Virtual patients improve history-taking competence and confidence in medical students.

PURPOSE: Klark is a novel online medical education tool (www.klark-cases.com) where students take histories from virtual patients with common presentations from multiple specialities. We investigated whether Klark could enhance student confidence and competence in history-taking, and whether students find Klark helpful. METHODS: A single cohort of first-year clinical medical students had access to Klark for three weeks. At both ends of the trial, participants were asked to complete feedback forms and participate in two mock Objective Structured Clinical Examination (OSCE) history stations. Outcome measures included self-reported confidence and competence in history-taking, performance in OSCE stations, and qualitative user experience data. RESULTS: Seventy participants successfully completed a case on Klark (mean 18.7), of which 63 (90% user retention) completed  ≥ 2 cases. Self-reported competence (p < 0.001) and confidence (p < 0.001) improved. Participants found Klark to be helpful, impactful, and would recommend it to other students. OSCE scores improved for medical (57% vs. 69%, p < 0.001) and surgical (58% vs. 70%, p < 0.001) histories. CONCLUSIONS: Klark improved competence and confidence in history-taking. Students found it helpful and chose to continue using the platform. By developing confidence and competence at their own pace in the Klark simulated environment, students can then maximise benefit from in-person clinical opportunities.

A graphical assessment of emergency surgical list efficiency to determine operating theatre capacity needs.

BACKGROUND: Unlike elective lists, full utilisation of an emergency list is undesirable, as it could prevent patient access. Conversely, a perpetually empty emergency theatre is resource wasteful. Separately, measuring delayed access to emergency surgery from time of booking the urgent case is relevant, and could reflect either deficiencies in patient preparation or be because of an occupied (over-utilised) emergency theatre. METHODS: We developed a graphical method recognising these two separate but linked elements of performance: (i) delayed access to surgery and (ii) operating theatre utilisation. In a plot of one against the other, data fell into one of four quadrants, with delays associated with high utilisation signifying the need for more emergency capacity. However, delays associated with low utilisation reflect process deficiencies in the emergency patient pathway. We applied this analysis to 73 consecutive lists (>300 cases) from two UK hospitals. RESULTS: Although both hospitals experienced similar rates of delayed surgery (21.8% vs 21.0%; P=0.872), in one hospital 83% of these were associated with low emergency theatre utilisation (suggesting predominant process deficiencies), whereas in the other 73% were associated with high utilisation (suggesting capacity deficiency; P<0.0001). Increasing emergency capacity in the latter resulted in shorter delays (just 6.7% cases excessively delayed; P<0.0001 for effect of intervention). CONCLUSIONS: This simple graphical analysis indicates whether more emergency capacity is necessary. We discuss potential applications in managing emergency surgery theatres.

Histaminergic Control of Corticostriatal Synaptic Plasticity during Early Postnatal Development.

A reduction in the synthesis of the neuromodulator histamine has been associated with Tourette's syndrome and obsessive-compulsive disorder. Symptoms of these disorders are thought to arise from a dysfunction or aberrant development ofcorticostriatal circuits. Here, we investigated how histamine affects developing corticostriatal circuits, both acutely and longer-term, during the first postnatal weeks, using patch-clamp and field recordings in mouse brain slices (C57Bl/6, male and female). Immunohistochemistry for histamine-containing axons reveals striatal histaminergic innervation by the second postnatal week, and qRT-PCR shows transcripts for H1, H2, and H3 histamine receptors in striatum from the first postnatal week onwards, with pronounced developmental increases in H3 receptor expression. Whole-cell patch-clamp recordings of striatal spiny projection neurons and histamine superfusion demonstrates expression of functional histamine receptors from the first postnatal week onwards, with histamine having diverse effects on their electrical properties, including depolarization of the membrane potential while simultaneously decreasing action potential output. Striatal field recordings and electrical stimulation of corticostriatal afferents revealed that histamine, acting at H3 receptors, negatively modulates corticostriatal synaptic transmission from the first postnatal week onwards. Last, we investigated effects of histamine on longer-term changes at developing corticostriatal synapses and show that histamine facilitates NMDA receptor-dependent LTP via H3 receptors during the second postnatal week, but inhibits synaptic plasticity at later developmental stages. Together, these results show that histamine acutely modulates developing striatal neurons and synapses and controls longer-term changes in developing corticostriatal circuits, thus providing insight into the possible etiology underlying neurodevelopmental disorders resulting from histamine dysregulation.SIGNIFICANCE STATEMENT Monogenic causes of neurologic disorders, although rare, can provide opportunities to both study and understand the brain. For example, a nonsense mutation in the coding gene for the histamine-synthesizing enzyme has been associated with Tourette's syndrome and obsessive-compulsive disorder, and dysfunction of corticostriatal circuits. Nevertheless, the etiology of these neurodevelopmental disorders and histamine's role in the development of corticostriatal circuits have remained understudied. Here we show that histamine is an active neuromodulator during the earliest periods of postnatal life and acts at developing striatal neurons and synapses. Crucially, we show that histamine permits NMDA receptor-dependent corticostriatal synaptic plasticity during an early critical period of postnatal development, which suggests that genetic or environmental perturbations of histamine levels can impact striatal development.

Beta-blockers for tenacious saliva: a case report.

This case report describes the care of a 75-year-old gentleman with metastatic head and neck cancer who was highly symptomatic with intractable tenacious oropharyngeal secretions. The patient reported subjective benefit from oral atenolol. A literature review was undertaken and identified no previous studies on the use of ß-blockers for secretions in malignant disease, although some anecdotal evidence for their use in motor neuron disease. The proposed underlying mechanism is that ß1-blockade reduced the protein content of salivary secretions, hence reducing its viscosity. Further studies of both the role of ß-adrenoreceptors in the control of secretion viscosity and the potential role of ß-blockers in alleviating symptomatic tenacious secretions are warranted.

Medium-term effects of SARS-CoV-2 infection on multiple vital organs, exercise capacity, cognition, quality of life and mental health, post-hospital discharge.

BACKGROUND: The medium-term effects of Coronavirus disease (COVID-19) on organ health, exercise capacity, cognition, quality of life and mental health are poorly understood. METHODS: Fifty-eight COVID-19 patients post-hospital discharge and 30 age, sex, body mass index comorbidity-matched controls were enrolled for multiorgan (brain, lungs, heart, liver and kidneys) magnetic resonance imaging (MRI), spirometry, six-minute walk test, cardiopulmonary exercise test (CPET), quality of life, cognitive and mental health assessments. FINDINGS: At 2-3 months from disease-onset, 64% of patients experienced breathlessness and 55% reported fatigue. On MRI, abnormalities were seen in lungs (60%), heart (26%), liver (10%) and kidneys (29%). Patients exhibited changes in the thalamus, posterior thalamic radiations and sagittal stratum on brain MRI and demonstrated impaired cognitive performance, specifically in the executive and visuospatial domains. Exercise tolerance (maximal oxygen consumption and ventilatory efficiency on CPET) and six-minute walk distance were significantly reduced. The extent of extra-pulmonary MRI abnormalities and exercise intolerance correlated with serum markers of inflammation and acute illness severity. Patients had a higher burden of self-reported symptoms of depression and experienced significant impairment in all domains of quality of life compared to controls (p<0.0001 to 0.044). INTERPRETATION: A significant proportion of patients discharged from hospital reported symptoms of breathlessness, fatigue, depression and had limited exercise capacity. Persistent lung and extra-pulmonary organ MRI findings are common in patients and linked to inflammation and severity of acute illness. FUNDING: NIHR Oxford and Oxford Health Biomedical Research Centres, British Heart Foundation Centre for Research Excellence, UKRI, Wellcome Trust, British Heart Foundation.