Livestreaming clinical experience to remotely located learners: A critical narrative review.

CONTEXT: Medical education relies on real patient learning (RPL) to provide medical students with essential clinical experience. However, growing demand for clinical placements continues to be a challenge in providing sufficient RPL opportunities. The COVID-19 pandemic forced academic institutions to rethink the delivery of traditional clinical training and innovations in online clinical learning experiences, specifically livestreamed clinical experiences, have emerged which show promise in addressing the capacity limitations of traditional placements. Although previous reviews have explored the use of livestreamed clinical experiences during the pandemic, there is a lack of rigorous theoretical framing to support these innovations. OBJECTIVES: The aim of this review is two-fold: to examine the effectiveness of livestreamed clinical experiences through an experience-based learning (ExBL) theory perspective and to provide practical recommendations to optimise and implement these innovations. METHODS: A review of literature was conducted to identify journal articles published between September 2019 and January 2023 reporting on innovations relating to livestreamed clinical experiences. The search focused on undergraduate and postgraduate medical education but relevant evidence from other healthcare professions were also included due to a limited evidence base. Strengths and weaknesses were derived from the literature and analysed in relation to ExBL components. RESULTS: Principal strengths of livestreamed clinical experiences included expanded access to RPL opportunities and medical specialties, enhanced standardisation of learning experiences and positive perceptions from students regarding convenience. Clinical educators found these innovations enabled teaching at scale. Patients did not perceive such innovations to negatively impact their standard of care. Limitations included the inability to practice physical examination skills, challenges in ensuring learner engagement and connectivity issues. CONCLUSION: Livestreamed clinical experiences have the potential to effectively expand placement capacity and provide high-quality educational experiences for medical students. Although certain limitations exist, technological and pedagogical adaptations can help overcome these challenges. The application of theoretical frameworks to future online innovations will be fundamental to ensure effective clinical learning.

The surface of leaves and fruits of Peruvian cacao is home for several Hannaella yeast species, including the new species Hannaella theobromatis sp. nov.

As part of a long-term study aiming to isolate and identify yeast species that inhabit the surface of leaves and fruits of native fine-aroma cacao in the department of Amazonas, Peru, we obtained multiple isolates of Hannaella species. Yeasts of the genus Hannaella are common inhabitants of the phyllosphere of natural and crop plants. On the basis of morphological, and physiological characteristics, and sequence analysis of the D1/D2 domains of the large subunit rRNA gene (LSU) and the internal transcribed spacer region (ITS), we identified five species of Hannaella from the phyllosphere of Peruvian cacao. Four have been previously described: H. phyllophila (isolates KLG-073, KLG-091), H. pagnoccae (KLG-076), H. sinensis (KLG-121), and H. taiwanensis (KLG-021). A fifth, represented by eight isolates (KLG-034, KLG-063, KLG-074, KLG-078, KLG-79, KLG-082, KLG-084, KLG-085), is not conspecific with any previously described Hannaella species, and forms the sister clade to H. surugaensis in the phylogenetic analysis. It has 2.6-3.9% (18-27 substitutions, 2-4 deletions, and 1-3 insertions in 610-938 bp-long alignments), and 9.8-10.0% nucleotide differences (37 substitutions and 14 insertions in 511-520 bp-long alignments) in the LSU and ITS regions, respectively, to H. surugaensis type strain, CBS 9426. Herein, the new species Hannaella theobromatis sp. nov. is described and characterised. The species epithet refers to its epiphytic ecology on its host Theobroma cacao.

Bioremediation Potential of Native Bacillus sp. Strains as a Sustainable Strategy for Cadmium Accumulation of Theobroma cacao in Amazonas Region.

Cacao plant cadmium accumulation has become a major concern, especially for small Amazonian producers. A sustainable alternative to address its toxicity is the use of cadmium removal bacteria. In this regard, 138 rhizosphere isolates from cacao were examined. Supported by their phenotypic characterization and in vitro cadmium tolerance, three hypertolerant bacteria were selected and identified as members of the Bacillus (S1C2, R1C2) and Pseudomonas (V3C3) genera. They were able to grow normally and reduce the cadmium content under in vitro conditions. However, only S1C2 and R1C2 evidenced to employ intracellular Cd2+ accumulation, suggesting the variability of bacterial detoxification mechanisms. Their bioremediation capacity for Theobroma cacao CCN51 was also analyzed. Surprisingly, we found high detectable levels of Cd2+ in the non-cadmium supplemented control, suggesting an extra source of cadmium in the pot. Moreover, despite their cadmium reduction performance under in vitro conditions, they exerted highly variable outcomes on stem cadmium accumulation. While S1C2 and R1C2 showed a considerable reduction of Cd content in cacao stems, the strain V3C3 did not show any effect on Cd content. This highlights the complexity of the plant-bacteria interactions and the importance of the in vivo test for the selection of promising PGPR bacteria. Overall, our results suggest the cadmium alleviation potential and promising prospects of native Bacillus strains associated with Amazonian cacao.

Prognostic factors for survival following emergency Hartmann's procedure.

INTRODUCTION: Patients presenting with peritonitis require rapid treatment initiation including laparotomy. In the older population, this often leads to Hartmann's procedure being performed. The decision to perform surgery may be a difficult, multidisciplinary decision balancing premorbid comorbidity and quality of life with knowledge of the postoperative outcome. However, the evidence for survival outcome of emergency surgery based on age is lacking. The aim of this study was therefore to assess the survival implication of age and other prognostic factors on the outcome after Hartmann's procedure. METHODS: A retrospective review of prospectively collected data of all patients undergoing emergency (National Confidential Enquiry into Patient Outcome and Death category 1-3) Hartmann's procedure in one NHS Health Board over a 5-year period. RESULTS: 129 patients underwent Hartmann's procedure between November 2004 and November 2009. The largest group, 61 patients (47.3%) had the procedure performed for perforated sigmoid diverticular disease. When examined at 5-year stratifications around the median, the most significant survival difference was seen at the age of 75 years (log rank χ(2) 11.246, p=0.001). Patients over 75 years had median survival significantly lower than those aged <75 years (p<0.001). However, Cox regression analysis showed that preoperative American Society of Anesthesiologists (ASA) status and haemoglobin were more significant independent predictors of mortality than this age strata (p=0.001 and 0.045 vs 0.660, respectively), adjusting for diagnosis. DISCUSSION: ASA grade and common blood abnormalities were more predictive of mortality after Hartmann's procedure than the most significant age stratification. Furthermore, age was not independently associated with survival. It would therefore be unreasonable to refuse Hartmann's procedure based on an age alone.

Lymphangiogenesis and lymph node metastasis in breast cancer.

INTRODUCTION: There have been few studies on lymphangiogenesis in the past due to the lack of specific lymphatic endothelial markers, and lymphatic-specific growth factors. Recently, these limitations have been relieved by the discovery of a small number of potential lymphatic-specific markers. The relationship between lymphangiogenesis and regional or distant metastasis has not previously been investigated in humans. Using these lymphatic markers, it is possible to explore the relationship between lymphangiogenesis and tumour metastasis. This study indirectly quantified lymphangiogenesis by measuring mRNA expression of all seven lymphatic markers described above in breast cancers and correlated these markers with lymphatic involvement and survival. The cDNA from 153 frozen archived breast samples were analysed with Q-PCR for all seven lymphangiogenic markers. This was correlated with various prognostic factors as well as patient survival. RESULTS: There was significantly greater expression of all 7 markers in malignant compared to benign breast tissue. In addition, there was greater expression in lymph node positive/grade 3 tumours when compared to lymph node negative/grade 1 tumours. In 5 of the markers, there was a greater expression in poor NPI prognostic tumours when compared to favourable prognostic tumours which was not statistically significant. There was no association between recurrence risk and lymphangiogenic marker expression. CONCLUSION: In summary, the findings from this study show that lymphangiogenesis, measured by specific lymphatic marker expression, is higher in breast cancers than in normal breast tissue. Secondly, breast cancers which have metastasised to the regional lymphatics show higher expression compared to those which have not, although the individual differences for all five markers were not statistically significant.

Expression of breast cancer specific gene-1 (BCSG-1/gamma-synuclein) is associated with tumour grade but not with clinical outcome of patients with breast cancer.

This study examined the expression and distribution of BCSG-1 in human breast cancer tissue. IHC revealed that BCSG-1 was primarily seen as a cytosolic protein, weakly staining normal mammary epithelial cells but increased in breast tumour cells. Q-PCR revealed that node negative and positive tumours had similar levels of BCSG-1 transcript and BCSG-1/CK19 ratio. There were significantly higher levels in grade 2 and grade 3 tumours compared to grade 1. Patients with NPI (Nottingham prognostic indicator) < 3.4, had a predicted 80% 15-year survival. After a 10-year follow-up, no significant difference was seen between tumours from patients remaining disease-free and those who died of breast cancer. The levels of BCSG-1 significantly correlated with an associated molecule, transglutaminase-3 (r = 0.307, P < 0.05), and weakly with transglutaminase-7 (r = 0.183). BCSG-1 is increased in breast tumour cells, is negatively associated with tumour grade and significantly correlates with levels of transglutaminase-3.