Re-examining single-moment-in-time high-stakes examinations in specialist training: A critical narrative review.

In this critical narrative review, we challenge the belief that single-moment-in-time high-stakes examinations (SMITHSEx) are an essential component of contemporary specialist training. We explore the arguments both for and against SMITHSEx, examine potential alternatives, and discuss the barriers to change.SMITHSEx are viewed as the "gold standard" assessment of competence but focus excessively on knowledge assessment rather than capturing essential competencies required for safe and competent workplace performance. Contrary to popular belief, regulatory bodies do not mandate SMITHSEx in specialist training. Though acting as significant drivers of learning and professional identity formation, these attributes are not exclusive to SMITHSEx.Skills such as crisis management, procedural skills, professionalism, communication, collaboration, lifelong learning, reflection on practice, and judgement are often overlooked by SMITHSEx. Their inherent design raises questions about the validity and objectivity of SMITHSEx as a measure of workplace competence. They have a detrimental impact on trainee well-being, contributing to burnout and differential attainment.Alternatives to SMITHSEx include continuous low-stakes assessments throughout training, ongoing evaluation of competence in the workplace, and competency-based medical education (CBME) concepts. These aim to provide a more comprehensive and context-specific assessment of trainees' competence while also improving trainee welfare.Specialist training colleges should evolve from exam providers to holistic education sources. Assessments should emphasise essential practical knowledge over trivia, align with clinical practice, aid learning, and be part of a diverse toolkit. Eliminating SMITHSEx from specialist training will foster a competency-based approach, benefiting future medical professionals' well-being and success.

Competency domains of educators in medical, nursing, and health sciences education: An integrative review.

PURPOSE: Competencies for educators of healthcare professionals are important for demonstrating accountability, defining roles and responsibilities, structuring activities for training and development, defining standards, quality assurance, performance reviews, career development, and promoting the professionalisation of teaching. The frameworks and domains of educator competencies have not previously been reviewed or systematically described. Through this integrative review, the authors sought to identify an inclusive structure for competency domains that may be applied to educators. METHODS: Keywords were identified in a pilot search, followed by a multi-database search strategy of records published from 2000 to January 2020 with subsequent backward and forward reference searches. We included all record types that listed or described educator competency domains in medical, nursing and health sciences education. We excluded records that described 'ideal traits' or 'characteristics of good teachers/educators,' presented competencies as part of a larger curricular framework, and teaching assessment tool content. RESULTS: The multi-database search retrieved 2942 initial citations. From a full-text review of 301 records, 67 were identified as describing educator competency domains eligible for analysis. Documents contained a median of six domains (interquartile range = 5-7) and 14.9% incorporated at least one overarching element across their domains. Following an inductive thematic analysis, six distinct domains of educator competence were identified: Teaching and facilitating learning; Designing and planning learning; Assessment of learning; Educational research and scholarship; Educational leadership and management; Educational environment, quality, and safety. The two latter domains contained sub-themes that were able to be further categorised. Documents and frameworks were described for a wide variety of health and allied health disciplines. CONCLUSION: Distinct educator competency domains were identified in this analysis, applicable across a range of healthcare disciplines. Along with the description of design elements, these provide a guide for the development and evaluation of educator competency frameworks.

Deliberate teaching tools for clinical teaching encounters: A critical scoping review and thematic analysis to establish definitional clarity.

PURPOSE AND METHOD: We conducted a scoping review of tools designed to add structure to clinical teaching, with a thematic analysis to establish definitional clarity. RESULTS: Six thousand and forty nine citations were screened, 434 reviewed for eligibility, and 230 identified as meeting study inclusion criteria. Eighty-nine names and 51 definitions were identified. Based on a post facto thematic analysis, we propose that these tools be named "deliberate teaching tools" (DTTs) and defined as "frameworks that enable clinicians to have a purposeful and considered approach to teaching encounters by incorporating elements identified with good teaching practice." We identified 46 DTTs in the literature, with 38 (82.6%) originally described for the medical setting. Forty justification articles consisted of 16 feedback surveys, 13 controlled trials, seven pre-post intervention studies with no control group, and four observation studies. Current evidence of efficacy is not entirely conclusive, and many studies contain methodology flaws. Forty-nine clarification articles comprised 12 systematic reviews and 37 narrative reviews. The most number of DTTs described by any review was four. A common design theme was identified in approximately three-quarters of DTTs. CONCLUSIONS: Applicability of DTTs to specific alternate settings should be considered in context, and appropriately designed justification studies are warranted to demonstrate efficacy.

Developing and validating a tool for measuring the educational environment in clinical anesthesia.

PURPOSE: We aimed to develop a contemporary measure for anesthesia teaching and learning in the operating theatre that was applicable to a variety of training jurisdictions, the Measure for the Anaesthesia Theatre Educational Environment (MATE). METHODS: A systematic review of the literature and modified Delphi approach was used to identify items for content validity. Reliability and exploratory factor analyses were conducted after a pilot survey of trainees to show construct validity, with removal of redundant items. Item domains were identified through a global assessment of factor structure accuracy and relation to real-world constructs. RESULTS: Literature review generated an initial 73-item list. A modified Delphi approach with 24 experts identified 44 relevant items. The pilot survey generated 390 responses. Reliability analysis, exploratory factor analysis, and global assessment refined the measure to 33 items. Four domains were identified according to factor structure: teaching preparation and practice, assessment and feedback, procedures and responsibility, and overall atmosphere. The educational environment was rated by trainees at 74.6 ± 15.6% with excellent internal consistency (Cronbach's α = 0.975). CONCLUSION: The MATE survey tool generated valid and reliable scores when measuring the educational environment in the operating theatre. Further research is required to investigate possible differences between the training countries and age of junior doctors and the associated underlying factors. Other researchers are invited to administer the survey and share results within a central database.

Structure of sulfamidase provides insight into the molecular pathology of mucopolysaccharidosis IIIA.

Mucopolysaccharidosis type IIIA (Sanfilippo A syndrome), a fatal childhood-onset neurodegenerative disease with mild facial, visceral and skeletal abnormalities, is caused by an inherited deficiency of the enzyme N-sulfoglucosamine sulfohydrolase (SGSH; sulfamidase). More than 100 mutations in the SGSH gene have been found to reduce or eliminate its enzymatic activity. However, the molecular understanding of the effect of these mutations has been confined by a lack of structural data for this enzyme. Here, the crystal structure of glycosylated SGSH is presented at 2 Å resolution. Despite the low sequence identity between this unique N-sulfatase and the group of O-sulfatases, they share a similar overall fold and active-site architecture, including a catalytic formylglycine, a divalent metal-binding site and a sulfate-binding site. However, a highly conserved lysine in O-sulfatases is replaced in SGSH by an arginine (Arg282) that is positioned to bind the N-linked sulfate substrate. The structure also provides insight into the diverse effects of pathogenic mutations on SGSH function in mucopolysaccharidosis type IIIA and convincing evidence for the molecular consequences of many missense mutations. Further, the molecular characterization of SGSH mutations will lay the groundwork for the development of structure-based drug design for this devastating neurodegenerative disorder.

Molecular architecture with carbohydrate functionalized ß-peptides adopting 314-helical conformation.

Carbohydrate recognition is essential in cellular interactions and biological processes. It is characterized by structural diversity, multivalency and cooperative effects. To evaluate carbohydrate interaction and recognition, the structurally defined attachment of sugar units to a rigid template is highly desired. ß-Peptide helices offer conformationally stable templates for the linear presentation of sugar units in defined distances. The synthesis and ß-peptide incorporation of sugar-ß-amino acids are described providing the saccharide units as amino acid side chain. The respective sugar-ß-amino acids are accessible by Michael addition of ammonia to sugar units derivatized as α,ß-unsaturated esters. Three sugar units were incorporated in ß-peptide oligomers varying the sugar (glucose, galactose, xylose) and sugar protecting groups. The influence of sugar units and the configuration of sugar-ß-amino acids on ß-peptide secondary structure were investigated by CD spectroscopy.

A singlet biradicaloid zinc compound and its nonradical counterpart.

Metal ions with radical centers in their coordination sphere are key participants in biological and catalytic processes. In the present study, we describe the synthesis of the cAAC:ZnCl2 adduct (1) using a cyclic alkylaminocarbene (cAAC) as donor ligand. Compound 1 was treated with 2 equiv of KC8 and LiB(sec-Bu)3H to yield a deep blue-colored dicarbene zinc compound (cAAC)2Zn (2) and the colorless hydrogenated zinc compound (cAACH)2Zn (3), respectively. Compounds 2 and 3 were well characterized by spectroscopic methods and single-crystal X-ray structural analysis. Density functional theory calculations were performed for 2 which indicate that this molecule possesses a singlet biradicaloid character. Moreover, we show the application of 2 in CO2 activation, which yields a zwitterionic cAAC·CO2 adduct.

Percutaneous Coronary Intervention in an Extremely Rare Case of Double Circumflex Coronary Arteries With Acute Myocardial Infarction.

The anomalous origin of the left circumflex (Cx) artery (LCX) from the right coronary sinus or the right coronary artery (RCA) has been reported as one of the most common congenital coronary anomalies. However, the occurrence of double or twin Cx coronary arteries has been sparsely reported in the literature. We describe a rare case of a middle-aged male with acute myocardial infarction (MI) who had double Cx coronary arteries, one arising from the RCA and the other from the left main coronary artery. He underwent successful angioplasty with the stenting of the culprit right Cx artery (RCX).

Double Whammy: Subacute Stent Thrombosis While Being Adherent to Dual Antiplatelet Therapy Including Ticagrelor, Followed by Multiple Coronary Artery Aneurysms in a COVID-19 Patient.

Coronavirus disease 2019 (COVID-19), although predominantly a respiratory illness, can have important cardiovascular implications, which include the development of myocardial injury/myocarditis, acute coronary syndromes, arrhythmias, pericarditis, and the occurrence of arterial and venous thrombosis. We describe a rare case of a middle-aged COVID-19 patient who developed sub-acute stent thrombosis after implantation of second-generation drug-eluting stents (DES) despite being adherent to dual antiplatelet therapy including ticagrelor and who subsequently developed multiple coronary artery aneurysms within a few weeks of the DES implantation.

Structure of a highly NADP+-specific isocitrate dehydrogenase.

Isocitrate dehydrogenase catalyzes the first oxidative and decarboxylation steps in the citric acid cycle. It also lies at a crucial bifurcation point between CO2-generating steps in the cycle and carbon-conserving steps in the glyoxylate bypass. Hence, the enzyme is a focus of regulation. The bacterial enzyme is typically dependent on the coenzyme nicotinamide adenine dinucleotide phosphate. The monomeric enzyme from Corynebacterium glutamicum is highly specific towards this coenzyme and the substrate isocitrate while retaining a high overall efficiency. Here, a 1.9 Šresolution crystal structure of the enzyme in complex with its coenzyme and the cofactor Mg2+ is reported. Coenzyme specificity is mediated by interactions with the negatively charged 2'-phosphate group, which is surrounded by the side chains of two arginines, one histidine and, via a water, one lysine residue, forming ion pairs and hydrogen bonds. Comparison with a previous apoenzyme structure indicates that the binding site is essentially preconfigured for coenzyme binding. In a second enzyme molecule in the asymmetric unit negatively charged aspartate and glutamate residues from a symmetry-related enzyme molecule interact with the positively charged arginines, abolishing coenzyme binding. The holoenzyme from C. glutamicum displays a 36° interdomain hinge-opening movement relative to the only previous holoenzyme structure of the monomeric enzyme: that from Azotobacter vinelandii. As a result, the active site is not blocked by the bound coenzyme as in the closed conformation of the latter, but is accessible to the substrate isocitrate. However, the substrate-binding site is disrupted in the open conformation. Hinge points could be pinpointed for the two molecules in the same crystal, which show a 13° hinge-bending movement relative to each other. One of the two pairs of hinge residues is intimately flanked on both sides by the isocitrate-binding site. This suggests that binding of a relatively small substrate (or its competitive inhibitors) in tight proximity to a hinge point could lead to large conformational changes leading to a closed, presumably catalytically active (or inactive), conformation. It is possible that the small-molecule concerted inhibitors glyoxylate and oxaloacetate similarly bind close to the hinge, leading to an inactive conformation of the enzyme.

Interviewer bias in selection of anaesthesia Fellows: A single-institution quality assessment study.

Fellowships are competitive training posts, often in a subspecialty area. We performed a quality assessment of potential interviewer bias on anaesthesia Fellow selection. After research locality approval, we analysed interview scores for all Fellowship applications to our department over six years. Panel interviewers participated in a structured interview process, asking a series of standardised questions to rate applicants. A mixed model analysis of total applicant rating with crossed effects of applicants and interviewers was used. A total of 94 applicants were interviewed by 27 panel members, with between two and four panel members per interview, giving a total of 329 applicant ratings. The random effect of applicants accounted for 45.8% of total variance in ratings (95% confidence intervals (CI) for intraclass correlation (ICC) 35.8%-57.2%) while interviewer effects accounted for 13.4% of total variance (95% CI for ICC 5.3%-30.0%). We found no evidence of bias for most potential sources after analysing multiple applicant and interviewer factors. After adjusting for interviewer training programme, applicants from other training programmes were rated a mean of 1.87 points lower than Australian and New Zealand College of Anaesthetists (ANZCA) applicants (95% CI 0.62-3.12, P = 0.003) and 1.84 points lower than Royal College of Anaesthetists (RCoA) applicants (95% CI 0.37-3.32, P = 0.014). After adjusting for applicant gender, female clinicians rated applicants 1.12 points higher (95% CI 0.19-2.06, P = 0.019) on average than male clinicians. The observed differences in interview scores amongst male and female clinicians and lower scores in applicants from programmes other than ANZCA/RCoA were small, and require confirmation in independent studies.

"Not-for-resuscitation" orders in Australian public hospitals: policies, standardised order forms and patient information leaflets.

OBJECTIVE: To determine the prevalence and content of policies, standardised order forms (SOFs) and patient information leaflets (PILs) pertaining to "not-for-resuscitation" (NFR) orders in Australian public hospitals. DESIGN AND SETTING: Cross-sectional postal survey conducted across Australia from August to December 2005, using a one-page questionnaire. PARTICIPANTS: Directors of Medical, Nursing or Clinical Services of all public hospitals in Australia with 60 or more beds, excluding psychiatric, military and private hospitals. MAIN OUTCOME MEASURES: Prevalence of documented NFR policies, by hospital characteristics, and content of these policies, SOFs and PILs. RESULTS: 222 hospitals were surveyed, and 157 responded (71%). Of these, 85 (54%) had NFR policies, 62 (39%) had SOFs, and four (3%) had PILs. Hospitals with more than 200 beds were more likely to have NFR policies than those with 60-200 beds (P = 0.04). More metropolitan than rural hospitals had NFR policies (P = 0.01). More hospitals with 60-100 beds had SOFs than hospitals with 101-200 beds (P = 0.03). "NFR" was defined in 53% of policies, while 97% of policies explicitly stated where NFR orders were to be documented, 89% stated who was allowed to make them, 37% stated that advanced care directives ("living wills") were to be respected, and 89% stated that competent patients should be involved in discussions regarding their NFR status. The most common items noted in SOFs were the name and signature of the issuing medical practitioner (92%) and documentation of the discussion with the patient (81%). CONCLUSIONS: There was wide variation in the content of hospital policies, SOFs and PILs pertaining to NFR orders. Aspects of current policies show room for improvement.