A neuroanatomical study of the feline brain using MRI and mulligan staining: functional and pathological considerations.

BACKGROUND: Despite multiple studies describing accurate diagnoses using advanced neuroimaging techniques, low and mid-field magnetic resonance imaging (MRI) are still the most frequent scanners in veterinary clinics. To date, these studies in cats do not show a clear distinction of nerve centres in MRI data. AIMS: The objective of this study is to determine the efficacy of Mulligan histological staining as a tool in facilitating the location and identification of the main structures of the feline brain in MRI. This study aims to facilitate the interpretation of MRI obtained with these types of scanners. METHODS: A total of 10 feline brains were used. One specimen was used for MRI (T2 sequence using a 1.5T scanner). The other 9 brains were sectioned and stained with the three Mulligan staining techniques (Mulligan, Le Masurier and Robert). RESULTS: The uptake of stain by the grey matter in these sections allowed the determination of the location and the limits of these nervous structures within the brain. The histological location of these structures was correlated with the MRI scans, leading to the successful identification of many small, indistinct nuclei. CONCLUSION: Mulligan staining is proposed as a tool that facilitates the location of nerve structures in comparison with data from the most frequently-used MRI scanners in veterinary clinics.

Sectional anatomic and tomographic study of the feline abdominal cavity for obtaining a three-dimensional vascular model.

BACKGROUND: Unlike dogs, feline abdominal studies are rare. Note that anatomical estudies in felines are scarce and almost unique using feline cadaver by means of sectional anatomy and computed tomography (CT) or magnetic resonance imaging (MRI). Aims: In this study, a non-pathological vascularization model of feline abdomen was conducted on three adult cats was using anatomical and diagnostic imaging techniques. METHODS: A live pet cat and two cat cadavers were used in this study. Cat cadavers were injected with colored latex to show well-differentiated vascular structures and serial sections of cat abdomen were then provided. Computed tomography was performed by injecting an iodinated contrast medium through the cephalic vein of a live cat immediately before scanning. The CT images showed the arterial and venous vascular formations hyper-attenuated with two tomographic windows. The correlation between anatomical sections and their CTs was studied to identify vascular and and visceral structures. RESULTS: Hyper-attenuated vascular structures with the contrast medium were identified and marked along their path in the series of Dicom images with the Amira program. In this approach, sequentially and semiautomatically, vascular volumetric reconstruction was obtained without visceral formations. With the OsiriX program, volumetric reconstruction was automatic and maintained the fidelity of all visceral and vascular formations. CONCLUSION: We conclude that these improved prototypes could be used in veterinary clinics as normal vascular models and as a basis for obtaining future 3D models of vascular anomalies such as portosystemic shunts.

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.

Determination of required pharmacological knowledge for clinical practice in emergency medicine using a modified Delphi technique.

AIMS: To identify the content of the national postgraduate pharmacology curriculum for trainees in UK emergency medicine. METHODS: Modified three-round iterated Delphi technique employing a participant panel of 160 randomly selected consultants in emergency medicine. Initial Delphi content was derived from objective analysis of pharmacy stock lists and patient record cards. The outcome measure was percentage agreement, among participants, to listed aspects of therapeutics as being core knowledge for autonomous clinical practice in the emergency department. A national curriculum document was derived from the study data. RESULTS: Response rates ranged from 66-76% after three Delphi rounds. From an initial overall questionnaire content of 526 discrete items, 59% was retained as core knowledge following iteration. The subsequent national curriculum document acts as a resource tool both for question setting in postgraduate examinations and for self-directed trainee learning before the sitting of these examinations. CONCLUSIONS: Application of a national consensus methodology allows determination of curricular content in pharmacology as part of the development of a robust College educational portfolio.

Clinical teaching in emergency medicine: the board round at Hope Hospital emergency department.

This article discusses the educational value of the "board round", a clinical teaching forum introduced at Hope Hospital, Manchester, UK. At midday on weekdays all available consultants and middle grade doctors, and any other staff who can attend, meet to discuss a case selected from the patients currently in the department. As several experienced clinicians are available to discuss a clinical problem, the round allows a broad debate during which the merits of several management options are discussed. In addition, attending a board round addresses in part the concerns which senior clinicians may have about the balance of service delivery and protected teaching time. The paper describes several other advantages of this method of teaching, which has been adopted by other hospitals in the region.

Clinical supervision in the emergency department: a critical incident study.

OBJECTIVES: To identify the key features of effective clinical supervision in the emergency department (ED) from the perspectives of enthusiastic consultants and specialist registrars. To highlight the importance of clinical supervision within emergency medicine, and identify obstructions to its occurrence in everyday practice. METHODS: A critical incident study was undertaken consisting of structured interviews, conducted by telephone or in person, with 18 consultants and higher level trainees selected for their interest in supervision. RESULTS: Direct clinical supervision of key practical skills and patient management steps was considered to be of paramount importance in providing quality patient care and significantly enhancing professional confidence. The adequacy of supervision varied depending upon patient presentation. Trainees were concerned with the competence and skills of their supervisor; consultants were concerned with wider systemic constraints upon the provision of adequate supervision to juniors. CONCLUSIONS: The value of supervision extends to all patient presentations in the ED. The study raised questions concerning the appropriate attitudes and qualifications for supervisors. Protected supervisory time for those with trainees is mandatory, and must be incorporated within ED consultant job planning.

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.

The Foundation Programme and the emergency department: a review of the curriculum and experience of a UK pilot.

The emergency department will have an important role within the Modernising Medical Careers Foundation Programme (FP) in the United Kingdom. Many of the key competencies required of Foundation training relate to acute medical care. However, the Foundation curriculum is a large and complex document. Some of the detail within it has particular implications for emergency medicine. Issues of curriculum content, teaching styles, and assessment have a potentially significant effect upon established working practices in a typical unit. This paper examines the FP curriculum to allow a clearer understanding of its key elements. Problems in relation to delivery of teaching and the quantity of assessment required are highlighted and solutions discussed. Experience from a UK pilot site for Foundation training in emergency medicine which began in August 2004 is used to illustrate how some of these issues have been addressed. The review concludes with a series of practical hints and tips which others may find useful as they prepare to incorporate FP trainees locally.

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.

Problem based learning.

Problem based learning (PBL) has been the subject of considerable interest and debate in medical undergraduate and, increasingly, postgraduate education in recent years. Its supporters maintain that PBL enhances learning by providing a highly motivational environment for acquisition of knowledge, which is well received by those who take part in it. Critics argue that PBL is a time consuming exercise, often undertaken by people with a limited appreciation of its complexities, and the lack of evidence that PBL translates into better clinical competence brings into question the relevance of such intensive learning methods in everyday practice. This article outlines the background to PBL, explains its mechanics in action, and considers the potential disadvantages of its use as a clinical learning tool in the emergency department.

Aspects of higher training in emergency medicine.

OBJECTIVES: To devise and develop a structured questionnaire addressing important issues relating to specialist registrar training in emergency medicine in the UK, and to then administer this questionnaire nationally to higher trainees in order to establish current practice and opinion regarding those issues. METHODS: Informal interviews with current trainees were undertaken to identify themes which might be of wider importance in relation to training. The transcriptions were incorporated into a discussion questionnaire which was circulated to other trainees and to members of the Joint Committee on Higher Training in Accident and Emergency. A postal survey was developed from this draft and distributed to all trainees currently registered with the Faculty of Accident and Emergency Medicine. RESULTS: The response rate was 75%. Collective responses to certain aspects of training are demonstrated in order to reflect current practice and opinion among UK specialist registrars and to allow further debate. CONCLUSION: Development of a structured questionnaire allows issues in relation to training in emergency medicine to be assessed. The findings of the survey allow national data to be presented which will be of interest to trainees and trainers in the UK as well as overseas.

Emergency department investigation of deep vein thrombosis.

OBJECTIVES: To apply a previously validated clinical model for predicting pre-test probability of deep vein thrombosis (DVT) to patients attending an emergency department with symptoms suggestive of DVT and assess its reproducibility in the patient population. To measure the diagnostic value of the SimpliRED D-dimer assay in effectively excluding DVT. METHOD: Prospective study between March 1999 and October 2000 of adult patients attending with suspected DVT. Patients were assessed using Wells' clinical prediction tool and risk stratified. SimpliRED D-dimer estimations were then performed and compression ultrasonography arranged. The pre-test probabilities of DVT in the low, moderate, and high risk groups of Wells' original cohort were compared with the authors' figures and the sensitivity, specificity, and predictive values of the SimpliRED assay calculated for the patient population. RESULTS: Application of Wells' criteria to patients in the department permitted stratification into high, moderate, and low risk groups (prevalence of DVT 58.3%, 8.9%, and 1.5% respectively). SimpliRED D-dimer assay sensitivity was 63.4% with specificity of 74.8%, with a likelihood ratio of 2.52 for a positive test and 0.49 for a negative test. CONCLUSIONS: Clinical risk stratification allowed patients to be categorised into high, moderate, and low risk groups, albeit with less discriminatory power than originally described by Wells. The low sensitivity of the SimpliRED D-dimer assay when used routinely in a busy emergency department raises substantial doubt over the use of this test to rule out DVT, even in low risk patients.