Undergraduate radiology teaching in a UK medical school: a systematic evaluation of current practice.

AIM: To use the Royal College of Radiologists' Undergraduate Radiology Curriculum (RCR URC) as an innovative tool to review undergraduate radiology teaching and ensure it is comprehensive and balanced. MATERIALS AND METHODS: Quantitative and qualitative methods were used to audit and review radiology teaching for students in years 1-3. All radiological teaching on the course was mapped against the RCR URC learning outcomes. An online survey of students in year 3 (n=138) was conducted using Likert (1-5), multiple choice, and free-text questions. RESULTS: There were 954 instances of radiology teaching, with 70% occurring during lectures. Radiology teaching was mapped to 81 of the 96 RCR URC learning outcomes (84.4%). Forty-seven of 138 students responded to the survey. They expressed confidence in understanding what basic imaging entails (x=4.23) and the risks associated with various imaging techniques (x=4.34). They were also confident in chest radiograph interpretation (x=3.62), but were less confident understanding abdominal radiographs (x=2.87). In free-text comments, students requested more tutorial-type teaching and ultrasound instruction. CONCLUSION: The RCR URC is an effective tool for auditing undergraduate radiology teaching, and other medical schools may, therefore, benefit from using this method. This evaluation process incorporating audit and feedback has identified areas for curriculum development. These include incorporating ultrasound into teaching sessions, delivering more small-group teaching, and introducing clinical placements in radiology departments.

Guidelines for chest drain insertion may not prevent damage to abdominal viscera.

OBJECTIVES: Guidelines to improve the ease and safety of chest drain insertion recommend using the fifth intercostal space, around the midaxillary line (MAL). This study aimed to assess whether compliance with published guidelines reliably ensured such placement and avoided the potentially serious complications of subdiaphragmatic insertion and peripheral nerve injury. METHODS: Three international guidelines were assessed by identifying the intercostal space for chest drain insertion using 16 cadavers (32 sides) at a point 1 cm anterior to MAL. The European Trauma Course method was compared with the British Thoracic Society's 'safe triangle' and the ATLS course technique. RESULTS: The level most commonly found was the sixth intercostal space (43%; 41 of 96 sides). Overall the sixth space or below was found in 83% of insertions (80 of 96 sides). In the fifth intercostal space, the long thoracic nerve ran posterior to the marker placed in all cases and the lateral cutaneous branches of intercostal nerves arose anteriorly to the marker in all but one case. CONCLUSIONS: The results suggest these guidelines may result in insertion of chest drains below the fifth intercostal space, potentially risking injury to subdiaphragmatic structures. Peripheral nerves of the lateral thoracic wall appear safe from incisions 1 cm anterior to MAL.

Finding the fifth intercostal space for chest drain insertion: guidelines and ultrasound.

OBJECTIVES: International guidelines exist for chest drain insertion and recommend identifying the fifth intercostal space or above, around the midaxillary line. In a recent study, applying these guidelines in cadavers risked insertion in the 6th intercostal space or below in 80% of cases. However, there are limitations of cadaveric studies and this investigation uses ultrasound to determine the intercostal space identified when applying these guidelines in healthy adult volunteers. METHODS: On each side of the chest wall in 31 volunteers, the position for drain insertion was identified using the European Trauma Course method, Advanced Trauma Life Support (ATLS) method, British Thoracic Society's 'safe triangle' and the 'traditional' method of palpation. Ultrasound imaging was used to determine the relationship of the skin marks with the underlying intercostal spaces. RESULTS: Five methods were assessed on 60 sides. In contrast to the cadaveric study, 94% of skin marks lay over a safe intercostal space. However, the range of intercostal spaces found spanned the second to the seventh space. In 44% of women, the inferior boundary of the 'safe triangle' and the ATLS guidelines located the sixth intercostal space or below. CONCLUSIONS: Current guidelines often identify a safe site for chest drain insertion, although the same site is not reproducibly found. In addition, women appear to be at risk of subdiaphragmatic drain insertion when the nipple is used to identify the fifth intercostal space. Real-time ultrasonography can be used to confirm the intercostal space during this procedure, although a safe guideline is still needed for circumstances in which ultrasound is not possible.

Defining a positive circumferential resection margin in oesophageal cancer and its implications for adjuvant treatment.

BACKGROUND: A positive circumferential resection margin (CRM) has been associated with a poorer prognosis in oesophageal and oesophagogastric junctional (OGJ) cancer. The College of American Pathologists defines the CRM as positive if tumour cells are present at the margin, whereas the Royal College of Pathologists also include tumour cells within 1 mm of this margin. The relevance of these differences is not clear and no study has investigated the impact of adjuvant therapy. The aim was to identify the optimal definition of an involved CRM in patients undergoing resection for oesophageal or OGJ cancer, and to determine whether adjuvant radiotherapy improved survival in patients with an involved CRM. METHODS: This was a single-centre retrospective study of patients who had undergone attempted curative resection for a pathological T3 oesophageal or OGJ cancer. Clinicopathological variables and distance from the tumour to the CRM, measured to ± 0.1 mm, were correlated with survival. RESULTS: A total of 226 patients were included. Sex (P = 0·018), tumour differentiation (P = 0·019), lymph node status (P < 0·001), number of positive nodes (P < 0·001), and CRM distance (P = 0·042) were independently predictive of prognosis. No significant survival difference was observed between positive CRM 0-mm and 0·1-0·9-mm groups after controlling for other prognostic variables. Both groups had poorer survival than matched patients with a CRM at least 1 mm clear of tumour cells. Among patients with a positive CRM of less than 1 mm, those undergoing observation alone had a median survival of 18·6 months, whereas survival was a median of 10 months longer in patients undergoing adjuvant radiotherapy, but otherwise matched for prognostic variables (P = 0·009). CONCLUSION: A positive CRM of 1 mm or less should be regarded as involved. Adjuvant radiotherapy confers a significant survival benefit in selected patients with an involved CRM.

Mutational analysis of the CD2/CD58 interaction: the binding site for CD58 lies on one face of the first domain of human CD2.

The adhesion interaction between the immunoglobulin superfamily molecules CD2 and CD58 (lymphocyte function-associated antigen 3) plays an important role in T cell and natural killer cell interaction with various antigen-presenting and target cells. Determination of the solution structure of rat CD2 domain 1 has allowed a model of human CD2 domain 1 to be generated, and a series of mutants based on this model have been made. Residues of domain 1 of human CD2 predicted to be solvent exposed were substituted with the equivalent residues present in the rat CD2 molecule. The ability of these mutants to mediate rosetting with human and sheep erythrocytes was studied. Results show that the binding site of CD2 for both human and sheep CD58 maps to the beta sheet containing beta strands CC'C"F and G. Residues K34 and E36 in beta strand C, R48 and K49 in beta strand C', and K91 and N92 in the loop connecting beta strands F and G are shown to be critical in the interaction. The data support the proposition that the interaction between CD2 and CD58 involves the major beta sheet face of CD2.

Postnatal modification of hippocampal circuitry alters avoidance learning in adult rats.

In rats and mice, the genetically mediated extent of the mossy fiber projection that synapses on the basal dendrites of hippocampal pyramidal cells is inversely correlated with rate of two-way avoidance (shuttle-box) learning. Postnatal hyperthyroidism, induced in 51 rat pups, resulted in marked variations of this infrapyramidal mossy fiber projection. The number of trials required for criterion performance of these rats in adulthood remained correlated with the neuroanatomical trait (r = 0.74, P less than 0.0001).

Memory formation: evidence for a specific neurochemical system in the amygdala.

beta-Adrenergic antagonists injected into the amygdala complex of rats trained in a passive avoidance task produced time-dependent and dose-dependent decreases in retention of the task. In addition, the effects observed with beta-adrenergic antagonists were both stereospecific and reversed by norepinephrine. The results support a role for an amygdala beta-adrenergic system in memory processes.

Content prioritisation of the College of Emergency Medicine specialty curriculum: an exploratory study using a modified Delphi approach.

AIMS: To determine opinion in relation to prioritisation of topics within the clinical curriculum of the College of Emergency Medicine. METHODS: A modified iterated Delphi technique was used employing a participant panel of 40 randomly selected consultants in emergency medicine. Free text was used in order to generate issues for opinion. Likert scales were then employed to refine this opinion. RESULTS: The overall response rate was 50%. Group opinion favoured curricular prioritisation based on a range of clinical indicators. Applying a prioritisation based on exit examination content was not supported. CONCLUSION: Application of a consensus methodology incorporating free text and Likert scales allows expert opinion to be generated in relation to curricular prioritisation. This helps shape the format and educational utility of the specialty curriculum.

The advanced life support group's view of HOSPEX.

This paper explores some of the principles and intentions behind simulation in medical education and explores the extent to which HOSPEX fits within an accepted design. It further points to the direction that HOSPEX will need to take in order to maximise its capacity to aid the delivery of exemplary patient safety.

Peripheral membrane proteins: FYVE sticky fingers.

The recently determined structure of the lipid-binding 'FYVE' domain provides several clues to the mode of interaction for this class of peripheral membrane proteins. However, the application of traditional modes of structural analysis to diffusible membrane-binding proteins exposes some limitations of these techniques.

Peptide selection by class I molecules of the major histocompatibility complex.

Class I molecules of the major histocompatibility complex (MHC) bind peptides derived from cytoplasmic proteins. Comparison of over 100 such peptides reveals the importance of the carboxy-terminal residue in selective binding. Recent evidence implicates the proteases and transporters of the processing pathway in providing peptides with the correct residues at the carboxyl terminus.

Endocytosis: How dynamin sets vesicles PHree!

The dynamin GTPase is required for clathrin-dependent, receptor-mediated endocytosis. Exciting new studies have shown that dynamin's pleckstrin homology domain binds to phosphatidylinositol 4, 5-bisphosphate in vivo, thus localising dynamin directly at the plasma membrane and ultimately enabling vesiculation.

Three-dimensional solution structure of the pleckstrin homology domain from dynamin.

BACKGROUND: The pleckstrin homology (PH) domain is a region of approximately 100 amino acids, defined by sequence similarity, that has been found in about 60 proteins, many of which are involved in signal transduction downstream of cell surface receptors; the function of PH domains is unknown. The only clue to the function of PH domains is the circumstantial evidence that they may link beta gamma subunits of G proteins to second messenger systems. Knowledge of the three-dimensional structures of PH domains should help to elucidate the roles they play in the proteins that contain them. RESULTS: Using homonuclear and heteronuclear magnetic resonance spectroscopy, we have determined the solution structure of the PH domain of the GTPase dynamin, one of a number of proteins that have PH domains and interact with GTP. The fold of the dynamin PH domain is composed of two antiparallel beta-sheets, which pack face-to-face at an angle of approximately 60 degrees. The first beta-sheet comprises four strands (residues 13-58) from the amino-terminal half of the protein sequence; the second beta-sheet contains three strands (residues 63-99). A single alpha-helix (residues 102-116) flanks one edge of the interface between the two sheets, parallel in orientation to the second sheet, in an alpha/beta roll motif similar to that of the B oligomer of verotoxin-1 from Escherichia coli. CONCLUSIONS: The structure of the dynamin PH domain is very similar to the recently reported structures of the pleckstrin and spectrin PH domains. This shows that, despite the low level of sequence similarity between different PH domains, they do have a characteristic polypeptide fold. On the basis of our structure, the suggestion that PH domains engage in coiled-coil interactions with G protein beta gamma subunits seems unlikely and should be re-evaluated.

Ontogenesis of prolactin receptors in the human fetus in early gestation. Implications for tissue differentiation and development.

To explore potential roles for lactogenic hormones in human fetal development, we examined the distribution and ontogenesis of expression of prolactin receptors (PRLRs) in human fetal tissues at 7.5-14 wk of gestation and in tissues of the embryonic and fetal rat on days e12.5-e20.5. Histochemical analysis of PRLR immunoreactivity in the human fetus and fetal rat revealed novel and unexpected patterns of receptor expression. Most remarkable was the appearance in early fetal development of intense PRLR immunoreactivity in tissues derived from embryonic mesoderm, including the periadrenal and perinephric mesenchyme, the pulmonary and duodenal mesenchyme, the cardiac and skeletal myocytes, and the mesenchymal precartilage and maturing chondrocytes of the endochondral craniofacial and long bones, vertebrae and ribs. Striking changes in the cellular distribution and magnitude of expression of PRLRs were noted in many tissues during development. In the fetal adrenal the initial mesenchymal PRLR expression is succeeded by the emergence of PRLR immunoreactivity in deeper fetal cortical cell layers. In the fetal kidney and lung, the invagination of cortical mesenchyme is accompanied by progressive PRLR immunoreactivity in bronchial and renal tubular epithelial cells. In the pancreas, the PRLR is expressed primarily in acinar cells and ducts in early gestation; in late gestation and in the postnatal period, the PRLR is expressed predominantly in pancreatic islets, co-localizing with insulin and glucagon. Finally in fetal hepatocytes, PRLR immunoreactivity increases significantly between embryonic days e52 and e96 in the human fetus and between days e16.5 and e18.5 in the fetal rat. In addition to playing important roles in reproduction, lactation, and immune function, the lactogenic hormones likely play roles in tissue differentiation and organ development early in gestation.

Glutathione supplementation to University of Wisconsin solution causes endothelial dysfunction.

INTRODUCTION: Glutathione (GSH) is added to University of Wisconsin (UW) organ preservation solution to protect against oxidative stress. This study assesses the effect of GSH-supplementation on endothelial function in tissues subjected to cold ischaemia and compares its effects to a mono-ethyl ester equivalent (GSH-MEE) and S-nitrosated GSH (GSNO). METHODS: Rat aortic rings were stored for 1 h or 48 h in cold, hypoxic UW solution with or without GSH (3 mM), GSH-MEE (3 mM) or GSNO (100 mciroM) supplementation. Aortic rings were reoxygenated in warm Krebs solution; smooth muscle function was assessed by responses to phenylephrine (PE), and endothelial function by vasodilatation to the endothelium-dependent dilator, acetylcholine (ACh). The protective effects against oxidant-induced endothelial cell death were assessed in cultured human umbilical vein endothelial cells (HUVEC). RESULTS: Supplementation of UW with either GSH or GSH-MEE had no effect on vascular responses to PE, but smooth muscle contraction was significantly attenuated in rings incubated for 48 h with GSNO. Endothelium-dependent relaxation was significantly impaired in tissues stored under hypoxic conditions in GSH, GSH-MEE and GSNO supplemented UW solution for 1 h. However, impairment at 48 h was significantly more pronounced in GSH-treated vessels. Cultured HUVEC death was exacerbated by GSH and GSH-MEE in unstressed cells and in those stressed with a superoxide anion generator. CONCLUSIONS: GSH supplementation of UW solution exacerbates cold-ischaemia induced endothelial dysfunction. GSNO did not share the detrimental effects of GSH and promoted NO-mediated vasodilatation.

Risk factors for methadone outside treatment programs: implications for HIV treatment among injection drug users.

BACKGROUND: Diversion of methadone outside treatment programs occurs, yet reasons for use of 'street methadone' are characterized poorly. Self-medication for withdrawal symptoms is one plausible hypothesis. Among HIV-infected drug users, some antiretroviral medications can reduce potency of methadone, yet any association between such effects and the use of supplemental methadone sources remains undetermined. OBJECTIVE: To estimate the frequency and risk factors for use of street methadone. METHODS: Injection drug users (IDUs) recruited through extensive community outreach in 1988-89 and 1994 were followed semi-annually with questionnaires about health history, use of licit and illicit drugs including methadone and HIV-related assays. Analyses were performed using generalized estimating equation logistic regression. RESULTS: Of 2811 IDUs enrolled and eligible for analysis, 493 people reported use of street methadone over 12 316 person-years of follow-up (4.0/100 person-years). In multivariate analyses, street methadone use was more common among women, whites, those 40-59 years old, those who reported withdrawal symptoms, past methadone program attendance (6-12 months before visit), recent heroin injection with or without cocaine (but not cocaine alone), smoking or sniffing heroin and reported trading sex. Street methadone was not associated with HIV infection or treatment. CONCLUSION: The results suggest that older IDUs still using heroin may be using street methadone to treat signs of withdrawal. The absence of a higher rate of street methadone use in HIV seropositive IDUs reveals that antiretroviral/methadone interactions are not a primary determinant of use outside of treatment settings.

The solution structure and backbone dynamics of the fibronectin type I and epidermal growth factor-like pair of modules of tissue-type plasminogen activator.

BACKGROUND: The thrombolytic serine protease tissue-type plasminogen activator (t-PA) is a classical modular protein consisting of three types of domain in addition to the serine protease domain: F1 (homologous to fibronectin type I); G (epidermal growth factor-like) and kringle. Biochemical data suggest that the F1 and G modules play a major role in the binding of t-PA to fibrin and to receptors on hepatocytes. RESULTS: We have derived the solution structure of the F1 and G pair of modules from t-PA by two- and three-dimensional NMR techniques, in combination with dynamical simulated annealing calculations. We have also obtained information about the molecule's backbone dynamics through measurement of amide 15N relaxation parameters. CONCLUSIONS: Although the F1 and G modules each adopt their expected tertiary structure, the modules interact intimately to bury a hydrophobic core, and the inter-module linker makes up the third strand of the G module's major beta-sheet. The new structural results allow the interpretation of earlier mutational data relevant to fibrin-binding and hepatocyte-receptor binding.

Determination of required anatomical knowledge for clinical practice in emergency medicine: national curriculum planning using a modified Delphi technique.

OBJECTIVES: To identify the content of the postgraduate anatomy curriculum for trainees in emergency medicine (EM) in the UK. METHODS: Modified Delphi technique involving 160 randomly sampled consultants in EM. The outcome measure was percentage agreement, based upon a three round iterated Delphi process, of participants to items derived from a standard anatomy text being core knowledge for postgraduate clinical practice in the specialty. A national curriculum document was derived as a result of the data obtained. RESULTS: Response rates ranged from 61% to 70% after three Delphi rounds. From an initial overall questionnaire content of 808 discrete items, 64% was retained as core required knowledge following iteration. This formed the basis of a national consensus anatomy curriculum both to inform question development in postgraduate EM examinations and to benchmark anatomical knowledge requirements for safe clinical practice. CONCLUSIONS: Application of a national consensus methodology allows for determination of curricular content in anatomy. The principles can be applied to all aspects of training and curricular policy at national collegiate level to guide the development of robust documentation.

Exposure or expert? Setting standards for postgraduate education through a Delphi technique.

OBJECTIVES: The aim of this study was to determine if a syllabus of upper limb anatomy for emergency clinicians composed by an expert panel reflected clinical practice as experienced by those at whom the syllabus would be directed. METHODS: A three round Delphi study was performed using an expert group. We compared this with a measure of the exposure to anatomical concepts in the day to day practice of trainees in emergency medicine. RESULTS: In total, 404 separate anatomical facts relating to the upper limb were reviewed by both groups. There was poor agreement (kappa = 0.348) between the expert group and the trainees. CONCLUSION: We have shown disparity between what an expert group believes trainees should know and what trainees are actually exposed to in clinical practice. We believe this demonstrates that curriculum development must strike a balance between important (expert) and common (exposure) information. We have shown how an expert:exposure matrix may be used to inform curriculum development.