Selecting Instruments for Measuring the Clinical Learning Environment of Medical Education: A 4-Domain Framework.

Learning environments shape the experiences of learners and practitioners, making them an important component of program evaluation. However, educators find it challenging to decide whether to measure clinical learning environments with existing instruments or to design their own new instrument and, if using an existing instrument, which to choose. To assist educators with these decisions, the authors compared clinical learning environment instruments based on their characteristics, underlying constructs, and degree to which items reflect 4 domains (personal, social, organizational, material) from a recently developed model for conceptualizing learning environments in the health professions. Building on 3 prior literature reviews as well as a literature search, the authors identified 6 clinically oriented learning environment instruments designed for medical education. They collected key information about each instrument (e.g., number of items and subscales, conceptual frameworks, operational definitions of the learning environment) and coded items from each instrument according to the 4 domains. The 6 instruments varied in number of items, underlying constructs, subscales, definitions of clinical learning environment, and domain coverage. Most instruments focused heavily on the organizational and social domains and less on the personal and material domains (half omitted the material domain entirely). The variations in these instruments suggest that educators might consider several guiding questions. How will they define the learning environment and which theoretical lens is most applicable (e.g., personal vitality, sociocultural learning theory)? What aspects or domains of the learning environment do they most wish to capture (e.g., personal support, social interactions, organizational culture, access to resources)? How comprehensive do they want the instrument to be (and correspondingly how much time do they expect people to devote to completing the instrument and how frequently)? Whose perspective do they wish to evaluate (e.g., student, resident, fellow, attending, team, patient)? Each of these considerations is addressed.

Medical Videography Using a Mobile App: Retrospective Analysis.

BACKGROUND: As mobile devices and apps grow in popularity, they are increasingly being used by health care providers to aid clinical care. At our institution, we developed and implemented a point-of-care clinical photography app that also permitted the capture of video recordings; however, the clinical findings it was used to capture and the outcomes that resulted following video recording were unclear. OBJECTIVE: The study aimed to assess the use of a mobile clinical video recording app at our institution and its impact on clinical care. METHODS: A single reviewer retrospectively reviewed video recordings captured between April 2016 and July 2017, associated metadata, and patient records. RESULTS: We identified 362 video recordings that were eligible for inclusion. Most video recordings (54.1%; 190/351) were captured by attending physicians. Specialties recording a high number of video recordings included orthopedic surgery (33.7%; 122/362), neurology (21.3%; 77/362), and ophthalmology (15.2%; 55/362). Consent was clearly documented in the medical record in less than one-third (31.8%; 115/362) of the records. People other than the patient were incidentally captured in 29.6% (107/362) of video recordings. Although video recordings were infrequently referenced in notes corresponding to the clinical encounter (12.2%; 44/362), 7.7% (22/286) of patients were video recorded in subsequent clinical encounters, with 82% (18/22) of these corresponding to the same finding seen in the index video. Store-and-forward telemedicine was documented in clinical notes in only 2 cases (0.5%; 2/362). Videos appeared to be of acceptable quality for clinical purposes. CONCLUSIONS: Video recordings were captured in a variety of clinical settings. Documentation of consent was inconsistent, and other individuals were incidentally included in videos. Although clinical impact was not always clearly evident through retrospective review because of limited documentation, potential uses include documentation for future reference and store-and-forward telemedicine. Repeat video recordings of the same finding provide evidence of use to track the findings over time. Clinical video recordings have the potential to support clinical care; however, documentation of consent requires standardization.

Paediatricians' opinions of microneedle-mediated monitoring: a key stage in the translation of microneedle technology from laboratory into clinical practice.

Microneedle (MN) arrays could offer an alternative method to traditional drug delivery and blood sampling methods. However, acceptance among key end-users is critical for new technologies to succeed. MNs have been advocated for use in children and so, paediatricians are key potential end-users. However, the opinions of paediatricians on MN use have been previously unexplored. The aim of this study was to investigate the views of UK paediatricians on the use of MN technology within neonatal and paediatric care. An online survey was developed and distributed among UK paediatricians to gain their opinions of MN technology and its use in the neonatal and paediatric care settings, particularly for MN-mediated monitoring. A total of 145 responses were obtained, with a completion response rate of 13.7 %. Respondents believed an alternative monitoring technique to blood sampling in children was required. Furthermore, 83 % of paediatricians believed there was a particular need in premature neonates. Overall, this potential end-user group approved of the MN technology and a MN-mediated monitoring approach. Minimal pain and the perceived ease of use were important elements in gaining favour. Concerns included the need for confirmation of correct application and the potential for skin irritation. The findings of this study provide an initial indication of MN acceptability among a key potential end-user group. Furthermore, the concerns identified present a challenge to those working within the MN field to provide solutions to further improve this technology. The work strengthens the rationale behind MN technology and facilitates the translation of MN technology from lab bench into the clinical setting.

Medical wikis dedicated to clinical practice: a systematic review.

BACKGROUND: Wikis may give clinician communities the opportunity to build knowledge relevant to their practice. The only previous study reviewing a set of health-related wikis, without specification of purpose or audience, globally showed a poor reliability. OBJECTIVE: Our aim was to review medical wiki websites dedicated to clinical practices. METHODS: We used Google in ten languages, PubMed, Embase, Lilacs, and Web of Science to identify websites. The review included wiki sites, accessible and operating, having a topic relevant for clinical medicine, targeting physicians or medical students. Wikis were described according to their purposes, platform, management, information framework, contributions, content, and activity. Purposes were classified as "encyclopedic" or "non-encyclopedic". The information framework quality was assessed based on the Health On the Net (HONcode) principles for collaborative websites, with additional criteria related to users' transparency and editorial policy. From a sample of five articles per wikis, we assessed the readability using the Flesch test and compared articles according to the wikis' main purpose. Annual editorial activities were estimated using the Google engine. RESULTS: Among 25 wikis included, 11 aimed at building an encyclopedia, five a textbook, three lessons, two oncology protocols, one a single article, and three at reporting clinical cases. Sixteen wikis were specialized with specific themes or disciplines. Fifteen wikis were using MediaWiki software as-is, three were hosted by online wiki farms, and seven were purpose-built. Except for one MediaWiki-based site, only purpose-built platforms managed detailed user disclosures. The owners were ten organizations, six individuals, four private companies, two universities, two scientific societies, and one unknown. Among 21 open communities, 10 required users' credentials to give editing rights. The median information framework quality score was 6 out of 16 (range 0-15). Beyond this score, only one wiki had standardized peer-reviews. Physicians contributed to 22 wikis, medical learners to nine, and lay persons to four. Among 116 sampled articles, those from encyclopedic wikis had more videos, pictures, and external resources, whereas others had more posology details and better readability. The median creation year was 2007 (1997-2011), the median number of content pages was 620.5 (3-98,039), the median of revisions per article was 17.7 (3.6-180.5) and 0.015 of talk pages per article (0-0.42). Five wikis were particularly active, whereas six were declining. Two wikis have been discontinued after the completion of the study. CONCLUSIONS: The 25 medical wikis we studied present various limitations in their format, management, and collaborative features. Professional medical wikis may be improved by using clinical cases, developing more detailed transparency and editorial policies, and involving postgraduate and continuing medical education learners.

Bone tissue engineering bioreactors: a role in the clinic?

Tissue engineered bone grafts have the potential to be used to treat large bone defects due to congenital abnormalities, cancer resections, or traumatic incidents. Recent studies have shown that perfusion bioreactors can be used to generate grafts of clinically relevant sizes and shapes. Despite these scientific and technological successes, there is uncertainty regarding the translational utility of bioreactor-based approaches due to the perceived high costs associated with these procedures. In fact, experiences over the past two decades have demonstrated that the widespread application of cell-based therapies is heavily dependent on the commercial viability. In this article, we directly address the question of whether bioreactors used to create bone grafts have the potential to be implemented in clinical approaches to bone repair and regeneration. We provide a brief review of tissue engineering approaches to bone repair, clinical trials that have employed cell-based methods, and advances in bioreactor technologies over the past two decades. These analyses are combined to provide a perspective on what is missing from the scientific literature that would enable an objective baseline for weighing the benefit of extended in vitro cultivation of cells into functional bone grafts against the cost of additional cultivation. In our estimation, the cost of bioreactor-based bone grafts may range from $10,000 to $15,000, placing it within the range of other widely used cell-based therapies. Therefore, in situations where a clear advantage can be established for engineered grafts comprising patient-specific, autologous cells, engineered bone grafts may be a clinically feasible option.

Microneedles in clinical practice--an exploratory study into the opinions of healthcare professionals and the public.

PURPOSE: Microneedles are being developed to administer vaccines and therapeutics to and through skin. To date there has been no qualitative or quantitative research into public and health professionals' views on this new delivery technique. METHODS: Focus groups (n=7) comprising public and healthcare professionals were convened to capture the perceived advantages for, and concerns with, microneedles. Discussions were audio-recorded and transcribed. Transcript analysis identified themes that were explored using a questionnaire identifying consensus or otherwise. RESULTS: Participants identified many potential benefits of the microneedle delivery system, including reduced pain, tissue damage and risk of transmitting infections compared with conventional injections, as well as potential for self-administration (subject to safeguards such as an indicator to confirm dose delivery). Delayed onset, cost, accurate and reliable dosing and the potential for misuse were raised as concerns. A range of potential clinical applications was suggested. The public (100%) and professional (74%) participants were positive overall about microneedle technology. CONCLUSIONS: This exploratory research study captured the views of the eventual end-users of microneedle technology. Microneedle researchers should now reflect on their research and development activities in the context of stakeholder engagement in order to facilitate the transfer of this new technology 'from bench to bedside.'

Guidewires in clinical practice: applications and troubleshooting.

Guidewires are commonly used in clinical practice over a wide range of specialties. Their use has become more popular as a result of advances in endourology and interventional radiology, as well as in angiographic procedures. While there are many papers regarding individual guidewires and certain technical aspects, for the interested clinician there is little to give a generalized overview within the literature. This paper aims to review guidewires in terms of their make-up, applications and potential complications. Technical points are described, as well as rescue methods for complications, in the hope of preventing future litigation for those reading the paper.

Stability of blood cell counts, hematologic parameters and reticulocytes indexes on the Advia A120 hematologic analyzer.

Delayed sample analysis is not a rare circumstance in clinical and laboratory practice, especially when blood samples are shipped to distant centralized laboratories, when the analysis can not be readily performed, or when retesting is appropriate. In this study we sought to evaluate the stability of conventional and new hematologic parameters in blood specimens stored for as long as 24 hours at 4 degrees C. Of the 21 hematologic parameters tested with the use of the Advia 120 hematologic analyzer (Bayer Diagnostics), means for paired samples of specimens differed significantly over the 24-hour storage period for hematocrit, main corpuscular volume, percentage of macrocytes, platelet count, main platelet volume, reticulocyte count and percentage, and reticulocyte hemoglobin content (all P < .01). We noted no significant changes in the other parameters tested or in the white blood cell differential. The overall distribution of the immature reticulocytes fractions remained substantially unchanged, though the high staining-intensity fraction showed a considerable shift from the baseline measure. Bland-Altman plots and limits-of-agreement analysis showed mean biases between -4.8% and 37.2% and relative coefficients of variations ranging from 0.4% to 32.7%. The 95% agreement interval in the set of differences was satisfactory and almost within the current analytic-quality specifications for desirable bias. The results of this investigation suggest that, within certain limitations for parameters derived or calculated from cellular volumes, blood specimens stored for as long as 24 hours at 4 degrees C may be suitable for hematologic testing.

The Abbott Architect c8000: analytical performance and productivity characteristics of a new analyzer applied to general chemistry testing.

Applying basic potentiometric and photometric assays, we evaluated the fully automated random access chemistry analyzer Architect c8000, a new member of the Abbott Architect system family, with respect to both its analytical and operational performance and compared it to an established high-throughput chemistry platform, the Abbott Aeroset. Our results demonstrate that intra- and inter-assay imprecision, inaccuracy, lower limit of detection and linear range of the c8000 generally meet actual requirements of laboratory diagnosis; there were only rare exceptions, e.g. assays for plasma lipase or urine uric acid which apparently need to be improved by additional rinsing of reagent pipettors. Even with plasma exhibiting CK activities as high as 40.000 U/l, sample carryover by the c8000 could not be detected. Comparison of methods run on the c8000 and the Aeroset revealed correlation coefficients of 0.98-1.00; if identical chemistries were applied on both analyzers, slopes of regression lines approached unity. With typical laboratory workloads including 10-20% STAT samples and up to 10% samples with high analyte concentrations demanding dilutional reruns, steady-state throughput numbers of 700 to 800 tests per hour were obtained with the c8000. The system generally responded to STAT orders within 2 minutes yielding analytical STAT order completion times of 5 to 15 minutes depending on the type and number of assays requested per sample. Due to its extended test and sample processing capabilities and highly comfortable software, the c8000 may meet the varying needs of clinical laboratories rather well.

Clinical applications of EPR: overview and perspectives.

The development and use of in vivo techniques for strictly experimental applications in animals has been very successful, and these results now have made possible some very attractive potential clinical applications. The area with the most obvious immediate, effective and widespread clinical use is oximetry, where EPR almost uniquely can make repeated and accurate measurements of pO2 in tissues. Such measurements can provide clinicians with information that can impact directly on diagnosis and therapy, especially for oncology, peripheral vascular disease and wound healing. The other area of immediate and timely importance is the unique ability of in vivo EPR to measure clinically significant exposures to ionizing radiation 'after-the-fact', such as may occur due to accidents, terrorism or nuclear war. There are a number of other capabilities of in vivo EPR that also potentially could become extensively used in human subjects. In pharmacology the unique capabilities of in vivo EPR to detect and characterize free radicals could be applied to measure free radical intermediates from drugs and oxidative process. A closely related area of potential widespread applications is the use of EPR to measure nitric oxide. These often unique capabilities, combined with the sensitivity of EPR spectra to the immediate environment (e.g. pH, molecular motion, charge) have already resulted in some very productive applications in animals and these are likely to expand substantially in the near future. They should provide a continually developing base for extending clinical uses of in vivo EPR. The challenges for achieving full implementation include adapting the spectrometer for safe and comfortable measurements in human subjects, achieving sufficient sensitivity for measurements at the sites of the pathophysiological processes that are being measured, and establishing a consensus on the clinical value of the measurements.

Molecular tools for a molecular medicine: analyzing genes, transcripts and proteins using padlock and proximity probes.

Procedures and reagents are needed to specifically detect all the macromolecules that are being identified in the course of genome projects. We discuss how this challenge may be met using a set of ligation-based reagents termed padlock probes and proximity ligation probes. These probes include elements with affinity for specific nucleic acid and protein molecules, respectively, along with unique identifier DNA sequence elements that encode the identity of the recognized target molecules. The information content of DNA strands that form in the detection reactions are recorded after amplification, allowing the recognized target molecules to be identified. The procedures permit highly specific solution-phase or localized analyses of large sets of target molecules as required in future molecular analyses.