Medical graduate views on statistical learning needs for clinical practice: a comprehensive survey.

BACKGROUND: This paper seeks to contribute to a reputable evidence base for required competencies across different topics in statistics and probability (statistical topics) in preparing medical graduates for clinical practice. This is in order to inform the prioritization of statistical topics within future undergraduate medical curricula, while exploring the need for preparing tomorrow's doctors to be producers, and not merely consumers, of statistics. METHODS: We conducted a comprehensive online survey from July 2013 to August 2014 for a target group of 462 medical graduates with current or prior experience of teaching undergraduate medical students of the University of Edinburgh of whom 278 (60.2%) responded. Statistical topics were ranked by proportion of respondents who identified the practice of statistics, performing statistical procedures or calculations using appropriate data, as a required competency for medical schools to provide in preparing undergraduate medical students for clinical practice. Mixed effects analyses were used to identify potential predictors for selection of the above competency and to compare the likelihood of this selection for a range of statistical topics versus critical appraisal. RESULTS: Evidence was gleaned from medical graduates' experiences of clinical practice for the need for, not only a theoretical understanding of statistics and probability but also, the ability to practice statistics. Nature of employment and statistical topic were highly significant predictors of choice of the practice of statistics as a required competency ((F = 3.777, p < 0.0005) and (F = 45.834, p < 0.0005), respectively). The most popular topic for this competency was graphical presentation of data (84.3% of respondents) in contrast to cross-over trials for the competency understanding the theory only (70.5% of respondents). Several topics were found to be more popular than critical appraisal for competency in the practice of statistics. CONCLUSIONS: The model of medical graduates as mere consumers of statistics is oversimplified. Contrary to what has been suggested elsewhere, statistical learning opportunities in undergraduate medicine should not be restricted to development of critical appraisal skills. Indeed, our findings support development of learning opportunities for undergraduate medical students as producers of statistics across a wide range of statistical topics.

Capnography for procedural sedation in the ED: a systematic review.

INTRODUCTION: Procedural sedation and analgesia (PSA) is commonplace in the ED. Previous studies have identified capnography as a reliable indicator of PSA-induced respiratory depression. This review investigates the potential effect on patient safety of the use of capnography in addition to standard monitoring for adult patients undergoing PSA in the ED. METHODS: MEDLINE, Embase, Scopus, CINAHL and Google Scholar were searched systematically for ED studies using capnography during PSA. Data extraction was performed by two independent authors. Using MedCalc V.13.3.3 and Meta-DiSc V.1.4, data were aggregated under the random-effects model and heterogeneity was assessed using Cochran's Q-test and the I2 statistic. RESULTS: Of the 737 studies that were screened, 7 studies met the eligibility criteria, representing a total of 662 patients. The aggregate diagnostic accuracy for capnography identifying an adverse event included a diagnostic OR of approximately 6 (OR: 5.87; 95% CI 2.41 to 14.3; p<0.001), sensitivity 0.82 (95% CI 0.76 to 0.87), specificity 0.6 (95% CI 0.55 to 0.64), negative likelihood ratio 0.3 (95% CI 0.12 to 0.75) and positive likelihood ratio 1.89 (95% CI 1.53 to 2.34). There was a lack of statistical evidence for a difference in the proportion of adverse events detected when capnography was used in addition to standard monitoring (48.8% (95% CI 32.85 to 64.92)) compared with chance alone (50%). CONCLUSIONS: There is no firm evidence that capnography provides additional safety compared with standard monitoring alone during PSA in adults in the ED. There is a paucity of published research involving preoxygenated patients who remain on high-flow oxygen throughout PSA. Well-powered randomised controlled trials, employing an accepted adverse event reporting tool in such patients, are required. Until then, we advocate continued compliance with current professional recommendations for the use of capnography during PSA in adults in the ED.

A systematic review of therapeutic hypothermia for adult patients following traumatic brain injury.

INTRODUCTION: Research into therapeutic hypothermia following traumatic brain injury has been characterised by small trials of poor methodological quality, producing variable results. The Cochrane review, published in 2009, now requires updating. The aim of this systematic review is to assess the effectiveness of the application of therapeutic hypothermia to reduce death and disability when administered to adult patients who have been admitted to hospital following traumatic brain injury. METHODS: Two authors extracted data from each trial. Unless stated in the trial report, relative risks and 95% confidence intervals (CIs) were calculated for each trial. We considered P < 0 · 05 to be statistically significant. We combined data from all trials to estimate the pooled risk ratio (RR) with 95% confidence intervals for death, unfavourable outcome, and pneumonia. All statistical analyses were performed using RevMan 5.1 (Cochrane IMS, Oxford, UK) and Stata (Intercooled Version 12.0, StataCorp LP). Pooled RRs were calculated using the Mantel-Haenszel estimator. The random effects model of DerSimonian and Laird was used to estimate variances for the Mantel-Haenszel and inverse variance estimators. RESULTS: Twenty studies are included in the review, while 18 provided mortality data. When the results of 18 trials that evaluated mortality as one of the outcomes were statistically aggregated, therapeutic hypothermia was associated with a significant reduction in mortality and a significant reduction in poor outcome. There was a lack of statistical evidence for an association between use of therapeutic hypothermia and increased onset of new pneumonia. CONCLUSIONS: In contrast to previous reviews, this systematic review found some evidence to suggest that therapeutic hypothermia may be of benefit in the treatment of traumatic brain injury. The majority of trials were of low quality, with unclear allocation concealment. Low quality trials may overestimate the effectiveness of hypothermia treatment versus standard care. There remains a need for more, high quality, randomised control trials of therapeutic hypothermia after traumatic brain injury.

Are the public ready for organ donation after out of hospital cardiac arrest?

OBJECTIVE: To assess Emergency Department (ED) relatives' and patients' opinions on: (1) discussing organ donation (OD) with relatives soon after ED death after cardiac arrest and (2) acceptability of organ preservation procedures both before and after discussion with relatives. METHODS: Questionnaire study; convenience sample. RESULTS: 200 questionnaires were completed. 37.5% of participants were male subjects; mean age was 40.4 (SD 16.9; range 15-85) years. There was no difference in the number willing to discuss OD after brainstem death in intensive care unit compared with circulatory death in the ED (72% vs 72%; p=0.146). The majority were willing to discuss OD soon after ED death after cardiac arrest (106; 54%). 41 (21%) were not willing and 43 (22%) had no strong views (n=198). Organ preservation procedures (groin tube insertion, continuation of mechanical cardiopulmonary resuscitation and continuation of ventilator) were acceptable to between 48% and 57% of respondents if performed before discussion with family increasing to an acceptability of between 64% and 69% after discussion with family. One in four respondents felt these procedures were not acceptable regardless of the timing of discussion with family and some felt these procedures were more acceptable if the patient was a registered organ donor. 122 (61%) patients wished to donate their organs after death but only 59 (30%) were registered donors. CONCLUSIONS: (1) The majority of patients and their relatives are not averse to OD being discussed shortly after ED death. (2) Organ preservation procedures are acceptable to many. Prior discussion and prior organ donor registration may improve acceptability.

Out-of-hours decision-making in deteriorating patients by foundation year doctors: Relationship to moral distress.

BACKGROUND: Moral distress (MD) refers to psychological unease when healthcare professionals identify morally correct actions to take but are constrained in their ability to take those actions. METHODS: This study evaluated the relationship between out-of-hours decisions and MD among 40 Foundation Year 2 (FY2) doctors. They were asked to choose the 'expected' and the 'right' management options for five out-of-hours scenarios and complete an adapted Measure of Moral Distress for Health Professionals (MMD-HP) questionnaire. RESULTS: 28/40 (70%) reported discordance between 'expected' and 'right' options more frequently than concordance. The mean total MMD-HP score was low: 64.9 (SD = 26.9), range 13-143, maximum 288. The association between decision-making discordance and MMD-HP score was weak. CONCLUSION: Out-of-hours decisions by FY2 doctors were characterised by doing what is 'expected' rather than what is perceived to be 'right'. Providing guidance regarding decision-making in deteriorating patients is needed for patient safety and staff well-being.

Initiating undergraduate medical students into communities of research practise: what do supervisors recommend?

BACKGROUND: Much has been written in the educational literature on the value of communities of practise in enhancing student learning. Here, we take the experience of senior undergraduate medical students involved in short-term research as a member of a team as a paradigm for learning in a community of practise. Based on feedback from experienced supervisors, we offer recommendations for initiating students into the research culture of their team. In so doing, we endeavour to create a bridge between theory and practise through disseminating advice on good supervisory practise, where the supervisor is perceived as an educator responsible for designing the research process to optimize student learning. METHODS: Using the questionnaire design tool SurveyMonkey and comprehensive lists of contact details of staff who had supervised research projects at the University of Edinburgh during 1995-2008, current and previous supervisors were invited to recommend procedures which they had found successful in initiating students into the research culture of a team. Text responses were then coded in the form of derivative recommendations and categorized under general themes and sub-themes. RESULTS: Using the chi-square tests of linear trend and association, evidence was found for a positive trend towards more experienced supervisors offering responses (χ2 = 16.833, p < 0.0005, n = 215) while there was a lack of evidence of bias in the gender distribution of respondents (χ2 = 0.482, p = 0.487, n = 203), respectively. A total of 126 codes were extracted from the text responses of 65 respondents. These codes were simplified to form a complete list of 52 recommendations, which were in turn categorized under seven derivative overarching themes, the most highly represented themes being Connecting the student with others and Cultivating self-efficacy in research competence. CONCLUSIONS: Through the design of a coding frame for supervisor responses, a wealth of ideas has been captured to make communities of research practise effective mediums for undergraduate student learning. The majority of these recommendations are underpinned by educational theory and have the potential to take the learner beyond the stage of initiation to that of integration within their community of research practise.

Change in plasma vascular endothelial growth factor during onset and recovery from acute mountain sickness.

There is an increasing body of evidence suggesting that altered vascular permeability may be an important component of the pathogenesis of acute mountain sickness (AMS). Vascular endothelial growth factor (VEGF) is a potent permeability factor subject to hypoxic regulation but its role in the pathogenesis of AMS is yet to be defined. We examined the relationship between plasma VEGF and AMS on ascent to high altitude and subsequent acclimatisation. Thirty-eight healthy lowlanders (median age 21, range 18-31) flew to La Paz, Bolivia (3650 m) on the Apex 2 research expedition. After 4-5 days acclimatisation, they ascended by vehicle over 90 min to the Chacaltaya laboratory (5200 m). We measured plasma VEGF in venous blood at sea level and at 6 h and 3 and 7 days at 5200 m. AMS was scored using the Lake Louise consensus system. Using serial measurement of plasma VEGF at 5200 m, following partial acclimatisation at 3650 m, we demonstrated a highly significant change in VEGF levels (P<0.0005) with a rise in VEGF in approximately 80% of subjects by day 7 at 5200 m. We found no evidence of an association between AMS and change in VEGF levels on ascent to either 3650 or 5200 m. We provide novel data of change in plasma VEGF levels during acclimatisation to high altitude, but our results do not support the hypothesis that circulating unbound VEGF is an important component of the pathogenesis of AMS.

The acceptability to patients of video-consulting in general practice: semi-structured interviews in three diverse general practices.

BACKGROUND: To improve patient access to healthcare, the UK government has encouraged technology-based approaches including internet video-consulting. However, little is known about patient acceptance of video-consulting as a consulting method. We aimed to explore primary care patients' views video-consulting. METHOD: We used semi-structured interviews to survey 270 patients in NHS Lothian. Three diverse General Practices were chosen purposively and sequential patients attending the practice at a range of different times of day were invited to participate. Patients were asked to indicate their level of computer proficiency and provide their views on the use of video-call consulting and what specific applications it might have. We found that 135 of 270 respondents (50%, 95% CI 43.9%-56.1%) would use video-consulting. Patients under 60 years were over two times more likely to use it (OR 2.2, 95% CI 2.1-6.6, n = 248) and evidence of a positive trend between increasing computer proficiency and those who would video-consult was found, (χ2 = 43.97, p < 0.0005, n=270). Patients who had previously used video-calling services (such as Skype™)were approximately six times more likely to favour video-consulting than those who had not (OR 5.9, 95% CI 3.5-9.9, n = 270). CONCLUSIONS: This suggests strong patient interest in video-consulting in primary care, however, it is possible that in the short to medium term there may be access inequality favouring younger and more technically able people. Further studies are needed to determine the content, safety, efficacy and cost-effectiveness of employing this medium.

Variation in assessment and standard setting practices across UK undergraduate medicine and the need for a benchmark.

OBJECTIVES: The principal aim of this study is to provide an account of variation in UK undergraduate medical assessment styles and corresponding standard setting approaches with a view to highlighting the importance of a UK national licensing exam in recognizing a common standard. METHODS: Using a secure online survey system, response data were collected during the period 13 - 30 January 2014 from selected specialists in medical education assessment, who served as representatives for their respective medical schools. RESULTS: Assessment styles and corresponding choices of standard setting methods vary markedly across UK medical schools. While there is considerable consensus on the application of compensatory approaches, individual schools display their own nuances through use of hybrid assessment and standard setting styles, uptake of less popular standard setting techniques and divided views on norm referencing. CONCLUSIONS: The extent of variation in assessment and standard setting practices across UK medical schools validates the concern that there is a lack of evidence that UK medical students achieve a common standard on graduation. A national licensing exam is therefore a viable option for benchmarking the performance of all UK undergraduate medical students.

Effects of Misoprostol on Contrast-Induced Renal Dysfunction.

Radiographic contrast-induced nephropathy (RCIN), defined by a variable rise in serum creatinine, occurs in up to 40% of contrast radiologic procedures. A prospective, randomized double-blind study was done to determine whether misoprostol prevented or modified RCIN. Patients with a serum creatinine less-than-or-equal2.0 mg dl(minus sign1), who were scheduled to undergo a radiologic contrast procedure (N = 125), were randomized to receive placebo (N = 62) or misoprostol (N = 63) given at 200 &mgr;g Q.I.D. for 72 h prior to contrast and for 48 h after contrast. Contrast significantly decreased creatinine clearance, and misoprostol significantly diminished the dysfunction. The effect was more pronounced in patients with diabetes mellitus (N = 24) and patients on nonsteroidal anti-inflammatory drugs (NSAIDs) (N = 47). Our findings are consistent with a functional role of prostaglandins in the renal response to contrast. We conclude that short-term administration of misoprostol is a useful adjunct for contrast procedures, especially in patients with diabetes and patients on NSAIDs.

What is the best method of proteinuria measurement in clinical trials of endothelin receptor antagonists?

AIMS: To determine whether protein-creatinine ratio (PCR) and albumin-creatinine ratio (ACR) are comparable to 24h urine protein in terms of agreement and repeatability, and therefore whether they are suitable for monitoring and comparing reduction in proteinuria in clinical trials of endothelin receptor antagonists. MAIN METHODS: Using data from a recent study of sitaxentan in 27 patients with proteinuric chronic kidney disease, the assays were compared with reference to their agreement, repeatability, the number of measurements required to obtain accurate results and correlation with reduction in proteinuria at baseline. KEY FINDINGS: The median coefficient of variation was lower for PCR than 24h urine protein (25 vs. 28%) but the range was higher (70 vs. 47%). When converted into the same units, mean difference between 24h urine protein and both PCR (0.03 g/day), and ACR (0.10 g/day), was small. However, scatter increased with mean level of proteinuria, such that agreement fell substantially above 1.5 g/day. According to 2-factor within-subjects ANOVA, the assay used was not a significant source of variation (PCR p=0.63, ACR p=0.38). With 3 measurements at each time point, baseline proteinuria correlated equally well with change in proteinuria, and percentage change was detected accurately by all 3 methods. SIGNIFICANCE: PCR and ACR may well be suitable replacements for 24h urine protein in the clinical trial context due to their similar accuracy and repeatability, greater convenience and lower cost. However, a randomised control trial comparing all 3 assays in a larger and more diverse population is necessary before 24h urine protein can be replaced.

Dyscalculia, dyslexia, and medical students' needs for learning and using statistics.

Much has been written on the learning needs of dyslexic and dyscalculic students in primary and early secondary education. However, it is not clear that the necessary disability support staff and specialist literature are available to ensure that these needs are being adequately met within the context of learning statistics and general quantitative skills in the self-directed learning environments encountered in higher education. This commentary draws attention to dyslexia and dyscalculia as two potentially unrecognized conditions among undergraduate medical students and in turn, highlights key developments from recent literature in the diagnosis of these conditions. With a view to assisting medical educators meet the needs of dyscalculic learners and the more varied needs of dyslexic learners, a comprehensive list of suggestions is provided as to how learning resources can be designed from the outset to be more inclusive. A hitherto neglected area for future research is also identified through a call for a thorough investigation of the meaning of statistical literacy within the context of the undergraduate medical curriculum.