Validity of Ultra-Short-Term Heart Rate Variability Derived from Femoral Arterial Pulse Waveform in a British Military Cohort.

Various non-electrocardiogram (ECG) based methods are considered reliable sources of heart rate variability (HRV) measurement. However, the ultra-short recording of a femoral arterial waveform has never been validated against the gold-standard ECG-based 300s HRV and was the aim of this study.A validity study was conducted using a sample from the first follow-up of the longitudinal ADVANCE study UK. The participants were adult servicemen (n = 100); similar in age, rank, and deployment period (Afghanistan 2003-2014). The femoral arterial waveforms (14s) from the pulse wave velocity (PWV) assessment, and ECG (300s) were recorded at rest in the supine position using the Vicorder™ and Bittium Faros™ devices, respectively, in the same session. HRV analysis was performed using Kubios Premium. Resting heart rate (HR) and root mean square of successive differences (RMSSD) were reported. The Bland-Altman %plots were constructed to explore the PWV-ECG agreement in HRV measurement. A further exploratory analysis was conducted across methods and durations.The participants' mean age was 38.0 ± 5.3 years. Both PWV-derived HR (r = 0.85) and RMSSD (rs=0.84) showed strong correlations with their 300s-ECG counterparts (p < 0.001). Mean HR was significantly higher with ECG than PWV (mean bias: -12.71 ± 7.73%, 95%CI: -14.25%, -11.18%). In contrast, the difference in RMSSD between the two methods was non-significant [mean bias: -2.90 ± 37.82% (95%CI: -10.40%, 4.60%)] indicating good agreement. An exploratory analysis of 14s ECG-vs-300s ECG measurement revealed strong agreement in both RMSSD and HR.The 14s PWV-derived RMSSD strongly agrees with the gold-standard (300s-ECG-based) RMSSD at rest. Conversely, HR appears method sensitive.

Post-traumatic growth amongst UK armed forces personnel who were deployed to Afghanistan and the role of combat injury, mental health and pain: the ADVANCE cohort study.

BACKGROUND: Post-traumatic growth (PTG) is a positive psychological consequence of trauma. The aims of this study were to investigate whether combat injury was associated with deployment-related PTG in a cohort of UK military personnel who were deployed to Afghanistan, and whether post-traumatic stress disorder (PTSD), depression and pain mediate this relationship. METHODS: 521 physically injured (n = 138 amputation; n = 383 non-amputation injury) and 514 frequency-matched uninjured personnel completed questionnaires including the deployment-related Post-Traumatic Growth Inventory (DPTGI). DPTGI scores were categorised into tertiles of: no/low (score 0-20), moderate (score 21-34) or a large (35-63) degree of deployment-related PTG. Analysis was completed using generalised structural equation modelling. RESULTS: A large degree of PTG was reported by 28.0% (n = 140) of the uninjured group, 36.9% (n = 196) of the overall injured group, 45.4% (n = 62) of amputee and 34.1% (n = 134) of the non-amputee injured subgroups. Combat injury had a direct effect on reporting a large degree of PTG [Relative risk ratio (RRR) 1.59 (95% confidence interval (CI) 1.17-2.17)] compared to sustaining no injury. Amputation injuries also had a significant direct effect [RRR 2.18 (95% CI 1.24-3.75)], but non-amputation injuries did not [RRR 1.35 (95% CI 0.92-1.93)]. PTSD, depression and pain partially mediate this relationship, though mediation differed depending on the injury subtype. PTSD had a curvilinear relationship with PTG, whilst depression had a negative association and pain had a positive association. CONCLUSIONS: Combat injury, in particular injury resulting in traumatic amputation, is associated with reporting a large degree of PTG.

Relationship between combat-related traumatic injury and its severity to predicted cardiovascular disease risk: ADVANCE cohort study.

BACKGROUND: This study investigated the relationship between combat-related traumatic injury (CRTI) and its severity and predicted cardiovascular disease (CVD) risk. MATERIAL AND METHODS: This was an analysis of comparative 10-year predicted CVD risk (myocardial infarction, stroke or CVD-death) using the QRISK®3 scoring-system among adults recruited into the Armed Services Trauma Rehabilitation Outcome (ADVANCE) cohort study. Participants with CRTI were compared to uninjured servicemen frequency-matched by age, sex, rank, deployment (Afghanistan 2003-2014) and role. Injury severity was quantified using the New Injury Severity Score (NISS). RESULTS: One thousand one hundred forty four adult combat veterans were recruited, consisting of 579 injured (161 amputees) and 565 uninjured men of similar age ethnicity and time from deployment/injury. Significant mental illness (8.5% vs 4.4%; p = 0.006) and erectile dysfunction (11.6% vs 5.8%; p < 0.001) was more common, body mass index (28.1 ± 3.9 vs 27.4 ± 3.4 kg/m2; p = 0.001) higher and systolic blood pressure variability (median [IQR]) (1.7 [1.2-3.0] vs 2.1 [1.2-3.5] mmHg; p = 0.008) lower among the injured versus uninjured respectively. The relative risk (RR) of predicted CVD (versus the population expected risk) was higher (RR:1.67 [IQR 1.16-2.48]) among the injured amputees versus the injured non-amputees (RR:1.60 [1.13-2.43]) and uninjured groups (RR:1.52 [1.12-2.34]; overall p = 0.015). After adjustment for confounders CRTI, worsening injury severity (higher NISS, blast and traumatic amputation) were independently associated with QRISK®3 scores. CONCLUSION: CRTI and its worsening severity were independently associated with increased predicted 10-year CVD risk.

Change in gait speed and adverse outcomes in patients with idiopathic pulmonary fibrosis: A prospective cohort study.

BACKGROUND AND OBJECTIVE: Gait speed is associated with survival in individuals with idiopathic pulmonary fibrosis (IPF). The extent to which four-metre gait speed (4MGS) decline predicts adverse outcome in IPF remains unclear. We aimed to examine longitudinal 4MGS change and identify a cut-point associated with adverse outcome. METHODS: In a prospective cohort study, we recruited 132 individuals newly diagnosed with IPF and measured 4MGS change over 6 months. Death/first hospitalization at 6 months were composite outcome events. Complete data (paired 4MGS plus index event) were available in 85 participants; missing 4MGS data were addressed using multiple imputation. Receiver-Operating Curve plots identified a 4MGS change cut-point. Cox proportional-hazard regression assessed the relationship between 4MGS change and time to event. RESULTS: 4MGS declined over 6 months (mean [95% CI] change: -0.05 [-0.09 to -0.01] m/s; p = 0.02). A decline of 0.07 m/s or more in 4MGS over 6 months had better discrimination for the index event than change in 6-minute walk distance, forced vital capacity, Composite Physiologic Index or Gender Age Physiology index. Kaplan-Meier curves demonstrated a significant difference in time to event between 4MGS groups (substantial decline: >-0.07 m/s versus minor decline/improvers: ≤-0.07 m/s; p = 0.007). Those with substantial decline had an increased risk of hospitalization/death (adjusted hazard ratio [95% CI] 4.61 [1.23-15.83]). Similar results were observed in multiple imputation analysis. CONCLUSION: In newly diagnosed IPF, a substantial 4MGS decline over 6 months is associated with shorter time to hospitalization/death at 6 months. 4MGS change has potential as a surrogate endpoint for interventions aimed at modifying hospitalization/death.

The educational value of an audience response system use in an Iraqi medical school.

BACKGROUND: Medical education is continually evolving particularly through the modern implementation of educational technology. Enhancing interactive learning in the classroom or lecture settings is one of the growing uses of educational technology. The role and potential benefits of such technology may not be as evident in developing educational systems like the one in Iraq. The purpose of this study was to examine the effect and perception of the use of an audience response system (ARS) on interactive medical education in Iraq. A mixed quantitative and qualitative research methodology approach was used to study the effects and users' perceptions (both student and tutor) of the ARS. METHOD: The study was conducted in an Iraqi medical school in the Head and Neck course during the spring semester for third-year medical students. The course involved fifteen one-hour lectures over fifteen weeks. Users' perceptions were evaluated by survey and focus group discussions (FGD). Descriptive statistics were used for quantitative measures and thematic analysis for the qualitative data. An ARS system was installed and integrated into the course lectures throughout the course period of three months to enhance interactive learning. Three to five interactive questions were used in each lecture. Anonymous participation and answers were maintained. The appropriate discussion was initiated when pertinent depending on students' answers. RESULT: Most students (77% of survey, 85% of FGD) perceived the use of ARS as impactful on their learning. They found the ARS engaging (70%), motivating (76%), promoting interactions (73%), and augment learning through better understanding and remembering (81%). Through the FGD, students expressed improved focus, enhanced thinking and reflection, and joyful learning. The educator perceived the ARS use as practical, interactive, thinking-stimulator, and reflective of student's understanding. The required technology skills were reasonable; however, it demanded extra non-insignificant time to learn the use. CONCLUSION: The perception of the ARS in this study was overall positive, providing encouragement for wide application of this technology in medical education in the developing world. Further studies are needed to validate and prioritize ARS usage in medical education in Iraq.

Exploring the impact of digital professionalism awareness training on dental undergraduate students.

INTRODUCTION: Since the publication of GDC guidance, there have been small, but rising numbers of Fitness to Practise (FtP) cases made against qualified dentists, relating to the use of social media. Prior to graduation, dental students currently receive training in the appropriate use of social media, but more work is needed to determine the most effective methods do this. The aim of this study is to explore the impact of the digital professionalism awareness training provided at one UK-based institution. MATERIALS AND METHODS: In year 2, a "brown envelope" is compiled using an online publicly available Facebook profile search for every student. All year 2 to 5 dental undergraduate students at one UK dental school who had completed the "brown envelope" were invited to participate in focus groups to examine its impact on behaviour change. A qualitative framework analysis method was applied to the transcripts. RESULTS: Eleven dental undergraduate students participated in two focus groups. All students had experienced the "brown envelope" intervention. Four main themes emerged, including: a clear expression of dental student autonomy and rejection of regulation; that online activity in dentistry is different to medicine; that the intervention is useful and changed online behaviour; and constructive suggestions for improving training. CONCLUSION: The interactive "brown envelope" intervention for digital professionalism awareness training was well received and appeared to result in actionable behavioural change on student profiles (eg alterations in privacy settings or restricting access to their own "friends lists").

'Doctor Brides': A narrative review of the barriers and enablers to women practising medicine in Pakistan.

This literature review explores the current issues and historical aspects of the problems faced by female medical students and doctors in Pakistan. The literature search comprised PubMed, Education Resources Information Centre and Google Scholar databases to look for resources from education as well as from health sector from 2009 to 2020. Due to lack of local literature on the subject, it was tried to make sense of the career barriers and enablers they face considering the underlying theory and evidence from other countries. Keeping the Pakistani context in view, it explored the interventions adopted in other countries to help reduce the gender-based issues which have resulted in the facilitation of women in health education and healthcare systems. The major gender issues identified were unequal representation of female doctors in leadership positions and in some specialties, work-life imbalances, socio-cultural norms and lack of professional development opportunities.

Chronic Obstructive Pulmonary Disease and Breathlessness in Older Workers Predict Economic Inactivity. A Prospective Cohort Study.

Rationale: There is an aspiration to retain increasing numbers of older workers in employment, and strategies to achieve this need to make provision for the increasing prevalence of chronic diseases with age. There is a consistent body of cross-sectional evidence that suggests that patients with chronic obstructive pulmonary disease are more likely to have adverse employment outcomes.Objectives: We report the findings of the first longitudinal study of this issue.Methods: We recruited full-time employed men and women in their 50s and followed them for a period of 18 months; we examined, after adjustment for potential confounders, the associations between breathlessness and airway obstruction at baseline and loss of employment in the intervening period.Measurements and Main Results: Among participants responding to the follow-up questionnaire (1,656 of 1,773 [93%]), the majority (78.5%) continued in full-time employment, but 10.6% were in part-time employment and 10.9% were no longer in paid employment. The adjusted risk of loss of employment was significantly increased for those with moderate or severe chronic obstructive pulmonary disease (risk ratio, 2.89; 95% confidence interval, 1.80-4.65) or breathlessness (risk ratio, 3.07; 95% confidence interval, 2.16-4.37) at baseline. There was no evident modification by sex or by manual/nonmanual work.Conclusions: Airway obstruction and breathlessness are independently associated with premature loss from the workforce in older workers; these observations provide strong support to the available cross-sectional evidence and suggest that interventions to help those with chronic obstructive pulmonary disease who wish to remain in work need to be tested.

A cognitive forcing tool to mitigate cognitive bias - a randomised control trial.

BACKGROUND: Cognitive bias is an important source of diagnostic error yet is a challenging area to understand and teach. Our aim was to determine whether a cognitive forcing tool can reduce the rates of error in clinical decision making. A secondary objective was to understand the process by which this effect might occur. METHODS: We hypothesised that using a cognitive forcing tool would reduce diagnostic error rates. To test this hypothesis, a novel online case-based approach was used to conduct a single blinded randomized clinical trial conducted from January 2017 to September 2018. In addition, a qualitative series of "think aloud" interviews were conducted with 20 doctors from a UK teaching hospital in 2018. The primary outcome was the diagnostic error rate when solving bias inducing clinical vignettes. A volunteer sample of medical professionals from across the UK, Republic of Ireland and North America. They ranged in seniority from medical student to Attending Physician. RESULTS: Seventy six participants were included in the study. The data showed doctors of all grades routinely made errors related to cognitive bias. There was no difference in error rates between groups (mean 2.8 cases correct in intervention vs 3.1 in control group, 95% CI -0.94 - 0.45 P = 0.49). The qualitative protocol revealed that the cognitive forcing strategy was well received and a produced a subjectively positive impact on doctors' accuracy and thoughtfulness in clinical cases. CONCLUSIONS: The quantitative data failed to show an improvement in accuracy despite a positive qualitative experience. There is insufficient evidence to recommend this tool in clinical practice, however the qualitative data suggests such an approach has some merit and face validity to users.

The influence of postgraduate qualifications on educational identity formation of healthcare professionals.

Demand for postgraduate qualifications in medical education can be judged by the increase in providers worldwide over the last two decades. However, research into the impact of such courses on identity formation of healthcare professionals is limited. This study investigates the influence of such programmes on graduates' educational identities, practices and career progression. Informed by constructivist grounded theory (CGT), semi-structured interviews were conducted with 27 graduates (2008-2012) from one postgraduate programme, who were at different stages in their careers worldwide. The audio data were transcribed and analysed using a CGT approach. Participants enrolled in award-bearing medical education courses for various intrinsic and extrinsic reasons. The findings from this study highlight their development as educators, and educational researchers, leaders and learners, as their self-efficacy in educational practices and engagement in scholarly activities increased. Graduates attributed career progression to the qualification, with many being promoted into senior positions. They also described substantial performance attainments in the workplace. The findings contribute to understanding the complexity and nuances of educational identity formation of healthcare professionals. A qualification in medical education encouraged transformational changes and epistemological development as an educator. Awareness of these findings will inform both those considering enrolment and those supporting them of potential benefits of these programmes.

Assisted conception and the risk of CHD: a case-control study.

Epidemiological studies suggest a higher prevalence of congenital malformations in children conceived through assisted reproductive technologies. There are a few studies that address CHD specifically and most have examined data from registries. We examined the relationship between CHD and assisted conception using data collected in a specialist paediatric cardiac service in the United Kingdom. Between April, 2010 and July, 2011, the parents of children attending paediatric cardiology clinics at the Royal Brompton Hospital, London, were invited to complete a questionnaire that enquired about the nature of their child's conception, the route for their original referral, and a number of potential confounding exposures. "Cases" were defined as children diagnosed with one or more carefully defined CHDs and "controls" as those with normal hearts. Of 894 new attendees with complete data, half of them were cases (n=410, 45.9%). The overall prevalence of assisted conception was 5.4% (n=44). Logistic regression analysis demonstrated a non-significant increase in the crude odds for the use of assisted reproduction (odds ratio 1.21, 95% confidence interval 0.66-2.22) in this group. After adjustment for gestation, parity, year of birth, and maternal age, the odds ratio reduced (odds ratio 0.95, 95% confidence interval 0.48-1.88). Increased rates of assisted conception were observed in a number of CHD subgroups, although no significant differences were found. These findings do not suggest an overall association between CHD and assisted reproduction in this population.

Exploring the tensions of being and becoming a medical educator.

BACKGROUND: Previous studies have identified tensions medical faculty encounter in their roles but not specifically those with a qualification in medical education. It is likely that those with postgraduate qualifications may face additional tensions (i.e., internal or external conflicts or concerns) from differentiation by others, greater responsibilities and translational work against the status quo. This study explores the complex and multi-faceted tensions of educators with qualifications in medical education at various stages in their career. METHODS: The data described were collected in 2013-14 as part of a larger, three-phase mixed-methods research study employing a constructivist grounded theory analytic approach to understand identity formation among medical educators. The over-arching theoretical framework for the study was Communities of Practice. Thirty-six educators who had undertaken or were undertaking a postgraduate qualification in medical education took part in semi-structured interviews. RESULTS: Participants expressed multiple tensions associated with both becoming and being a healthcare educator. Educational roles had to be juggled with clinical work, challenging their work-life balance. Medical education was regarded as having lower prestige, and therefore pay, than other healthcare career tracks. Medical education is a vast speciality, making it difficult as a generalist to keep up-to-date in all its areas. Interestingly, the graduates with extensive experience in education reported no fears, rather asserting that the qualification gave them job variety. CONCLUSION: This is the first detailed study exploring the tensions of educators with postgraduate qualifications in medical education. It complements and extends the findings of the previous studies by identifying tensions common as well as specific to active students and graduates. These tensions may lead to detachment, cynicism and a weak sense of identity among healthcare educators. Postgraduate programmes in medical education can help their students identify these tensions in becoming and develop coping strategies. Separate career routes, specific job descriptions and academic workload models for medical educators are recommended to further the professionalisation of medical education. (Tensions, Fears, Healthcare Educators, Medical Education, Postgraduate Programmes, Identity, Career Choice, Faculty Development, Communities of Practice).

Are welders more at risk of respiratory infections? Findings from a cross-sectional survey and analysis of medical records in shipyard workers: the WELSHIP project.

BACKGROUND: Exposure to welding fume increases the risk of pneumococcal infection; whether such susceptibility extends to other respiratory infections is unclear. We report findings from a survey and from medical consultation data for workers in a large shipyard in the Middle East. METHODS: Between January 2013 and December 2013, we collected cross-sectional information from 529 male workers variously exposed to welding fume. Adjusted ORs for respiratory symptoms (cough, phlegm, wheezing, shortness of breath and 'chest illness') were estimated using multivariable logistic regression. Subsequently, we examined consultation records from 2000 to 2011 for 15 954 workers who had 103 840 consultations for respiratory infections; the associations between respiratory infections and levels of welding exposure were estimated using a count regression model with a negative binomial distribution. RESULTS: 13% of surveyed workers reported respiratory symptoms with a higher prevalence in winter, particularly among welders. The adjusted OR in welders versus other manual labourers was 1.72 (95% CI 1.02 to 3.01) overall and 2.31 (1.05 to 5.10) in winter months; no effect was observed in summer. The risk of consultation for respiratory infections was higher in welders than in manual labourers, with an adjusted incidence rate ratio of 1.45 (1.59 to 1.83) overall, 1.47 (1.42 to 1.52) in winter and 1.33 (1.23 to 1.44) in summer (interaction, p<0.001). CONCLUSIONS: The observation that respiratory symptoms and consultations for respiratory infection in welders are more common in winter may indicate an enhanced vulnerability to a broad range of infections. If confirmed, this would have important implications for the occupational healthcare of a very large, global workforce.

What's in a name? Word inflation, punctuation, abbreviation and cloud formation.

The title of a journal paper offers a crucial portal into any scientific field. It determines whether interested readers locate the paper and whether others have enough interest sparked to lead them to read the abstract. This article looks at authored journal paper titles in Medical Education over its first 50 years (n = 6357) of publication and Medical Teacher over its first 35 years of publication, revealing both trends in areas of interest and how those interests are worded. Word clouds per decade showed a shift from teaching to learning and from examination to assessment, and new foci on learning, patients, research and feedback in both journals. The average length of title in Medical Education peeked in the 2000s, dropping to 70 characters in the 2010s, with no titles being longer than 140 characters (the length of a tweet) in this last decade. Abbreviations were used sparingly. The use of humorous titles, although not common, has increased in recent years. The use of the colon showed a marked increase in the 1980s, dropping a little in the 2000s but resurging in the 2010s. Titles posed as a question increased steadily, appearing to plateau in the 2000s at 11%. The use of humour and questions suggests that the authors of these articles are submitting papers to be selected by the human rather than just the virtual eye. We also hypothesise that the use of humour may indicate a maturation of medical education as a subject.

How do postgraduate qualifications in medical education impact on health professionals?

BACKGROUND AND PURPOSE: The number of degree-awarding programmes in medical education is steadily increasing. Despite the popularity and extensive investment in these courses, there is little research into their impact. This study investigated the perceived impact of an internationally-renowned postgraduate programme in medical education on health professionals' development as educators. METHODS: An online survey of the 2008-12 graduates from the Centre for Medical Education, University of Dundee was carried out. Their self-reported shifts in various educational competencies and scholarship activities were analysed using non-parametric statistics. Qualitative data were also collected and analysed to add depth to the quantitative findings. RESULTS: Of the 504 graduates who received the online questionnaire 224 responded. Participants reported that a qualification in medical education had significantly (p < 0.001) improved their professional educational practices and engagement in scholarly activities. Masters graduates reported greater impact compared to Certificate graduates on all items, including ability to facilitate curriculum reforms, and in assessment and feedback practices. Masters graduates also reported more engagement in scholarship activities, with significantly greater contributions to journals. These qualifications equally benefited all participants regardless of age. International graduates reported greater impact of the qualification than their UK counterparts. CONCLUSION: A postgraduate medical education programme can significantly impact on the practices and behaviours of health professionals in education, improving self-efficacy and instilling an increased sense of belonging to the educational community.

Translating evidence-based guidelines to improve feedback practices: the interACT case study.

BACKGROUND: There has been a substantial body of research examining feedback practices, yet the assessment and feedback landscape in higher education is described as 'stubbornly resistant to change'. The aim of this paper is to present a case study demonstrating how an entire programme's assessment and feedback practices were re-engineered and evaluated in line with evidence from the literature in the interACT (Interaction and Collaboration via Technology) project. METHODS: Informed by action research the project conducted two cycles of planning, action, evaluation and reflection. Four key pedagogical principles informed the re-design of the assessment and feedback practices. Evaluation activities included document analysis, interviews with staff (n = 10) and students (n = 7), and student questionnaires (n = 54). Descriptive statistics were used to analyse the questionnaire data. Framework thematic analysis was used to develop themes across the interview data. RESULTS: InterACT was reported by students and staff to promote self-evaluation, engagement with feedback and feedback dialogue. Streamlining the process after the first cycle of action research was crucial for improving engagement of students and staff. The interACT process of promoting self-evaluation, reflection on feedback, feedback dialogue and longitudinal perspectives of feedback has clear benefits and should be transferable to other contexts. CONCLUSIONS: InterACT has involved comprehensive re-engineering of the assessment and feedback processes using educational principles to guide the design taking into account stakeholder perspectives. These principles and the strategies to enact them should be transferable to other contexts.

Gait speed and readmission following hospitalisation for acute exacerbations of COPD: a prospective study.

BACKGROUND: Hospitalisation for acute exacerbations of COPD is associated with high risk of readmission. However, no tool has been validated to stratify patients at discharge for risk of readmission. AIM: To evaluate the ability of the 4 m gait speed (4MGS), a surrogate marker of frailty, to predict risk of future readmission in hospitalised patients with an acute exacerbation of COPD (AECOPD). METHODS: 213 patients hospitalised with an AECOPD were recruited prospectively. 4MGS was measured on day of discharge. Logistic regression models were used to assess the association between 4MGS and readmission at 90 days after discharge. RESULTS: Baseline characteristics of the cohort: 52% men; mean age 72 years; median FEV1 35%predicted. Mean (SD) 4MGS at hospital discharge was 0.61 (0.26) ms(-1). Significant increased rates of all-cause readmission at 90 days were seen across quartiles of decreasing 4MGS (Q4 fastest: 11.5%; Q3: 20.4%; Q2: 30.2%; Q1 slowest: 48.2%; p trend<0.001). Compared with Q4, those in the slowest 4MGS quartile had unadjusted ORs (95% CIs) for 90-day readmission of 7.12 (2.61 to 19.44) for the whole cohort and 11.56 (3.08 to 43.35) in those aged 65 or over. A multivariate model incorporating 4MGS, Charlson Index, hospital admission in past year, FEV1%predicted and number of exacerbations in past year in those aged 65 or over predicted 90-day readmission with a C-statistic of 0.86. CONCLUSIONS: The 4MGS, a surrogate marker of physical frailty, independently predicts the risk of readmission in older patients hospitalised for acute exacerbation of COPD. TRIAL REGISTRATION NUMBER: NCT01507415.

How do junior doctors in the UK learn to provide end of life care: a qualitative evaluation of postgraduate education.

BACKGROUND: The fundamental importance of good end of life care has been well documented however recent national publications have high-lighted inadequacies in training in this area. For many patients dying in the UK today care is provided in hospital and the number of inpatient deaths is forecast to climb significantly in future. The demands of providing medical care for these patients by junior doctors will continue to rise. However, there is currently only limited research on training for doctors in this setting. METHODS: A qualitative study using semi-structured interviews of trainees working in general medicine analysed utilising a grounded theory approach. RESULTS: Eleven medical trainees from nine different medical schools participated. They had worked in fifteen different UK hospitals in the course of their careers. All of the doctors interviewed felt generally confident in managing a dying patient. This had developed at postgraduate level and increased when working in certain key specialties. Emerging themes fell into five main categories: perceived ability in clinical management, different learning opportunities experienced, the impact of variations in approach to end of life care, the role of the specialist palliative care team and suggestions for improvements to training. All participants felt further teaching would be beneficial. CONCLUSIONS: This study identified key areas where training could be improved. This included small changes in everyday practice to shift the emphasis for trainees to education. There also needs to be focus on end of life care in the curriculum, formal teaching programmes and assessment of junior doctors. The specialist palliative care team played a vital role in training as well as service provision. For those working in this specialty, every clinical encounter provides an opportunity for education. Specifically targeting junior doctors will not only improve patient care today but empower the consultants of the future.

The Influence of Physical and Mental Health Mediators on the Relationship Between Combat-Related Traumatic Injury and Ultra-Short-Term Heart Rate Variability in a U.K. Military Cohort: A Structural Equation Modeling Approach.

INTRODUCTION: Combat-related traumatic injury (CRTI) adversely affects heart rate variability (HRV). The mediating effect of mental and physical health factors on the relationship between CRTI, its severity and HRV has not been previously studied and investigated. MATERIALS AND METHODS: A cross-sectional mediation analysis of the ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) prospective cohort study was performed. The sample consisted of injured and uninjured British male servicemen who were frequency-matched based on their age, rank, role-in-theater, and deployment to Afghanistan (2003-2014). CRTI and injury severity (the New Injury Severity Scores [NISS] [NISS < 25 and NISS ≥ 25]) were included as exposure variables. HRV was quantified using the root mean square of successive differences (RMSSD) obtained using pulse waveform analysis. Depression and anxiety mediators were quantified using the Patient Health Questionnaire and Generalized Anxiety Disorder, respectively. Body mass index and the 6-minute walk test (6MWT) represented physical health measures. Two mediation pathways between exposure and outcome variables were examined in comparison with the uninjured group using structural equation modeling. RESULTS: Of 862 servicemen, 428 were injured and 434 were uninjured with the mean age at assessment of 33.9 ± 5.4 (range 23-59) years. Structural equation modeling revealed that depression, anxiety, and body mass index did not significantly mediate the relationship between injury/injury severity and RMSSD. However, the 6MWT significantly mediated the relationship between CRTI and RMSSD (27% mediation). The indirect effect of 6MWT on the relationship between injury severity (NISS ≥ 25 vs. uninjured) and RMSSD was -0.06 (95% CI: -0.12, -0.00, P < .05). CONCLUSIONS: The findings suggest that greater physical function may improve HRV following CRTI. Longitudinal studies are warranted to further validate these findings.