Online patient simulation training to improve clinical reasoning: a feasibility randomised controlled trial.

BACKGROUND: Online patient simulations (OPS) are a novel method for teaching clinical reasoning skills to students and could contribute to reducing diagnostic errors. However, little is known about how best to implement and evaluate OPS in medical curricula. The aim of this study was to assess the feasibility, acceptability and potential effects of eCREST - the electronic Clinical Reasoning Educational Simulation Tool. METHODS: A feasibility randomised controlled trial was conducted with final year undergraduate students from three UK medical schools in academic year 2016/2017 (cohort one) and 2017/2018 (cohort two). Student volunteers were recruited in cohort one via email and on teaching days, and in cohort two eCREST was also integrated into a relevant module in the curriculum. The intervention group received three patient cases and the control group received teaching as usual; allocation ratio was 1:1. Researchers were blind to allocation. Clinical reasoning skills were measured using a survey after 1 week and a patient case after 1 month. RESULTS: Across schools, 264 students participated (18.2% of all eligible). Cohort two had greater uptake (183/833, 22%) than cohort one (81/621, 13%). After 1 week, 99/137 (72%) of the intervention and 86/127 (68%) of the control group remained in the study. eCREST improved students' ability to gather essential information from patients over controls (OR = 1.4; 95% CI 1.1-1.7, n = 148). Of the intervention group, most (80/98, 82%) agreed eCREST helped them to learn clinical reasoning skills. CONCLUSIONS: eCREST was highly acceptable and improved data gathering skills that could reduce diagnostic errors. Uptake was low but improved when integrated into course delivery. A summative trial is needed to estimate effectiveness.

An observational study of initial HIV RNA decay following initiation of combination antiretroviral treatment during pregnancy.

BACKGROUND: In pregnancy, reduction of HIV plasma viral load (pVL) for the prevention of vertical transmission is time-constrained. The study primary objective is to investigate factors associated with faster initial HIV RNA half-life decay when combination antiretroviral treatment (cART) is initiated in pregnancy. METHODS: This was a multicentre, retrospective, observational study, conducted in south England, United Kingdom, between August 2001 and February 2018. Data were extracted from case notes of eligible women initiating cART during the index pregnancy. Anonymised data were collated and analysed centrally. Regression analyses were conducted to determine factors associated with faster HIV RNA half-life decay in the first 14 days after commencing cART (first-phase), and with achieving an undetectable maternal pVL by 36 weeks' gestation. We then assessed whether HIV- and obstetric- related parameters differed by antiretroviral third agent class and whether the proportions of women with undetectable pVL at 36 weeks' gestation and at delivery differed by antiretroviral third agent class. RESULTS: Baseline pVL was the only independent factor associated with faster first-phase HIV RNA half-life decay on commencing cART. Lower pVL on day 14 after starting cART was associated with an increased likelihood of achieving an undetectable pVL by 36 weeks' gestation. Integrase inhibitor-based cART was associated with a faster first-phase HIV RNA half-life decay on commencing cART. Overall, 73% and 85% of women had an undetectable pVL at 36 weeks' gestation and at delivery respectively, with no significant difference by antiretroviral third agent class. CONCLUSIONS: Only high baseline pVL independently contributed to a faster rate of first-phase viral half-life decay. pVL at 14 days after initiating cART allows early identification of treatment failure. In the first 14 days after initiating cART in pregnancy, integrase inhibitor-based cART reduced maternal pVL faster than protease inhibitor- and non-nucleoside reverse transcriptase-based cART. While our study findings support INSTI use when initiated in pregnancy especially when initiated at later gestations and in those with higher baseline pVL, other non-INSTI based cART with more data on safety in pregnancy also performed well.

Pre-travel malaria enquiries to the United Kingdom national travel advice line 2016: Advice mainly needed on malaria maps and risk groups.

BACKGROUND: Malaria prevention in travellers can be complex and requires consideration of a number of factors. UK healthcare professionals providing pre-travel malaria advice can access specialist support from the National Travel Health Network and Centre (NaTHNaC) telephone advice line. The aim of this study is to characterise queries to the NaTHNaC telephone advice line regarding pre-travel malaria advice. METHOD: Telephone calls received to NaTHNaC's advice line are recorded using an online data capture form. All calls relating to malaria advice during 2016 were selected and data extracted. Analysis was undertaken using Microsoft Excel and STATA. RESULTS: During 2016, 1803 malaria-related calls were received; the majority from general practice and calls were from across the UK. The most common type of pre-travel malaria query was country-specific followed by travellers with special health needs. Many queries related to pregnant and breastfeeding travellers, children under 5 years and travellers over 60 years. CONCLUSIONS: This review presents a large and exceptional dataset and reflects the ambiguity amongst some healthcare professionals regarding malaria advice. We have identified potential knowledge gaps, and as a result will strengthen future guidance, enhance existing malaria maps, and inform the development of future clinical educational activity.

International exchanges in primary care-learning from thy neighbour.

This systematic review describes how international exchange programmes in primary care have been received and evaluated. Electronic databases (MEDLINE, Embase, PsycINFO, EBM reviews, CAB abstracts and PubMED) were searched to identify articles where the main focus of the study was exchanges undertaken in primary care/family medicine until March 2016. Articles were included if they (i) discussed participant exchanges in primary care; (ii) presented associated outcome data-this included (a) individual/group experience of exchange; (b) mechanism of exchange and (c) observations during the exchange. A narrative synthesis was performed of the heterogeneous data identified. Twenty-nine studies were included. Exchange locations varied across the world with the largest number in Europe. Participants came from a range of backgrounds including medical students, nurses, General Practitioners (GP), GP trainees (GPTs) and visiting scholars/professors. Exchange duration ranged from 3 days to 2 years. Key themes were identified from analysis of the studies with illustrative quotes from the included studies provided. Four key areas were discussed in relation to exchange experience: learning opportunities and new knowledge; comparative observation; knowledge gained and translational learning. Primary care international exchanges provide a rich source of cross-country learning. This review identified that exchange participants benefit both personally and professionally, equipping them with translatable skills to improve the care provided to their patients.

State of the art syphilis diagnostics: rapid point-of-care tests.

Syphilis remains an important and entirely preventable cause of stillbirth and neonatal mortality. More than 1 million women with active syphilis become pregnant each year. Without treatment, 25% of them will deliver a stillborn baby, 33% will deliver a live low-birth weight baby with an increased chance of dying in the first month of life. Adverse pregnancy outcomes due to syphilis can be prevented by screening pregnant women, and treating those who test positive with a single dose of penicillin before 28 weeks gestation. Until recently access to screening in low- and middle-income countries has been limited, since screening tests have been laboratory based, requiring equipment, electricity and trained laboratory staff. Now a number of rapid, cheap, simple and accurate screening tests are available and can give a result in 15-20 min, enabling those who require treatment to be treated at their first visit.

Should doctors who make clinical errors be charged with manslaughter? A survey of medical professionals and members of the public.

If a doctor is grossly negligent and the patient dies as a result, the doctor can be charged with manslaughter. We have investigated the difference in opinion between medical professionals and the public on whether doctors should face criminal charges following different fatal medical errors. We conducted a survey of 40 medical professionals and 40 members of public, using a set of questions about negligence and manslaughter relating to four real-life cases of doctors charged with manslaughter where eventual outcomes were known. Medical professionals and the public agreed that lessons could be learnt from all four cases and that an independent review of each case should be carried out. However, across all cases, the public were more likely to respond that the doctor should be charged with manslaughter (OR = 2.1; 95% CI = 1.3-3.2). The public and, to a lesser extent, medical professionals still hold individuals responsible following a death due to medical error. This has implications for those who advocate a systems-based approach for assessing the root causes of medical errors, where there is a limited focus on individual accountability.