Mobile learning in medicine: an evaluation of attitudes and behaviours of medical students.

BACKGROUND: Mobile learning (mLearning) devices (such as tablets and smartphones) are increasingly part of the clinical environment but there is a limited and somewhat conflicting literature regarding the impact of such devices in the clinical learning environment. This study aims to: assess the impact of mLearning devices in the clinical learning environment on medical students' studying habits, attitudes towards mobile device supported learning; and the perceived reaction of clinicians and patients to the use of these devices as part of learning in the clinical setting. METHODS: Over three consecutive academic years, 18 cohorts of medical students (total n = 275) on a six-week rotation at a large teaching hospital in London were supplied with mLearning devices (iPad mini) to support their placement-based learning. Feedback on their experiences and perceptions was collected via pre- and post-use questionnaires. RESULTS: The results suggest mLearning devices have a positive effect on the students' perceived efficiency of working, while experience of usage not only confirmed pre-existing positive opinions about devices but also disputed some expected limitations associated with mLearning devices in the clinical workplace. Students were more likely to use devices in 'down-time' than as part of their clinical learning. As anticipated, both by users and from the literature, universal internet access was a major limitation to device use. The results were inconclusive about the student preference for device provision versus supporting a pre-owned device. CONCLUSION: M-learning devices can have a positive impact on the learning experiences medical students during their clinical attachments. The results supported the feasibility of providing mLearning devices to support learning in the clinical environment. However, universal internet is a fundamental limitation to optimal device utilisation.

Assessing the impact of mHealth interventions in low- and middle-income countries--what has been shown to work?

BACKGROUND: Low-cost mobile devices, such as mobile phones, tablets, and personal digital assistants, which can access voice and data services, have revolutionised access to information and communication technology worldwide. These devices have a major impact on many aspects of people's lives, from business and education to health. This paper reviews the current evidence on the specific impacts of mobile technologies on tangible health outcomes (mHealth) in low- and middle-income countries (LMICs), from the perspectives of various stakeholders. DESIGN: Comprehensive literature searches were undertaken using key medical subject heading search terms on PubMed, Google Scholar, and grey literature sources. Analysis of 676 publications retrieved from the search was undertaken based on key inclusion criteria, resulting in a set of 76 papers for detailed review. The impacts of mHealth interventions reported in these papers were categorised into common mHealth applications. RESULTS: There is a growing evidence base for the efficacy of mHealth interventions in LMICs, particularly in improving treatment adherence, appointment compliance, data gathering, and developing support networks for health workers. However, the quantity and quality of the evidence is still limited in many respects. CONCLUSIONS: Over all application areas, there remains a need to take small pilot studies to full scale, enabling more rigorous experimental and quasi-experimental studies to be undertaken in order to strengthen the evidence base.

Aetiology and management of malnutrition in HIV-positive children.

Worldwide, more than 3 million children are infected with HIV and, without treatment, mortality among these children is extremely high. Both acute and chronic malnutrition are major problems for HIV-positive children living in resource-limited settings. Malnutrition on a background of HIV represents a separate clinical entity, with unique medical and social aetiological factors. Children with HIV have a higher daily calorie requirement than HIV-negative peers and also a higher requirement for micronutrients; furthermore, coinfection and chronic diarrhoea due to HIV enteropathy play a major role in HIV-associated malnutrition. Contributory factors include late presentation to medical services, unavailability of antiretroviral therapy, other issues surrounding healthcare provision and food insecurity in HIV-positive households. Treatment protocols for malnutrition have been greatly improved, yet there remains a discrepancy in mortality between HIV-positive and HIV-negative children. In this review, the aetiology, prevention and treatment of malnutrition in HIV-positive children are examined, with particular focus on resource-limited settings where this problem is most prevalent.

Impact of spiral computed tomography on the diagnosis of pulmonary embolism in a community hospital setting.

BACKGROUND: While the optimal role of spiral CT angiography (CTA) in the diagnosis of pulmonary embolism (PE) remains controversial, this technology is already being widely utilized in the community setting. OBJECTIVES: To assess the impact CTA has had on angiography utilization rates and the overall diagnostic rate of PE. METHODS: All patients evaluated for PE during a 4-year period were studied. PE was defined as either a high-probability V/Q scan, a positive conventional angiogram, or a CTA with emboli in the segmental or larger pulmonary vessels. Diagnostic rates of PE per 1,000 hospital admissions were determined and analyzed for time periods before and after the introduction of CTA. CT reports were compared with their concurrent chest radiograph (CXR) reports and additional findings that were not apparent on CXR were abstracted. RESULTS: The diagnostic rate of PE per 1,000 hospital admissions was 1.8 prior to the introduction of CTA and increased to 2.8 per 1,000 admissions after the introduction of CTA (p < 0.0001). Total costs for diagnostic testing per PE diagnosis made went from US 2,518 dollars to US 2,572 dollars. While the number of PE diagnosed by V/Q scan remained constant, the number of PE diagnosed by conventional angiography decreased while the number diagnosed by CTA increased. In patients with intermediate probability V/Q scan results, the percentage of patients receiving subsequent angiography (conventional or CTA) increased from 17 to 26% (p = 0.043). When conventional angiography was performed, CT imaging of the chest still had to be ordered for other reasons 38% of the time. Additional information was obtained in 78% of cases when CTA was performed. CONCLUSIONS: Increased utilization of CTA was associated with an increase in angiography utilization rates and diagnostic rates of PE, was cost effective, and often provided additional, useful, and unanticipated diagnostic information.

Acute exacerbations in chronic obstructive pulmonary disease: current strategies with pharmacological therapy.

In acute exacerbation of chronic obstructive pulmonary disease (AECOPD), short-acting inhaled bronchodilators, such as salbutamol (albuterol) and ipratropium bromide, have proven useful. In patients who are refractory to these agents, intravenous aminophylline should be considered. Corticosteroids should also be used, either in the outpatient or inpatient setting. The duration of corticosteroids should probably not exceed 2 weeks and the optimum dosage is yet to be determined. Antibacterials, especially in patients with purulent or increased sputum, should be used, guided by the local antibiogram of the key microbes. Controlled oxygen therapy improves outcome in hypoxaemic patients and arterial blood gases should be performed to ensure hypercarbia is not becoming excessive. Should patients be in distress despite the above measures or if there is acidaemia or hypercarbia, noninvasive positive pressure ventilation could be used to improve outcomes without resorting to invasive mechanical ventilation. Mucous-clearing drugs and chest physiotherapy have no proven beneficial role in AECOPD.

Decision analysis of antibiotic and diagnostic strategies in ventilator-associated pneumonia.

The optimal strategy for ventilator-associated pneumonia remains controversial. To clarify the tradeoffs involved, we performed a decision analysis. Strategies evaluated included antibiotic therapy with and without diagnostic testing. Tests that were explored included endotracheal aspirates, bronchoscopy with protected brush or bronchoalveolar lavage, and nonbronchoscopic mini-bronchoalveolar lavage (mini-BAL). Outcomes included dollar cost, antibiotic use, survival, cost-effectiveness, antibiotic use per survivor, and the outcome perspective of financial cost-antibiotic use per survivor. Initial coverage with three antibiotics was better than expectant management or one or two antibiotic approaches, leading to both improved survival (54% vs. 66%) and decreased cost (US dollars 55447 vs. US dollars 41483 per survivor). Testing with mini-BAL did not improve survival but did decrease costs (US dollars 41483 vs. US dollars 39967) and antibiotic use (63 vs. 39 antibiotic days per survivor). From the perspective of minimizing cost, minimizing antibiotic use, and maximizing survival, the best strategy was three antibiotics with mini-BAL.