An undergraduate Otolaryngology curriculum comparison in the United Kingdom using a curriculum evaluation framework.

OBJECTIVE: To compare undergraduate otolaryngology curricula in the United Kingdom. To develop a tool which would allow undergraduate specialty curricula to be compared. DESIGN: Development of a curriculum evaluation framework (CEF) and survey. SETTING: UK medical schools. PARTICIPANTS: Otolaryngology curricula were requested from all 32 UK medical schools who award a primary medical qualification. Nineteen curricula were received and examined. MAIN OUTCOME MEASURES: Thematic and content analysis of curriculum documents were undertaken. Outcome measures include an examination of curriculum content and methods, type of assessment and alignment of curricula with the General Medical Council's Tomorrow's Doctors document. RESULTS: Learning objectives were listed by 18 of the 19 medical schools who responded. The most commonly included theme was clinical conditions (100%). Psychosocial aspects of otolaryngology was the least covered theme (37%). Examination skills was covered by the majority (74%). Outpatient clinics and theatre attendance were the most commonly utilised teaching methods (47%). Student checklists were the most common form of assessment (32%). Only four medical schools linked their curricula to the GMC's Tomorrow's Doctors document. CONCLUSIONS: The development of a CEF allowed for a systematic comparison of curricula. This study, evaluating otolaryngology curricula, has highlighted the variability of curricula from both a content and methods perspective in the UK. The study provides those involved with curriculum planning an overview of the main themes currently taught in the UK and offers examples of individual topics. It also offers an insight into the way in which otolaryngology is taught in the UK.

Defining performance levels in undergraduate otolaryngology education.

OBJECTIVES: This study seeks the opinions of qualified doctors on what they feel medical students should learn about otolaryngology. It aims to identify both the content deemed relevant and the performance levels for medical students in otolaryngology. METHODS: A national survey developed from a content analysis of undergraduate otolaryngology curricula from the UK was undertaken, accompanied by a review of the literature and input from an expert group. Data were collected from a wide range of doctors. RESULTS: Participants felt that graduating students should be able to: recognise, assess and initiate management for common and life-threatening acute conditions; take an appropriate patient history; and perform an appropriate examination for the majority of otolaryngology clinical conditions but manage only a select few. CONCLUSION: This study reports performance levels for otolaryngology topics at an undergraduate level. Participating doctors felt that a higher level of performance should be expected of students treating life-threatening, acute and common otolaryngology conditions.

Neonatal cerebral Doppler flow velocity waveforms in the pre-term infant with cerebral pathology.

In a longitudinal study of 217 infants delivering at < 37 completed weeks gestation, Doppler flow velocity waveforms were obtained, and resistance index (RI) values calculated from the middle (MCA) and anterior (ACA) cerebral arteries during the first 10 days of life. Sixty infants demonstrated ultrasound evidence of cerebral pathology, of which five cases were congenital, and an additional 13 cases were complicated by patent ductus arteriosus during the study period. The Doppler data obtained during the first week of life from the remaining 42 infants who developed cerebral pathology, and 15 infants who had evidence of metabolic acidosis at delivery without ultrasound evidence of cerebral pathology were compared with local reference data obtained from non-acidotic infants with normal cranial ultrasound from 24 h of age. In those infants who had evidence of minor periventricular haemorrhage alone (Grade I/II PVH), there was no significant difference between the ACA or MCA RI during the study period compared with the reference data. In those groups of infants who demonstrated major PVH (Grade III/IV) or persistent periventricular flares, the ACA and MCA RI was found to be consistently significantly higher than the reference group throughout the study period. In those infants who developed ultrasound evidence of periventricular cystic leukomalacia (PVCL), the MCA RI was significantly lower than the reference data between 48 and 72 h of age, there being no significant difference in the ACA RI. The Doppler findings in those infants with evidence of metabolic acidosis at delivery (umbilical arterial pH < 7.20; BD > 8 mmol/l) but with normal ultrasound findings were similar to those infants who developed PVCL, namely a significant fall in MCA RI between 48 and 72 h of life, with no significant difference in the ACA RI during the study period. These findings suggest that variable changes in cerebral vascular resistance occur with the evolution of, or as a consequence of the development of cerebral pathology in the pre-term infant, and these changes of increased and decreased vascular resistance are discussed. Further investigation of the changes occurring in the cerebral circulation in the early neonatal period of infants who develop PVCL is required to clarify the vascular changes taking place, but if the findings of this study are confirmed, this technique may provide a means of identifying infants at risk of developing ischaemic cerebral pathology at an early stage when it may be possible to initiate therapeutic intervention to limit the cerebral damage.

Neonatal cerebral Doppler flow velocity waveforms in the uncomplicated pre-term infant: reference values.

In a longitudinal study of 217 infants delivering at < 37 completed weeks gestation, Doppler flow velocity waveforms were obtained and resistance index (RI) values calculated from the middle (MCA) and anterior (ACA) cerebral arteries during the first 10 days of life. One hundred thirty-seven of these infants were non-acidotic at delivery and during the early neonatal period, and had normal cerebral ultrasound scans throughout the study period. These infants formed the reference group. In three gestational subgroups considered (< or = 32 weeks, 33-34 weeks, > or = 35 weeks) from the reference group, the median RI for both the ACA and MCA was noted to fall significantly during the first 12 h of life (P < 0.01 for all groups). For infants delivering at > or = 33 weeks gestation, both MCA and ACA RI values reached a steady state with no significant change in the median value for the remainder of the study period. For infants delivering at < or = 32 weeks, there was a further significant fall in both the MCA and ACA RI between 12 and 24 h of life (P < 0.05), after which a steady state value was reached. During the first 12 h of life the RI for both vessels was significantly higher in infants delivering at < or = 32 weeks compared to the more mature infants (P < 0.01), but for the remainder of the study period, there were no significant differences in RI values between the gestational subgroups.(ABSTRACT TRUNCATED AT 250 WORDS)

Neonatal cerebral arterial flow velocity waveforms in term infants with and without metabolic acidosis at delivery.

To define the effects of acid base status at delivery on neonatal cerebral artery flow velocity waveform patterns obtained using Doppler ultrasound during the first week of life, a longitudinal comparative study of neonates born at term with and without evidence of metabolic acidosis in the umbilical artery was undertaken. Eighty-two appropriate for gestational age infants delivered after uncomplicated pregnancies with non-acidotic umbilical artery blood gases and in whom no neonatal complications were noted were studied to establish reference values of neonatal cerebral arterial vascular resistance index (RI) in normal term infants during the first week of life. A further 189 infants were grouped according to the presence and severity of metabolic acidosis at delivery, and also the presence of high risk features in the antenatal period. In the normal non-acidotic infants, over the first 24 h of life, there was a significant fall in the cerebral arterial resistance index (RI) in all the vessels examined, after which a steady state value was attained with no significant changes in vascular resistance index being noted during the remainder of the study period. The fall in RI between 12 and 24 h of age was consistent in all study groups. Infants with metabolic acidosis at delivery had blood flow patterns compatible with decreased resistance to flow in both anterior and middle cerebral arteries which persisted throughout the first week of life. This reduction in cerebral vascular resistance was most marked in those infants with severe metabolic acidosis. The majority of severely acidotic infants had a benign clinical outcome in the first week of life and all infants had normal cerebral ultrasound scans during the neonatal period. These findings suggest that metabolic acidosis at birth is associated with changes in neonatal cerebral arterial vascular resistance during the first week of life, and in the presence of benign clinical course the significance of this observation with regard to neurodevelopmental outcome requires evaluation.

Cerebral pathology in the very low birthweight infant: predictive value of peripartum metabolic acidosis.

One-hundred-and-three infants with a birthweight of less than 1500 g and delivering at a gestation of less than 32 weeks were examined by serial cranial ultrasound scans. A capillary blood sample was drawn for blood gas analysis within 1 h of birth in all cases. The subsequent development of intracranial pathology was found to be significantly associated with gestation at delivery (P less than 0.01), birthweight (P less than 0.01) and base deficit within 1 h of birth (P less than 0.001). For infants with a base deficit of greater than 5.0 mmol/l within the first hour of life, the sensitivity for predicting the subsequent development of cerebral pathology was 51.5% with a specificity of 97.3%, and a positive predictive value of 97.1%. This relationship between a metabolic acidosis within 1 h of birth and the subsequent development of cerebral pathology held for both major and minor degrees of pathology, but was stronger in those infants developing major cerebral pathology. The study suggests that improved surveillance of the very preterm infant during labour and at birth with the aim of reducing the incidence of metabolic acidosis at birth, may help to reduce subsequent intracranial pathology, and thereby perinatal and long-term morbidity.

Fetal umbilical artery flow velocity waveforms: prediction of small for gestational age infants and late decelerations in labour.

The relationship between fetal umbilical artery waveform patterns and (a) small for gestational age infants or (b) late fetal heart rate (FHR) decelerations in labour was examined in 205 clinically high-risk pregnancies. All pregnancies were studied using continuous-wave Doppler Ultrasound within 7 days of delivery. Waveforms were analysed by calculating a ratio of peak systolic frequency to end diastolic frequency (A/B ratio). An abnormal Doppler result was defined as being above the 97th centile for gestation from our previously derived normal values. Abnormal Doppler results occurred in only 38% of small for gestational age (SGA) infants and in 70% of those developing late decelerations in labour. Doppler ultrasound is a poor predictor of SGA infants, but may identify a high proportion of cases at risk of developing late FHR decelerations in labour.

Epidural analgesia and its effect on umbilical artery flow velocity waveform patterns in uncomplicated labour and labour complicated by pregnancy-induced hypertension.

Umbilical artery flow velocity waveforms were obtained using continuous-wave Doppler ultrasound to examine the effect of epidural analgesia on peak systolic/least diastolic ratio (A/B ratio) in 38 women in uncomplicated labour, and 12 women with pregnancy-induced hypertension (PIH). In the uncomplicated group there was no significant change in A/B ratio after epidural analgesia, but in the PIH group there was significant correlation between the fall in mean blood pressure and the fall in A/B ratio at 30 min after induction of epidural analgesia (r = 0.85, p less than 0.001). This suggests that epidural analgesia in PIH is associated with a reduction in placental resistance and may be beneficial to the fetus.

The use of audit to improve clinical effectiveness in an infrequent obstetric therapy: magnesium sulphate in severe pre-eclampsia.

Magnesium sulphate has been established as the drug of choice in the management of eclampsia and even when used in cases of severe pre-eclampsia it is given infrequently. It is recognised to have potentially severe toxic effects but there is a need to achieve therapeutic levels quickly enough to prevent seizures. This paper reports an audit following the introduction of a protocol for the use of magnesium sulphate in eclampsia and severe pre-eclampsia at Ninewells hospital, Dundee. Problems were identified with both the time taken to reach therapeutic levels and clinical monitoring of magnesium levels despite the use of loading doses commonly recommended. Reaudit after changes to the protocol and the introduction of an administration/monitoring chart showed a significant improvement in both monitoring and the adequacy of prophylaxis. This demonstrates how audit of clinical practice has been used to improve clinical effectiveness in an area in which a potentially toxic drug is used infrequently but with potentially life saving benefits.

A comparison of performance by medical and midwifery students in multiprofessional teaching.

AIM: At Dundee University, midwifery and medical students are taught obstetrics together in a 2-week intensive course. We set out to test the hypothesis that staff time and effort could be saved by using shared resources in teaching a multidisciplinary group of students to an acceptable level. METHOD: In order to measure the knowledge gain by two different groups of students, we tested the students before and after a timetabled computer-assisted learning (CAL) session focusing on how to interpret a cardiotocograph (CTG). Also, half of each student group was given extra CTG teaching before the CAL session. RESULTS: The medical students (n=38) increased their median score from 9 to 17 after the CAL (P<0.001) but the midwifery students (n=13) only increased their median score from 12 to 14 after the CAL (n.s.). However, when given a tutorial and CAL, the post-test scores for both medical and midwifery students were similar and significantly higher than pre-test scores (median score increase from 8.5 to 18 for medical students, P<0.001, n=34, and from 9 to 16 for midwifery students, P<0.01 n=11). There was no significant knowledge gain by the medical students who undertook the additional tutorial. CONCLUSION: We conclude that shared resources could be used by medical and midwifery students to reach equivalent levels of skill in CTG interpretation. However, in order to achieve equivalence, staff time and effort was wasted as medical students were given unnecessary tuition.

Cerebral pathology in the pre-term infant and associated peripartum metabolic acidosis.

In a prospective study of 217 infants who were delivered before 37 weeks' gestation and in whom serial cranial ultrasound scans were performed to identify cerebral pathology, multivariate analysis, including a wide range of peripartum and neonatal variables, demonstrated that metabolic acidosis present at delivery and persisting during the early neonatal period was associated with the development of cerebral pathology in these infants. These findings support the hypothesis that the condition at birth of the preterm infant as assessed by acid/base balance, which reflects events occurring during labour and delivery, is an important factor in the subsequent development of cerebral pathology. In addition, the data support the view that obstetric policies aimed at avoiding metabolic acidosis at birth are likely to be of benefit to the pre-term infant.

A prospective evaluation of the value of intrapartum biophysical and Doppler parameters in identifying the potentially compromised fetus.

This study was designed to evaluate the use of the biophysical profile and umbilical arterial Doppler in early labour in identifying the potentially compromised fetus. Two hundred and forty-two women attending the labour suite in early labour were studied. One hundred and fifty-one were in spontaneous labour and the remaining 91 had labour induced. All women had intrapartum biophysical profile assessment and umbilical arterial Doppler performed. Umbilical arterial Doppler and fetal movements were variously identified as being independently and significantly associated with adverse perinatal outcomes. Positive predictive values for adverse outcomes were however poor. Umbilical arterial Doppler used individually or in combination with clinical risk, gave no advantage over the use of clinically assigned risk alone in identifying fetuses at risk of subsequent adverse outcome. The assignment of clinical risk on admission in labour remains the most predictive 'test' for identifying the fetus at risk of subsequent adverse outcome. The routine addition of intrapartum biophysical parameters and umbilical arterial Doppler as methods of assessment is not justified.

Use of a computerised maternity information system to improve clinical effectiveness: thromboprophylaxis at caesarean section.

An audit of the introduction of a protocol for thromboprophylaxis at caesarean section revealed over treatment of low risk women and the under treatment of high risk women. A routine computer generated risk assessment profile was introduced as part of a maternity information system. Reaudit showed a significant improvement in adherence to the thromboprophylaxis protocol in all risk groups.

Screening practices for gestational diabetes mellitus in UK obstetric units.

AIM: To identify current screening practices for gestational diabetes mellitus (GDM) in all maternity units. METHODS: A questionnaire was sent to the senior obstetrician of all obstetric units known to the UK Royal College of Obstetricians and Gynaecologists. RESULTS: A response rate of 84% was achieved. 89% of units reported that they screened for GDM with a wide variation in the screening methods used, both between and within units. The most commonly employed procedure (81% of units) was screening based on the presence of maternal risk factors. The 75 g oral glucose tolerance test (OGTT) was the commonest diagnostic test (79% of units). Sixty-six per cent of units operate a combined diabetic antenatal clinic and 58% of units have written guidelines for screening. Seventy-six per cent of units would welcome national guidelines. CONCLUSION: The majority of obstetric units in the UK screen for GDM but with little consensus on the appropriate screening methods. National guidelines would probably be welcomed.

The reliability of the detection of an early diastolic notch with uterine artery Doppler velocimetry.

This study evaluates the ability of two reviewers to detect independently an early diastolic notch in 1371 uterine artery Doppler velocity waveform recordings. Agreement between the two reviewers for the detection of uterine artery notching was assessed by using the Kappa statistic. The inter-rater reliability for the detection of unilateral notching was 0.75 (95% CI 0.70-0.80), whereas that for the presence or absence of bilateral notching was 0.66 (95% CI 0.60-0.71). The results suggest that there was good reviewer agreement for the presence or absence of a notch on uterine artery Doppler velocimetry.

Foetal growth velocities in twin pregnancies.

A retrospective longitudinal study was performed to quantify foetal growth velocities in twin pregnancies and to determine the effect of variables specific to twin pregnancies on growth velocity. Foetal growth velocity standard deviation (Z) scores were calculated from serial ultrasound data using published singleton reference data for 131 consecutive sets of twins from 30 to 37 weeks' gestation. Compared with low-risk pregnancies, the twin foetal abdominal area growth velocity Z scores were significantly reduced from 30 to 37 weeks and biparietal diameter growth velocity Z scores were also significantly lower, from 30 to 33 weeks. Amongst the twin pairs there were no significant differences in Z scores with respect to chorionicity, foetal sex, birth order to whether delivery was premature or term. This retrospective study has demonstrated that twin foetal growth velocity is reduced when compared to singletons from at least as early as 30 weeks' gestation. Twin specific variables such as chorionicity, sex, birth order and subsequent premature birth do not need to be accounted for in the interpretation of growth velocities in twins. The clinical importance of determining foetal growth velocity in twin pregnancies awaits further prospective study.

Umbilical artery velocity waveforms: poor association with small-for-gestational-age babies.

A total of 205 high-risk pregnancies was studied using continuous wave Doppler ultrasound examination of the umbilical artery to investigate the ability of the test to detect small-for-gestational-age (SGA) infants. The waveforms were analysed by calculating a ratio of the peak systolic to end diastolic frequency (A/B ratio). An A/B ratio greater than 95th centile from our derived normal values was classified as abnormal. Three outcome variables were examined: birthweight for gestational age, the standard deviation birthweight score and the ponderal index. Although of the 56 pregnancies with an abnormal Doppler result 34 (61%) were associated with a SGA infant, only 41% of all the SGA infants had an abnormal Doppler result. Alternative measures of growth, the ponderal index and the SD birthweight score, showed that on average the babies in the Doppler abnormal group were smaller than those in the Doppler normal group, but the overlap between the normal and abnormal groups was large. Therefore although Doppler ultrasound appears to identify groups of smaller babies, it does not identify individual pregnancies where the baby will be small at birth.

Educational benefits of student self-marking of short-answer questions.

A pilot study was undertaken to evaluate the feasibility and reliability of undergraduate medical student selfmarking of degree written examinations, and to survey student opinion regarding the process. The correlation between student and faculty staff scores for individual questions and the total examination was high (correlation coefficient ranged from 0.77 to 0.91: p < 0.001). There were no significant differences between the mean student and mean faculty staff scores for individual questions or the total examination: 98% (97199) of student scores fell within ± 15% of the faculty staff score, with 92% (91199) of students falling within ± 10%. Although the approach was demonstrated to be reliable, students generally failed to acknowledge the potential value of self-marking in terms of feedback and as a learning opponunity, and found the process stressful.

Episiotomy and perineal tears in low-risk UK primigravidae.

BACKGROUND: The aim of the study was to determine the rates and to describe the risk factors for episiotomy and perineal tears in low-risk primigravidae. METHOD: A cross-sectional survey of 101 randomly selected NHS hospitals in the UK was carried out between February 1993 and January 1994. Subjects were 40 consecutive low-risk primigravidae in each hospital. The main outcome measures were number and reasons for episiotomy, and number and degree of perineal tears. RESULTS: A large proportion of women (83 per cent) experienced some form of perineal trauma. Forty per cent of the women had an episiotomy only, 6 per cent an episiotomy and perineal tear, and 37 per cent perineal or other tears without episiotomy. The main reasons for performing an episiotomy were foetal distress (27 per cent), impending tear (25 per cent) and delay of the second stage of labour (21 per cent). Fifty-nine per cent of women with a delayed second stage had a spontaneous vaginal delivery and 41 per cent required instrumental assistance. The likelihood of having an episiotomy increased with the duration of the second stage of labour, irrespective of type of delivery. Episiotomy rates varied appreciably throughout regions and hospitals in the United Kingdom, ranging from 26 to 67 per cent. There was also a large regional variation in the rates of perineal trauma; generally, high rates of one outcome were associated with low rates of the other. Compared with white women, women from the Indian sub-continent were almost twice as likely and those from the Orient almost five times as likely to have an episiotomy. CONCLUSIONS: The magnitude of the geographical variation suggests a lack of uniformity in indications for performing episiotomies and that guidelines for performing episiotomies may need to be reviewed. The rates of episiotomy in women from the Indian sub-continent and Orient were very high compared with those for white women, and this requires clarification and explanation, as they are contrary to rates experienced in these ethnic groups in other countries.