Perceptions of preparedness: How hospital-based orientation can enhance the transition from academic to clinical learning.

BACKGROUND: Clinical placements are essential for applied learning experiences in health professions education. Unfortunately, there is little consensus on how best to prepare learners for the transition between academic and clinical learning. We explored learners' perceptions of hospital-based orientation and resulting preparedness for clinical placement. METHODS: Sixty-three learners participated in a total of 18 semi-structured focus groups, during their clinical placements. Data were analyzed thematically. RESULTS: We organized learners' perceptions of hospital-based orientation that support their preparedness for placement into three themes: (1) adequate site orientation for learner acquisition of organization acumen and (2) clinical preceptor training to support unit/service and (3) individual components. CONCLUSION: Thoughtful attention to hospital-based orientation can support learners in transitioning from academic to clinical learning. Hospital organizations should attend to all three components during orientation to better support learners' preparedness for clinical learning.

CONTEXTE: Les stages cliniques sont essentiels aux expériences d'apprentissage appliquées dans l'enseignement médical. Malheureusement, il n'existe pas de consensus sur la meilleure manière de préparer les étudiants à la transition entre l'apprentissage académique et l'apprentissage clinique. Nous avons exploré la perception des étudiants de l'orientation en milieu hospitalier et de l'état de préparation qui en résulte pour les stages cliniques. MÉTHODES: Au total, 63 étudiants ont participé 'à travers 18 groupes de discussion semi-structurés lors de leurs stages cliniques. Les données ont été analysées de manière thématique. RÉSULTATS: Nous avons classé les perceptions des étudiants relativement à l'orientation en milieu hospitalier qui soutient leur état de préparation pour un stage en trois thèmes différents : (1) une orientation adéquate du site pour l'acquisition par l'étudiant de l'expertise de l'organisation et (2) la formation du précepteur clinique pour soutenir l'unité/le service et (3) les composantes individuelles. CONCLUSION: Une attention particulière centrée sur l'orientation en milieu hospitalier peut soutenir les étudiants dans leur transition de l'apprentissage académique à l'apprentissage clinique. Les organismes hospitaliers doivent inclure les trois composantes pendant l'orientation pour mieux soutenir l'état de préparation des étudiants pour leur apprentissage clinique.

Maternal side-effects after multiple courses of antenatal corticosteroids (MACS): the three-month follow-up of women in the randomized controlled trial of MACS for preterm birth study.

OBJECTIVE: A single course of antenatal corticosteroids (ACS) is associated with a reduction in respiratory distress syndrome and neonatal death. Multiple Courses of Antenatal Corticosteroids Study (MACS), a study involving 1858 women, was a multicentre randomized placebo-controlled trial of multiple courses of ACS, given every 14 days until 33+6 weeks or birth, whichever came first. The primary outcome of the study, a composite of neonatal mortality and morbidity, was similar for the multiple ACS and placebo groups (12.9% vs. 12.5%), but infants exposed to multiple courses of ACS weighed less, were shorter, and had smaller head circumferences. Thus for women who remain at increased risk of preterm birth, multiple courses of ACS (every 14 days) are not recommended. Chronic use of corticosteroids is associated with numerous side effects including weight gain and depression. The aim of this postpartum assessment was to ascertain if multiple courses of ACS were associated with maternal side effects. METHODS: Three months postpartum, women who participated in MACS were asked to complete a structured questionnaire that asked about maternal side effects of corticosteroid use during MACS and included the Edinburgh Postnatal Depression Scale. Women were also asked to evaluate their study participation. RESULTS: Of the 1858 women randomized, 1712 (92.1%) completed the postpartum questionnaire. There were no significant differences in the risk of maternal side effects between the two groups. Large numbers of women met the criteria for postpartum depression (14.1% in the ACS vs. 16.0% in the placebo group). Most women (94.1%) responded that they would participate in the trial again. CONCLUSION: In pregnancy, corticosteroids are given to women for fetal lung maturation and for the treatment of various maternal diseases. In this international multicentre randomized controlled trial, multiple courses of ACS (every 14 days) were not associated with maternal side effects, and the majority of women responded that they would participate in such a study again.

Multiple courses of antenatal corticosteroids for preterm birth study: 2-year outcomes.

OBJECTIVE: The aim of this study was to determine the effects of repeated courses of prenatal corticosteroid therapy versus placebo on death or neurologic impairment among the children enrolled in the Multiple Courses of Antenatal Corticosteroids for Preterm Birth Study, at 18 to 24 months of age. METHODS: A total of 2305 infants were eligible for follow-up evaluation; 2104 infants (1069 in the prenatal corticosteroid therapy group and 1035 in the placebo group) were monitored. The primary outcome was death or neurologic impairment, defined as either cerebral palsy or cognitive delay, at 18 to 24 months of age. The secondary outcomes were measurements of growth (height, weight, and head circumference). RESULTS: Children exposed to multiple courses of prenatal corticosteroid therapy had similar rates of death or neurologic impairment, compared with children exposed to placebo (148 children [13.8%] vs 142 children [13.7%]; odds ratio: 1.001[95% confidence interval: 0.75-1.30]; P = .95). They had a mean weight of 11.94 kg, compared with 12.14 kg in the placebo group (P = .04), a mean height of 85.51 cm, compared with 85.46 cm (P = .87), and a mean head circumference of 48.18 cm, compared with 48.25 cm (P = .45). CONCLUSIONS: Multiple courses of prenatal corticosteroid therapy, given every 14 days, did not increase or decrease the risk of death or neurologic impairment at 18 to 24 months of age, compared with a single course of prenatal corticosteroid therapy. Continued follow-up monitoring of these children is necessary to assess neurobehavioral function, school performance, and possible susceptibility to disease.

Facial paralysis measurement with a handheld ruler.

BACKGROUND: Evaluation of the severity of facial paralysis deformity and the effectiveness of reconstructive surgery requires a measurement tool that is practical and simple enough for daily use. It should be able to objectively measure facial asymmetry at rest and the amount of facial movement during expression. The authors present and assess a simple measurement technique that is readily usable in the clinic. Designed to evaluate smile reconstruction, the technique can be used to evaluate other parts of the paralyzed face, such as the eye, nose, and forehead. METHODS: A standardized handheld ruler measuring technique is described for the assessment of the position and the movement of five points marked on the lips. The measured points are used to characterize the position of the mouth at rest and the movement that occurs with smiling. The technique uses two transparent rulers that are held in the examiner's hand. Using this technique, two experienced examiners separately measured the rest position of 21 unilateral facial paralysis patients twice, creating 84 sets of measurements. Accuracy was assessed by simultaneously measuring the movement of the commissure and mid upper lip during smiling on 10 normal persons using both handheld ruler and a proven technique, the facial reanimation measurement system. RESULTS: The average intraclass correlation coefficients for interrater and intrarater reliability exceed 0.89. The mean difference between the handheld ruler and facial reanimation measurement system measurements was 1.7 mm. CONCLUSION: The handheld ruler technique is simple, reliable, and accurate, providing useful measurements for the evaluation of facial paralysis reconstructions.

Smile reconstruction in adults with free muscle transfer innervated by the masseter motor nerve: effectiveness and cerebral adaptation.

BACKGROUND: This study assesses the ability of the masseter motor nerve-innervated microneurovascular muscle transfer to produce an effective smile in adult patients with bilateral and unilateral facial paralysis. METHODS: The operation consists of a one-stage microneurovascular transfer of a portion of the gracilis muscle that is innervated with the masseter motor nerve. The muscle is inserted into the cheek and attached to the mouth to produce a smile. The outcomes assessed were the amount of movement of the transferred muscle; the aesthetic quality of the smile; the control, use, and spontaneity of the smile; and the functional effects on eating, drinking, and speech. The study included 27 patients aged 16 to 61 years who received 45 muscle transfers. RESULTS: All 45 muscle transfers developed movement. The commissure movement averaged 13.0 +/- 4.7 mm at an angle of 47 +/- 15 degrees above the horizontal, and the mid upper lip movement averaged 8.3 +/- 3.0 mm at 42 +/- 17 degrees. Age did not affect the amount of movement. Patients older than 50 years had the same amount of movement as patients younger than 26 years (p = 0.605). Ninety-six percent of patients were satisfied with their smile. CONCLUSIONS: A spontaneous smile, the ability to smile without thinking about it, occurred routinely in 59 percent and occasionally in 29 percent of patients. Eighty-five percent of patients learned to smile without biting. Age did not affect the degree of spontaneity of smiling or the patient's ability to smile without biting.

The use of local anesthetic motor block to demonstrate the potential outcome of depressor labii inferioris resection in patients with facial paralysis.

BACKGROUND: If a patient with unilateral facial paralysis has marked depressor activity on the normal side, the appearance of the lower lip when smiling is asymmetrical. Defunctioning the muscle on the contralateral side to the palsy can restore balance. This can be achieved by resecting a portion of the depressor labii inferioris muscle on the nonparalyzed side. However, the decision to resect normal muscle may be difficult for many patients. This article presents the role of a local anesthetic motor block in temporarily paralyzing the muscle before patients decide whether permanent resection will meet their needs. METHOD: A phone questionnaire with 15 patients who received motor muscle blockage before deciding to have depressor labii inferioris muscle resection was conducted. RESULTS: Ninety-three percent of the patients who underwent the local anesthetic motor block stated that it gave them valuable information regarding the outcome of their surgery and influenced their decision to undertake definitive depressor muscle resection. CONCLUSION: A trial by local anesthetic before depressor inferioris muscle resection provides patients with valuable insight into the likely outcome of the surgery.

Evaluation of a new measurement tool for facial paralysis reconstruction.

Evaluation of facial movement, including distance and direction, is essential for anyone interested in facial paralysis reconstruction. The authors' goal was to develop a measurement system that is simple, uses commercially available equipment, takes little time, and provides meaningful and accurate measurements. This technique is called the facial reanimation measurement system. It involves placing dots around the patient's mouth and video recording the patient performing maximal effort smiles. Using a video editing program, one frame showing the patient at rest is overlaid with a second frame showing the patient's smile. This overlaid image is imported into Adobe PhotoShop, where measurements are obtained using tools available in the program. Twenty patients were used to test interrater and intrarater reliability of the facial reanimation measurement system. The accuracy of the measurement process was tested by comparing 10 known distances and angles with those obtained using the facial reanimation measurement system. Both intrarater and interrater reliability of the distance and angle measurements are highly accurate, with intraclass correlations greater than 0.9. The facial reanimation measurement system is accurate to within 0.6 mm and 2.0 degrees when compared with a "known" distance and angle. The facial reanimation measurement system has been used to measure smile movements of more than 200 patients and has been demonstrated to be valuable for detecting changes of facial movements over time. This system is simple and economical and only requires 20 minutes to perform. Although the authors demonstrated evaluation of smile movement, the system may be used to evaluate other movements, such as mouth puckering, eye closure, and forehead elevation.

Carpal tunnel syndrome: cross-sectional and outcome study in Ontario workers.

PURPOSE: To carry out an analytic cross-sectional study of Ontario workers with carpal tunnel syndrome (CTS) and to assess workers' symptoms, functional disabilities, recreational difficulties, and work capability 4 years after treatment of their CTS. METHODS: Data were obtained by review of Ontario Workers Safety and Insurance Board (WSIB) files and by completion of self-assessment questionnaires. Inclusion criteria included all workers registered with the Ontario WSIB who were off work with newly diagnosed carpal tunnel syndrome in 1996. RESULTS: There are 3 million workers covered by the WSIB in the province of Ontario. In 1996, 964 of them developed work-related CTS that required time off for treatment. Of these patients 53% were women and 75% had bilateral CTS. Eighty-one percent of the unilateral cases involved the dominant extremity. The average age at the time of claim was 41 years and workers were at the same job type for an average of 7.4 years (unilateral) and 8.5 years (bilateral), respectively. Thirty-nine percent of workers had a history of another tendonitis or epicondylitis. Seventy-five percent of workers had surgery and on average returned to work 3 months later. Four years after treatment, outcome was assessed by self-administered questionnaires, for which there was a 73% response rate. Forty-six percent of workers experienced moderate to severe pain, 47% had moderate to severe numbness, and 40% had difficulty grasping and using small objects. Only 14% were symptom free. Successful return to work was considered to be a return to the same job with or without modifications, and it occurred in 64% of cases. Better clinical outcome scores were found to occur with surgery and abnormal nerve conduction study results. Worse clinical outcome scores were present with repeat surgery and surgical complications. Concurrent diagnoses of either tendonitis or epicondylitis also resulted in worse clinical outcome scores and worse return-to-work outcomes. The average total cost in Canadian dollars to the WSIB exceeded $13,700 per worker for a total cost in excess of $13,200,000 per year. (In 1996, $1 Canadian = $1.365 US.) CONCLUSIONS: These outcomes indicate that Canadian workers have a large amount of permanent pain and suffering, a large loss of work productivity, and incur a considerable financial cost as a result of work-related CTS.