Will clinical signs become myth? Developing structured Signs Circuits to improve medical students' exposure to and confidence examining clinical signs.

BACKGROUND: Correctly eliciting and interpreting physical examination (PEx) signs contributes to successful diagnosis and is fundamental to patient care. A significant decline in the time spent acquiring these skills by medical students, and the decreased ability to elicit and recognise signs is widely acknowledged. However, organising teaching to counteract this in the busy clinical environment is challenging. We evaluated the prior exposure to clinical signs, and experience of examination teaching among a cohort of final-year medical students. Following this, we assessed the utility of a structured circuit-based approach (Signs Circuits) using hospital inpatients and junior doctors to provide high-yield PEx teaching and overcome these limitations. MATERIALS AND METHODS: Qualitative and quantitative survey feedback, including a standardised list of 62 clinical signs, was sought from final-year medical students during their rotations at a teaching hospital in London, UK, before and after the provision of Signs Circuits. RESULTS: Prior to the course the 63 students reported limited exposure to even the most common clinical signs. For example, the murmurs of mitral and tricuspid regurgitation and the sound of lung crackles eluded 43%, 87%, and 32%, respectively. From qualitative feedback, the reasons for this included that much of their prior PEx experience had focused on the performance of appropriate examination steps and techniques in patients without pathology. During the course, students were exposed to an average of 4.4 new signs, and left with increased confidence examining and eliciting signs, and a firmer belief in their importance to diagnosis. CONCLUSION: Medical students continue to have limited exposure to clinical signs in medical school. This signs-focused approach to PEx teaching is an effective and reproducible way to counter the deficiencies identified in signsexposure.

A new ketogenic formulation improves functional outcome and reduces tissue loss following traumatic brain injury in adult mice.

Rationale: Traumatic brain injury (TBI) leads to neurological impairment, with no satisfactory treatments available. Classical ketogenic diets (KD), which reduce reliance on carbohydrates and provide ketones as fuel, have neuroprotective potential, but their high fat content reduces compliance, and experimental evidence suggests they protect juvenile brain against TBI, but not adult brain, which would strongly limit their applicability in TBI. Methods: We designed a new-KD with a fat to carbohydrate plus protein ratio of 2:1, containing medium chain triglycerides (MCT), docosahexaenoic acid (DHA), low glycaemic index carbohydrates, fibres and the ketogenic amino acid leucine, and evaluated its neuroprotective potential in adult TBI. Adult male C57BL6 mice were injured by controlled cortical impact (CCI) and assessed for 70 days, during which they received a control diet or the new-KD. Results: The new-KD, that markedly increased plasma Beta-hydroxybutyrate (ß-HB), significantly attenuated sensorimotor deficits and corrected spatial memory deficit. The lesion size, perilesional inflammation and oxidation were markedly reduced. Oligodendrocyte loss appeared to be significantly reduced. TBI activated the mTOR pathway and the new-KD enhanced this increase and increased histone acetylation and methylation. Conclusion: The behavioural improvement and tissue protection provide proof of principle that this new formulation has therapeutic potential in adult TBI.