The effect of a novel, digital physical activity and emotional well-being intervention on health-related quality of life in people with chronic kidney disease: trial design and baseline data from a multicentre prospective, wait-list randomised controlled trial (kidney BEAM).

BACKGROUND: Physical activity and emotional self-management has the potential to enhance health-related quality of life (HRQoL), but few people with chronic kidney disease (CKD) have access to resources and support. The Kidney BEAM trial aims to evaluate whether an evidence-based physical activity and emotional wellbeing self-management programme (Kidney BEAM) leads to improvements in HRQoL in people with CKD. METHODS: This was a prospective, multicentre, randomised waitlist-controlled trial, with health economic analysis and nested qualitative studies. In total, three hundred and four adults with established CKD were recruited from 11 UK kidney units. Participants were randomly assigned to the intervention (Kidney BEAM) or a wait list control group (1:1). The primary outcome was the between-group difference in Kidney Disease Quality of Life (KDQoL) mental component summary score (MCS) at 12 weeks. Secondary outcomes included the KDQoL physical component summary score, kidney-specific scores, fatigue, life participation, depression and anxiety, physical function, clinical chemistry, healthcare utilisation and harms. All outcomes were measured at baseline and 12 weeks, with long-term HRQoL and adherence also collected at six months follow-up. A nested qualitative study explored experience and impact of using Kidney BEAM. RESULTS: 340 participants were randomised to Kidney BEAM (n = 173) and waiting list (n = 167) groups. There were 96 (55%) and 89 (53%) males in the intervention and waiting list groups respectively, and the mean (SD) age was 53 (14) years in both groups. Ethnicity, body mass, CKD stage, and history of diabetes and hypertension were comparable across groups. The mean (SD) of the MCS was similar in both groups, 44.7 (10.8) and 45.9 (10.6) in the intervention and waiting list groups respectively. CONCLUSION: Results from this trial will establish whether the Kidney BEAM self management programme is a cost-effective method of enhancing mental and physical wellbeing of people with CKD. TRIAL REGISTRATION: NCT04872933. Registered 5th May 2021.

Identifying stressor criteria that hinder or challenge junior clinical medical student learning.

INTRODUCTION: What makes something a stressor within clinical students' education is unclear. Medical students moving from a predominantly protected classroom environment to a situated-work environment provided an ideal transition point to explore the criteria that might make a learning experience a stressor and whether these stressors hinder or challenge learning. METHOD: Data on the stressors associated with learning experiences in clinical education were collected from New Zealand undergraduate medical students. Free text comments, in a survey-based questionnaire were supplemented by focus group data. Using inductive thematic analysis with grounded theory, themes were generated about the characteristics of stressors; referred to here as stressor criteria. These stressor criteria were then classified according to their impact on perceived learning. RESULTS: Under the broad headings of the nature of the learning task, external factors, internal factors, and social interaction; 12 stressor criteria groupings were defined. Some of these criteria were a positive challenge to learning (e.g. legitimacy of the task, novelty of the learning, social interactions) and others a hindrance. DISCUSSION: Not all stressors hinder learning. Instead, and depending on their nature, many result in perceived assistance to learning. Stressors hindering learning need to be recognised by the teacher, especially those that can be converted from a hindrance to an assistance.

Relationships among perceived learning, challenge and affect in a clinical context.

BACKGROUND: Challenge, sometimes perceived as stress, may be beneficial or detrimental to learning but the circumstances when it may be beneficial are not clear. This study looks at the association of challenge with perceived learning and how this might be influenced by affect, context or the type of learning. METHOD: The participants, medical students in their first years of experiential clinical exposure, rated specified learning episodes (LEs) on the perceived learning (low to high), challenge (low to high) and affect (feeling positive to negative). Such learning episodes were self-identified or identified by course organisers. Correlations, using Kendall's tau-b test, were conducted to explore the associations among learning, challenge and affect. In the second stage the types of LEs were then thematically classified in order to determine those that were positive for learning and challenging and/or associated with positive affect. RESULT: There were positive correlations between perceived learning and challenge, and between perceived learning and affect for both types of LEs. The circumstances in which challenge (stress) promoted learning were authentic environments, authentic tasks and simulated clinical activities; most requiring a degree of social interaction. CONCLUSION: Challenge and positive affect are beneficial in the perception of discrete learning, but are two separate constructs. Ideally both challenge and affect need to operate alongside authentic supportive clinical activities, that by their nature involve others, to maximise perceived learning.

Symptom-burden in people living with frailty and chronic kidney disease.

BACKGROUND: Frailty is independently associated with worse health-related quality of life (HRQOL) in chronic kidney disease (CKD). However, the relationship between frailty and symptom experience is not well described in people living with CKD. This study's aim was to evaluate the relationship between frailty and symptom-burden in CKD. METHODS: This study is a secondary analysis of a cross-sectional observational study, the QCKD study (ISRCTN87066351), in which participants completed physical activity, cardiopulmonary fitness, symptom-burden and HRQOL questionnaires. A modified version of the Frailty Phenotype, comprising 3 self-report components, was created to assess frailty status. Multiple linear regression was performed to assess the association between symptom-burden/HRQOL and frailty. Logistic regression was performed to assess the association between experiencing symptoms frequently and frailty. Principal Component Analysis was used to assess the experienced symptom clusters. RESULTS: A total of 353 patients with CKD were recruited with 225 (64%) participants categorised as frail. Frail participants reported more symptoms, had higher symptom scores and worse HRQOL scores. Frailty was independently associated with higher total symptom score and lower HRQOL scores. Frailty was also independently associated with higher odds of frequently experiencing 9 out of 12 reported symptoms. Finally, frail participants experienced an additional symptom cluster that included loss of appetite, tiredness, feeling cold and poor concentration. CONCLUSIONS: Frailty is independently associated with high symptom-burden and poor HRQOL in CKD. Moreover, people living with frailty and CKD have a distinctive symptom experience. Proactive interventions are needed that can effectively identify and address problematic symptoms to mitigate their impact on HRQOL.

Student belief about the value of challenge.

BACKGROUND: The undergraduate curriculum tends to focus on how individuals can cope with stress especially when transitioning from the classroom to the clinical workplace environment. Often this carries the message that stress is bad, yet little attention has been paid to the influence of one's belief regarding the value of stress for learning. Because stress is often perceived as bad, we chose to use the term 'challenge' in exploring the associations amongst belief of the value of challenge, the challenge experienced, the perceived learning, affect and staff support. METHODS: At the end of each clinical module within a medical curriculum, medical students rated the perceived learning, degree of challenge, affect, support and the value of challenge for learning. The value and associations amongst these variables were analysed. RESULTS: The challenge for students varied according to the type of module. Students generally considered that challenge promoted rather than hindered learning. The level of challenge experienced may influence the perception of the value of challenge for learning. However, when challenge was regarded as beneficial, this was strongly, positively associated with perceived learning, positive affect and support. DISCUSSION: Students who believe challenge is positive also perceive that such challenges promote learning. Likewise students who regard challenge as negative are less likely to learn from such challenges. The positive relationship between the belief of the value of challenge with affect and support may have positive implications for well-being. It is contended that curriculum planners should acknowledge the potential positive influence of stressors in clinical education and that challenge can be seen as valuable when there is student support and measures associated with maintaining a positive affect.

Quantifying Anterior Chest Wall Deformity in Adolescent Idiopathic Scoliosis: Correlation With Other Deformity Measures and Effects of Anterior Thoracoscopic Scoliosis Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: This study investigated how anterior chest wall deformity is affected by thoracoscopic anterior scoliosis fusion (TASF) surgery in adolescent idiopathic scoliosis patients. We aimed to determine correlations pre- and postoperatively with other clinical and radiological scoliosis measures. BACKGROUND DATA: Scoliosis surgery aims to halt progression of the deformity, and to reduce its severity. Currently, deformity correction is clinically measured in terms of Cobb angle and rib hump (RH); however, a significant cosmetic concern for patients is anterior chest wall deformity. METHODS: Pre- and postoperative CT scans of 28 female, Lenke type 1 patients with a mean preoperative Cobb angle of 50.2° ± 7.1° were retrieved from the Research Group's surgical database. Using ImageJ, 3D reconstructions of the thorax were created. Two observers measured the anterior chest wall deformity as a chest wall angle (CWA) and posterior deformity as a posterior apical deformity angle (PDA). We investigated pre- to postoperative changes in CWA, PDA, RH, and Cobb angle as well as their interrelationship. RESULTS: All deformity parameters (Cobb angle, RH, CWA, and PDA) showed statistically significant improvement post TASF. Correlation was found between RH and Cobb angle pre- and postoperatively, Cobb angle and CWA preoperatively and between postoperative change in Cobb angle and CWA. No relationship was found between CWA and RH or PDA. CONCLUSIONS: Anterior chest wall deformity is independent from the posterior chest wall measures RH and PDA, indicating that the anterior chest wall deformity is not reflected in the posterior rib cage. The correlation between Cobb angle and CWA indicates that the deformity in the spine and the deformity in the ribs are related, and shows that the anterior chest wall deformity is improved post thoracoscopic anterior scoliosis fusion surgery as the lateral deviation of the spine is corrected. LEVEL OF EVIDENCE: Level III.

Certainty and safe consequence responses provide additional information from multiple choice question assessments.

BACKGROUND: Clinicians making decisions require the ability to self-monitor and evaluate their certainty of being correct while being mindful of the potential consequences of alternative actions. For clinical students, this ability could be inferred from their responses to multiple-choice questions (MCQ) by recording their certainty in correctness and avoidance of options that are potentially unsafe. METHODS: Response certainty was assessed for fifth year medical students (n = 330) during a summative MCQ examination by having students indicate their certainty in each response they gave on the exam. Incorrect responses were classified as to their inherent level of safeness by an expert panel (response consequence). Analyses compared response certainty, response consequence across student performance groupings. RESULTS: As students' certainty in responses increased, the odds they answered correctly increased and the odds of giving unsafe answers decreased. However, from some ability groups the odds of an incorrect response being unsafe increased with high certainty. CONCLUSIONS: Certainty in, and safeness of, MCQ responses can provide additional information to the traditional measure of a number correct. In this sample, even students below standard demonstrated appropriate certainty. However, apart from those scoring lowest, student's incorrect responses were more likely to be unsafe when they expressed high certainty. These findings suggest that measures of certainty and consequence are somewhat independent of the number of correct responses to MCQs and could provide useful extra information particularly for those close to the pass-fail threshold.

Predicting medical students who will have difficulty during their clinical training.

BACKGROUND: We aimed to classify the difficulties students had passing their clinical attachments, and explore factors which might predict these problems. METHODS: We analysed data from regular student progress meetings 2008-2012. Problem categories were: medical knowledge, professional behaviour and clinical skills. For each category we then undertook a predictive risk analysis. RESULTS: Out of 561 students, 203 were found to have one or more problem category and so were defined as having difficulties. Prevalences of the categories were: clinical skills (67%), knowledge (59%) and professional behaviour (29%). A higher risk for all categories was associated with: male gender, international entry and failure in the first half of the course, but not with any of the minority ethnic groups. Professional and clinical skills problems were associated with lower marks in the Undergraduate Medical Admissions Test paper 2. Clinical skills problems were less likely in graduate students. CONCLUSIONS: In our students, difficulty with clinical skills was just as prevalent as medical knowledge deficit. International entry students were at highest risk for clinical skills problems probably because they were not selected by our usual criteria and had shorter time to become acculturated.

Correction: Long Term Population, City Size and Climate Trends in the Fertile Crescent: A First Approximation.

[This corrects the article DOI: 10.1371/journal.pone.0152563.].

"Exercise as medicine" in chronic kidney disease.

Exercise and physical activity are increasingly becoming key tools in the treatment and prevention of several medical conditions including arthritis and diabetes; this notion has been termed "exercise as medicine". Exercise has favorable effects on reducing cardiovascular risk, inflammation, cachexia, and hypertension, in addition to increasing physical functioning, strength, and cardio-respiratory capacity. Chronic kidney disease, a condition that affects around 10% of the population, is often overlooked as a target for exercise-based therapy. Despite the vast range of severity in kidney disease (e.g., pre-dialysis, dialysis, transplant), exercise has a potential role in all patients suffering from the condition. In this review, we summarise the important role exercise may have in the clinical management of kidney disease and how this form of 'medicine' should be best administered and 'prescribed'.

Long Term Population, City Size and Climate Trends in the Fertile Crescent: A First Approximation.

Over the last 8000 years the Fertile Crescent of the Near East has seen the emergence of urban agglomerations, small scale polities and large territorial empires, all of which had profound effects on settlement patterns. Computational approaches, including the use of remote sensing data, allow us to analyse these changes at unprecedented geographical and temporal scales. Here we employ these techniques to examine and compare long term trends in urbanisation, population and climate records. Maximum city size is used as a proxy for the intensity of urbanisation, whilst population trends are modelled from settlement densities in nine archaeological surveys conducted over the last 30 years across the region. These two measures are then compared with atmospheric moisture levels derived from multiple proxy analyses from two locations close to the study area, Soreq Cave in Israel and Lake Van in south-eastern Turkey, as well as wider literature. The earliest urban sites emerged during a period of relatively high atmospheric moisture levels and conform to a series of size thresholds. However, after the Early Bronze Age maximum urban size and population levels increase rapidly whilst atmospheric moisture declines. We argue that although the initial phase of urbanization may have been linked to climate conditions, we can see a definitive decoupling of climate and settlement patterns after 2000 BC. We relate this phenomenon to changes in socio-economic organisation and integration in large territorial empires. The complex relationships sustaining urban growth during this later period resulted in an increase in system fragility and ultimately impacted on the sustainability of cities in the long term.

Warfarin-related intracerebral haemorrhage: better outcomes when reversal includes prothrombin complex concentrates.

BACKGROUND: Warfarin-related intracerebral haemorrhage (WRICH) has high mortality. Haematoma expansion is prolonged in WRICH and independently predicts worse outcomes. Guidelines recommend prompt reversal of the warfarin coagulopathy, but evidence of benefit is lacking. AIMS: To determine whether the introduction of a WRICH reversal protocol (late 2008), which includes prothrombin complex concentrates (PCC), improves outcomes METHODS: All patients presenting with WRICH between January 2004 and July 2010 were included. Retrospective case note and radiology review was performed, collecting data on intracerebral haemorrhage (ICH) severity, degree and timeliness of reversal, and patient outcomes. Cox's proportional hazards analysis was used to compare outcomes associated with and without PCC after controlling for ICH severity. RESULTS: Eighty-eight patients were included (27 treated palliatively). Mean international normalised ratio was 2.9. Vitamin K, PCC and fresh frozen plasma were given alone or in combination to 68, 23 and 44 patients, and mean time from computed tomography scanning to administration was 2.2, 3.3 and 3.1 h respectively. Four patients received PCC pre-protocol (none before 2007), two during development and seventeen patients post-protocol. Those who received PCC had improved survival (P < 0.001). After controlling for ICH score, hazard ratio for death was 0.27 (P < 0.01) for use of PCC. Survival tended to be greater with earlier administration of PCC (P = 0.053). Despite improved survival, discharge domicile and function were not significantly worse. CONCLUSIONS: PCC reversal was associated with improved survival without worsened disability. Delays in administration may have reduced the potential benefits.

Stroke discharges from a rehabilitation unit: 1-year and 5-year domicile outcomes. Function is important.

BACKGROUND: Stroke units save lives, reduce disability and increase the chances of the person returning to their own home. Following the introduction of a stroke rehabilitation unit, we assessed the durability of stroke discharges over a 1-year period and predictors of early 'failed' home discharges. Stability of discharge domicile and survival over 5 years was also reviewed. METHODS: A 6-month cohort of all discharges was followed for 5 years. Changes in domicile, including entry into institutional care, were recorded out to 5 years or until death. Predictors of early (3 months) and later (1 year) discharge stability were assessed. RESULTS: There were 142 discharges. Fifty-eight (76%) of those who returned home were still at home 12 months later. In contrast, there was a high mortality of dependent patients who were discharged to high dependency care (9 (29%) and 13 (42%) at 3 and 12 months, respectively). The chance of an early failed discharge was associated with lower functional ability on discharge (P= 0.012). Lower function on discharge was also independently associated with death in the next 12 months (P < 0.0001). At 5 years the mortality for the whole sample was 55% (78 of 141) and 38 (61%) of the survivors still lived in the community whereas 24 (39%) resided in institutional care. CONCLUSION: Functional ability on discharge is a key predictor of ability to remain at home as well as survival and therefore every effort should be made to maximize function.

The reliability of long and short cases undertaken as practice for a summative examination.

BACKGROUND: This study explores whether long and short cases performed in the workplace during training could be integrated into an overall summative assessment. Less examiner training and a less formalized structure might compromise reliability, but increased testing time might improve it. METHODS: Results of practice long and short cases, undertaken in preparation for the Royal Australasian College of Physicians clinical examination, were compared with actual examination results. The effects on reliability of the examination were compared by modelling varying combinations of practice and examination long and short cases. RESULTS: Fifty-nine candidates in two centres undertook 256 practice long cases and 154 practice short cases. Two practice long cases correlated with two examination long cases (r= 0.46). The reliability of a single long case was 0.22 under practice conditions and 0.36 under examination conditions. The reliability of a single short case was similar under either condition (0.18 vs 0.21). Reliability of over 0.80 could be achieved by assimilating two examination long cases and four examination short cases with varying combinations of seven practice cases. CONCLUSIONS: Long cases undertaken in the workplace are not as reliable those undertaken under examination conditions, but short cases have similar reliability under either condition.

Predictors of discharge stability in the first year following hospital admission for a frail elderly population.

The frail elderly are a group of patients who are at high risk of institutionalization and death. Specialist older person's health care aims to maximize function and independence. However, there is little published work on the long-term outcomes following hospitalization in a frail elderly population. This study examines the outcomes in the first year after hospitalization for this group. We find that 62% are able to remain in their own homes and that functional status is the strongest predictor of outcome, with age and living arrangements also significant.

Developing the accredited postgraduate assessment program for Fellowship of the Australian College of Rural and Remote Medicine.

INTRODUCTION: Accreditation of the Australian College of Rural and Remote Medicine (ACRRM) as a standards and training provider, by the Australian Medical Council (AMC) in 2007, is the first time in the world that a peak professional organisation for rural and remote medical education has been formally recognised. As a consequence, the Australian Government provided rural and remote medicine with formal recognition under Medicare as a generalist discipline. This accreditation was based on the ability of ACRRM to meet the AMC's guidelines for its training and assessment program. METHODS: The methodology was a six-step process that included: developing an assessment blueprint and a classification scheme; identifying an assessment model; choosing innovative summative and formative assessment methods that met the needs of rural and remote located medical practitioner candidates; 21 rural doctors and academics developing the assessment items as part of a week-long writing workshop; investigating the feasibility of purchasing assessment items; and 48 rural candidates piloting three of the assessment items to ensure they would meet the guidelines for national accreditation. RESULTS: The project resulted in an innovative formative and summative assessment program that occurs throughout 4 years of vocational training, using innovative, reliable, valid and acceptable methods with educational impact. The piloting process occurred for 3 of the 6 assessment tools. Structured Assessment Using Multiple Patient Scenarios (StAMPS) is a new assessment method developed as part of this project. The StAMPS pilot found that it was reliable, with a generalisability coefficient of >0.76 and was a valid, acceptable and feasible assessment tool with desired educational impact. The multiple choice question (MCQ) examination pilot found that the applied clinical nature of the questions and their wide range of scenarios proved a very acceptable examination to the profession. The web based in-training assessment examination pilot revealed that it would serve well as a formative process until ACRRM can further develop their MCQ database. CONCLUSIONS: The ACRRM assessment program breaks new ground for assessing rural and remote doctors in Australia, and provides new evidence regarding how a comprehensive and contemporary assessment system can work within a postgraduate medical setting.

Assessment of clinical performance: gathering evidence.

The focus of assessment of clinical performance has moved from over-reliance on individual tools to constructing a coherent assessment programme. The purpose of such an assessment programme is to gather high-quality evidence to make well-informed decisions. This requires clarity on the decisions to be made and an ability to gather a sufficient amount of high-quality data. The assessment programme should be aligned to doing the job well so that a successful assessment result reflects what is valued. A variety of assessments over a variety of times, matched against the areas of interest and value, enhances both reliability and validity. Workplace-based assessment tools can complement centralized assessment tools. Multiple snapshots, even if some are not totally in focus, give a better picture than one poorly aimed photograph.

The risk of recurrent stroke after intracerebral haemorrhage.

BACKGROUND AND AIM: The risks of recurrent intracerebral haemorrhage (ICH) vary widely (0-24%). Patients with ICH also have risk factors for ischaemic stroke (IS) and a proportion of ICH survivors re-present with an IS. This dilemma has implications for prophylactic treatment. This study aims to determine the risk of recurrent stroke events (both ICH and IS) following an index bleed and whether ICH recurrence risk varies according to location of index bleed. PATIENTS AND METHODS: All patients diagnosed with an acute ICH presenting over an 8.5 year period were identified. Each ICH was confirmed by reviewing all of the radiology results and, where necessary, the clinical case notes or post-mortem data. Recurrent stroke events (ICH and IS) were identified by reappearance of these patients in our stroke database. Coronal post-mortem results for the same period were also reviewed. Each recurrent event was reviewed to confirm the diagnosis and location of the stroke. RESULTS: Of the 7686 stroke events recorded, 768 (10%) were ICH. In the follow-up period, there were 19 recurrent ICH and 17 new IS in the 464 patients who survived beyond the index hospital stay. Recurrence rate for ICH was 2.1/100 in the first year but 1.2/100/year overall. This compares with 1.3/100/year overall for IS. Most recurrences were "lobar-lobar" type. CONCLUSION: The cumulative risk of recurrent ICH in this population is similar to that of IS after the first year.

Identification of recently handled materials by analysis of latent human fingerprints using infrared spectromicroscopy.

Analysis of fingerprints has predominantly focused on matching the pattern of ridges to a specific person as a form of identification. The present work focuses on identifying extrinsic materials that are left within a person's fingerprint after recent handling of such materials. Specifically, we employed infrared spectromicroscopy to locate and positively identify microscopic particles from a mixture of common materials in the latent human fingerprints of volunteer subjects. We were able to find and correctly identify all test substances based on their unique infrared spectral signatures. Spectral imaging is demonstrated as a method for automating recognition of specific substances in a fingerprint. We also demonstrate the use of attenuated total reflectance (ATR) and synchrotron-based infrared spectromicroscopy for obtaining high-quality spectra from particles that were too thick or too small, respectively, for reflection/absorption measurements. We believe the application of this rapid, nondestructive analytical technique to the forensic study of latent human fingerprints has the potential to add a new layer of information available to investigators. Using fingerprints to not only identify who was present at a crime scene, but also to link who was handling key materials, will be a powerful investigative tool.