Return to work and activity after rib-fixation for acute chest trauma: first application of a validated patient-reported outcomes assessment tool.

OBJECTIVES: Rib fractures present a heavy pain and functional burden in trauma. Our primary aim was to determine return to work in patients with acute rib fractures requiring surgical stabilisation of rib fractures. Our secondary outcomes were pain and quality of life. We also document the first application of the Work Productivity and Activity Impairment Instrument, a validated injury-specific patient-reported outcome measure, for chest wall injury in the literature. METHODS: A retrospective review was conducted of patients with rib fractures requiring surgical fixation in a single centre between 2008-2020. After applying inclusion and exclusion criteria to ensure relevance, all eligible patients were asked to complete patient reported outcome measure questionnaires. RESULTS: Of 1841 trauma patients with rib fractures, 66 underwent surgical fixation. Thirty-nine patients were eligible and thirty-one completed the questionnaires. Pre-injury and post-injury answers were compared. The number of patients in employment decreased post-operatively from 22 to 16 (p = 0.006). For those that returned to work there was no difference in hours missed but reduced weekly hours and productivity scores. There were significantly more patients with pain and on pain relief. There was a lower quality of life score post-operatively. CONCLUSIONS: Approximately 1-in-5 patients who require surgical fixation for rib fractures will not return to work. This is the first chest wall trauma study that uses the Work Productivity and Activity Impairment Instrument, a validated tool for work productivity outcomes. We recommend this instrument as a reliable tool for investigating return to work outcomes in trauma patients.

Outcomes of Selective Arthrodesis Based on Joints Affected in 33 Feet With Müller-Weiss Disease.

No consensus exists regarding operative treatment of Müller-Weiss disease (MWD). Its only classification is based solely on Méary's angle and serves neither as guide to management nor prognosis. We report on 33 feet that underwent surgery following failed conservative management. Treatment was directed towards joint(s) involved, as determined by clinical examination, plain radiography and SPECT-CT. Thus, surgery consisted of isolated talonavicular in 6 feet, triple in 8, subtalar and talonavicular in 7, talonaviculocuneiform in 4, talonaviculocuneiform with interpositional tricortical iliac crest graft in 6 and pantalar arthrodesis in 2. PROMIS scores for pain interference and depression decreased significantly (p < .001) with significant accompanying increase in physical function (p = .003). Union occurred in 31 of 33 feet (94%) with complete resolution of pain at an average follow-up of 84 months. Of the 2 nonunions, 1 had fracture through the lateral navicular, and the other marked sclerosis and avascularity of the lateral navicular. We describe our pathways for selecting arthrodesis based on the joints affected. Isolated talonavicular arthrodesis was performed in early stages of MWD, which begins at the talonavicular articulation. When disease extended to both sides of the navicular, we performed talonaviculocuneiform arthrodesis. When considering isolated talonavicular, double medial or triple arthrodesis, there should be adequate cancellous bone stock remaining in the lateral part of the navicular, as determined on medial oblique radiographs and CT scan. In case of inadequate bone stock or fracture through the lateral navicular, talonaviculocuneiform arthrodesis with interpositional iliac crest bone graft is recommended.

Virtual teaching in the COVID era: Providing surgical core trainee teaching via online webinars and videoconferencing.

OBJECTIVE: During the COVID-19 pandemic, regular teaching for core surgical trainees (CSTs) in Northern Ireland was cancelled at short notice, leaving a significant gap in training. We aimed to develop an effective core surgical teaching programme, within the remit of government regulations, to ensure training was not negatively affected by COVID-19. DESIGN, SETTING AND PARTICIPANTS: A novel virtual teaching programme was designed and implemented regionally across Northern Ireland. One-year free Affiliate Membership to the Royal College of Surgeons of Edinburgh (RCSEd) was provided for Northern Ireland CSTs, allowing access to RCSEd online webinars. A weekly teaching schedule based on the Member of the Royal College of Surgeons (MRCS) exam curriculum and accompanied by a webinar was created and disseminated to trainees. Senior surgeons were recruited to conduct a virtual teaching session via videoconferencing. RESULTS: Ten teaching sessions were conducted over three months. Feedback was collated, with positive results and requests for virtual teaching to continue. As such, the Northern Ireland Medical and Dental Training Agency (NIMDTA) adopted the teaching programme as their new primary method of central teaching for Northern Ireland CSTs during the pandemic. CONCLUSION: A novel, highly successful teaching programme was developed in Northern Ireland to meet the training needs of CSTs resulting in a sustained change to training. Virtual surgical teaching can be as effective as face-to-face didactic learning and may be imperative in a foreseeably socially distanced world.

"Just Engage in It or Not, You Get Out What You Put In": Student and Staff Experiences of Feedback and Feedforward in Workplace-Based Learning Environments.

Feedback is central to student learning in the veterinary workplace. Feedforward, a related concept, is used to describe the way information about a student's performance may be used to improve their future performance. Feedback and feedforward practices are diverse, with varied student and staff understandings of the nature and purpose of feedback (feedback literacy). This study compared the practices of feedback and feedforward in a range of programs in one institution during student transitions from the classroom to workplace-based learning environments. The study adopted a broad inter-professional approach to include health care programs and social work and theater and performance studies. Profession-specific focus groups were conducted with contribution from 28 students and 31 staff from five different professions. Thematic analysis revealed that students and staff shared an understanding of the feedback and feedforward concepts, and both groups recognized the importance of emotional and relational aspects of the process. Students and staff across all professions recognized the impact of time constraints on the feedback process, although this was particularly highlighted in the health science professions. Social work and theater and performance studies students demonstrated a more nuanced understanding of the emotional and relational aspects of feedback and feedforward. Overall, the approach highlights similarities and differences in practices and experiences in different workplace contexts, creating opportunities for cross-disciplinary learning, which may have relevance more widely in higher education programs with workplace-based elements. The study underpinned the development of the LeapForward feedback training resource (https://bilt.online/the-leapforward-project/).

Are remote clinical assessments a feasible and acceptable method of assessment? A systematic review.

The COVID-19 pandemic presented an enormous and immediate challenge to assessing clinical skills in healthcare professionals. Many institutions were unable to deliver established face-to-face assessment methods such as Objective Structured Clinical Examinations (OSCEs). Assessors needed to rapidly institute alternative assessment methods to ensure that candidates met the clinical competences required for progression. Using a systematic review, we aimed to evaluate the feasibility, and acceptability of remote methods of clinical skills assessment, including remote structured clinical assessments and the submission of video recordings. We searched for studies reporting on Remote Clinical Assessments or its variants in MEDLINE, Embase and The Cochrane library from 2000 to March 2021. Twenty eight studies were included in the review; 20 studies related to remote structured clinical examinations or OSCEs and 8 reported the use of video submissions. The participants of the different studies included medical students, nursing students, dental students and doctors in training. A variety of different online platforms were utilised including Zoom, Skype, webcams, and Adobe Connect online. The studies found that delivery of remote clinical assessments is possible and provides an alternative method of assessing many clinical skills, but most also acknowledge limitations and challenges. They are acceptable to both candidates and examiners, and where measured, show moderate agreement with on-site clinical assessments. Current evidence is based on studies with low methodological quality and for the most part, small sample sizes.

Out of hours, out of sight? Uncovering the education potential of general practice urgent care for UK undergraduates.

There is a need to increase undergraduate primary care exposure and subsequently enhance primary care recruitment. This study aimed to establish the current use and education potential of the primary care out of hours (OOH) learning environment. This was a mix methods study. A questionnaire was sent to UK primary care heads of teaching nationally to explore the current use of GP OOHs in the undergraduate curriculum and focus groups evaluated final year medical students' experience of an OOH placement. There was a 100% response rate from primary care heads of teaching. Despite 86% being in favour of integrating OOH placements within the undergraduate curriculum, only 28% of medical schools currently offer primary care OOH placements. 36 out of 240 students volunteered for a clinical OOH session. Focus group data from 6 of these students revealed that the placements provided unique learning opportunities and allowed students to appreciate the organisational structure of the National Health Service (NHS). However, barriers included logistical difficulties with the OOH providers and inadequate supervision. It appears that we are overlooking a unique educational opportunity for medical undergraduates. With increasing demands for GP exposure within the undergraduate curriculum, GP OOH is a useful resource for UK medical schools.

How can medical schools create the general practice workforce? An international perspective.

This article was migrated. The article was marked as recommended. Medical schools are responsible for producing the future medical workforce that is fit for purpose to meet the needs of patients. The burden of care largely falls upon primary care, a specialty which has been under-doctored, under-resourced, culturally not valued, and whose status has been subordinate to secondary care. In addition, the demographic changes of increasing longevity and chronic diseases, have increased the demand for healthcare at a time when governments' finances are stretched more than ever. The poor state of recruitment to the primary care workforce is a global phenomenon as evidenced by similar issues in North America, UK and the Middle East including Turkey. This contradicts the fact that the strength of primary care has a direct effect on the health of the nation. This paper presents an international perspective of why primary care is important, the reasons why new graduates shy away from a career in primary care, and what steps medical schools, residency programmes and governments should undertake to encourage medical students to make primary care a preferred career choice.

Online Graduation of Doctors During the COVID-19 Pandemic.

This article was migrated. The article was marked as recommended. In March 2020, the United Kingdom declared a nationwide lockdown, a public health intervention in response to the COVID-19 pandemic. In addition, the increasing pressures on the country's publicly funded healthcare system, the National Health Service, required the early graduation of final year medical students so that they could join the workforce. Bristol Medical School responded to this health crisis by graduating 226 final year students. Since social distancing policies resulted in the prohibition of social gatherings, university graduation ceremonies were cancelled. The medical school felt it important to mark the students' qualification as these young doctors were to begin their careers amidst an unprecedented global health emergency. An online graduation ceremony was held on the video conferencing platform Zoom. This was attended by university staff and students from their homes across the UK and elsewhere in the world. Students commemorated their qualification by submitting photographs of themselves celebrating in homemade graduation robes and mortar boards which were included in the online event. The ceremony was a memorable occasion and created a sense of community in a time of social isolation. This novel situation gave rise to a unique celebration attracting media coverage and was reported on national TV and radio news bulletins along with newspapers. The structure for the online graduation ceremony outlined in this paper may be replicated for other graduation ceremonies or celebrations affected by the COVID-19 lockdown.

Use of consumer monitors for estimating energy expenditure in youth.

The purpose of this study was to compare energy expenditure (EE) estimates from 5 consumer physical activity monitors (PAMs) to indirect calorimetry in a sample of youth. Eighty-nine youth (mean (SD); age, 12.3 (3.4) years; 50% female) performed 16 semi-structured activities. Activities were performed in duplicate across 2 visits. Participants wore a Cosmed K4b2 (criterion for EE), an Apple Watch 2 (left wrist), Mymo Tracker (right hip), and Misfit Shine 2 devices (right hip; right shoe). Participants were randomized to wear a Samsung Gear Fit 2 or a Fitbit Charge 2 on the right wrist. Oxygen consumption was converted to EE by subtracting estimated basal EE (Schofield's equation) from the measured gross EE. EE from each visit was summed across the 2 visit days for comparison with the total EE recorded from the PAMs. All consumer PAMs estimated gross EE, except for the Apple Watch 2 (net Active EE). Paired t tests were used to assess differences between estimated (PAM) and measured (K4b2) EE. Mean absolute percent error (MAPE) was used to assess individual-level error. The Mymo Tracker was not significantly different from measured EE and was within 15.9 kcal of measured kilocalories (p = 0.764). Mean percent errors ranged from 3.5% (Mymo Tracker) to 48.2% (Apple Watch 2). MAPE ranged from 16.8% (Misfit Shine 2 - right hip) to 49.9% (Mymo Tracker). Novelty Only the Mymo Tracker was not significantly different from measured EE but had the greatest individual error. The Misfit Shine 2 - right hip had the lowest individual error. Caution is warranted when using consumer PAMs in youth for tracking EE.

Tests of Eustachian Tube Function: the Effect of Testing Technique on Tube Opening in Healthy Ears.

OBJECTIVE: There is no agreement on the best clinical test for Eustachian tube (ET) dysfunction. Numerous tests have been developed to detect ET opening, and all require a patient to perform a Valsalva, Toynbee or sniff maneuver, or to swallow on demand. We aimed to characterize existing tests of ET function in healthy ears, and identify the optimal method and patient maneuver for each test. Our own normative data is presented alongside published comparisons. STUDY DESIGN: Diagnostic test cohort study. SETTING: Tertiary referral center. PATIENTS: Seventy-five healthy ears from 42 volunteers. INTERVENTIONS: Six tests of ET function, each performed using multiple different patient maneuvers. MAIN OUTCOME MEASURE: Detected ET opening rate for each test-maneuver combination. RESULTS: The highest detected opening rates were: Sonotubometry 94%; nine-step test inflation/deflation 93/94%; continuous impedance 88%, patient-reported opening 79%; observed tympanic membrane movement 78%; and Tubo-tympano-aerodynamic-graphy 76%. Valsalva maneuvers were most effective at opening the ET. Toynbee and swallow maneuvers were more effective when performed without water, when compared to with water. For Valsalva and sniff maneuvers, there was significant correlation between the peak nasopharyngeal pressure generated and the ET opening rate. CONCLUSION: Based on ET opening detection rates, we recommend the use of dry swallows with sonotubometry and the nine-step test. When testing patient-reported opening and observed membrane movement, and when performing Tubo-tympano-aerodynamic-graphy and impedance tests, we recommend the use of Valsalva maneuvers. Further studies are required to explore the association between the test technique and results in ears with ET dysfunction.

The repeatability of tests of eustachian tube function in healthy ears.

OBJECTIVES/HYPOTHESIS: Many objective tests of eustachian tube (ET) function have been devised for clinical and research use but they have not been directly compared or characterized. As a first step to identifying tests to incorporate into an outcome set for ET dysfunction, we assessed repeatability of a panel of eight of these tests in healthy ears. STUDY DESIGN: Comparison of eight tests of ET function. METHODS: The following tests were investigated in combination with Valsalva, Toynbee, swallow, or sniff maneuvers: 1) patient-reported ET opening, 2) observed tympanic membrane movement, 3) continuous impedance, 4) canal manometry, 5) sonotubometry, 6) nine-step test, 7) tubomanometry, and 8) tympanometry at rest. Forty-two healthy volunteers were recruited. Each test was performed in 20 different ears and repeated immediately three times in each cycle, with four cycles performed at 20-minute intervals. Repeatability of detected ET opening was compared using the intraclass correlation coefficient (ICC). RESULTS: Mean ET opening rate with each test ranged from 30% to 95%. Variation in detection of ET opening was less when tests were repeated immediately (ICC = 0.61) when compared to between cycles (ICC = 0.49), suggesting there may be significant changes in ET function in the short term. Tubomanometry was the only test to combine a detected ET opening rate of >85% and substantial agreement of results (ICC >0.61) between test cycles. CONCLUSIONS: Tubomanometry was the most reliable test at detecting ET opening. When tests of ET function are used in clinical practice, they should be performed more than once to gain a more reliable result. LEVEL OF EVIDENCE: 3b. Laryngoscope, 127:2619-2626, 2017.

Tuboimpedance: A New Test of Eustachian Tube Function.

Objective Eustachian tube (ET) dysfunction is most frequently caused by a failure of the ET to adequately open; however, there is currently no reliable method of assessing this. Tubomanometry has recently shown good interindividual repeatability as a measure of ET function by measuring middle ear pressure after the application of regulated nasopharyngeal pressures during swallowing. We present the first reports of a novel test: middle ear impedance measurements during standard nasopharyngeal pressure application (tuboimpedance). We assess repeatability in healthy ears and any advantages over tubomanometry. Study Design Exploratory cohort diagnosis study. Setting Tertiary referral center. Subjects Twenty screened, healthy ears (10 volunteers). Methods Tubomanometry and tuboimpedance tests were performed while individuals swallowed with applied nasopharyngeal pressures of 20, 30, 40, and 50 mbar. Eustachian tube opening detection rate and test repeatability (measured by intraclass correlation coefficient [ICC]) for immediate and delayed repeats at each pressure were compared. Results ET opening was detected more frequently using tuboimpedance, with a 100% detection rate using a nasopharyngeal pressure of 30 mbar or more, compared to 88% to 96% with tubomanometry. Detection of ET opening at 20 mbar was possible with tuboimpedance. Repeatability of both tests was mostly strong (ICC >0.7) for both immediate and delayed repeats. Repeatability for the tubomanometry R value was only fair to moderate. Conclusion Tuboimpedance may provide a repeatable measure of ET opening that is easier to perform due to lower nasopharyngeal pressures required and fewer issues with poor ear-probe sealing. Further assessment in patients with different forms of ET dysfunction is required.

Medical undergraduate primary care teaching across the UK: what is being taught?

BACKGROUND: All UK medical schools use primary care settings to deliver their undergraduate courses. However there is no national undergraduate curriculum for primary care and it is thought that the learning objectives of primary care teaching vary considerably between medical schools. AIM: The overall aim was to establish what is being taught within and by primary care across UK medical schools. We did this by collating learning objectives from the primary care department at each school. In order to categorise and compare the list of learning objectives from each school we mapped the learning objectives to the postgraduate curriculum of the Royal College of General Practitioners (RCGP). DESIGN AND SETTING: Cross sectional survey sent to heads of teaching of primary care at all 32 UK medical schools. METHOD: GP teacher handbooks for primary care modules at each medical school were requested. Information was extracted based on key headings from the RCGP postgraduate curriculum. RESULTS: Topics taught by primary care at all medical schools include: consulting and communication skills, leading and working in teams, and developing yourself and others. Novel topics, taught at a few medical schools include: learning disability, genetics and multi-morbidity. The majority of medical schools address aspects of over half of the RCGP postgraduate curriculum headings in their learning objectives for primary care. CONCLUSION: This project provides valuable information about primary care teaching at an undergraduate level across the UK. Although it confirms widespread variation in learning objectives, it also highlights considerable common ground and opportunities for sharing teaching resources between schools.

Therapeutic relationships and involuntary treatment orders: service users' interactions with health-care professionals on the ward.

There is increasing evidence that an involuntary hospital admission and treatment can undermine the therapeutic relationship. While good relationships with staff are important factors influencing long-term recovery, there is little information on how people experience their relationships with staff while under an involuntary treatment order (ITO). Twenty-five involuntary inpatients were interviewed about their experiences of an ITO. The interviews were analysed by a general inductive approach. Participants described the following themes: (i) the ITO admission was a daunting and frightening experience; (ii) staff behaviours and attitudes shaped their experiences in hospital; (iii) importance of staff listening to their concerns; (iv) importance of having a space to make sense of their experiences; (v) importance of staff ability to look beyond their illness and diagnosis; and (vi) importance of staff working in partnership. These findings highlight that when using recovery principles, such as an empathic engagement with the patients' lived experience, forging partnerships with patients in treatment decision-making to enhance agency, an involuntary treatment order does not have to limit the ability to establish positive relationships.