Symptoms Associated With Exercise Intolerance and Resting Heart Rate Following Mild Traumatic Brain Injury.

OBJECTIVES: People may experience a myriad of symptoms after mild traumatic brain injury (mTBI), but the relationship between symptoms and objective assessments is poorly characterized. This study sought to investigate the association between symptoms, resting heart rate (HR), and exercise tolerance in individuals following mTBI, with a secondary aim to examine the relationship between symptom-based clinical profiles and recovery. METHODS: Prospective observational study of adults aged 18 to 65 years who had sustained mTBI within the previous 7 days. Symptoms were assessed using the Post-Concussion Symptom Scale, HR was measured at rest, and exercise tolerance was assessed using the Buffalo Concussion Bike Test. Symptom burden and symptom-based clinical profiles were examined with respect to exercise tolerance and resting HR. RESULTS: Data from 32 participants were assessed (mean age 36.5 ± 12.6 years, 41% female, 5.7 ± 1.1 days since injury). Symptom burden (number of symptoms and symptom severity) was significantly associated with exercise intolerance (P = .002 and P = .025, respectively). Physiological and vestibular-ocular clinical profile composite groups were associated with exercise tolerance (P = .001 and P = .014, respectively), with individuals who were exercise intolerant having a higher mean number of symptoms in each profile than those who were exercise tolerant. Mood-related and autonomic clinical profiles were associated with a higher resting HR (>80 bpm) (P = .048 and P = .028, respectively), suggesting altered autonomic response for participants with symptoms relating to this profile. After adjusting for age and mechanism of injury (sports- or non-sports-related), having a higher mood-related clinical profile was associated with persisting symptoms at 3 months postinjury (adjusted odds ratio = 2.08; 95% CI, 1.11-3.90; P = .013). CONCLUSION: Symptom-based clinical profiles, in conjunction with objective measures such as resting HR and exercise tolerance, are important components of clinical care for those having sustained mTBI. These results provide preliminary support for the concept that specific symptoms are indicative of autonomic dysfunction following mTBI.

Caring for persons with Dementia: a qualitative study of the needs of carers following care recipient discharge from hospital.

BACKGROUND: A randomised clinical trial titled the Carer End of Life Planning Intervention (CELPI) in people dying with dementia evaluated the effect of carer education and support about palliative care on care recipient outcomes. We present a pre-planned qualitative analysis of data collected during the CELPI trial in which needs of carers randomised to the study intervention group were assessed using a novel instrument (Carer Needs Directed Assessment in Dementia (CANDID). This tool aimed to identify carers' perceptions of their own and their care-recipients' needs and is an important step in identifying support provision for dementia-specific, palliative cares services upon hospital discharge. METHODS: The CANDID tool was designed to identify the needs and experiences of primary carers and of their care recipients during the last twelve months of the care recipient's life. The tool consisted of 33 open-ended questions evaluating: symptom management, emergency contacts, advance care planning, carer's perception of the care recipient's future needs, carer's current needs, and a proposed current and future care plan. The researcher's philosophical assumption of interpretative phenomenology informed the study and approach to data collection and analysis. Qualitative data collected during interviews using this tool were thematically analysed in five steps: compiling, disassembling, reassembling, interpreting and concluding. An interpretation of participants' reality emerged from their common experiences and the subjective meanings assigned to actions attached to the phenomena studied. RESULTS: Thirty carer participants were included. Analysis identified three major themes: Carers' perceived stressors, systemic barriers to care provision, and future planning. Issues identified included barriers to accessing supports, carer health and division between roles, financial burden, familial conflicts, adquate care in hospital and aged care facilities, concern about future needs, and end-of-life discussions. CONCLUSION: The CANDID tool enabled an evaluation of carer needs and concerns. Identifying those needs may inform a referral to palliative care services where the level of management required may be benenficial for both the person living with dementia and their primary carer. TRIAL REGISTRATION: Australian Clinical Trials Registration: (ACTRN12619001187134).

The Schweitzer effect: The fundamental relationship between experience and medical students' opinions on professional behaviours.

PURPOSE: We examined whether medical students' opinions on the acceptability of a behaviour were influenced by previously encountering a similar professionally challenging situation, assessed the magnitude of effect of 'experience' compared to other demographic factors which influence medical students' opinions, and evaluated whether opinions regarding some situations/behaviours were more susceptible to 'experience' bias? METHODS: Confidential, on-line survey for medical students distributed to Australian and New Zealand (AUS/NZ) medical schools. Students submitted de-identified demographic information, provided opinions on the acceptability of a wide range of student behaviours in professionally challenging situations, and whether they had encountered similar situations. RESULTS: 3171 students participated from all 21 Aus/NZ medical schools (16% of registered students). Medical students reported encountering many of the professionally challenging situations, with varying opinions on what was acceptable behaviour. The most significant factor influencing acceptability towards a behaviour was whether the student reported encountering a similar situation. The professional dilemmas most significantly influenced by previous experience typically related to behaviours that students could witness in clinical environments, and often involved breaches of trust. CONCLUSIONS: Our results demonstrate the relationship between experience and medical students' opinions on professional behaviour- the 'Schweitzer effect'. When students encounter poor examples of professional behaviour, especially concerning trust breaches, it significantly influences their perception of the behaviour. These results highlight the importance of placing students in healthcare settings with positive professional role modelling/work cultures.

Medical students report encountering a wide range of professionally challenging situations, and have varying opinions on acceptable professional behavioursAlthough medical students' opinions on professional behaviours are influenced by their demography, the most significant factor influencing the acceptability towards a behaviour was whether the student reported encountering a similar professional dilemmaStudents appear to be susceptible to normalising counter productive work behaviours, particularly those related to breaches of trustBy placing students in toxic work culture environments with poor role models, we may inadvertently enable healthcare systems to perpetuate poor professional behaviour.

Twelve tips for improving the quality of assessor judgements in senior medical student clinical assessments.

Assessment of senior medical students is usually calibrated at the level of achieving expected learning outcomes for graduation. Recent research reveals that clinical assessors often balance two slightly different perspectives on this benchmark. The first is the formal learning outcomes at graduation, ideally as part of a systematic, program-wide assessment approach that measures learning achievement, while the second is consideration of the candidate's contribution to safe care and readiness for practice as a junior doctor. The second is more intuitive to the workplace, based on experience working with junior doctors. This perspective may enhance authenticity in assessment decisions made in OSCEs and work-based assessments to better align judgements and feedback with professional expectations that will guide senior medical students and junior doctors' future career development. Modern assessment practices should include consideration of qualitative as well as quantitative information, overtly including perspectives of patients, employers, and regulators. This article presents 12 tips for how medical education faculty might support clinical assessors by capturing workplace expectations of first year medical graduates and develop graduate assessments based on a shared heuristic of 'work-readiness'. Peer-to-peer assessor interaction should be facilitated to achieve correct calibration that 'merges' the differing perspectives to produce a shared construct of an acceptable candidate.

When the wheels fall off - Medical students' experiences of interrupted academic progression.

INTRODUCTION: There is limited published research on medical students' perspectives of a significant interruption to their academic progression. This study sought to identify the factors that contribute to difficulties with academic progression and to understand how medical students successfully respond. METHODS: This interpretive phenomenological study reports on the findings from in-depth interviews of 38 final year medical students who had experienced a significant academic interruption. RESULTS: The two superordinate themes were: the factors contributing to the interruption and their experience of the interruption. Factors identified as contributing to the interruption were: workload, learning in medicine, motivation for medicine, isolation, adapting to local culture, health and external factors. Their experience of the interruption focused on stages of working through the process: 'what happened,' 'how it felt,' 'managing the failure,' 'accepting the failure' and 'making some changes.' DISCUSSION: Each factor affected how the participants reacted and responded to the interruption. Regardless of the origins of the interruption, most reacted and responded in a comparable process, albeit with varying timespans. These reactions and responses were in a state of fluctuation. In order to succeed many stated they shifted their motivation from external to internal, in direct response to the interruption, resulting in changed learning behaviours. CONCLUSIONS: The process of working through an interruption to academic progression for students may benefit from a model of interval debriefing, restorative academic and personal development support. Facilitation of this process could enable students to face an interruption constructively rather than as an insurmountable emotionally burdensome barrier. Medical schools could utilise these findings to implement further support strategies to reduce the number of significant academic disruptions.

Twelve tips for medical students experiencing an interruption in their academic progress.

For every commencing cohort of medical students, a small but significant number will experience an interruption to their academic progression because of academic difficulties, health concerns or external influences outside of the students' control. During the process of researching the factors surrounding difficulties with academic progression, students told us many ways that they have learned from that experience, which then allowed most of them to graduate. This paper combines the shared experiences of students who have had an interruption, and those of the authors as medical educators.

Prehospital continuous positive airway pressure (CPAP) for acute respiratory distress: a randomised controlled trial.

OBJECTIVE: To compare the efficacy of continuous positive airway pressure (CPAP) versus usual care for prehospital patients with severe respiratory distress. METHODS: We conducted a parallel group, individual patient, non-blinded randomised controlled trial in Western Australia between March 2016 and December 2018. Eligible patients were aged ≥40 years with acute severe respiratory distress of non-traumatic origin and unresponsive to initial treatments by emergency medical service (EMS) paramedics. Patients were randomised (1:1) to usual care or usual care plus CPAP. The primary outcomes were change in dyspnoea score and change in RR at ED arrival, and hospital length of stay. RESULTS: 708 patients were randomly assigned (opaque sealed envelope) to usual care (n=346) or CPAP (n=362). Compared with usual care, patients randomised to CPAP had a greater reduction in dyspnoea scores (usual care -1.0, IQR -3.0 to 0.0 vs CPAP -3.5, IQR -5.2 to -2.0), median difference -2.0 (95% CI -2.5 to -1.6); and RR (usual care -4.0, IQR -9.0 to 0.0 min-1 vs CPAP -8.0, IQR -14.0 to -4.0 min-1), median difference -4.0 (95% CI -5.0 to -4.0) min-1. There was no difference in hospital length of stay (usual care 4.2, IQR 2.1 to 7.8 days vs CPAP 4.8, IQR 2.5 to 7.9 days) for the n=624 cases admitted to hospital, median difference 0.36 (95% CI -0.17 to 0.90). CONCLUSIONS: The use of prehospital CPAP by EMS paramedics reduced dyspnoea and tachypnoea in patients with acute respiratory distress but did not impact hospital length of stay. TRIAL REGISTRATION NUMBER: ACTRN12615001180505.

Examiners' decision-making processes in observation-based clinical examinations.

BACKGROUND: Objective structured clinical examinations (OSCEs) are commonly used to assess the clinical skills of health professional students. Examiner judgement is one acknowledged source of variation in candidate marks. This paper reports an exploration of examiner decision making to better characterise the cognitive processes and workload associated with making judgements of clinical performance in exit-level OSCEs. METHODS: Fifty-five examiners for exit-level OSCEs at five Australian medical schools completed a NASA Task Load Index (TLX) measure of cognitive load and participated in focus group interviews immediately after the OSCE session. Discussions focused on how decisions were made for borderline and clear pass candidates. Interviews were transcribed, coded and thematically analysed. NASA TLX results were quantitatively analysed. RESULTS: Examiners self-reported higher cognitive workload levels when assessing a borderline candidate in comparison with a clear pass candidate. Further analysis revealed five major themes considered by examiners when marking candidate performance in an OSCE: (a) use of marking criteria as a source of reassurance; (b) difficulty adhering to the marking sheet under certain conditions; (c) demeanour of candidates; (d) patient safety, and (e) calibration using a mental construct of the 'mythical [prototypical] intern'. Examiners demonstrated particularly higher mental demand when assessing borderline compared to clear pass candidates. CONCLUSIONS: Examiners demonstrate that judging candidate performance is a complex, cognitively difficult task, particularly when performance is of borderline or lower standard. At programme exit level, examiners intuitively want to rate candidates against a construct of a prototypical graduate when marking criteria appear not to describe both what and how a passing candidate should demonstrate when completing clinical tasks. This construct should be shared, agreed upon and aligned with marking criteria to best guide examiner training and calibration. Achieving this integration may improve the accuracy and consistency of examiner judgements and reduce cognitive workload.

Step-up, step-down mental health care service: evidence from Western Australia's first - a mixed-method cohort study.

BACKGROUND: Mental health Step-up, Step-down services (SUSD), also known as subacute services or Prevention and Recovery Services, have emerged to fill an identified gap between hospital-based inpatient care and clinical community-based mental health support. Evidence for the effectiveness of the SUSD service model is limited but growing. Accordingly, this study looked to add to the extant body of knowledge, by (i) assessing change outcomes in mental health and wellbeing, and predictors of these changes, for patients who accessed Western Australia's first SUSD service; and (ii) evaluating patients' satisfaction with service, and what patients value from their stay. METHODS: This was a mixed-method retrospective cohort study. Participants comprised 382 patients who accessed a 22-bed Mental Health SUSD facility and incurred 551 episodes of care during the 01/07/2014-30/06/2016 period. Patients' change outcomes in psychological distress, general self-efficacy, and work and social adjustment from service entry to service exit were analyzed using generalized linear modeling. Simple Pearson's correlation coefficients were calculated for preliminary assessment of the associations between patients' service satisfaction and their change outcomes. Qualitative outcomes that patients valued from their stay were analyzed thematically according to a semi-grounded theoretical approach. RESULTS: Significant improvements were observed in patients' self-reported psychological distress, self-efficacy, and work and social adjustment (all p < 0.0001). A strong and persistent baseline effect existed across the three measures. Older age, female gender, and having a dependent child in the same household were protective/enhancing factors for the patients' recovery. Satisfaction with service was high. Patients valued having the time and space to recuperate, gain insight, focus, and create changes in their lives. CONCLUSION: The encouraging findings, regarding both patients' change outcomes and satisfaction with service, support the value of the SUSD service model for patients with mental illnesses. Strengths and limitations were discussed; ensued recommendations were offered to both service providers and researchers to enhance the robustness of future research findings, to help inform more effective policy and funding decisions related to mental health care.

Twelve tips for enhancing student engagement.

Student engagement refers to a broad range of activities where students participate in management, education, research, and community activities within their institutions. It is a mutually beneficial collaborative approach between students and their institutions. This article provides practical advice for the implementation or further development of student engagement at medical, dental, and veterinary schools. The tips provided are based on the experiences of a group of universities recently recognized for best practice in student engagement, and are supported by evidence from the literature. The tips cover overarching themes which include the creation of an institutional culture and formal framework for student engagement, and maximize communication routes between students with peers and faculty. Tips are for specific areas of active student engagement, covering curriculum design and development, peer teaching, governance processes, research activities, peer support programs, and interaction with the local community.

Student motivation to learn: is self-belief the key to transition and first year performance in an undergraduate health professions program?

BACKGROUND: Student motivation to learn has been undervalued to date though has been identified as an area influencing student success and retention at university. The transition into university has been highlighted as a key period affecting student outcomes as well as well-being. Early identification of those students at risk may assist the transition for many students moving into higher education. Previous research has identified the Motivation and Engagement Scale - University/College (MES-UC) as a valid instrument for measuring motivation to learn in physiotherapy students. The aim of this study was to determine the relationship between a student's motivation to learn on entry into an undergraduate physiotherapy program and their performance through first year. The relationship of admissions scores, to motivation to learn on entry, were also considered, to determine any link between these measures. METHODS: An observational longitudinal study was conducted on one cohort of undergraduate physiotherapy students commencing their studies in 2015 with a response rate of 67%. Correlations were performed between admission variables and Year 1 MES-UC scoring; and between Year 1 MES-UC scoring and subsequent academic performance across first year, taking into consideration gender and age. RESULTS: Self-belief was identified as the key dimension of motivation influencing student success in the transition into university. Results identified the link between self-belief scores on entry and academic performance in first year, including grade point average and performance in six of nine courses. Courses where there was no significant relationship were identified as curriculum areas where students may be less motivated. There was a relationship between the admissions interview and MES-UC scoring, demonstrating a link between non-cognitive selection measures and student motivation to learn on entry into the program. CONCLUSION: Motivation to learn and specifically self-belief with learning, may be influential in the transition into higher education. Undertaking measures of academic motivation may be useful to determine student engagement with curriculum, through identifying any link between student self-belief and performance in specific courses. Changes to curriculum based on student motivation as well as targeting early those students with reduced self-belief may improve student success, psychosocial wellbeing and retention.

Predicting performance of junior doctors: Association of workplace based assessment with demographic characteristics, emotional intelligence, selection scores, and undergraduate academic performance.

INTRODUCTION: Predicting workplace performance of junior doctors from before entry or during medical school is difficult and has limited available evidence. This study explored the association between selected predictor variables and workplace based performance in junior doctors during their first postgraduate year. METHODS: Two cohorts of medical students (n = 200) from one university in Western Australia participated in the longitudinal study. Pearson correlation coefficients and multivariate analyses utilizing linear regression were used to assess the relationships between performance on the Junior Doctor Assessment Tool (JDAT) and its sub-components with demographic characteristics, selection scores for medical school entry, emotional intelligence, and undergraduate academic performance. RESULTS: Grade Point Average (GPA) at the completion of undergraduate studies had the most significant association with better performance on the overall JDAT and each subscale. Increased age was a negative predictor for junior doctor performance on the Clinical management subscale and understanding emotion was a predictor for the JDAT Communication subscale. Secondary school performance measured by Tertiary Entry Rank on entry to medical school score predicted GPA but not junior doctor performance. DISCUSSION: The GPA as a composite measure of ability and performance in medical school is associated with junior doctor assessment scores. Using this variable to identify students at risk of difficulty could assist planning for appropriate supervision, support, and training for medical graduates transitioning to the workplace.

Failure of falls risk screening tools to predict outcome: a prospective cohort study.

OBJECTIVE: To compare the Falls Risk for Older Persons-Community Setting Screening Tool (FROP Com Screen) with the Two-Item Screening Tool in older adults presenting to the ED. METHODS: A prospective cohort study, comparing the efficacy of the two falls risk assessment tools by applying them simultaneously in a sample of hospital ED presentations. RESULTS: Two hundred and one patients over 65 years old were recruited. Thirty-six per cent reported falls in the 6-month follow-up period. The area under the receiver operating characteristic curve was 0.57 (95% CI 0.48 to 0.66) for the FROP Com Screen and 0.54 (95% CI 0.45 to 0.63) for the Two-Item Screening Tool. FROP Com Screen had a sensitivity of 39% (95% CI 0.27 to 0.51) and a specificity of 70% (95% CI 0.61 to 0.78), while the Two-Item Screening Tool had a sensitivity of 48% (95% CI 0.36 to 0.60) and a specificity of 57% (95% CI 0.47 to 0.66). CONCLUSION: Both tools have limited predictive ability in the ED setting.

Community-associated Clostridium difficile infection in emergency department patients in Western Australia.

Clostridium difficile infection (CDI) is primarily associated with hospitalised patients, however, community-associated CDI (CA-CDI) has increased in Australia. We aimed to investigate the epidemiology and outcomes of CA-CDI cases presenting to hospital emergency departments in Western Australia (WA). A retrospective case-control study of CA-CDI cases presenting at six emergency departments in WA from July 2013 to June 2014 was performed. Clinical signs, recent medication, hospitalisations and potential risk factors for CA-CDI were investigated for cases (n = 34) and unmatched controls (n = 62) who were infected with another gastrointestinal pathogen, including Campylobacter spp., Salmonella spp., Aeromonas spp., Shigella sonnei and Escherichia coli O157. Elevated white cell count (31.3% vs 8.2%, p < 0.01), female gender (67.6% vs 41.9%, p < 0.05), age ≥65 years (41.2% vs 21.0%, p < 0.05) and antimicrobial use in the previous month (41.2% vs 11.3%, p < 0.01) were significantly more frequent among cases compared to controls. After multivariable analysis, antibiotic use (odds ratio 8.49, 95% confidence interval 2.75-26.21) and age ≥65 years (3.03, 1.05-8.75) were significantly associated with CA-CDI. Ribotype (RT) 014/020 was most common (40.7%) among 27 C. difficile isolates followed by RTs 002 (14.8%), 001, 056 and 244 (all 7.4%). CA-CDI was associated with advanced age and recent antibiotic use compared to those infected with other gastrointestinal pathogens. RT 014 has also recently been found at high prevalence in public lawn spaces, and previously RT 014 strains from humans and pigs in Australia were closely genetically related, suggesting CA-CDI may be linked with these community reservoirs.

Is it Appropriate for Patients to be Discharged at the Scene by Paramedics?

BACKGROUND: Outcomes of patients who are discharged at the scene by paramedics are not fully understood. OBJECTIVE: We aimed to describe the risk of re-presentation and/or death in prehospital patients discharged at the scene. METHODS: We conducted a retrospective cohort study using linked ambulance, emergency department (ED), and death data. We compared outcomes in patients who were discharged at the scene by paramedics with those who were transported to ED by paramedics and then discharged from ED between January 1 and December 31, 2013 in metropolitan Perth, Western Australia. Occurrences of subsequent ambulance requests, ED attendance, hospital admission and death were compared between those discharged at the scene and those discharged from ED. RESULTS: There were 47,330 patients during the study period, of whom 19,732 and 27,598 patients were discharged at the scene and from ED, respectively. Compared to those discharged from ED, those discharged at the scene were more likely to subsequently: request an ambulance (6.1% vs. 1.8%, adjusted odds ratio [adj OR] 3.4; 95% confidence interval [CI] 3.0-3.9), attend ED (4.6% vs. 1.4%, adj OR 3.3; 95% CI 2.8-3.8), be admitted to hospital (3.3% vs. 0.8%, adj OR 4.2; 95% CI 3.4-5.1). Those discharged at the scene tended towards an increased likelihood of death (0.2% vs. 0.1%, adj OR 1.8; 95% CI 0.99-3.2) within 24 hours of discharge compared to those discharged from ED. CONCLUSION: Patients attended by paramedics who were discharged at the scene had more subsequent events than those who were transported to and discharged from ED. Further consideration needs to be given to who is suitable to be discharged at the scene by paramedics.

Factors Associated with Discussion of Disasters by Final Year High School Students: An International Cross-sectional Survey.

UNLABELLED: Introduction The effect on behavioral change of educational programs developed to reduce the community's disaster informational vulnerability is not known. This study describes the relationship of disaster education, age, sex, and country-specific characteristics with students discussing disasters with friends and family, a measure of proactive behavioral change in disaster preparedness. METHODS: Three thousand eight hundred twenty-nine final year high school students were enrolled in an international, multi-center prospective, cross-sectional study using a pre-validated written questionnaire. In order to obtain information from different educational systems, from countries with different risk of exposure to disasters, and from countries with varied economic development status, students from Bahrain, Croatia, Cyprus, Egypt, Greece, Italy, Portugal, Romania, and Timor-Leste were surveyed. Logistic regression analyses examined the relationship between the likelihood of discussing disasters with friends and family (dependent variable) and a series of independent variables (age, gender, participation in school lessons about disasters, existence of a national disaster educational program, ability to list pertinent example of disasters, country's economic group, and disaster risk index) captured by the questionnaire or available as published data. RESULTS: There was no statistically significant relationship between age, awareness of one's surroundings, planning for the future, and foreseeing consequences of events with discussions about potential hazards and risks with friends and/or family. The national educational budget did not have a statistically significant influence. Participants who lived in a low disaster risk and high income Organization for Economic Co-operation and Development (OECD) country were more likely to discuss disasters. While either school lessons or a national disaster education program had a unique, significant contribution to the model, neither had a better predictive utility. CONCLUSIONS: The predictors (national disaster program, school lessons, gender, ability to list examples of disasters, country's disaster risk index, and level of economic development), although significant, were not sufficient in predicting disaster discussions amongst teenagers.

The effect of presenting symptoms and patient characteristics on prehospital delay in MI patients presenting to emergency department by ambulance: a cohort study.

INTRODUCTION: There is little recent information about prehospital delay time for Australian patients with myocardial infarction (MI). OBJECTIVES: This study: (1) describes prehospital delay time for patients with MI; (2) identifies variables and presenting symptoms which contribute to the delay. METHODS: This retrospective cohort study identified patients with an Emergency Department (ED) discharge diagnosis of MI, transported by ambulance to one of the seven Perth metropolitan EDs, between January 2008 and October 2009. Prehospital delay times were analysed using linear regression models. Non-numeric (word descriptions) of delay time were categorised. RESULTS: Of 1,633 patients, symptom onset-time was available for 1,003. For 829 patients with a numeric onset-time, median delay was 2.2hours; decreased delay was associated with age <70 years, presenting with chest pain, and diaphoresis. Increased delay was associated with being with a primary health care provider, and if the patient was at home and if the person who called the ambulance was anyone other than the spouse. For 174 patients with non-numeric onset-times, 37% patients delayed one to three days and 110 (64.0%) patients described their symptoms as intermittent and/or of gradual onset. CONCLUSION: Given that prehospital delay times remain longer than is optimal, public awareness of MI symptoms should be enhanced in order to decrease prehospital delay.

Characteristics and Outcomes of MI Patients with and without Chest Pain: A Cohort Study.

INTRODUCTION: There are conflicting data on patient characteristics and outcomes of myocardial infarction (MI) patients presenting with and without the symptom of chest pain. OBJECTIVES: Compare the characteristics and survival of patients stratified by the symptom chest pain. METHODS: This retrospective cohort study identified patients with an emergency department discharge diagnosis of MI, who arrived by ambulance at a teaching hospital in Perth, Western Australia, between January 2008 to October 2009. The cohort was linked to hospital data and the state-based death register; clinical data were extracted by medical record review. Patient characteristics were compared using logistic regression models and survival analysis using Kaplan-Meier curves and Cox regression models. RESULTS: Of 382 patients, 26% presented without chest pain. The odds of presenting without chest pain were increased if aged 80+ (OR 7.54; 95%CI 2.81-20.3) and aged 70-79 years (OR 4.33; 95% CI 1.50-12.5), and female (OR 1.67; 95%CI 0.99-2.82). The adjusted hazard (median follow-up time 2.2 years) of presenting without chest pain was not significantly associated with survival (HR 1.03; 95%CI 0.71-1.48). CONCLUSION: Characteristics differed between patients with and without chest pain. However, the symptom of chest pain was not associated with survival.

Relationships between academic performance of medical students and their workplace performance as junior doctors.

BACKGROUND: Little recent published evidence explores the relationship between academic performance in medical school and performance as a junior doctor. Although many forms of assessment are used to demonstrate a medical student's knowledge or competence, these measures may not reliably predict performance in clinical practice following graduation. METHODS: This descriptive cohort study explores the relationship between academic performance of medical students and workplace performance as junior doctors, including the influence of age, gender, ethnicity, clinical attachment, assessment type and summary score measures (grade point average) on performance in the workplace as measured by the Junior Doctor Assessment Tool. RESULTS: There were two hundred participants. There were significant correlations between performance as a Junior Doctor (combined overall score) and the grade point average (r = 0.229, P = 0.002), the score from the Year 6 Emergency Medicine attachment (r = 0.361, P < 0.001) and the Written Examination in Year 6 (r = 0.178, P = 0.014). There was no significant effect of any individual method of assessment in medical school, gender or ethnicity on the overall combined score of performance of the junior doctor. CONCLUSION: Performance on integrated assessments from medical school is correlated to performance as a practicing physician as measured by the Junior Doctor Assessment Tool. These findings support the value of combining undergraduate assessment scores to assess competence and predict future performance.