Postgraduate Medical Journal

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Objective

To identify pandemic and disaster medicine-themed training programmes aimed at medical students and to assess whether these interventions had an effect on objective measures of disaster preparedness and clinical outcomes. To suggest a training approach that can be used to train medical students for the current COVID-19 pandemic.

Results

23 studies met inclusion criteria assessing knowledge (n=18, 78.3%), attitude (n=14, 60.9%) or skill (n=10, 43.5%) following medical student disaster training. No studies assessed clinical improvement. The length of studies ranged from 1 day to 28 days, and the median length of training was 2 days (IQR=1–14). Overall, medical student disaster training programmes improved student disaster and pandemic preparedness and resulted in improved attitude, knowledge and skills. 18 studies used pretest and post-test measures which demonstrated an improvement in all outcomes from all studies.

Conclusions

Implementing disaster training programmes for medical students improves preparedness, knowledge and skills that are important for medical students during times of pandemic. If medical students are recruited to assist in the COVID-19 pandemic, there needs to be a specific training programme for them. This review demonstrates that medical students undergoing appropriate training could play an essential role in pandemic management and suggests a course and assessment structure for medical student COVID-19 training.

Registration

The search strategy was not registered on PROSPERO—the international prospective register of systematic reviews—to prevent unnecessary delay.

Author: Ashcroft, J., Byrne, M. H. V., Brennan, P. A., Davies, R. J.
Posted: May 20, 2021, 8:03 am
Background

The National Resident Matching Program (NRMP) policy requires interview officials to refrain from asking illegal or coercive questions that may introduce discrimination; however, compliance is insufficient.

Method

An Institutional Review Board-approved 12 question survey was distributed to 130 allopathic medical schools with 551 responses from 18 187 students applying in the 2015–2016 residency match. In addition, a 16-question survey was distributed through residency coordinators to residency programme interviewers with 481 responses from 21 of 22 residency specialities.

Results

Discriminatory topics were frequently discussed across all specialities. Surgical interviews were significantly more likely to discuss age (relative risk (RR) 2.0, p<0.01) and gender (RR 2.7, p<0.01) during formal interviews. More-competitive specialities more frequently discussed age (RR 1.9, p<0.01) and gender (RR 2.0, p<0.01) during the formal interview, and gender (RR 1.4, p<0.05) during informal interview events. 47.8% of interviewers discussed potentially coercive topics during the interview, 57.5% considered these topics when evaluating candidates and 72.6% had misunderstandings. Interviewers given both oral and written instruction showed the greatest effect change towards discussing coercive topics (p<0.01) and correctly identifying non-discriminatory and discriminatory topics (p<0.01). While age and gender both constitute discriminatory topics, each of these topics is included in the majority of written The Electronic Residency Application System applications (85.5% and 89.8%, respectively).

Conclusions

In modern recruitment where differential attainment is of interest, the presence of such explicit discrimination is worrisome. Formal interview training might reduce discrimination, but more active overnight is needed and a zero-tolerance approach to overt discrimination should be the ambition.

Author: Harkin, E., Murphy, M., Liskutin, T., Nystrom, L., Wu, K., Schiff, A.
Posted: May 20, 2021, 8:03 am
Aims

The purpose of this study was to (1) characterise the procedure of phlebotomy, deconstruct it into its constituent parts and develop a performance metric for the purpose of training healthcare professionals in a large teaching hospital and to (2) evaluate the construct validity of the phlebotomy metric and establish a proficiency benchmark.

Method

By engaging with a multidisciplinary team with a wide range of experience of preanalytical errors in phlebotomy and observing video recordings of the procedure performed in the actual working environment, we defined a performance metric. This was brought to a modified Delphi meeting, where consensus was reached by an expert panel. To demonstrate construct validity, we used the metric to objectively assess the performance of novices and expert practitioners.

Results

A phlebotomy metric consisting of 11 phases and 77 steps was developed. The mean inter-rater reliability was 0.91 (min 0.83, max 0.95). The expert group completed more steps of the procedure (72 vs 69), made fewer errors (19 vs 13, p=0.014) and fewer critical errors (1 Vs 4, p=0.002) than the novice group.

Conclusions

The metrics demonstrated construct validity and the proficiency benchmark was established with a minimum observation of 69 steps, with no critical errors and no more than 13 errors in total.

Author: OHerlihy, N., Griffin, S., Henn, P., Gaffney, R., Cahill, M. R., Gallagher, A. G.
Posted: May 20, 2021, 8:03 am
Purpose of the study

The aim of our study was to investigate potential adverse reactions in healthcare professionals working in Level 3 barrier protection personal protective equipment (L3PPE) to treat patients with COVID-19.

Study design

By using a convenience sampling approach, 129 out of 205 randomly selected healthcare professionals from the First Affiliated Hospital of Zhejiang University School of Medicine were invited to take part in a WeChat messaging app survey, Questionnaire Star, via a survey link. Healthcare personnel details were collected, including profession, years of professional experience and adverse reactions while wearing L3PPE. Survey results were divided by profession and years of professional experience; differences in adverse reactions were compared.

Results

Among the 129 healthcare professionals surveyed, 21 (16.28%) were doctors and 108 (83.72%) were nurses. A total of 122 (94.57%) healthcare professionals experienced discomfort while wearing L3PPE to treat patients with COVID-19. The main reasons for adverse reactions and discomfort include varying degrees of adverse skin reactions, respiratory difficulties, heat stress, dizziness and nausea. Doctors had a lower incidence of rashes (2=4.519, p=0.034) and dizziness (2=4.123, p=0.042) when compared with nurses. Junior (8.5 years of experience or fewer) healthcare personnel also experienced a higher rate of heat stress when compared with senior personnel (more than 8.5 years greater) (2=5.228, p=0.022).

Conclusion

More attention should be offered to healthcare personnel wearing L3PPE to treat patients with COVID-19 because they are susceptible to developing adverse reactions.

Author: Yuan, N., Yang, W.-X., Lu, J.-L., Lv, Z.-H.
Posted: May 20, 2021, 8:03 am

A 67-year-old woman with adenocarcinoma of the lung, who previously received chemotherapy and radiation therapy, presented with acute-onset right lower extremity weakness. She began radiation therapy to the lumbar spine after MRI demonstrated spinal cord compression. She then developed sudden-onset difficulty with swallowing approximately 6 hours after taking her scheduled morning medications. Of note, she had no prior known difficulties with eating. A barium swallow study revealed narrowing in the mid-thoracic oesophagus with an associated filling defect, reflecting the presence of a foreign body (figure 1A). Subsequent esophagogastroduodenoscopy revealed an extended-release potassium chloride tablet corresponding to the filling defect seen on the barium swallow study (figure 1B); the obstruction was relieved after the tablet was crushed endoscopically, displaying mucosal breaks with bleeding along the oesophageal circumference (figure 1C). Findings were consistent with pill-induced oesophagitis from an extended-release potassium chloride tablet, in the setting of...

Author: Syed, M.
Posted: May 20, 2021, 8:03 am
Aim

Human factors, surgery and aviation are intimately tied together by the common threads of error, risk and interpersonal relationships. A plethora of research abounds in all disciplines individually. The lessons learnt in one domain however are not unique and can be shared between all to promote best practice, further research and a greater understanding at a fundamental level.

Methods

A structured, thematic, literature review was performed. PubMed, EMBASE and Ovid MEDLINE databases were interrogated directly. The Health Foundation, National Health Service and Department of Health online databases were used through querying intrinsic search functions.

Results

With expanding use of technologies such as checklists, there is a gap left to better address and understand the nuances and roles of stress, communication and emotion on both learning and clinical practice. These can be prominent in the high-pressure environments shared between aviation and surgery.

Conclusions

The authors explore lessons learnt from aviation, the human factors applicable to both and how they can be extrapolated to improve patient safety outcomes and promote the use of the ‘Software, Hardware, Environment, Liveware’ tool to aid practice.

Author: Ahmed, H., Scott, A.
Posted: May 20, 2021, 8:03 am

HbA1c is a biomarker with a central role in the diagnosis and follow-up of patients with diabetes, although not a perfect one. Common comorbidities encountered in patients with diabetes mellitus, such as renal insufficiency, high output states (iron deficiency anaemia, haemolytic anaemia, haemoglobinopathies and pregnancy) and intake of specific drugs could compromise the sensitivity and specificity of the biomarker. COVID-19 pandemic poses a pressing challenge for the diabetic population, since maintaining optimal blood glucose control is key to reduce morbidity and mortality rates. Alternative methods for diabetes management, such as fructosamine, glycosylated albumin and device-based continuous glucose monitoring, are discussed.

Author: Kaiafa, G., Veneti, S., Polychronopoulos, G., Pilalas, D., Daios, S., Kanellos, I., Didangelos, T., Pagoni, S., Savopoulos, C.
Posted: May 20, 2021, 8:03 am

Type 1 diabetes (T1D) is an autoimmune condition that affects a significant number of people worldwide, with higher prevalence in white European populations. The condition is responsible for a high burden of microvascular complications, especially when poorly controlled. The condition is also burdensome on the patient and has major psychosocial and occupational impacts. It requires lifelong frequent blood glucose monitoring and regular insulin injections. Important technological advances in the management of T1D have occurred in recent years. These include the advent of new glucose testing devices using interstitial glucose, and new insulin delivery devices. These technologies may improve quality of life, and glucose management in this condition. This review aims to outline the current advances in the management of T1D for the general physician, with a particular focus on new technologies.

Author: Wunna, W., Tsoutsouki, J., Chowdhury, A., Chowdhury, T. A.
Posted: May 20, 2021, 8:03 am

The greatest English cricket captain of the last fifty years is generally reckoned to be Mike Brearley.1 He led England in 31 international test matches, winning 18 of them and losing only four, a record that no-one has ever exceeded. He famously returned from retirement to lead his country to victory in the 1981 match series against Australia, turning the result around from one that seemed beyond rescue. It made him a national hero even to those who barely followed the sport. His fame as a cricketer was in many ways unusual. He did not play for England until he was 34 years old, having taken time out for his other occupation as a university lecturer in philosophy. His record as a batsman was modest, with an average test match score of 23, less than half that of his contemporary Geoffrey Boycott. He never bowled at international...

Author: Launer, J.
Posted: May 20, 2021, 8:03 am

Dear editor,

Coronavirus Disease 2019 (COVID-19) is a potentially fatal respiratory illness, caused by a novel strain of coronavirus, SARS-CoV-2. The COVID-19 pandemic has had a profound impact globally, affecting more than 5 million people worldwide.1 Medical students and training doctors have been redeployed in many of the countries affected, taking on roles beyond the scope of their normal training. The move can have advantages and disadvantages for their education.

In the UK, medical school completion usually takes 5–6 years. Final examinations, in the form of written exams and Objective Structured Clinical Exams (OSCEs), are required in order to obtain a medical degree. As a result of COVID-19, some institutions have shifted forward the dates for final examinations, while many others have decided to cancel OSCEs, and opting to move written examinations to an online format. Cancellation of finals may be a disappointment to many, missing...

Author: Ding, A.
Posted: May 20, 2021, 8:03 am

Effective communication is a cornerstone of a healthy doctor–patient relationship in almost any clinical setting. As physicians, we find that our empathetic communication is of paramount importance to our patients and may even be therapeutic to some. A significant proportion of this communication is non-verbal.1

Usage of personal protective equipment is undoubtedly necessary for prevention of spread of infection from patients to healthcare workers and vice versa. However, the masks, goggles and other headgear make it impossible to even maintain eye contact with patients, let alone effective communication. The spacesuit-like attire creates a rift between the doctor and patient at first sight itself.

Talking through all the headgear has an effect on voice modulation and sometimes one has to shout out loud to get the message across. Intonation of voice to convey appropriate emotions is made impossible by the tight-fitting masks.

Differently abled patients who...

Author: Samarasekara, K.
Posted: May 20, 2021, 8:03 am
 

A 39-year-old woman presented with localized urticaria following N95 respirator use in a COVID-19 unit. After approximately 15 minutes of wear, she developed pruritus on her face, without associated angioedema or dyspnea. She had no history of cutaneous reactions to N95 respirators. Physical examination revealed several wheals with surrounding erythema limited to the area occluded by the N95 respirator (figure 1). On evaluation, firm stroking of the volar aspect of her forearm produced linear wheals (figure 2); she was subsequently diagnosed with dermatographism. Symptoms resolved within 1 hour of antihistamine use.

Dermatographism is characterised by the development of a wheal and flare reaction after pressure is applied to the skin by stroking or scratching, typically within minutes and persisting up to an hour.1 Symptoms typically self-resolve within an hour. Antihistamines can be used in symptomatic dermatographism. The pathogenesis is likely related to...

Author: Wong, K. H., Murray, T., Osborn, R., Soffer, G. K.
Posted: May 20, 2021, 8:03 am

The spectrum of diseases of optic neuromyelitis corresponds to a set of rare inflammatory and autoimmune diseases of the central nervous system (CNS), with consequent demyelination of CNS neurons that predominantly affects the spinal cord, optic nerve and brainstem causing respiratory insufficiency in 6.3% of cases. Neuromyelitis optica (NMO) was until recently considered a variant of multiple sclerosis (MS). Its aetiopathogenesis remains unknown, but recent advances describe an association with an autoimmunity production of IgG against the aquoporin-4 (AQ4) receptor.1–3A 19-year-old Brazilian woman presents with decreased visual acuity, left hemi-hypoesthesia with progression to left hemiparesis with inability to walk without support. On day 3 of admission, the patient develops severe hypoventilation and global respiratory failure requiring mechanical ventilation. Further brain and spine MRI revealed an extensive area of focal anomaly hypointense in postcontrast T1 fat-saturated images between C1 and C5 (

Author: Sousa, D., Rodrigues, A. I., Carvalho, M., Ferreira de Almeida, R., Castro, S., Nunez, D.
Posted: May 20, 2021, 8:03 am

A 53-year-old man presented to the emergency room (ER) with fever, dry cough and shortness of breath for 6 days. Clinically he had tachycardia (114 beats per minute), tachypnoea (30 per minute) and was maintaining oxygen saturation of 88% on room air. He had acute respiratory distress syndrome (ARDS) (PaO2/FiO2 of 0.28), and there was no leucopaenia or lymphopaenia. Chest X-ray revealed peripheral consolidations with base towards pleura and sparing of peri-hilar region consistent with a reverse batwing appearance (figure 1). The patient’s nasopharyngeal swab was tested for SARS Cov-2 RT-PCR, and it was positive. He was diagnosed to have COVID-19 pneumonia and started on oxygen supplementation and supportive care. The patient gradually improved and was discharged. In resource-constrained settings, a chest radiograph is the only investigation available for most patients. The findings have been used to support the diagnosis, determine the severity, guide the...

Author: Arora, N., Kumar H, M.
Posted: May 20, 2021, 8:03 am

COVID-19 has been the single greatest public health emergency in the history. The global demand for vaccine vastly outstrip available supply during this scale-up period. There is therefore a need to train up more vaccinators to maximise vaccine uptake in short time period.

Like most other vaccines, the COVID-19 vaccine should be given intramuscularly. Muscles have good vascularity, and therefore allowing injected drug to reach systemic circulation quickly, bypassing the first-pass metabolism.1 Intramuscular injection of the deltoid muscle should be given along a line drawn vertically downwards from the mid acromion.2 The manufacturers advise that the vaccine should not be injected intravascularly, subcutaneously or intradermally.3 Injecting a vaccine into the layer of subcutaneous fat with poor vascularity resulting in slow mobilisation and processing of antigen leading to vaccine failure.4 The antigen may take longer to reach the circulation after being deposited...

Author: Ng, J. Y.
Posted: May 20, 2021, 8:03 am

A 38-year-old man presented with dyspnoea and myalgia. Examination revealed tachycardia at 115 beats per minute and oxygen saturation (SpO2) of 88% on room air. He had lower extremity muscle weakness. Motor testing revealed a bilateral ankle plantarflexion deficit graded at 3/5 on the Medical Research Council muscle scale. All nerve reflexes were normal. The patient’s medical history was unremarkable.

On admission, blood work-up revealed creatine kinase (CK) of 19.250 IU/L (n<195 IU/L), C reactive protein (CRP) of 72 mg/L (n<5 mg/L), D-dimer of 1430 ng/ mL and lymphocytopenia. CT of the lung revealed bilateral ground-glass opacities (figure 1A). PCR testing for SARS-CoV-2 was positive. The results of influenza PCR were negative. A distal lower limb MRI showed bilateral gastrocnemius oedema, compatible with bilateral myositis (figure 1B). All immunological tests looking for any forms of myositis were negative. The diagnosis of COVID-19-associated myositis and pneumonitis was established, and a 5-day...

Author: Uslu, S.
Posted: May 20, 2021, 8:03 am
Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been caused the greatest pandemic of our century. Many of the deaths related to it are due to a systemic inflammatory response, which has been called ‘cytokine storm’.

Objectives

We developed a comprehensive review of the pathophysiology mechanisms of COVID-19 and of the rationale for drugs and therapeutics that have been tested in clinical trials.

Methods

A narrative review of the literature was conducted using PubMed, SciELO, Bireme, Google Scholar and ClinicalTrials.

Results

SARS-CoV-2 has evolutive mechanisms that made it spread all around the globe, as a higher latency period and a lesser lethality than other coronaviruses. SARS-CoV-2 causes a delay in the innate immune response and it disarranges the immune system leading to an overwhelming inflammatory reaction (the ‘cytokine storm’). In this scenario, high levels of interleukins (IL), notably IL-6 and IL-1, create a positive feedback of chemokines and immune responses, and powers pulmonary and systemic tissue damage, leading to capillary leakage and SARS, the main cause of death in patients with COVID-19. On 17 July 2020, there were 1450 entries on ClinicalTrials.gov of ongoing studies on COVID-19. The mechanisms of the main therapeutic approaches were comprehensively reviewed throughout the text. Therapies focus on blocking viral entry (remdesivir, umifenovir, among others) and blocking of immune system for cytokine storm control (IL-1 and IL-6 inhibitors, glucocorticoids, convalescent plasma, among others).

Conclusions

Understanding of action mechanisms of SARS-CoV-2 enables us to direct efforts on effective therapeutic targets. This comprehensive review helps to interpret the clinical results of the several trials ongoing.

Author: Melo Silva Junior, M. L. d., Souza, L. M. A. d., Dutra, R. E. M. C., Valente, R. G. d. M., Melo, T. S.
Posted: May 20, 2021, 8:03 am

‘People who are trying their best do not respond to criticism. They respond to help’.

David Crisp circa 2007

Dr Piotr Szawarski1 in the first paper identifies important features of our health service that may lead to burnout and asks important questions, whereas Ahmed and Scott2 outline similar concerns along with structured suggestions as to how these might be addressed.

Healthcare is an industry like no other. To treat humans as if they were a part of an industrial system is not humane. We have to cope with long working hours, dynamic situations, clinical uncertainties, equivocal or unhelpful results, colleagues who may or may not be supportive, and increasing patient expectations. In addition, artificial Intelligence is on the March and will deliver high (?higher) standards of algorithmic driven measures of performance.

Healthcare systems are increasingly expected to deliver efficacy and reliability. We...

Author: Welsby, P. D.
Posted: May 20, 2021, 8:03 am

Waiting patiently to get myself tested for COVID-19, several thoughts crossed my mind; Did I sign up for this? Do I risk my safety for others? Is this my moral responsibility? And how did I find myself outside the testing booth? The answer to the last question was that I was a primary suspect in contact with the nursing officer in my department who had tested positive for the dreaded COVID a day before. Although my result was negative and I have been put under quarantine, several questions trouble me. And some go as far back as to why did I step foot into a medical school? Is it all worth it?

Not just me, these are some of the questions facing every healthcare professional working as a frontline warrior battling this deadly pandemic that has befallen mankind. Over 9 months and millions infected, the end seems nowhere in sight....

Author: Talwar, H. S., Narain, T. A.
Posted: May 20, 2021, 8:03 am