Adverse effects of biologic anti-inflammatory agents on the respiratory system: A review.

The therapy of autoimmune rheumatological conditions has undergone significant changes with the introduction of biologic antiinflammatory agents including cytokine antagonists and agents that interfere with the function of T and B cells or those that inhibit intracellular enzymes such as Janus kinase (JAK). Although useful to control inflammation, these agents may be associated with druginduced lung disease, which may be difficult to differentiate from pulmonary disorders caused by the underlying autoimmune diseases. This review aims to provide a description of lung disease, both infectious and non-infectious, that may be induced by the administration of biologic anti-inflammatory agents with emphasis on inhibitors of tumour necrosis factor, interleukin-1, interleukin-6 and JAK.

Burning issues in the prevention of heart failure

Chronic heart failure is common, debilitating, and often the culmination of pervasive cardiovascular insults that systematically undermine the heart's circulatory capacity and invoke counterproductive neuro-hormonal compensatory changes. Prevention of chronic heart failure therefore requires minimising the impact of traditional cardiovascular risk factors with incisive treatment of hypertension and type II Diabetes Mellitus (T2DM) and prompt lifestyle interventions for smoking, lack of exercise, obesity and hypercholesterolemia. This review is narrative, with selected emphasis on major studies, rather than structured on a specific clinical question, and should be read as such

Burning issues in blood pressure control

Globally more than 1 billion people have hypertension and it is predicted that because of ageing populations and increasing sedentary lifestyles, this figure will rise to about 1.5 billion by 2025. Elevated blood pressure (BP) is the leading cause of premature death and morbidity due to stroke and ischemic heart disease. Hypertension is also a major risk factor for heart failure, atrial fibrillation, chronic kidney disease, peripheral arterial disease and cognitive decline. This article discusses the current evidencebased treatment guidelines and pressing temporal issues in optimal blood pressure control

Exploring the influence of context on feedback at medical school: a video-ethnography study.

Feedback in medical education is complicated by the multiple contexts within which learning occurs. However, feedback research in medical education has typically focused on information provided by tutors to students with limited exploration of the influence of context. This research seeks to address this gap by exploring the influence of multiple contexts upon feedback processes. Employing video-ethnography methodology we explored feedback in two common contexts for medical student learning: the simulated clinical environment and the medical workplace. Learning and teaching sessions were filmed in each of these contexts, capturing diverse feedback processes. Data were analysed for key themes using a Framework Analysis approach and similarities and differences between the two contexts identified. In total 239 distinct feedback episodes across 28 different teaching and learning sessions were captured, with feedback processes relating to the patient, practice, educational and institutional contexts observed. In this paper, we concentrate on key similarities and differences in feedback processes between the two contexts with respect to six themes: feedback interlocutors, interlocutor positioning, feedback types, feedback foci, feedback styles and feedback milieu. We argue that feedback is inextricably linked to the multiple contexts in which feedback is enacted. It is only by exploring these contextual influences that feedback can be understood more fully. With such understanding we should be better placed to develop interventions capable of improving the long elusive experience of successful feedback.

Unilateral atrial fibrillation - how common is atrial divorce?

Atrial fibrillation is the most common pathologic supraventricular tachycardia. It has many causes, is an expensive disease, impairs quality of life and leads to an increased risk of death. Atrial dissociation is characterised by the presence of two independent sets of P-waves. This peculiar abnormality may give rise to the scenario where one atrium is in atrial fibrillation while the other is in sinus rhythm. This is the first published case of atrial dissociation where the phenomenon is demonstrated by transmitral and transtricuspid pulsed wave Doppler.

'Trochars no more': Teaching chest drain insertion to remote and rural practitioners using a mobile skills unit.

BACKGROUND: There are a number of approaches to teaching high-risk clinical skills, such as a large bore chest drain insertion, although effectiveness is limited and realism is only achieved at great expense. Summary of work: In response to a training needs' analysis of practitioners in remote and rural areas in Scotland, training in chest drains was identified as an urgent priority need. Subsequently, the Clinical Skills Managed Educational Network (CSMEN) developed an evidence-based multi-professional clinical skills pack. This e-learning resource encompasses all aspects of chest drain management, both pre and in-hospital. The pack and an interactive workshop is used to deliver 'blended' chest drain training on a mobile clinical skills unit. Evaluation confirms that the chest drain training is a valuable resource and has been widely used to deliver skills training in remote and rural areas. Feedback from all professional groups is positive. CONCLUSIONS: Developing shared national resources, with standardised workshops taught in local contexts via a mobile skills unit is one approach to the challenges associated with delivering high-risk clinical skills education.

The Kuwait-Scotland eHealth Innovation Network (KSeHIN): a sustainable approach to quality improvement in healthcare.

BACKGROUND: The rising prevalence of obesity and diabetes in Kuwait represents a significant challenge for the country's healthcare system. Diabetes care in Scotland has improved by adopting a system of managed clinical networks supported by a national informatics platform. In 2010, a Kuwait-Dundee collaboration was established with a view to transforming diabetes care in Kuwait. This paper describes the significant progress that has been made to date. METHODS: The Kuwait-Scotland eHealth Innovation Network (KSeHIN) is a partnership among health, education, industry and government. KSeHIN aims to deliver a package of clinical service development, education (including a formal postgraduate programme and continuing professional development) and research underpinned by a comprehensive informatics system. RESULTS: The informatics system includes a disease registry for children and adults with diabetes. At the patient level, the system provides an overview of clinical and operational data. At the population level, users view key performance indicators based on national standards of diabetes care established by KSeHIN. The national childhood registry (CODeR) accumulates approximately 300 children a year. The adult registry (KHN), implemented in four primary healthcare centres in 2013, has approximately 4000 registered patients, most of whom are not yet meeting national clinical targets. A credit-bearing postgraduate educational programme provides module-based teaching and workplace-based projects. In addition, a new clinical skills centre provides simulator-based training. Over 150 masters students from throughout Kuwait are enrolled and over 400 work-based projects have been completed to date. CONCLUSION: KSeHIN represents a successful collaboration between multiple stakeholders working across traditional boundaries. It is targeting patient outcomes, system performance and professional development to provide a sustainable transformation in the quality of diabetes healthcare for the growing population of Kuwaitis with diabetes in Kuwait.

Laparoscopic surgical skills are significantly improved by the use of a portable laparoscopic simulator: results of a randomized controlled trial.

BACKGROUND: There is growing evidence that training on virtual reality simulators leads to improved performance in the animate and human operating room. However, they are expensive, have a limited availability, and involve complex systems. Portable simulators are significantly cheaper, more user-friendly, and are flexible systems that are more suited to a surgical trainee's busy schedule. The use of portable surgical simulators to train skills and reduce errors has never been evaluated in prospective, randomized clinical settings. The objective of this study was to determine if training on the portable Integrated Laparoscopic Simulator leads to improved performance of core laparoscopic skills. METHODS: Core laparoscopic skills were identified by five experienced laparoscopic surgeons and modeled into two exercises and three basic tasks. Twenty surgically naive medical students had baseline laparoscopic skills assessed on a fixed simulator. Participants were randomized to either 14 h training on a portable laparoscopic simulator over a 3 week period, or control with no training. At 3 weeks two expert laparoscopic surgeons blinded to the allocation of participants assessed their pre- and post-intervention performances recorded on a CD-ROM. The outcome measures included time to complete and global rating scores of clipping and dissection tasks. RESULTS: No differences were observed in baseline skills level between the two groups. The intervention group had better quality of scissors dissection (p = 0.0038) and improved clipping skills (p = 0.0051), and they took less time to accomplish the tasks (p = 0.0099) in comparison to control. CONCLUSIONS: Training on the portable Integrated Laparoscopic Simulator significantly improved core laparoscopic skills in medical students with no prior experience.

A brief report on perceptions of alcohol and society among Scottish medical students.

AIMS: To assess perceptions on alcohol misuse and addiction among medical students prior to in-depth training in order to determine areas of the curriculum that need to be reshaped or focused on. METHODS: A questionnaire assessment of first- and second-year medical students' perceptions of alcohol misuse. RESULTS: Students had some misconceptions about current alcohol misuse rates, including a perception that addiction is common among health professionals, that the under-25s had the fastest increasing rate of alcohol addiction and that British women had a more rapidly increasing rate of alcohol addiction than British men. CONCLUSION: Encouragingly, students overwhelmingly felt that alcohol addiction was something to which they could make a difference. It highlights that early education about alcohol misuse is important in terms of teaching students how to recognize hazardous and harmful drinkers and how to manage them.

Subendocardial fibrosis in left ventricular hypertrabeculation-cause or consequence?

Left ventricular noncompaction has been classified as a primary cardiomyopathy with a genetic origin. This condition is morphologically characterized by a thickened, two-layered myocardium with numerous prominent trabeculations and deep, intertrabecular recesses. Recently, it has become clear that these pathological characteristics extend across a continuum with left ventricular hypertrabeculation at one end of the spectrum.The histological findings include areas of interstitial fibrosis.We present a case of left ventricular hypertrabeculation which presented as sudden infant death syndrome. Histologically areas of subendocardial fibrosis was prominent and we propose that this entity may be a hidden cause of arrhythmic death in some infants presenting as sudden infant death syndrome., with areas of subendocardial fibrosis as possible arrhythmogenic foci.

The reliability of chest radiographs in predicting left atrial enlargement.

INTRODUCTION: Estimates of left atrial size in patients with suspected cardiac disease play an important role in predicting prognosis and events, as well as treatment decisions. Two methods are commonly used to estimate left atrial size: chest radiography and cardiac ultrasound. This study aims to determine the test characteristics by comparing the use of radiographs to cardiac ultrasound (the gold-standard test). METHODS: Data from patients older than 18 years admitted to Steve Biko Academic Hospital during 2000-2003 who had both chest radiographs and cardiac ultrasound were included in this cross-sectional, retrospective analysis. Chest radiographs were classified into three quality classes, and the sub-carinal angle (SCA) and sub-angle distance (SAD) were measured twice in all available radiographs by two observers. Intra- and inter-observer variability (three methods) as well as the predictive value of the carinal angle and sub-angle distance measurements were determined using logistic regression (with left atrial enlargement - determined by ultrasound as comparator). RESULTS: Data for 159 patients were available (154 cardiac ultrasounds and 178 chest radiographs). Intra-observer variability for chest radiograph measurements was low with almost perfect concordance (p = 0.000). Inter-observer variability was higher for supine radiographs. Using logistic regression, a linear model was identified which was statistically significant only for erect radiographs. While goodness-of-fit analysis showed that the model fits the data, performance characteristics were poor, with high sensitivity and low specificity, and an area under the ROC curve of 0.62-0.63, depending on type of radiograph and measurement (SCA or SAD). Linearity in the logit of the dependent variable was assessed, and found to be present at the extremes of SCA measurements for the supine radiograph data and in the first three quartiles for erect radiograph data. A nonlinear model determined by fractional polynomial analysis did not perform significantly better than the original linear model. Cut-off values for the SCA of 72° and 84° (erect and supine radiographs, respectively) were found to give the best compromise between sensitivity and specificity. The corresponding cut-off values for SAD were 24.1 and 26.9 mm. CONCLUSION: Assessment of either SCA or SAD to determine left atrial size was equivalent and repeatable, both with the same observer and between two observers (less so for supine radiographs). While this measure was precise, it was found not to be very accurate. Therefore, chest radiographs are not reliable in predicting left atrial enlargement.

Sudden infant death syndrome and left ventricular hypertrabeculation-hidden arrhythmogenic entity?

Left ventricular noncompaction/hypertrabeculation is a condition which is characterized by a highly trabeculated, "spongy" myocardium.It can present at any age with heart failure, arrhythmia and/or thromboembolic events.A wide variety of mutations have been found to be a cause of hypertrabeculation and it is possible that there is a continuum of hypertrophic cardiomyopathy, dilated cardiomyopathy and hypertrabeculation/noncompaction.We present a case of left ventricular hypertrabeculation which presented as sudden infant death syndrome and we propose that this entity may be a hidden cause of arrhythmic death in some infants presenting as sudden infant death syndrome.

Post-mortem echocardiography as a guide to cardiac autopsy-a worthwhile concept?

Sudden and unexpected death in the young is a common and worldwide problem. Sudden, unexpected death in infancy (SUDI), clinically unexpected death in an infant between one week and one year of age, affects around 1 in 1000 infants. Autopsy will reveal a specific cause of death in only one third of cases. This has led to various ancillary examinations in an effort to increase the diagnostic yield of the autopsy.In this case report it is suggested that another diagnostic modality, that of the post-mortem echocardiogram might be a worthwhile concept to explore.

Subaortic (type 6) muscular band-innocent bystander or pathologic structure?

Intraventricular tendons are structures that was identified more than a hundred years ago. It has been suggested that they represent intracavitary radiations of the bundle of His and that they may be an isolated finding or be associated with structural cardiac abnormalities.Loukas et al divided these structures into five categories and recently a sixth type have been added.Various physiological disturbances have been observed due to the sixth type of tendon, such as ST segment elevation and right bundle branch block. It has been noted that this peculiar structure appears too thick to be called a tendon, thus the term band.This retrospective analysis analyzed the incidence of the thick, subaortic (type 6) muscular band in a cardiovascular clinic.

Evaluation of a new core curriculum on alcohol use disorders for undergraduate medical students.

AIMS: This study was aimed to review and rewrite the undergraduate curriculum on alcohol use disorders, implement the changes and assess for any early evidence of an improvement in knowledge. METHODS: A three-stage process was used to review the old curriculum and a new one was designed around the five undergraduate years. Students' opinions were sought about the acceptability of the new curriculum using a questionnaire, to which 93 responded and 70 volunteers were objectively assessed using an examination based on questions from the text of the Medical Students' Handbook on Alcohol and Health. RESULTS: There was no evidence of any improvement in the students' knowledge using the old curriculum. After teaching with the new curriculum, examination scores significantly increased (P < 0.0001). There was no difference between the sexes. The new curriculum was assessed as acceptable to the students. CONCLUSION: This new curriculum reflects the need for a new teaching method and not only offers improved teaching, but also produces a generation of doctors equipped to identify alcohol-related problems and to deliver brief interventions, helping to reduce the projected consequences of alcohol abuse and the associated burden on the health service.

From Bowditch to beta-blockers: evolution of the understanding of the importance of heart rate and myocardial energetics in cardiomyopathy - with reference to : a comparison of stimulation frequency and electro-augmentation on myocardial function, extensibility, coronary flow rate, oxygen consumption and glucose metabolism.

During the past three decades, every aspect of cardiomyopathy has undergone dramatic change. When examining the literature on the physiological aspects of the failing heart, one immediately recognises that South Africa has made a contribution: Brink, Bester and Lochner evaluated the possible therapeutic aspects of the Bowditch phenomenon and myocardial energetics in cardiomyopathy almost four decades ago, at a time when the condition even had another name, myocardiopathy.

The Brody effect induced by premature ventricular complexes in the ovine heart.

The QRS response of the electrocardiogram to bleeding has been a source of interest to the physiologist for more than a century. Studies in the dog, cat and chicken have shown a reduction in QRS amplitude in response to bleeding. This effect has been explained by the so-called Brody effect, in which the intraventricular mass of blood acts as a conducting medium, augmenting radial conduction, thus resulting in the subsequent reduction in QRS amplitude in conditions where the intraventricular mass of blood is reduced. The aim of this study was to evaluate whether the Brody effect will be present in the ovine heart and, furthermore, to evaluate if the right and left ventricles will demonstrate the same QRS change if the Brody effect is indeed present. This study clearly demonstrated that the Brody effect is present in the ovine heart. Furthermore, two unique aspects emanating from this study are firstly the fact that this is the first study to show that premature ventricular complexes are able to induce the Brody effect and, secondly that there is a very clear difference in the response of the right and the left ventricles when the Brody effect is induced in the ovine heart.

From Bowditch to Beta-Blockers : Evolution of the Understanding of the Importance of Heart Rate and Myocardial Energetics in Cardiomyopathy

During the past three decades; every aspect of cardiomyopathy has undergone dramatic change. When examining the literature on the physiological aspects of the failing heart; one immediately recognises that South Africa has made a contribution : Brink; Bester and Lochner evaluated the possible therapeutic aspects of the Bowditch phenomenon and myocardial energetics in cardiomyopathy almost four decades ago; at a time when the condition even had another name; myocardiopathy

From theory to practice in learning about healthcare associated infections: reliable assessment of final year medical students' ability to reflect.

BACKGROUND: Healthcare associated infection affects 9% of patients admitted to hospital. One of the greatest challenges in addressing this problem is transferring theory to practice in relation to hand hygiene. Developing the ability to reflect can promote this transfer. This study illustrates how an instrument to assess the reflective ability of final year medical students was applied to the context of hand hygiene within the infection control cleanliness champion programme (CCP) and demonstrated inter-rater reliability at all three levels of reflection. The results suggest behaviour change in relation to practice. METHODS: One hundred and thirty two reflective accounts were used for this study, provided by 44 5th year medical students. Each student had written three reflective accounts for each part of the hand hygiene unit. Results show that the inter-rater agreement was consistently high for all three levels of reflection. However, the least consistent was at reflective level three. CONCLUSIONS: These results suggest that the students were able to link theory to practice following the completion of the CCP. It could also indicate that assessors might require more skills and knowledge to enable effective and consistent examination of all areas of reflection.