Long-term psychological outcomes following stroke: the OX-CHRONIC study.

BACKGROUND: Stroke survivors rate longer-term (> 2 years) psychological recovery as their top priority, but data on how frequently psychological consequences occur is lacking. Prevalence of cognitive impairment, depression/anxiety, fatigue, apathy and related psychological outcomes, and whether rates are stable in long-term stroke, is unknown. METHODS: N = 105 long-term stroke survivors (M [SD] age = 72.92 [13.01]; M [SD] acute NIH Stroke Severity Score = 7.39 [6.25]; 59.0% Male; M [SD] years post-stroke = 4.57 [2.12]) were recruited (potential N = 208). Participants completed 3 remote assessments, including a comprehensive set of standardized cognitive neuropsychological tests comprising domains of memory, attention, language, and executive function, and questionnaires on emotional distress, fatigue, apathy and other psychological outcomes. Ninety participants were re-assessed one year later. Stability of outcomes was assessed by Cohen's d effect size estimates and percent Minimal Clinically Important Difference changes between time points. RESULTS: On the Montreal Cognitive Assessment 65.3% scored < 26. On the Oxford Cognitive Screen 45.9% had at least one cognitive impairment. Attention (27.1%) and executive function (40%) were most frequently impaired. 23.5% and 22.5% had elevated depression/anxiety respectively. Fatigue (51.4%) and apathy (40.5%) rates remained high, comparable to estimates in the first-year post-stroke. Attention (d = -0.12; 85.8% stable) and depression (d = 0.09, 77.1% stable) were the most stable outcomes. Following alpha-adjustments, only perceptuomotor abilities (d = 0.69; 40.4% decline) and fatigue (d = -0.33; 45.3% decline) worsened over one year. Cognitive impairment, depression/anxiety, fatigue and apathy all correlated with worse quality of life. CONCLUSION: Nearly half of participants > 2 years post-event exhibited psychological difficulties including domains of cognition, mood, and fatigue, which impact long-term quality of life. Stroke is a chronic condition with highly prevalent psychological needs, which require monitoring and intervention development.

From principles to practice: embedding clinical reasoning as a longitudinal curriculum theme in a medical school programme.

There is consensus that clinical reasoning (CR) is crucial for increasing the value of diagnosis, medical decision-making and error reduction. These skills should be developed throughout medical education, starting with undergraduate study. International guidance provides principles for CR curricula but interventions to date, are short term in nature. In this report, we describe the creation of a longitudinal, spiral CR curriculum within a large UK medical school programme (2500 students). A working group drove systematic evidence-based reform of existing structures. We utilised recognised models for curriculum development and mapping, relating learning outcomes to competency frameworks. Application of multiple teaching methodologies, rooted in enquiry-based learning and reported in CR literature, encourage metacognition for information-processing and illness script development. Development of CR is emphasised with recurrent, progressive learning opportunities, each stage purposefully building upon previous experiences. Formative and summative assessment approaches to drive learning, encouraging students' ability to apply and articulate CR, is constructed via Miller's Prism of Clinical Competence. Implementation of pedagogy is contingent on faculty development. Whilst many clinicians practice sound CR, the ability to articulate it to students is often a novel skill. Engagement in faculty development was strengthened through cross-institutional recognition of teaching workload and flexibility of delivery. We report lessons learned from the implementation phase and plans for measuring impact.

Assessing arthritis in the context of cystic fibrosis.

Inflammatory arthritis in the context of cystic fibrosis (CF) can represent a diagnostic and therapeutic challenge. Poor recognition and under-treatment of musculoskeletal conditions increases symptom burden, affects quality of life, and may lead to changes to an individual's ability to carry out activities of daily living and to exercise. A careful assessment and multidisciplinary approach is essential when considering a diagnosis of CF-associated arthritis (CFA), both in terms of identifying other treatable conditions, such as rheumatoid arthritis, and effectively addressing symptoms. In this collaboration between CF specialists and Rheumatologists, we consider joint symptoms in patients with CF, with a focus on CFA. We offer a differential diagnosis list and consider steps to assess and manage CF patients presenting with arthralgia including appropriate up-to-date rheumatological assessment.

Teaching knee joint aspiration to medical students-an effective training with long-term benefits.

The objective of this study was to assess the effectiveness of undergraduate training in knee aspiration and to determine the impact this had on subsequent postgraduate clinical practice. This paper is a cohort study of undergraduate training with a cross-sectional questionnaire study of postgraduate practice. The study was held at the University of Cambridge and NHS hospitals in the Eastern Region Postgraduate Deanery (England). The main outcome measures are the undergraduate competence in practical skills in a simulated setting and the differences in postgraduate practice with or without prior undergraduate training in knee aspiration. Implementing an undergraduate training programme in knee aspiration resulted in student competence in this skill. Undergraduate teaching of knee aspiration also improved postgraduate clinical practice, significantly increasing trainee doctor confidence and also increasing the frequency with which knee aspiration was undertaken. Postgraduate reinforcement of learning was identified as an additional requirement. Undergraduate teaching of knee aspiration not only results in competent performance in end of course assessments but also improves postgraduate confidence that potentially translates into improved clinical practice.