Bronchiectasis in yellow nail syndrome.

BACKGROUND AND OBJECTIVE: Yellow nail syndrome (YNS) is a rare and poorly described disease process. In this case-control study, clinical features and findings on HRCT were compared with idiopathic bronchiectasis (IBx). METHODS: A review of all patients attending an adult bronchiectasis clinic between 2007 and 2013 identified 25 YNS patients. IBx patients were matched in a 2:1 ratio for age, duration of symptoms and gender. RESULTS: Median age of onset was 53 years. There were 12 male and 23 Caucasian YNS patients. Respiratory manifestations included chronic productive cough (100%), chronic rhinosinusitis (88%), pleural effusions (20%) and lymphoedema (12%). Chest symptoms preceded yellow nails in the majority (68%). Abnormal nails persisted at follow-up in 23 of 25 patients but improved in 14. In both disorders, there was symmetrical, predominantly lower lobe bronchiectasis on HRCT. Extent (P = 0.04), severity (P = 0.03) and bronchial wall thickness (P = 0.05) scores were lower in YNS, with less upper and middle lobe disease. Multivariate analysis showed an independent association with increased mucus plugging in YNS. There was a similar prevalence of Pseudomonas aeruginosa infection and mild lung function abnormalities. CONCLUSION: Bronchiectasis in YNS is less severe than IBx but is associated with increased mucus plugging, onset is in middle age and there is no female predominance. Treatment targeted at improved secretion clearance may improve both chest and nail symptoms, with consideration of long-term macrolide antibiotics.

Development of a north-west London paracentesis simulation course for core medical trainees.

We designed, implemented and evaluated a near-peer simulation training programme teaching diagnostic and therapeutic abdominal paracentesis to core medical trainees (CMTs). We taught diagnostic and therapeutic abdominal paracentesis to 77 north-west London CMTs over 8 training days over 4 years, 2015 to 2019. The programme was optimised by use of plan, do, study, act (PDSA) cycles and the content was evaluated by anonymous pre- and post-course questionnaires. There was a need for this training; 89% of participants reported inadequate training opportunities pre-course and only 28% felt 'confident' or 'very confident' to insert an ascitic drain. Simulation training appears effective when teaching these skills. Having been low in confidence before the course, all participants reported increased confidence after completing the course. Simulation training has been highlighted as a key aspect of the new internal medicine training programme, which replaces CMT. We would recommend using PDSA cycles to implement effective simulation programmes.

Feasibility and acceptability of breath research in primary care: a prospective, cross-sectional, observational study.

OBJECTIVES: To examine the feasibility and acceptability of breath research in primary care. DESIGN: Non-randomised, prospective, mixed-methods cross-sectional observational study. SETTING: Twenty-six urban primary care practices. PARTICIPANTS: 1002 patients aged 18-90 years with gastrointestinal symptoms. MAIN OUTCOME MEASURES: During the first 6 months of the study (phase 1), feasibility of patient enrolment using face-to-face, telephone or SMS-messaging (Short Message Service) enrolment strategies, as well as processes for breath testing at local primary care practices, were evaluated. A mixed-method iterative study design was adopted and outcomes evaluated using weekly Plan-Do-Study-Act cycles, focus groups and general practitioner (GP) questionnaires.During the second 6 months of the study (phase 2), patient and GP acceptability of the breath test and testing process was assessed using questionnaires. In addition a 'single practice' recruitment model was compared with a 'hub and spoke' centralised recruitment model with regards to enrolment ability and patient acceptability.Throughout the study feasibility of the collection of a large number of breath samples by clinical staff over multiple study sites was evaluated and quantified by the analysis of these samples using mass spectrometry. RESULTS: 1002 patients were recruited within 192 sampling days. Both 'single practice' and 'hub and spoke' recruitment models were effective with an average of 5.3 and 4.3 patients accrued per day, respectively. The 'hub and spoke' model with SMS messaging was the most efficient combined method of patient accrual. Acceptability of the test was high among both patients and GPs. The methodology for collection, handling and analysis of breath samples was effective, with 95% of samples meeting quality criteria. CONCLUSIONS: Large-scale breath testing in primary care was feasible and acceptable. This study provides a practical framework to guide the design of Phase III trials examining the performance of breath testing in primary care.

Clinical teaching fellows: everyone's a winner.

BACKGROUND: The principle teachers of the undergraduate medical curriculum are junior doctors and consultants, who may not necessarily be trained to teach. In addition, pressurised clinical environments may limit teaching time and decrease teaching quality. Clinical teaching fellows (CTFs) are doctors employed to teach, often undergoing a teaching qualification. This makes them well placed to bridge this gap between clinical practice and medical education. QUESTION: How useful are CTFs as a teaching resource for medical students, from a student perspective? METHODS: This is an evaluation of CTF teaching from student perspectives, with discussion relating to the role of CTFs. Questionnaires were given to 70 final-year medical students during the academic year 2011-2012. Questions related to teaching throughout medical school and involved scoring teaching numerically, with additional free-text sections for qualitative data. RESULTS: A total of 38/70 (54%) students responded. All had received CTF teaching. All of the students said that CTFs were 'extremely useful' for teaching. There were many reasons given for this. Students also highlighted the managerial and pastoral benefits of CTFs. DISCUSSION: We believe that CTFs could be a useful asset in all medical schools by delivering high-quality, reliable, standardised teaching for students, as an adjunct to consultant teaching, with additional managerial roles and trainee benefits. CTFs can benefit non-CTF trainees by facilitating and encouraging them to teach. CTFs can organise sessions and advise on curriculum topics, allowing trainees to deliver more targeted teaching. Teaching students may improve trainees' communication, management and leadership skills, which are useful for clinical practice.

Using simulation for prescribing: an evaluation.

BACKGROUND: Drug errors are a major cause of patient morbidity. The UK General Medical Council has highlighted that prescribing teaching should be prioritised. How should medical teachers best teach the practical aspects of prescribing? METHOD: We piloted a set of eight prescribing simulation tutorials for 35 final-year undergraduate medical students in Great Western Hospital, Swindon, UK. Students completed baseline questionnaires addressing confidence levels in prescribing. They then prescribed independently for simulated cases of common medical emergencies within tutor-led tutorials (n = 17) or self-directed prescribing tutorials (n = 18). Confidence scores and numbers of drug errors were documented at baseline and following four tutorials. Drug errors were categorised according to potential harm. Students then swapped to receive the alternative tutorial type. RESULTS: Both tutorial types resulted in a statistically significant decrease in the number of unsafe drug errors: from 57 to three in the tutor-led group (p = 0.003) and from 60 to 14 in the self-directed learning group (p = 0.001). Both tutorial types led to statistically significant increases in confidence scores for global prescribing, prescribing in medical emergencies and managing medical emergencies (with a median increase of one point on a modified Likert scale). Confidence using the British National Formulary improved, but reached statistical significance for the self-directed group only. DISCUSSION: Simulating cases and using real drug charts is an effective method for improving students' prescribing ability and confidence in common medical emergencies. Tutorials like these, whether tutor-led or self-directed, could be incorporated into medical curricula. This could help prevent drug errors in practice, thereby improving patient care and safety.