Situational awareness within objective structured clinical examination stations in undergraduate medical training - a literature search.

BACKGROUND: Medical students may not be able to identify the essential elements of situational awareness (SA) necessary for clinical reasoning. Recent studies suggest that students have little insight into cognitive processing and SA in clinical scenarios. Objective Structured Clinical Examinations (OSCEs) could be used to assess certain elements of situational awareness. The purpose of this paper is to review the literature with a view to identifying whether levels of SA based on Endsley's model can be assessed utilising OSCEs during undergraduate medical training. METHODS: A systematic search was performed pertaining to SA and OSCEs, to identify studies published between January 1975 (first paper describing an OSCE) and February 2017, in peer reviewed international journals published in English. PUBMED, EMBASE, PsycINFO Ovid and SCOPUS were searched for papers that described the assessment of SA using OSCEs among undergraduate medical students. Key search terms included "objective structured clinical examination", "objective structured clinical assessment" or "OSCE" and "non-technical skills", "sense-making", "clinical reasoning", "perception", "comprehension", "projection", "situation awareness", "situational awareness" and "situation assessment". Boolean operators (AND, OR) were used as conjunctions to narrow the search strategy, resulting in the limitation of papers relevant to the research interest. Areas of interest were elements of SA that can be assessed by these examinations. RESULTS: The initial search of the literature retrieved 1127 publications. Upon removal of duplicates and papers relating to nursing, paramedical disciplines, pharmacy and veterinary education by title, abstract or full text, 11 articles were eligible for inclusion as related to the assessment of elements of SA in undergraduate medical students. DISCUSSION: Review of the literature suggests that whole-task OSCEs enable the evaluation of SA associated with clinical reasoning skills. If they address the levels of SA, these OSCEs can provide supportive feedback and strengthen educational measures associated with higher diagnostic accuracy and reasoning abilities. CONCLUSION: Based on the findings, the early exposure of medical students to SA is recommended, utilising OSCEs to evaluate and facilitate SA in dynamic environments.

The development and implementation of quality assurance programs to support nutritional measurements.

The National Institute of Standards and Technology administers quality assurance programs devoted to improving measurements of nutrients and related metabolites in foods, dietary supplements, and serum and plasma samples. These programs have been developed in collaboration with the National Institutes of Health to assist measurement communities in their efforts to achieve accurate results that are comparable among different laboratories and over time. Targeted analytes include micronutrients, botanical markers, nutritional elements, contaminants, fatty acids, and vitamin D metabolites.

Certification of vitamins and carotenoids in SRM 3280 multivitamin/multielement tablets.

A new multivitamin/multielement dietary supplement Standard Reference Material (SRM) has been issued by the National Institute of Standards and Technology (NIST), with certified and reference concentration values for 13 vitamins, 24 elements, and 2 carotenoids. The constituents have been measured by multiple analytical methods with data contributed by NIST and by collaborating laboratories. This effort included the first use of isotope dilution mass spectrometry for value assignment of both fat-soluble vitamins (FSVs) and water-soluble vitamins (WSVs). Excellent agreement was obtained among the methods, with relative expanded uncertainties for the certified concentration values typically ranging from <2% to 15% for vitamins.

Interns' attitudes to IV cannulation: a KAP study.

UNLABELLED: One of the most common procedures for junior medical doctors is peripheral intravenous cannulation (PIVC). Considering this, an understanding of the peripheral intravenous cannulation procedure is paramount. AIM: The objective of this study was to identify the level of understanding of interns regarding intravenous cannulation. METHOD: An anonymized structured questionnaire using a knowledge attitude and practices (KAP) format was distributed to 60 interns affiliated to a university college hospital in Ireland. FINDINGS: This study suggests that interns are poorly prepared for one of the most common clinical skills they will perform. They showed poor understanding of whether peripheral cannulation is a clean or aseptic technique, and lacked knowledge of the potential side effects of peripheral cannulation and IV therapy. RECOMMENDATIONS: A structured learning module on peripheral intravenous cannulation is required. A rigid, evidence-based, Objective Structured Clinical Examination (OSCE) on peripheral cannulation is recommended. The reduction of junior doctors' weekly working hours to 48 under the European Working Time Directive offers the potential for nurses to take ownership of IV cannulation. This will allow junior doctors to focus on other clinical skills and assessments, which can only be to the advantage of the patient.

Individuals with gluteal tendon repair display similar hip biomechanics to those of a healthy cohort during a sit-to-stand task.

BACKGROUND: Gluteal-tendon repair (GTR) is reported to be effective for relieving pain and improving clinical function in patients with gluteal-tendon tears. The sit-to-stand (STS) task is an important activity of daily living and is often used to assess functional capacity in clinical populations. Understanding if and how STS performance is altered in individuals with gluteal tendon repair may be an effective marker of GTR outcomes as well as a possible therapeutic target for post-operative rehabilitation. RESEARCH QUESTION: Do biomechanical parameters during STS differ between age- and sex-matched participants with and without gluteal-tendon repair? METHODS: 27 participants with a GTR and 29 healthy participants performed the STS task. Data were acquired using the three-dimensional motion capture system and forceplates. Outcomes of interest were task duration, rate of force development, trunk, pelvis, and hip joint angles, moments and powers. Differences were assessed using Generalised linear multivariate models and statistical parametric mapping. RESULTS: GTR patients performed the STS movement significantly slower (1.4+/- 0.40 s) compared to controls (1.1+/ -0.2 s) with a significantly lower rate of force development (35.1+/- 5.7 N/kg/ms vs 30.3+/- 8.5 N/kg/ms). There were no group differences for hip, pelvis, or trunk angle over the movement cycle or for maximal or minimal values. Furthermore, there were no significant differences detected in hip joint kinetics. However, there appeared to be substantial between-subject variability indicating different patient-specific movements patterns. SIGNIFICANCE: Individuals with a GTR performed the STS task about 20 % slower than healthy controls with a lower rate of force development. The individual variations indicate that participants likely employed different movement strategies to achieve STS. While the lack of differences between groups could suggest that GTR helps restore function and corrects the proposed underlying aetiology, it is possible that the STS task was not sufficiently challenging to discriminate between groups.

General practitioners' attitudes and preparedness towards Clinical Decision Support in e-Prescribing (CDS-eP) adoption in the West of Ireland: a cross sectional study.

BACKGROUND: Electronic clinical decision support (CDS) is increasingly establishing its role in evidence-based clinical practice. Considerable evidence supports its enhancement of efficiency in e-Prescribing, but some controversy remains. This study evaluated the practicality and identified the perceived benefits of, and barriers to, its future adoption in the West of Ireland. METHODS: This cross sectional study was carried out by means of a 27-part questionnaire sent to 262 registered general practitioners in Counties Galway, Mayo and Roscommon. The survey domains encompassed general information of individual's practice, current use of CDS and the practitioner's attitudes towards adoption of CDS-eP. Descriptive and inferential analyses were performed to analyse the data collected. RESULTS: The overall response rate was 37%. Nearly 92% of respondents employed electronic medical records in their practice. The majority acknowledged the value of electronic CDS in improving prescribing quality (71%) and reducing prescribing errors (84%). Despite a high degree of unfamiliarity (73%), the practitioners were open to the use of CDS-eP (94%) and willing to invest greater resources for its implementation (62%). Lack of a strategic implementation plan (78%) is the main perceived barrier to the incorporation of CDS-eP into clinical practice, followed by i) lack of financial incentives (70%), ii) lack of standardized product software (61%), iii) high sensitivity of drug-drug interaction or medication allergy markers (46%), iv) concern about overriding physicians' prescribing decisions(44%) and v) lack of convincing evidence on the systems' effectiveness (22%). CONCLUSIONS: Despite favourable attitudes towards the adoption of CDS-eP, multiple perceived barriers impede its incorporation into clinical practice. These merit further exploration, taking into consideration the structure of the Irish primary health care system, before CDS-eP can be recommended for routine clinical use in the West of Ireland.

People after gluteal tendon repair have gait characteristics which are similar to those of a healthy cohort.

BACKGROUND: Gluteal-tendon repair is reported to be effective for relieving pain and improving function in patients with gluteal-tendon tears. However, post-operative three-dimensional gait analysis has never been conducted in gluteal-tendon repair patients. Thus, our primary aim was to investigate how biomechanical gait parameters differ between age- and sex-matched participants with and without gluteal-tendon repair. METHODS: Vicon motion analysis technology was used to measure gait characteristics of 25 gluteal-tendon repair participants and 29 matched healthy comparison group participants. A generalised linear multivariate model was used to compare external hip-adduction moment, range of movement in hip adduction and internal rotation, pelvic obliquity, trunk lean, stride length and velocity of both cohorts throughout stance. FINDINGS: There were no differences between the groups in external hip adduction moment, pelvic obliquity and range of movement in hip adduction and internal rotation. Gluteal-tendon repair participants had a shorter stride length (P = 0.031) and reduced walking velocity (P = 0.015). Ipsilateral trunk lean was reduced in gluteal-tendon repair participants at the first-peak external hip-adduction moment (P = 0.016), mid-stance minimum external hip-adduction moment (P = 0.029) and second-peak external hip-adduction moment (P = 0.006). INTERPRETATION: There were no differences between the gluteal-tendon repair and comparison groups for external hip-adduction moment and pelvic obliquity. This suggests that gluteal-tendon repair may restore hip control in stance. Slower walking speed, reduced stride length and decreased ipsilateral trunk lean may reflect persistence of pre-operatively developed gait adaptations. Future studies of gait biomechanics before and after gluteal-tendon repair would be needed to substantiate this theory.

Cell recognition during neuronal development.

Insect embryos, with their relatively simple nervous systems, provide a model system with which to study the cellular and molecular mechanisms underlying cell recognition during neuronal development. Such an approach can take advantage of the accessible cells of the grasshopper embryo and the accessible genes of Drosophila. The growth cones of identified neurons express selective affinities for specific axonal surfaces; such specificities give rise to the stereotyped patterns of selective fasciculation common to both species. These and other results suggest that early in development cell lineage and cell interactions lead to the differential expression of cell recognition molecules on the surfaces of small subsets of embryonic neurons whose axons selectively fasciculate with one another. Monoclonal antibodies reveal surface molecules in the Drosophila embryo whose expression correlates with this prediction. It should now be possible to isolate the genes encoding these potential cell recognition molecules and to test their function through the use of molecular genetic approaches in Drosophila.

A GABAergic Maf-expressing interneuron subset regulates the speed of locomotion in Drosophila.

Interneurons (INs) coordinate motoneuron activity to generate appropriate patterns of muscle contractions, providing animals with the ability to adjust their body posture and to move over a range of speeds. In Drosophila larvae several IN subtypes have been morphologically described and their function well documented. However, the general lack of molecular characterization of those INs prevents the identification of evolutionary counterparts in other animals, limiting our understanding of the principles underlying neuronal circuit organization and function. Here we characterize a restricted subset of neurons in the nerve cord expressing the Maf transcription factor Traffic Jam (TJ). We found that TJ+ neurons are highly diverse and selective activation of these different subtypes disrupts larval body posture and induces specific locomotor behaviors. Finally, we show that a small subset of TJ+ GABAergic INs, singled out by the expression of a unique transcription factors code, controls larval crawling speed.

The Drosophila islet gene governs axon pathfinding and neurotransmitter identity.

We have isolated the Drosophila homolog of the vertebrate islet-1 and islet-2 genes, two members of the LIM homeodomain family implicated in the transcriptional control of motor neuronal differentiation. Similar to vertebrates, Drosophila islet is expressed in a discrete subset of embryonic motor neurons and interneurons that includes the dopaminergic and serotonergic cells of the ventral nerve cord. In contrast to mouse where mutation of islet-1 leads to loss of neurons due to programmed cell death, Drosophila islet is not required for neuron survival. Instead, loss of islet function causes defects in axon pathfinding and targeting plus loss of dopamine and serotonin synthesis. Ectopic expression of islet induces both specific alterations in pathfinding and changes in neurotransmitter identity. These findings indicate that islet coordinately controls two distinct aspects of neuronal identity.

The Drosophila bendless gene encodes a neural protein related to ubiquitin-conjugating enzymes.

The bendless (ben) mutation of Drosophila alters synaptic connectivity between a subset of CNS neurons. Here, we show that ben also causes morphological abnormalities within the visual system, suggesting that ben functions in a number of different developmental processes. We show that the ben gene encodes a protein which is closely related to ubiquitin-conjugating enzymes and that a missense mutation in the highly conserved active site region is associated with the ben mutation. High levels of ben expression are restricted to the nervous system during development. These results suggest a role for ubiquitin-mediated protein modification in nervous system development, including, but not exclusive to, the regulation of synaptic connectivity.

Apterous is a Drosophila LIM domain gene required for the development of a subset of embryonic muscles.

The recently discovered LIM motif is found in a set of homeodomain-containing proteins thought to mediate the generation of particular cell types. Of the four LIM domain family members described to date, mec-3 and lin-11 determine cell lineages in C. elegans. Isl-1 and Xlim-1 may play similar roles in vertebrates. We have identified a Drosophila member of this class, the product of the apterous (ap) gene. During embryogenesis, ap is expressed in a small subset of fusing mesodermal precursors that give rise to 6 muscles in each abdominal hemisegment and in 5 neurons within each corresponding CNS hemisegment. Lack of ap function results in loss of ap-expressing muscles, while misexpression of ap using a heterologous promoter produces ectopic muscles.

Axon guidance: crossing the midline.

Neurons that connect the two sides of the nervous system project their axons across the midline. New studies provide evidence for a conserved gatekeeping mechanism that controls this midline crossing.

How people who self-harm negotiate the inpatient environment: the mental healthcare workers perspective.

WHAT IS KNOWN ABOUT THE SUBJECT?: Self-harm plays a function, commonly in the form of distress management. There has been little focussed exploration of how individuals who use self-harm to manage distress cope when prevented from self-harm in an inpatient environment and how staff respond to this issue. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE: This paper uses the experiences of mental health staff to add to the existing knowledge that self-harm has a functional role and supports the notion that interventions for self-harm should focus on the origins of distress. It describes the potential consequences that focussing on prevention of self-harm as opposed to actually managing distress may have on service-users, how staff attempt to manage these consequences and factors that may impact on staff interventions to prevent further distress/harm. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The findings suggest that mental healthcare staff should aim to understand the function of self-harm, use this understanding to develop an individualized care plan with the aim of managing distress and identify barriers to the effectiveness of the interventions so they can be worked around. ABSTRACT: Introduction Literature describes self-harm as functional and meaningful. This creates difficulties for service-users detained in an inpatient environment where self-harm is prevented. Aim Mental healthcare staff were interviewed to build on existing evidence of issues with the prevention approach and explore, from a staff perspective, how self-harm prevention impacts on service-users, how they manage distress and how this impacts on staff and their approach to care. Methods Qualitative methods were used to allow unexpected themes to arise. Ten semi-structured interviews were carried out with mental healthcare staff and thematically analysed. Findings and discussion The findings provide new evidence on the benefits and limitations of the inpatient environment for individuals who self-harm. Findings indicate that being unable to self-harm can lead to a continuation of distress and subsequent potentially harmful attempts to manage distress. Staff described experiencing a struggle for control in preventing self-harm, leading to increasingly harmful methods of self-harm. Alternatively some staff were able to support service-users with distress management. We discuss factors influencing which of these 'paths' service-users followed. Implications Considerations for care planning including understanding self-harm, using individualized care planning and attending to barriers are outlined with the ultimate aim of reducing distress and the impact of prevention of self-harm.

Tracing axons.

For more than a century, neuroscientists have gained insight into brain function by examining its complex patterns of connectivity. To achieve this, a wide variety of axon-tracing techniques have been employed to chart the projections of neurons. New, experimentally flexible, reporter-based tracers, many of which are fusion proteins designed to target axons and dendrites, are being developed and are assisting the molecular characterization of the nervous system.

Transcriptional mechanisms in the development of motor control.

Considerable progress has been made in understanding how combinatorially expressed transcription factors control the development of neuronal subtypes in the fly and vertebrate central nervous systems. The mode of action of many of these factors has been conserved from invertebrates to vertebrates throughout evolution, such as the formation and regulation of specific transcriptional complexes, the utilization of repressors for maintaining specificity, and the use of phosphorylation as an important means for transiently altering transcriptional activity.

Effects of ageing on the biomechanical properties of rat articular cartilage.

Previous studies have demonstrated that male Sprague Dawley (SD) rats experience age-related bone loss with the same characteristics as that in ageing men. As articular cartilage, like bone, is a critical component of the health and function of the musculoskeletal system, the authors hypothesized that articular cartilage in the untreated male SD rats could be a suitable model for studying the age-related deterioration of articular cartilage in men. To test this hypothesis, male SD rats were killed at between 6 and 27 months. The right femur of each rat was removed. The effects of ageing on the structural integrity of the distal femoral articular cartilage were studied by biomechanical testing with a creep indentation apparatus. The aggregate modulus, Poisson's ratio, permeability, thickness, and percentage recovery of articular cartilage were determined using finite element/non-linear optimization modelling. No significant differences were observed in these biomechanical properties of the distal femoral articular cartilage as a function of age. Therefore, untreated male SD rats appear to be unsuitable for studying the age-related changes of articular cartilage as they occur in men. However, and more intriguingly, it is also possible that ageing does not affect the biomechanical properties of articular cartilage in the absence of cartilage pathology.

The derailed guidance receptor does not require kinase activity in vivo.

The Drosophila Derailed (DRL) receptor tyrosine kinase (RTK) controls key guidance events in the developing nervous system and mesoderm. Like other members of the "related to tyrosine kinases" (RYK) subfamily of RTKs, DRL has several highly unusual amino acid substitutions within the catalytic domain, raising the possibility that members of this subfamily are catalytically inactive. To test the role of DRL kinase activity in vivo, we mutated the invariant lysine required for catalytic activity of known kinases and examined the ability of this mutant to function in two assays: a dominant gain-of-function axon switch assay in the nervous system and phenotypic rescue of muscle attachment in drl mutants. We show that this predicted kinase-deficient DRL mutant is capable of functioning in both assays. Our results indicate that DRL does not require kinase activity in vivo and suggest that members of the RYK subfamily of RTKs transduce signals unconventionally.

Intramembranous particles and chlorophyll complexes in chloroplasts.

The size and population density of large and small particles from freeze-fractured chloroplasts of three wild-type algae and of normal spinach were determined. Computer analyses of low-temperature absorption spectra of chloroplast preparations from these species were performed, and a possible correlation between the occurrence of seven chlorophyll complexes and the aforementioned properties of the intramembranous particles was studies. It was found that only single-sized particles occur in a species containing neither chlorophyll b nor chlorophyll a-685 complexes. The three remaining species carry particles of two sizes, termed large and small particles. However, from quantitative considerations it is concluded that the chlorophyll content of none of the various pigment complexes is related to the size and the population density of the studied particles. If such a relationship exists, it seems likely to be due to the carrier moiety of the chorophyll b-chlorophyll a-685 complex.

The mathematics of mosaic analysis. I: The relationship between sturts and distance.

In mosaic fate mapping the fraction of mosaics in which two structures are of different genotype is calculated. This frequency of separation has been called a "distance" and the units of this distance are called "sturts". The fundamental assumption of fate mapping is that the frequency of separation increases continuously with the actual distance between the anlage for these structures on the blastoderm. This paper shows that the frequency of separation does not increase beyond a certain value. --For the current theory to work as proposed, each mosaic animal must be half mutant and half normal. This is rarely the case in collections of mosaics. It has been thought that if some flies are less than half mutant and others more than half, these two types would introduce compensating errors in mapping distance. We show that this is not true and describe the nature of the errors introduced. It is probable that these errors are the main reason that mapping distances reported from different sets of mosaics have not been reproducible. This paper presents methods for the proper handling of data from mosaics with different amounts of mutant tissue.--We prove here that for mosaics with an arbitrary fraction of mutant tissue (m), the largest frequency of separation that can occur is 2m. We prove that sturts underestimate actual distance on the blastoderm by a factor of r/m, where r is the radius of the mutant patch, and that sturts give no information on distances greater than 2r. This, and not double crossing over, is the reason for the nonadditivity of sturts and the shrinking of large distances in sturt measures. Sturtoids overestimate distances by a factor of 1/(2r) and also give no information on distances over 2r. This paper gives formulae for correctly estimating distance when using a collection of mosaics with varying amounts of mutant tissue. We also describe the nature of the errors introduced by convoluted or elongate mosaic boundaries and by multiple mosaic patches.