Comparison of Commercial Versus Homemade Models for Teaching Ultrasound-Guided Peripheral I.V. Placement.

BACKGROUND: Various commercially available and do-it-yourself (DIY) models are used to teach emergency medicine (EM) residents and medical students ultrasound (US)-guided i.v. insertion. Expensive commercial models degrade over time, but DIY models are inexpensive, easily prepared, and readily discarded. OBJECTIVE: We tested the hypothesis that DIY models are equally effective as commercial models for teaching US-guided i.v. insertion, and using a controlled trial to subjectively evaluate how well DIY models and commercially manufactured models compare with human tissue both tactilely and sonographically. METHODS: We tested three models for US-guided i.v. teaching-a commercially available model US training block model, a homemade tofu model, and a homemade gelatin model. All three models were compared with US-guided i.v. insertion involving human tissue. Study participants were EM residents and EM attendings experienced in US-guided i.v. placement in real patients. After practicing peripheral i.v. placement under US guidance using the three media, participants at various levels of training and experience with US-guided i.v. insertion subjectively described how each media compared tactilely and sonographically, which model was most similar to a live human overall, and which model was best for instructing learners. RESULTS: The overall score (sum of visual and sonographic scores) for the gelatin model was significantly higher than either of the other models, indicating that the gelatin model was evaluated as most approximate to the anatomy of a human compared with the other models. CONCLUSIONS: Inexpensive homemade alternatives to commercial simulators can be realistic and effective surrogates for learning US-guided peripheral i.v.

Ultrasound-Guided Retroclavicular Approach to the Infraclavicular Region (RAPTIR) Brachial Plexus Block for Anterior Shoulder Reduction.

BACKGROUND: Shoulder dislocations are a common presenting injury to the emergency department (ED), with anterior dislocations comprising the majority of these cases. Some patients may tolerate gentle manipulation and reduction, but many require analgesia of some type. Oral or parenteral pain medication is often used alone or in combination with procedural sedation if gentle manipulation fails to achieve reduction. Recently, this treatment algorithm has grown to include regional anesthesia as a mode of analgesia for reduction of shoulder dislocations in the form of brachial plexus blocks. It has been well described that the interscalene and supraclavicular approach to the brachial plexus can be used to assist in reduction of anterior shoulder dislocations; however, there has yet to be any published literature regarding the use of ultrasound-guided retroclavicular approach to the infraclavicular region (RAPTIR) brachial plexus blocks for shoulder reduction. CASE REPORT: We describe three patients who presented to the ED with anterior shoulder dislocations. The RAPTIR block was performed, provided effective analgesia, and facilitated successful shoulder reduction in all three patients.Why Should an Emergency Physician Be Aware of This? The RAPTIR nerve block is a safe and effective option for analgesia in the patient with an anterior shoulder dislocation. It may have advantages over other brachial nerve blocks and avoids the risks and disadvantages of procedural sedation and opioids.

The undergraduate 'corridor of uncertainty': teaching core concepts for managing clinical uncertainty as the 'special technique' of general practice.

McWhinney's first principle of family medicine states that GPs 'are committed to the person rather than to a particular body of knowledge, group of diseases, or special technique'. While indeed committed to the person, we propose that the 'special technique' of general practice exists in the form of core clinical concepts for managing uncertainty (e.g. time as a tool, therapeutic examination, safety netting and doctor as drug). Managing clinical uncertainty calls for GPs (and trainees) to operate in a 'corridor of uncertainty', a cricketing analogy where the batter is unsure whether to play a defensive or attacking shot. For students to recognise and value these concepts requires longitudinal learning and simulation. Here we describe a GP module at Brighton medical school where core concepts are 'drip fed' through small group sessions across year 4. Formative simulated surgeries constitute a 'corridor of uncertainty' where simulated patients drive students into using concepts in practice (e.g. through shared management plans). Although recognised in postgraduate training, these concepts should be taught formally within the undergraduate curriculum. Doing so helps students distinguish general practice from hospital generalism and prepares them for clinical placements in general practice. These concepts are inherently 'soft' and founded upon the GP paradigm of understanding medicine. In the eyes of the specialist, they risk being unacknowledged, misinterpreted as ignoring guidelines or, worse still, as bad medicine. Soft core concepts constitute the tools to prepare students for managing clinical uncertainty and serve to inscribe the art of medicine within the undergraduate curriculum.

Overreporting of the disc herniation in lumbar spine MRI scans performed for patients with spondylolisthesis.

BACKGROUND: Spondylolisthesis is often misdiagnosed on magnetic resonance imaging (MRI) as the slip may reduce to a normal alignment when the patient lies supine. Often, disc herniation is reported at the level of spondylolisthesis. PURPOSE: To determine the incidence rates of disc herniation at the level of spondylolisthesis. MATERIAL AND METHODS: This is a retrospective study included 258 consecutive patients with spondylolisthesis who had lumbar spine MRI. The archived reports were collectively put in Group 1. A musculoskeletal radiologist and a spine surgeon reviewed the imaging studies together. Their readings were referred to as Group 2. The findings of both groups were compared to evaluate whether disc herniation was overreported. RESULTS: Group 1 reported findings of true disc herniation in 112 (41.6%) cases and pseudo disc herniation or no findings of disc herniation at the level of spondylolisthesis in 157 (58.4%) cases. Group 2 reported findings of a true disc herniation in 25 (9.3%) cases and pseudo disc herniation or no findings of disc herniation in the remaining 244 (90.7%) cases. There was a statistically significant difference in the reporting rates between these two groups (P < 0.02). The most overreported finding was the disc bulging (P < 0.01). CONCLUSION: The current study showed overreporting of disc herniation in lumbar spine MRI scans performed for patients with established spondylolisthesis. The majority of disc pathology at the level of spondylolisthesis are pseudo disc rather than a true disc herniation. An accurate diagnosis is vital in planning surgical intervention.

Statistical learning of blunt cerebrovascular injury risk factors using the elastic net.

PURPOSE: To compare logistic regression to elastic net for identifying and ranking clinical risk factors for blunt cerebrovascular injury (BCVI). MATERIALS AND METHODS: Consecutive trauma patients undergoing screening CTA at a level 1 trauma center over a 2-year period. Each internal carotid artery (ICA) and vertebral artery (VA) was independently graded by 2 neuroradiologists using the Denver grading scale. Unadjusted odds ratios were calculated by univariate and adjusted odds ratios by multiple logistic regression with FDR correction. We applied logistic regression with the elastic net penalty and tenfold cross-validation. RESULTS: Total of 467 patients; 73 patients with BCVI. Maxillofacial fracture, basilar skull fracture, and GCS had significant unadjusted odds ratios (OR) for ICA injury and C-spine fracture, spinal ligamentous injury, and age for VA injury. Only transverse foramen fracture had significant adjusted OR for VA injury, with none for ICA injury, after FDR correction. Using elastic net, ICA injury variables included maxillofacial fracture, basilar skull fracture, GCS, and carotid canal fracture. For VA injury, these included cervical spine transverse foramen fracture, ligamentous injury, C1-C3 fractures, posterior element fracture, and vertebral body fracture. CONCLUSION: Elastic net statistical learning methods identified additional risk factors and outperformed multiple logistic regression for BCVI. Elastic net allows the study of a large number of variables, and is useful when covariates are correlated.

"One Big Family": Pastoral Care and Treatment Seeking in an Egyptian Coptic Church in England.

Little is known about Coptic migrants' chronic disease health beliefs and treatment-seeking behaviours. Interviews to explore these issues and their relationship with church membership were conducted with 15 Coptic migrants in Southern England. Obesity and cardiovascular disease (CVD) were most frequently identified as health risks for Coptic migrants. CVD was ascribed to stress and considered amenable to spiritual healing. Lay referral to medical practitioners who were church members was common but may devalue perceptions of family medicine. The Coptic Church functions as a community that addresses members' wider vulnerability. Central to this is the "parish nurse" role of the priest.

Phosphorylation of CDK9 at Ser175 enhances HIV transcription and is a marker of activated P-TEFb in CD4(+) T lymphocytes.

The HIV transactivator protein, Tat, enhances HIV transcription by recruiting P-TEFb from the inactive 7SK snRNP complex and directing it to proviral elongation complexes. To test the hypothesis that T-cell receptor (TCR) signaling induces critical post-translational modifications leading to enhanced interactions between P-TEFb and Tat, we employed affinity purification-tandem mass spectrometry to analyze P-TEFb. TCR or phorbal ester (PMA) signaling strongly induced phosphorylation of the CDK9 kinase at Ser175. Molecular modeling studies based on the Tat/P-TEFb X-ray structure suggested that pSer175 strengthens the intermolecular interactions between CDK9 and Tat. Mutations in Ser175 confirm that this residue could mediate critical interactions with Tat and with the bromodomain protein BRD4. The S175A mutation reduced CDK9 interactions with Tat by an average of 1.7-fold, but also completely blocked CDK9 association with BRD4. The phosphomimetic S175D mutation modestly enhanced Tat association with CDK9 while causing a 2-fold disruption in BRD4 association with CDK9. Since BRD4 is unable to compete for binding to CDK9 carrying S175A, expression of CDK9 carrying the S175A mutation in latently infected cells resulted in a robust Tat-dependent reactivation of the provirus. Similarly, the stable knockdown of BRD4 led to a strong enhancement of proviral expression. Immunoprecipitation experiments show that CDK9 phosphorylated at Ser175 is excluded from the 7SK RNP complex. Immunofluorescence and flow cytometry studies carried out using a phospho-Ser175-specific antibody demonstrated that Ser175 phosphorylation occurs during TCR activation of primary resting memory CD4+ T cells together with upregulation of the Cyclin T1 regulatory subunit of P-TEFb, and Thr186 phosphorylation of CDK9. We conclude that the phosphorylation of CDK9 at Ser175 plays a critical role in altering the competitive binding of Tat and BRD4 to P-TEFb and provides an informative molecular marker for the identification of the transcriptionally active form of P-TEFb.

Dr. Russell Davies (1914-1991): Pioneer of theatre recovery and of anaesthetics in Yugoslavia.

Dr. Russell Davies is a largely forgotten pioneer of both post-operative theatre recovery but also a key figure in the establishment of anaesthetics services in Yugoslavia in the late 1940s. Davies spent the majority of his career working as an anaesthetist at Queen Victoria Hospital, East Grinstead, Sussex, England, later being promoted to the head anaesthetist role. Davies set up one of the first recovery wards in the United Kingdom at Queen Victoria Hospital, the ward being named after him in 1989. Here he became a founding member of the Guinea Pig Club, alongside Dr. Archibald McIndoe. The Guinea Pig Club was founded in 1941 to support airmen in the Second World War undergoing plastic surgery at Queen Victoria Hospital. Davies was crucial to the pastoral care of the Club, providing clinical care and guiding members over access to pensions they would have previously been denied. Little is recognised of Davies's achievement of establishing anaesthetics services in Yugoslavia. Davies and his contributions have been largely overlooked. Davies should be considered one of the foremost British anaesthetists of the 20th century.

Consulting in the dark: Robert Hamilton (1749-1830) and the importance of 'tenderness' towards patients.

Robert Hamilton (1749-1830) was born in Coleraine, Ireland, attended medical school in Edinburgh, Scotland, served in the British army and practised in South-East England. In order to differentiate him from his contemporary and namesake, Hamilton is identified by having worked in Ipswich, Suffolk and Colchester, Essex. This submission considers Hamilton's biography, his 1787 book on the British regimental surgeon and his ideas therein about professionalism. Central to his concept of professionalism is 'tenderness', a notion that broadly equates to empathy. He notes that tenderness brings improvement in clinical outcome and he has the foresight to recognise nurses as key to such care. The authors explore the concept of 'consulting in the dark', i.e. without access to clinical investigations. This is exemplified by doctors of the eighteenth century and earlier. Today general practitioners must still be comfortable 'consulting in the dark', e.g. when attending a patient's home. Hamilton's biography offers a further example of 'consulting in the dark': In later life, he lost his vision but continued to practise successfully. Central to his gift of consulting 'in the dark' was likely to be 'tenderness' for his patients, expressed through language and gentle touch. Hamilton's entreaty for 'tenderness' contrasts with modern medical education where reliance upon clinical tests, technology and pharmacology risksblinding young doctors towards patients and their lives.

Interrater Agreement of BT-RADS for Evaluation of Follow-Up MRI in Treated Primary Brain Tumor Patients.

BACKGROUND AND PURPOSE: The Brain Tumor Reporting and Data System (BT-RADS) is a structured radiology reporting algorithm that was introduced to provide uniformity in post-treatment primary brain tumor follow-up and reporting, but its interrater reliability (IRR) assessment has not been widely studied. Our goal is to evaluate the IRR among neuroradiologists and radiology residents in the use of BT-RADS. MATERIALS AND METHODS: This retrospective study reviewed 103 consecutive MR studies in 98 adult patients previously diagnosed with and treated for primary brain tumor (January 2019 to February 2019). Six readers with varied experience (4 neuroradiologists and 2 radiology residents) independently evaluated each case and assigned a BT-RADS score. Readers were blinded to the original score reports and the reports from other readers. Cases in which at least one neuroradiologist scored differently were subjected to consensus scoring. After the study, a post-hoc reference score was also assigned by 2 readers using future imaging and clinical information previously unavailable to readers. The interrater reliabilities were assessed using Gwet's AC2 index with ordinal weights and percent agreement. RESULTS: Of the 98 patients evaluated (median age, 53 years; interquartile range, 41-66 years), 53% were males. The most common tumor type was astrocytoma (77%) of which 56% were grade 4 glioblastoma. Gwet's index for interrater reliability among all six readers was 0.83 (95% CI: 0.78, 0.87). The Gwet's index for the neuroradiologists' group (0.84 [95% CI: 0.79, 0.89]) was not statistically different from that for the residents' group (0.79 [95% CI: 0.72, 0.86]) (χ2 = 0.85; p = 0.36). All four neuroradiologists agreed on the same BT-RADS score in 57 of the 103 studies, three neuroradiologists agreed in 21 of the 103 studies, and two neuroradiologists agreed in 21 of the 103 studies. Percent agreement between neuroradiologist blinded scores and post-hoc reference scores ranged from 41%-52%. CONCLUSIONS: A very good interrater agreement was found when tumor reports were interpreted by independent blinded readers using BT-RADS criteria. Further study is needed to determine if this high overall agreement can translate into greater consistency in clinical care. ABBREVIATIONS: BI-RADS = Breast Imaging Reporting and Data System; BT-RADS = Brain Tumor Reporting and Data System; IQR = interquartile range; IRR = interrater reliability; NI-RADS = Neck Imaging Reporting and Data System.

Sir Benjamin William Rycroft OBE (1902-1967): British ophthalmologist and pioneer in corneal surgery.

An unsung hero of British ophthalmology is the largely forgotten Sir Benjamin Rycroft (1902-1967). This paper will discuss and analyse the undervalued career of this great man. Upon graduating from medical school, Rycroft became a General Practitioner. Rycroft then decided to train to become an ophthalmologist. Rycroft began his ophthalmology career in 1930s London focusing on the new ground-breaking surgery of keratoplasty (corneal grafting) before serving with distinction in the medical corps during the Second World War. He is chiefly remembered for his work after the war at the Queen Victoria Hospital in East Grinstead, Sussex, where he worked with renowned plastics surgeon Archibald McIndoe. During his time, there Rycroft became globally recognised for his skill in keratoplasty and started a campaign which radically changed the legal framework behind organ donation in the UK. Despite few knowing of him today, Rycroft is undoubtedly one of the most influential British ophthalmologists of the past century. He was for decades seen as one of the world's leading practitioners of keratoplasty and established a unit which restored sight to wounded veterans. His greatest achievement lies in his organ donation reform, which started the process of allowing organ donation to be carried out on a nationwide scale for the first time.

Unearthing a provincial medical school and its students - A history of the 1834 'School of Practical Medicine and Surgery' at the Sussex County Hospital, Brighton, England.

The 19th century was a period of rapid change in English medical education. Little is known about the important contribution of smaller, hospital-based, provincial medical schools which sprang up to provide important practical training opportunities for students, typically as a foundation for further training and examination in London. One such example is the 1834 Brighton 'School of Practical Medicine and Surgery', which was based at the Sussex County Hospital and recognised by the Royal College of Surgeons and Worshipful Society of Apothecaries. Unlike many other 19th century medical schools, the history of the Brighton school is largely undocumented. Although it remained dependent upon London through the 'College and Hall' examination system, this article shows that the school's pragmatic and adaptive educational approach allowed it to play an important role in educating future doctors in Brighton from 1834 into at least the early 20th century.

A 'worthy disciple of Galen', 'ardent sportsman' and 'expert swordsman': Henry Kipping (1726-1785) apothecary and surgeon at Brighton, England.

Henry Kipping (1726-1785) was an apothecary and surgeon in Brighton, England. Here we present a series of contemporary references to Kipping from newspaper, book, archive and web-based resources. Some relate to his medical practice (resuscitating a 'drowned' elderly physician and a fisherman, bleeding a member of parliament who had fallen from his horse and praising a nostrum for the 'gravel and stone'). Social references include a duel with an army officer whose sword Kipping confiscated. Kipping appears to have been popular, connected with members of Brighton's high society and passionate about traditional past times, e.g. swordsmanship, horse riding and hunting on the Sussex downs. Indeed, Kipping's horse ran in the earliest known horse race in Brighton (1770). He was consulted by notable local residents including the Thrale family of Brighton and Lady Wilhelmina Shelley (the latter evidenced by Kipping partaking in her funeral procession in 1772). Kipping lived and practised at 28 West street, a road most famous for its (now lost) George Inn where King Charles II stayed just prior to his escape to Normandy. Kipping comes across as a colourful and eccentric clinician.

Trevor Mann (1916-1996): Paediatrician responsible for the development of hospital services for children in Brighton, England.

Trevor Philip Mann (1916-1996) was the first consultant paediatrician at the Royal Alexandra Children's Hospital (RACH) in Brighton, since its foundation in 1881. Here, he was responsible for significant service developments, including establishing a department of paediatric surgery and the first neonatal unit in England outside of London. Mann grew up in South London, and aged 14 had a lengthy admission to hospital with tuberculosis. He studied medicine at St Mary's Hospital, London. During World War II he was a Royal Navy Surgeon-Lieutenant, aboard the Atlantic destroyer, HMS Georgetown, and with the Russian convoys, before completing paediatric training in London. Here, he was involved in treating paediatric tuberculous meningitis; clinical work that formed part of one of the earliest randomised controlled trials. In 1951 Mann moved to the RACH where he researched infantile infectious gastroenteritis and introduced (now commonplace) practices at the hospital, including barrier nursing. He lived in Rottingdean, Sussex, and enjoyed sailing, gardening and wood turning. Mann's impact on paediatric care in Brighton was recognised by the hospital, naming the Trevor Mann Baby Unit in his honour, upon his retirement in 1981. This article seeks to record his contributions and reconnect local clinicians with his memory.

William Attree (died 1846): Royal and army surgeon who underwent amputation of the leg at Brighton, England (1807).

William Attree (1780-1846) came from a prominent family in Brighton, England. He studied medicine at St Thomas' Hospital, London, and there was unwell for nearly 6 months with severe 'spasms' of the hand/arm/chest (1801-1802). Attree qualified Member of the Royal College of Surgeons in 1803 and served as dresser to Sir Astley Paston Cooper (1768-1841). In 1806 Attree is recorded as 'Surgeon and Apothecary' of Prince's street, Westminster. In 1806 Attree's wife died in childbirth and the following year he underwent emergency amputation of the foot in Brighton following a road traffic accident. Attree served as surgeon in the Royal Horse Artillery at Hastings, presumably in a regimental or garrison hospital. He went onto become surgeon to the Sussex County Hospital, Brighton, and Surgeon Extraordinary to two Kings: George IV and William IV. In 1843 Attree was appointed as one of the original 300 Fellows of the Royal College of Surgeons. He died in Sudbury, near Harrow. His son William Hooper Attree (1817-1875) was surgeon to Don Miguel de Braganza, the former King of Portugal. The medical literature appears to lack a history of nineteenth century doctors (especially military surgeons) with physical disability. Attree's biography goes a small way towards developing this field of enquiry.

Diagnostic Excellence in Pediatric Spine Imaging: Using Contextualized Imaging Protocols.

Contextual design and selection of MRI protocols is critical for making an accurate diagnosis given the wide variety of clinical indications for spine imaging in children. Here, we describe our pediatric spine imaging protocols in detail, tailored to specific clinical questions.

'A chronic disease is a disease which keeps coming back it is like the flu': chronic disease risk perception and explanatory models among French- and Swahili-speaking African migrants.

BACKGROUND: African migrants to the West are at increased risk of hypertensive related diseases and certain cancers compared with other ethnic groups. Little is known about their awareness of this risk or knowledge of associated risk factors. OBJECTIVES: To explore African migrants' perceptions of chronic disease risk, risk factors and underlying explanatory models. DESIGN: In-depth interviews with 19 Africans from French- or Swahili-speaking countries living in Glasgow were conducted. Interviews were transcribed and 10 translated (3 Swahili and 7 French). Analysis was informed by a grounded theory approach. RESULTS: Narratives suggested low awareness of chronic disease risk among participants. Africans reported a positive outlook on life that discouraged thought about future sickness. Infectious diseases were considered the dominant health threat for African migrants, mainly HIV but also TB and 'flu'. Chronic diseases were sometimes described as contagious. Explanatory models of chronic disease included bodily/dietary imbalance, stress/exertion, heredity/predisposition and food contamination. Cancer was feared but not considered a major threat. Cancer was considered more common in Europe than Africa and attributed to chemical contamination from fertilisers, food preservatives and industrial pollution. Evidence cited for these chemicals was rapid livestock/vegetable production, large size of livestock (e.g., fish), softness of meat and flavourless food. Chemicals were reported to circulate silently inside the body and cancer to form in the part where they deposit, sometimes years later. Cardiovascular diseases were described in terms of acute symptoms that required short-term medication. Confidentiality concerns were reported to prevent discussion of chronic disease between Africans. CONCLUSION: This study suggests a need to improve chronic disease health literacy among African migrants to promote engagement with preventive behaviours. This should build on not only participants' existing knowledge of disease causation and risk factors but also their self-reliance in the pursuit of a healthy lifestyle and desire to retain cultural knowledge and practice.

William chambers: British army surgeon (Toulon, 1793) and his vaccination institution (1803) in Brighton, England.

Following Edward Jenner's research into cowpox, a wave of vaccination services emerged across England. Despite some resistance, these began to promote population prevention where variolation had failed. Sussex's first vaccine institution has long been considered to be that of Sir Matthew Tierney (1776-1845). Founded in 1804, Tierney's "Royal Sussex Jennerian Society for the Extermination of the Small-pox" comprised sixteen stations, including one in Kent. This article presents an earlier example: the 1803 "Brighton Royal Jennerian Institution", founded by a "Mr Chambers" to serve "the indigent poor". Given that both held royal and military appointments in Brighton, Tierney must have been aware of Chambers' efforts in vaccination. It is unclear why Tierney's 1804 plan for the Sussex Vaccine Institution makes no mention of Chambers. In 1803 Chambers also directed the establishment of Brighton's first military hospital and is noted as "surgeon extraordinary" to the Prince Regent. Chambers is identified as William Chambers of the 10th Royal Dragoons, who served at Toulon (1793) as a surgeon's mate. He is also documented at Corsica in 1794 where he examined Nelson's injured eye following the siege of Calvi. Mr Chambers' origin and more details of his biography remain unknown.