Bridging Thrombolysis versus Direct Mechanical Thrombectomy in Stroke Due to Basilar Artery Occlusion / 대한뇌졸중학회지

Background@#and Purpose Mechanical thrombectomy (MT) is an effective treatment for patients with basilar artery occlusion (BAO) acute ischemic stroke. It remains unclear whether bridging intravenous thrombolysis (IVT) prior to MT confers any benefit. This study compared the outcomes of acute BAO patients who were treated with direct MT versus combined IVT plus MT. @*Methods@#This multicenter retrospective cohort study included patients who were treated for acute BAO from eight comprehensive stroke centers between January 2015 and December 2019. Patients received direct MT or combined bridging IVT plus MT. Primary outcome was favorable functional outcome defined as modified Rankin Scale 0–3 measured at 90 days. Secondary outcome measures included mortality and symptomatic intracranial hemorrhage (sICH). @*Results@#Among 322 patients, 127 (39.4%) patients underwent bridging IVT followed by MT and 195 (60.6%) underwent direct MT. The mean±standard deviation age was 67.5±14.1 years, 64.0% were male and median National Institutes of Health Stroke Scale was 16 (interquartile range, 8 to 25). At 90-day, the rate of favorable functional outcome was similar between the bridging IVT and direct MT groups (39.4% vs. 34.4%, P=0.361). On multivariable analyses, bridging IVT was not asComorbidisociated with favorable functional outcome, mortality or sICH. In subgroup analyses, patients with underlying atherosclerosis treated with bridging IVT compared to direct MT had a higher rate of favorable functional outcome at 90 days (37.2% vs. 15.5%, P=0.013). @*Conclusions@#Functional outcomes were similar in BAO patients treated with bridging IVT versus direct MT. In the subgroup of patients with underlying large-artery atherosclerosis stroke mechanism, bridging IVT may potentially confer benefit and this warrants further investigation.

Acceptability of medical students by patients from private and public family practices and specialist outpatient clinics

<p><b>INTRODUCTION</b>Previous studies on patient acceptance of medical student teaching were from Western populations and in one setting only. However, there has been no prospective study comparing patient acceptability before and after an actual experience. We studied patient acceptability of medical student teaching in private and public family practices and public hospital specialist outpatient clinics in Singapore, and before and after an actual medical student teaching consultation.</p><p><b>MATERIALS AND METHODS</b>We conducted an anonymous cross-sectional survey from March through October 2007 of Singaporean or permanent resident patients attending 76 teaching private family practices, 9 teaching public family practices and 8 specialty clinics in a teaching public hospital. We used pre-consultation cross-sectional patient surveys in all three settings. For private family practice setting only, post-consultation patient survey was conducted after an actual experience with medical student presence.</p><p><b>RESULTS</b>Out of 5123 patients, 4142 participated in the cross-sectional survey (80.9%) and 1235 of 1519 patients in the prospective cohort study (81.3%). Eighty percent were comfortable with medical students present, 79% being interviewed and 60% being examined. Regarding being examined by medical students, parents of children were least comfortable while patients between 41 to 60 years were most comfortable (adjusted OR = 1.99 [1.55-2.57]). Females were less comfortable with medical student teaching than males. Chinese patients were the least comfortable about being interviewed or examined by medical students among the ethnic groups. Indians were most comfortable with being interviewed by medical students (adjusted OR = 1.38 [1.02-1.86]) but Malays were the most comfortable being examined by them (adjusted OR = 1.32 [1.07-1.62]). Family practice patients were more receptive to medical student teaching than the hospital's specialist outpatients. Common barriers to patient acceptance were lack of assurance of patient privacy, dignity and confidentiality. Actual exposure to medical student teaching did not change levels of patient acceptance.</p><p><b>CONCLUSIONS</b>Compared to similar studies from Western countries, Asian patients appear to be less receptive to medical student teaching than Western patients. Family practice settings offer medical students a more receptive learning environment.</p>

The challenges of "continuing medical education" in a pandemic era

Closure of medical schools or the barring of "live patient" contact during an epidemic or pandemic is potentially disruptive to medical education. During the SARS epidemic, the use of web-based learning, role play, video vignettes and both live and mannequin-based simulated patients minimised disruptions to medical education. This article examines the pedagogical innovations that allow clinical teaching to continue without medical students examining actual patients, and proposes a contingency plan in the event of future outbreaks that may necessitate similar containment measures.

Harnessing the IT factor in medical education

Escalating healthcare costs in Singapore have produced a significant movement of patients into ambulatory care, and the consequent dearth of clinical teaching materials. This deficiency has likewise prompted the creation of ambulatory teaching clinics and the use of standardised patients and simulators. In the last few decades, educators have utilised digital technology, for instance, digitally recorded heart and breath sounds, and digitised video vignettes, in medical education. We describe several pedagogical initiatives that we have undertaken at our university school of medicine.

Take a bao if you are not superstitious

<p><b>INTRODUCTION</b>Singaporeans are superstitious, and medical staff are no exception to the rule. We conducted a survey to determine the prevalence of superstitious beliefs and practices amongst doctors, nurses and medical students in Singapore.</p><p><b>METHODS</b>Internet and face-to-face surveys of 68 respondents, all of whom completed the survey after being threatened with curses and hexes.</p><p><b>RESULTS</b>Sixty-eight doctors, nurses and medical students responded to our survey. Only 11 admitted to being superstitious, yet 31 believed in the ill-fortune associated with eating bao or meat dumplings, 6 in the nefarious powers of black (5) or red (1) outfits on call, and 14 believed that bathing (6 insisting on the powers of the seven-flower bath) prior to the onset of a call portended good fortune, in terms of busy-ness of a call. Twenty-four believed in "black clouds", i.e. people who attracted bad luck whilst on call, and 32 refused to mouth the words "having a good call" until the day after the event. We discovered 2 hitherto undescribed and undiscovered superstitions, namely the benefits of eating bread and the need to avoid beef, for the good and ill fortune associated with their ingestion.</p><p><b>DISCUSSION</b>Superstitious practices are alive and well in modern-day Singapore, the practice not necessarily being restricted to the poorly-educated or foolish.</p>

Is there a place for placebo in management of psychogenic movement disorders?

<p><b>INTRODUCTION</b>The management of psychogenic movement disorders is fraught with difficulties. Empathy and a non-judgmental manner are essential in dealing with patients, and a neurobiological explanation of the symptoms may help to foster trust, acceptance, understanding and recovery.</p><p><b>CLINICAL PICTURE</b>We report a 17-year-old Chinese girl with psychogenic blepharospasm. Her parents refused psychotherapy and pharmacotherapy.</p><p><b>TREATMENT AND OUTCOME</b>Placebo therapy (with parental consent) was prescribed with favourable results.</p><p><b>CONCLUSION</b>We examine the ethical considerations for and against placebo therapy, and explore the role of placebo therapy in the management of psychogenic movement disorders.</p>

Computer-based versus pen-and-paper testing: students' perception

<p><b>BACKGROUND</b>Computer-based testing (CBT) has become increasingly popular as a testing modality in under- and postgraduate medical education. Since 2004, our medical school has utilised CBT to conduct 2 papers for the third- and final-year assessments - Paper 3, with 30 multiple choice questions featuring clinical vignettes, and the modified essay question (MEQ) paper.</p><p><b>AIMS</b>To obtain feedback from final-year students on their preferred mode of testing for Paper 3 and MEQ components of the Medicine track examination, and the reasons underlying their preferences.</p><p><b>METHODS</b>An online survey was carried out on 213 final-year undergraduates, in which they were asked to provide feedback on Paper 3 and MEQ papers. Students were asked if they thought that the CBT format was preferable to the pen-and-paper (PNP) format for Paper 3 and the MEQ, and why.</p><p><b>RESULTS</b>One hundred and fourteen out of 213 (53.5%) students completed the online survey. For Paper 3, 91 (79.8%) felt that CBT was preferable to PNP, 11 (9.6%) preferred the PNP format and 12 (10.5%) were unsure. For the MEQ, 62 (54.4%) preferred CBT over PNP, 30 (26.3%) preferred the PNP format and 22 (19.3%) were unsure. Reasons given to explain preference for CBT over PNP for Paper 3 included independence from seating position, better image quality (as images were shown on personal computer screens instead of projected onto a common screen) and the fact that CBT allowed them to proceed at their own pace. For the MEQ, better image quality, neater answer scripts and better indication of answer length in CBT format were cited as reasons for their preference.</p><p><b>CONCLUSIONS</b>Our survey indicated that whereas the majority of students preferred CBT over PNP for Paper 3, a smaller margin had the same preference for the MEQ.</p>

Interesting in- and outpatient attendances at Hogwarts Infirmary and St Mungo's Hospital for magical maladies

Ailments afflicting wizarding folk are underreported in the muggle world. The recent integration of muggles and magical folk with the return of You-Know-Who (aka He Who Must Not Be Named) may result in a similar affliction of inhabitants of both worlds. We describe interesting maladies afflicting muggles and wizarding folk alike, arising from the use and misuse of magic. We also provide a basic glossary of magical ailments, and describe their muggle corollaries. Further studies will hopefully result in the development of immunity against the unforgivable curses.