13.5° (2.4°, 24.5°)) and transverse planes (9.9° (0.7, 19°)) and pelvis movement in the transverse plane (6.1° (1.7, 10.5°). An association existed between stance time and mediolateral centre of pressure sway (p < 0.01), with an average reduction in stance time of 0.15 s for every 1 mm/s increase in mediolateral sway. INTERPRETATION: Children with cerebral palsy showed poor mediolateral control of centre of pressure sway, leading to shorter stance time. They have a less effective coronal foot-tilt strategy and excessive trunk and pelvis movement. Interventions aimed at improving single leg stance performance should consider addressing both ankle / foot and trunk motor control.

Assessing operative competence in core surgical training: A reliability analysis.

BACKGROUND: This study quantifies the number of observations required to reliably assess the operative competence of Core Surgical Trainees (CSTs) in Ireland, using the Supervised Structured Assessment of Operative Performance (SSAOP) tool. METHODS: SSAOPs (April 2016-February 2021) were analysed across a mix of undifferentiated procedures, as well as for three commonly performed general surgery procedures in CST: appendicectomy, abdominal wall hernia repair, and skin/subcutaneous lesion excision. Generalizability and Decision studies determined the number of observations required to achieve dependability indices ≥0.8, appropriate for use in high-stakes assessment. RESULTS: A total of 2,294 SSAOPs were analysed. Four assessors, each observing 10 cases, can generate scores sufficiently reliable for use in high-stakes assessments. Focusing on a selection of core procedures yields more favourable reliability indices. CONCLUSION: Trainers should conduct repeated assessments across a smaller number of procedures to improve reliability. Programs should increase the assessor mix to yield sufficient dependability indices for high-stakes assessment.

Comparative evaluation of urolithiasis management options in patients with horseshoe kidney: A systematic review and meta-analysis.

Background: Horseshoe kidney is a rare congenital anomaly commonly complicated by urolithiasis. Extracorporeal shockwave lithotripsy (ESWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL) are treatment options for horseshoe kidney stones. The aim of this systematic review is to compare the benefits and risks of these management options. Methods: MEDLINE, EMBASE, and Cochrane Library databases were searched from inception to February 2022. A total of 516 nonduplicate studies were screened against the inclusion and exclusion criteria. Studies comparing at least 2 interventions with ≥10 patients per intervention were included. Results: Nine retrospective observational studies published from 2007 to 2021 with a total of 565 patients were included. Reported mean ± SD or mean (range) stone sizes ranged between 17.90 ± 2.43 mm and 27.9 ± 8.6 mm for PCNL, 8.4 (2-25) mm and 22.3 ± 9.1 mm for URS, and 11.9 ± 2.0 mm and 16.8 ± 4.4 mm for ESWL. There was no difference in single-session and overall stone-free rate (SFR) between PCNL and URS, with a risk ratio of 1.04 (95% confidence interval, 0.95-1.13; I2 = 20.63%). Ureteroscopy had better stone clearance than ESWL, with an overall SFR risk ratio of 1.38 (95% confidence interval, 1.04-1.82; I2 = 0%). There was no statistically significant difference in overall SFR between PCNL and ESWL. Most patients who underwent URS and ESWL experienced Clavien-Dindo (CD) grade I-II complications. Percutaneous nephrolithotomy was associated with the highest complication rates, including 5 CD grade III and 3 CD grade IV complications and a mean postoperative hemoglobin drop of 0.47 to 1.83 g/dL. There were no CD grade V complications across all studies. Conclusions: There was no difference in SFR between PCNL and URS. Ureteroscopy was associated with a smaller stone burden and fewer and less severe complications. Ureteroscopy was found to be more effective than ESWL with a higher SFR and comparable safety profile. Further large-scale randomized controlled trials are needed to confirm these findings.

GP preferences for, access to, and use of evidence in clinical practice: a mixed-methods study.

BACKGROUND: GPs aim to provide patient-centred care combining clinical evidence, clinical judgement, and patient priorities. Despite a recognition of the need to translate evidence to support patient care, barriers exist to the use of evidence in practice. AIM: To ascertain the needs and preferences of GPs regarding evidence-based guidance to support patient care. The study also aimed to prioritise content and optimise structure and dissemination of future evidence-based guidance. DESIGN & SETTING: This was a convergent parallel mixed-methods study in collaboration with the national GP professional body in the Republic of Ireland (Irish College of General Practitioners [ICGP]). Quantitative and qualitative findings were integrated at the interpretive level. METHOD: A national GP survey was administered via the ICGP (December 2020) and seven GP focus groups were undertaken (April-May 2021). RESULTS: Of 3496 GPs, a total of 509 responders (14.6%) completed the survey and 40 GP participants took part in focus groups. Prescribing updates, interpretation of test results, chronic disease management, and older person care were the preferred topics for future evidence-based guidance. GPs reported that they required rapid access to up-to-date and relevant evidence summaries online for use in clinical practice. Access to more comprehensive reviews for the purposes of continuing education and teaching was also a priority. Multimodal forms of dissemination were preferred to increase uptake of evidence in practice. CONCLUSION: GPs indicated that rapid access to up-to-date, summarised evidence-based resources, available from their professional organisation, is preferred. Evidence should reflect the disease burden of the population and involve multifaceted dissemination approaches.

Developmental and behavioural outcomes at 2 years in babies born during the COVID-19 pandemic: communication concerns in a pandemic birth cohort.

INTRODUCTION: The CORAL (Impact of Corona Virus Pandemic on Allergic and Autoimmune Dysregulation in Infants Born During Lockdown) study reported a reduction in social communication milestones in 12-month-old infants born into the COVID-19 pandemic. AIMS: To look at 24-month developmental and behavioural outcomes in the CORAL cohort. DESIGN: The CORAL study is a longitudinal prospective observational study of Irish infants born in the first 3 months of the pandemic. At 24 months of age, the Ages and Stages Developmental Questionnaire (ASQ24) and the Child Behaviour Checklist (CBCL) were completed and compared with prepandemic BASELINE (Babies After SCOPE: Evaluating the Longitudinal Impact Using Neurological and Nutritional Impact) cohort. RESULTS: 917 babies (312 CORAL infants and 605 BASELINE infants) were included. At 24 months of age, infants in the CORAL and BASELINE cohorts had similar developmental ASQ24 scores in fine motor, problem solving and personal and social domains but ASQ24 communication scores were significantly lower in the CORAL group compared with the BASELINE cohort (mean (SD) 49.5 (15.1) vs 53.7 (11.6), p<0.01). Infants from the CORAL cohort were more likely to score below standardised cut-offs for developmental concern in the communication domain (11.9% CORAL compared with 5.4% BASELINE, p<0.01). Unadjusted ASQ24 gross motor scores were lower for the pandemic cohort. Fewer CORAL infants fell under 2 SD cut-off in personal-social subdomain. For CBCL, there was no evidence of difference in scores between the cohorts on multivariable analysis. CONCLUSION: 24-month-old pandemic-born infants had largely similar developmental and behavioural scores compared with their prepandemic counterparts. Concerns have been raised in the communication developmental domain.

Varicose Vein Education and Informed coNsent (VVEIN) study: a randomised controlled pilot feasibility study.

INTRODUCTION: Doctors have a legal requirement and duty of care to ensure patients are enabled to make an informed decision about their treatment, including discussion of the benefits, risks and alternatives to a procedure. A patient-centred approach to consent has been firmly established in Ireland, and fundamental to this is the ability to engage in a dialogue that offers comprehensible information to patients. Telemedicine has revolutionised the way we can deliver care to patients in the modern era of computers, tablets, and smartphones, and its use has been rapidly expanded. Novel digital strategies to improve the informed consent process for surgical procedures have been increasingly under investigation over the last 10-15 years and may offer a low cost, accessible and tailored solution to consent for surgical interventions. Within vascular surgery, superficial venous interventions have been associated with a high number medicolegal claims and also represents an area within the specialty with rapidly evolving technology and techniques. The ability to communicate comprehensible information to patients has never been greater. Thus, the author's aim is to explore whether it is feasible and acceptable to deliver a digital health education intervention to patients undergoing endovenous thermal ablation (EVTA) to supplement the consent process. METHODS: This is a prospective, single centre, randomised controlled, feasibility trial recruiting patients with chronic venous disease deemed suitable to undergo EVTA. Patients will be randomised to receive either standard consent (SC) or a newly developed digital health education tool (dHET). The primary outcome is feasibility; assessing the recruitment and retention rate of participants and assessing acceptability of the intervention. Secondary outcomes include knowledge retention, anxiety and satisfaction. This feasibility trial is designed to recruit 40 patients, which will allow for a moderate dropout rate. This pilot study will inform the authors of the appropriateness of an adequately powered multicentre trial. DISCUSSION: To examine the role of a digital consent solution for EVTA. This may improve and standardise the consent dialogue with patients and may have the potential to reduce claims related to poor consent processes and disclosure of risks. ETHICAL COMMITTEE REFERENCE: Ethical approval has been sought and received from both the Bon Secours Hospital and RCSI (202109017), on 14 May 2021 and 10 October 2021, respectively. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05261412 , registered on 1 March 2022.

The impact of lidocaine plaster prescribing reduction strategies: A comparison of two national health services in Europe.

AIMS: In 2017, two distinct interventions were implemented in Ireland and England to reduce prescribing of lidocaine medicated plasters. In Ireland, restrictions on reimbursement were introduced through implementation of an application system for reimbursement. In England, updated guidance on items which should not be routinely prescribed in primary care, including lidocaine plasters, was published. This study aims to compare how the interventions impacted prescribing of lidocaine plasters in these countries. METHODS: We conducted an interrupted time-series study using general practice data. For Ireland, monthly dispensing data (2015-2019) from the means-tested General Medical Services (GMS) scheme was used. For England, data covered all patients. Outcomes were the rate of dispensings, quantity and costs of lidocaine plasters, and we modelled level and trend changes from the first full month of the policy/guidance change. RESULTS: Ireland had higher rates of lidocaine dispensings compared to England throughout the study period; this was 15.22/1000 population immediately pre-intervention, and there was equivalent to a 97.2% immediate reduction following the intervention. In England, the immediate pre-intervention dispensing rate was 0.36/1000, with an immediate reduction of 0.0251/1000 (a 5.8% decrease), followed by a small but significant decrease in the monthly trend relative to the pre-intervention trend of 0.0057 per month. CONCLUSIONS: Among two different interventions aiming to decrease low-value lidocaine plaster prescribing, there was a substantially larger impact in Ireland of reimbursement restriction compared to issuing guidance in England. However, this is in the context of much higher baseline rates of use in Ireland compared to England.

Impact of changes to the delivery of opioid agonist treatment, introduced during the COVID-19 pandemic, on treatment access and dropout in Ireland: An interrupted time series analysis.

BACKGROUND: Following the emergence of COVID-19, Ireland introduced national contingency guidelines to ensure rapid and uninterrupted access to opioid agonist treatment (OAT). This study aims to assess the impact of changes introduced to the delivery of OAT on the number of people accessing treatment and treatment dropout. METHODS: The study conducted interrupted time series analyses, with separate segmented regression models (March 2019-February 2020) vs (April 2020-March 2021), for (A) total number of people accessing OAT, (B) the number initiating treatment, and (C) the number dropping out of treatment, using data from the National OAT treatment register. The study examined immediate (change in level or intercept: ß2) and long-term impacts (change in slope; i.e., the difference between the slope before and after the intervention: ß3). We performed total and stratified analyses by gender, age group (<40/≥40 years), and OAT drug (methadone or buprenorphine). RESULTS: A total of 10,251 people accessed OAT in Ireland in March 2019 (2 % buprenorphine, n = 178), increasing to 11,441 (4 % buprenorphine, n = 471) in March 2021. The study observed an immediate (ß2 = 504.3, p < 0.001) and continued (ß3 = 31.9, p < 0.001) increase of people accessing treatment following the introduction of the OAT contingency guidelines. In contrast, observed changes in level and slope were not significant for treatment initiation or dropout. The study did find, however, a modest reduction in dropout among those receiving buprenorphine (ß3 = -0.6, p = 0.036). CONCLUSIONS: Changes introduced to the delivery of OAT, under the COVID-19 contingency guidelines, are associated with increased access to OAT in Ireland, with no evidence of increase in treatment dropout. Whether these effects will be maintained over time remains to be seen.

Association between patient attitudes towards deprescribing and subsequent prescription changes.

Deprescribing is an essential component of safe prescribing, especially for people with higher levels of polypharmacy. Identifying individuals prepared to consider medicine changes may facilitate deprescribing-orientated reviews. We aimed to explore the relationship between revised patients' attitudes towards deprescribing (rPATD) scores and medication changes in older people prescribed ≥15 medicines. A secondary analysis of rPATD scores and prescription data from a cluster randomised controlled trial of a GP-delivered, deprescribing-orientated medication review was conducted. The association between number of medicines stopped, started and changed and baseline rPATD scores was assessed using Poisson regression, adjusting for patient age, gender, study group allocation, baseline number of medicines and effects of clustering. Participants (n = 404) had a mean age of 76.4 years and were prescribed a mean of 17.1 medicines at baseline. Willingness to stop a medicine was associated with higher rates of both deprescribing (IRR: 1.40; 95% CI: 1.06-1.84) and initiating medicines (IRR: 1.43; 95% CI: 1.09-1.88). Satisfaction with current medicines was associated with a lower rate of deprescribing (IRR: 0.69; 95% CI: 0.57-0.85). The rPATD questionnaire could be used as part of a deprescribing intervention to identify participants who may be prepared to engage in deprescribing, enabling more efficient use of clinician time during complex consultations.

How has medical student learning changed with the pivot to online delivery of ophthalmology in the pandemic?

PURPOSE: This study aimed to measure stakeholder satisfaction with our usual delivery format, which previously relied on a blend of didactic lectures and clinical skills sessions compared to a revised format, which had more emphasis on online learning. We hypothesised that the online flipped classroom (OFC) would facilitate delivery of content in the wake of the pandemic, and result in improved levels of student satisfaction and knowledge gain. DESIGN: Non randomised intervention study. Group 1 = Traditional delivery (TD) and Group 2 = OFC group. METHODS: A validated course evaluation questionnaire (CEQ) compared perspectives of teaching faculty (n = 5) and students with the traditional delivery (TD) of the 4th year ophthalmology clinical attachment and an OFC approach (TD n = 129 v OFC n = 114). RESULTS: The OFC group (n = 114; response rate = 24.6%) reported significantly reduced satisfaction with staff motivation of students and provision of feedback, compared to TD (n = 129; response rate = 17.8%). OFC students also felt it was harder to determine what standard of work was expected and found the course less beneficial at helping develop problem-solving skills. Students were dissatisfied with the level of choice afforded by the OFC, specifically how they would learn and assessment options. No significant difference in exam score was observed between the TD and OFC groups. For faculty (n = 5), there was no evidence of a difference between OFC and TD. CONCLUSIONS: Students indicated a preference for the TD compared to the OFC approach. However, both delivery approaches led to comparable student performances as determined by MCQ examination.