Evaluation of the contribution of theatre attendance to medical undergraduate neuroscience teaching - a pilot study.

Introduction: Medical students often attend the neurosurgical theatre during their clinical neurosciences attachment. However, few studies have been performed to objectively assess the value of this theatre-based learning experience. The main aim of this study was to explore student perceptions on the contribution of neurosurgical theatre attendance to clinical neuroscience teaching.

Materials and Methods: Third-year medical students undergoing their 2-week clinical neurosciences rotation at the Royal Hospitals Belfast were invited to participate in this study. A multi-method strategy was employed using a survey questionnaire comprising of closed and open-ended questions followed by semi-structured interviews to gain a greater 'in-depth' analysis of the potential contribution of neurosurgical theatre attendance to neuroscience teaching.

Results: Based on the completed survey responses of 22 students, the overall experience of neurosurgical theatre-based learning was a positive one. 'In-depth' analysis from semi-structured interviews indicated that students felt that some aspects of their neurosurgical theatre attendance could be improved. Better preparation such as reading up on the case in hand and an introduction to simple theatre etiquette to put the student at ease (in particular, for students who had never attended theatre previously), would improve the learning experience. In addition, having an expectation of what students are expected to learn in theatre making it more learning outcomes-based would probably make it feel a more positive experience by the student.

Conclusions: The vast majority of students acknowledged the positive learning outcomes of neurosurgical theatre attendance and felt that it should be made a mandatory component of the curriculum.

Streptococcus bovis bacteraemia: an evaluation of the long-term effect on cardiac outcomes

Introduction: Streptococcus bovis can lead to bacteraemia, septicaemia, and ultimately endocarditis. The objective of this study was to evaluate the long-term implications of S. bovis endocarditis on cardiac morbidity and mortality. 

Methods: A retrospective cohort study was performed between January 2000 and March 2009 to assess all patients diagnosed with S. bovis bacteraemia from the Belfast Health and Social Care Trust. The primary end-point for cardiac investigations was the presence of endocarditis. Secondary end-points included referral for cardiac surgery and overall mortality. 

Results: Sixty-one positive S. bovis blood cultures from 43 patients were included. Following echocardiography, seven patients were diagnosed with infective endocarditis (16.3 % of total patients); four patients (9.3 %) had native valve involvement while three (7.0 %) had prosthetic valve infection. Five of these seven patients had more than one positive S. bovis culture (71.4 %). Three had significant valve dysfunction that warranted surgical repair/replacement, one of whom was unfit for surgery. There was a 100 % recurrence rate amongst the valve replacement patients (n = 2) and six patients with endocarditis had colorectal pathology. Patients with endocarditis had similar long-term survival as those with non-endocarditic bacteraemia (57.1 % alive vs. 50 % of non-endocarditis patients, p = 0.73). 

Conclusion: Streptococcus bovis endocarditis patients tended to have pre-existing valvular heart disease and those with prosthetic heart valves had higher surgical intervention and relapse rates. These patients experienced a higher rate of co-existing colorectal pathology but currently have reasonable long-term outcomes. This may suggest that they represent a patient population that merits consideration for an early surgical strategy to maximise long-term results, however, further evaluation is warranted. © 2013 The Japanese Association for Thoracic Surgery.

Optical coherence tomography for the diagnosis, monitoring and guiding of treatment for neovascular age-related macular degeneration:a systematic review and economic evaluation

BACKGROUND: Age-related macular degeneration is the most common cause of sight impairment in the UK. In neovascular age-related macular degeneration (nAMD), vision worsens rapidly (over weeks) due to abnormal blood vessels developing that leak fluid and blood at the macula.

OBJECTIVES: To determine the optimal role of optical coherence tomography (OCT) in diagnosing people newly presenting with suspected nAMD and monitoring those previously diagnosed with the disease.

DATA SOURCES: Databases searched: MEDLINE (1946 to March 2013), MEDLINE In-Process & Other Non-Indexed Citations (March 2013), EMBASE (1988 to March 2013), Biosciences Information Service (1995 to March 2013), Science Citation Index (1995 to March 2013), The Cochrane Library (Issue 2 2013), Database of Abstracts of Reviews of Effects (inception to March 2013), Medion (inception to March 2013), Health Technology Assessment database (inception to March 2013).

REVIEW METHODS: Types of studies: direct/indirect studies reporting diagnostic outcomes.

INDEX TEST: time domain optical coherence tomography (TD-OCT) or spectral domain optical coherence tomography (SD-OCT).

COMPARATORS: clinical evaluation, visual acuity, Amsler grid, colour fundus photographs, infrared reflectance, red-free images/blue reflectance, fundus autofluorescence imaging, indocyanine green angiography, preferential hyperacuity perimetry, microperimetry. Reference standard: fundus fluorescein angiography (FFA). Risk of bias was assessed using quality assessment of diagnostic accuracy studies, version 2. Meta-analysis models were fitted using hierarchical summary receiver operating characteristic curves. A Markov model was developed (65-year-old cohort, nAMD prevalence 70%), with nine strategies for diagnosis and/or monitoring, and cost-utility analysis conducted. NHS and Personal Social Services perspective was adopted. Costs (2011/12 prices) and quality-adjusted life-years (QALYs) were discounted (3.5%). Deterministic and probabilistic sensitivity analyses were performed.

RESULTS: In pooled estimates of diagnostic studies (all TD-OCT), sensitivity and specificity [95% confidence interval (CI)] was 88% (46% to 98%) and 78% (64% to 88%) respectively. For monitoring, the pooled sensitivity and specificity (95% CI) was 85% (72% to 93%) and 48% (30% to 67%) respectively. The FFA for diagnosis and nurse-technician-led monitoring strategy had the lowest cost (£39,769; QALYs 10.473) and dominated all others except FFA for diagnosis and ophthalmologist-led monitoring (£44,649; QALYs 10.575; incremental cost-effectiveness ratio £47,768). The least costly strategy had a 46.4% probability of being cost-effective at £30,000 willingness-to-pay threshold.

LIMITATIONS: Very few studies provided sufficient information for inclusion in meta-analyses. Only a few studies reported other tests; for some tests no studies were identified. The modelling was hampered by a lack of data on the diagnostic accuracy of strategies involving several tests.

CONCLUSIONS: Based on a small body of evidence of variable quality, OCT had high sensitivity and moderate specificity for diagnosis, and relatively high sensitivity but low specificity for monitoring. Strategies involving OCT alone for diagnosis and/or monitoring were unlikely to be cost-effective. Further research is required on (i) the performance of SD-OCT compared with FFA, especially for monitoring but also for diagnosis; (ii) the performance of strategies involving combinations/sequences of tests, for diagnosis and monitoring; (iii) the likelihood of active and inactive nAMD becoming inactive or active respectively; and (iv) assessment of treatment-associated utility weights (e.g. decrements), through a preference-based study.

STUDY REGISTRATION: This study is registered as PROSPERO CRD42012001930.

FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Evaluation of infilled frames: an updated in-plane-stiffness macro-model considering the effects of vertical loads

The influence of masonry infills on the in-plane behaviour of RC framed structures is a central topic in the seismic evaluation and retrofitting of existing buildings. Many models in the literature use an equivalent strut member in order to represent the infill but, among the parameters influencing the equivalent strut behaviour, the effect of vertical loads acting on the frames is recognized but not quantified. Nevertheless a vertical load causes a non-negligible variation in the in-plane behaviour of infilled frames by influencing the effective volume of the infill. This results in a change in the stiffness and strength of the system. This paper presents an equivalent diagonal pin-jointed strut model taking into account the stiffening effect of vertical loads on the infill in the initial state. The in-plane stiffness of a range of infilled frames was evaluated using a finite element model of the frame-infill system and the cross-section of the strut equivalent to the infill was obtained for different levels of vertical loading by imposing the equivalence between the frame containing the infill and the frame containing the diagonal strut. In this way a law for identifying the equivalent strut width depending on the geometrical and mechanical characteristics of the infilled frame was generalized to consider the influence of vertical loads for use in the practical applications. The strategy presented, limited to the initial stiffness of infilled frames, is preparatory to the definition of complete non-linear cyclic laws for the equivalent strut.

Introducing an obstetric emergency training strategy into a simulated environment

Midwifery educators are challenged to produce registrants who are fit for practice at the point of registration with competence at the heart of this expectation. In addition to achieving expertise in normal pregnancy, it is recognised that students need to have the skills of critical decision making where normal processes become adversely affected.
An evaluation was undertaken with final year direct entry midwifery students using questionnaires and focus group interviews to determine whether simulated learning, such as the Practical Obstetric Multi-Professional Training (PROMPT) package, for emergency obstetric training would enhance self-efficacy and confidence levels in preparation for post-registration practice. The main themes that emerged from the study indicate that this style of learning increased midwifery students’ feelings of self-efficacy; highlighted the importance of a safe learning environment; reduced their anxiety regarding their ability to make decisions in clinical practice and reinforced confidence in their level of knowledge.

A strategy towards professionalism in the dissecting room

The teaching and cultivation of professionalism is an integral part of medical education as professionalism is central to maintaining the public’s trust in the medical profession. Traditionally professional values would have been acquired through an informal process of socialisation and observation of role models. Recently, however, medical educators have accepted the responsibility to explicitly teach and effectively evaluate professionalism. A comprehensive working definition of the term professionalism and a universally agreed list of the constituent elements of professionalism are currently debated. The School of Medicine and Dentistry of The Queen’s University of Belfast uses an approach of self-directed learning for teaching anatomy, and students are given the opportunity to learn anatomy from human dissection. Self-directed learning teams have been found to be underutilised as educational strategies and presented an opportunity to utilise the first year dissection room teaching environment to nurture the development of the attributes of professionalism. An educational strategy based on role-playing was developed to engage all students around the dissection table. Students received comprehensive background reviews on professionalism, its attributes and the identification of such attributes in the context of the dissection room. Roles, with specific duties attached, were allocated to each team member. Circulating academic staff members directly observed student participation and gave formative feedback. Students were given the opportunity to reflect on their ability to identify the attributes and reflect on their own and their peer’s ability to develop and practise these attributes. This strategy indicated that small group learning teams in the dissection room utilise widely accepted principles of adult learning and offer an opportunity to create learning activities that will instil in students the knowledge, values, attitudes and behaviours that characterise medical professionalism. Anatomy faculty have a responsibility to nurture and exemplify professionalism and play a significant role in the early promotion and inculcation of professionalism. It remains imperative not only to assess this strategy but also to create opportunities for critical reflection and evaluation within the strategy. Key words: Medical Education – Professionalism – Anatomy - Reflective Practise – Role-play

Evaluation of biomarkers for the prediction of pre-eclampsia in women with type 1 diabetes mellitus: A systematic review.

BACKGROUND: Pre-eclampsia is a leading cause of maternal and perinatal morbidity and mortality. Women with type 1 diabetes are considered a high-risk group for developing pre-eclampsia. Much research has focused on biomarkers as a means of screening for pre-eclampsia in the general maternal population; however, there is a lack of evidence for women with type 1 diabetes.
OBJECTIVES: To undertake a systematic review to identify potential biomarkers for the prediction of pre-eclampsia in women with type 1 diabetes.
SEARCH STRATEGY: We searched Medline, EMBASE, Maternity and Infant Care, Scopus, Web of Science and CINAHL SELECTION CRITERIA: Studies were included if they measured biomarkers in blood or urine of women who developed pre-eclampsia and had pre-gestational type 1 diabetes mellitus Data collection and analysis A narrative synthesis was adopted as a meta-analysis could not be performed, due to high study heterogeneity.
MAIN RESULTS: A total of 72 records were screened, with 21 eligible studies being included in the review. A wide range of biomarkers was investigated and study size varied from 34 to 1258 participants. No single biomarker appeared to be effective in predicting pre-eclampsia; however, glycaemic control was associated with an increased risk while a combination of angiogenic and anti-angiogenic factors seemed to be potentially useful.
CONCLUSIONS: Limited evidence suggests that combinations of biomarkers may be more effective in predicting pre-eclampsia than single biomarkers. Further research is needed to verify the predictive potential of biomarkers that have been measured in the general maternal population, as many studies exclude women with diabetes preceding pregnancy.

The effects of chemicals in isopods : a multi-organizational evaluation

The global aim of this thesis was to evaluate and assess the effects of a pesticide (dimethoate) and a metal (nickel), as model chemicals, within different organization levels, starting at the detoxification pathways (enzymatic biomarkers) and energy costs associated (energy content quantification, energy consumption and CEA) along with the physiological alterations at the individual and population level (mortality), leading to a metabolomic analysis (using liquid 1H-NMR) and finally a gene expression analysis (transcriptome and RT-qPCR analysis). To better understand potential variations in response to stressors, abiotic factors were also assessed in terrestrial isopods such as temperature, soil moisture and UV radiation. The evaluation performed using biochemical biomarkers and energy related parameters showed that increases in temperature might negatively affect the organisms by generating oxidative stress. It also showed that this species is acclimated to environments with low soil moisture, and that in high moisture scenarios there was a short gap between the optimal and adverse conditions that led to increased mortality. As for UV-R, doses nowadays present have shown to induce significant negative impact on these organisms. The long-term exposure to dimethoate showed that besides the neurotoxicity resulting from acetylcholinesterase inhibition, this stressor also caused oxidative stress. This effect was observed for both concentrations used (recommended field dose application and a below EC50 value) and that its combination with different temperatures (20ºC and 25ºC) showed different response patterns. It was also observed that dimethoate’s degradation rate in soils was higher in the presence of isopods. In a similar study performed with nickel, oxidative stress was also observed. But, in the case of this stressor exposure, organisms showed a strategy where the energetic costs necessary for detoxification (biomarkers) seemed to be compensated by positive alterations in the energy related parameters. In this work we presented for the first time a metabolomic profile of terrestrial isopods exposed to stressors (dimethoate and niquel), since until the moment only a previous study was performed on a metabolomic evaluation in nonexposed isopods. In the first part of the study we identify 24 new metabolites that had not been described previously. On the second part of the study a metabolomic profile variation of abstract non-exposed organism throughout the exposure was presented and finally the metabolomic profile of organisms exposed to dimethoate and nickel. The exposure to nickel suggested alteration in growth, moult, haemocyanin and glutathione synthesis, energy pathways and in osmoregulation. As for the exposure to dimethoate alterations in osmoregulation, energy pathways, moult and neurotransmission were also suggested. In this work it was also presented the first full body transcriptome of a terrestrial isopod from the species Porcellionides pruinosus, which will complement the scarce information available for this group of organisms. This transcriptome also served as base for a RNA-Seq and a RT-qPCR analysis. The results of the RNA-Seq analysis performed in organisms exposed to nickel showed that this stressor negatively impacted at the genetic and epigenetic levels, in the trafficking, storage and elimination of metals, generates oxidative stress, inducing neurotoxicity and also affecting reproduction. These results were confirmed through RT-qPCR. As for the impact of dimethoate on these organisms it was only accessed through RT-qPCR and showed oxidative stress, an impact in neurotransmission, in epigenetic markers, DNA repair and cell cycle impairment. This study allowed the design of an Adverse Outcome Pathway draft that can be used further on for legislative purposes.

Evaluation of the matabolic response of osteosarcoma cells to conventional and new anticancer drugs by NMR metabolomics

The main scope of this work was to evaluate the metabolic effects of anticancer agents (three conventional and one new) in osteosarcoma (OS) cells and osteoblasts, by measuring alterations in the metabolic profile of cells by nuclear magnetic resonance (NMR) spectroscopy metabolomics. Chapter 1 gives a theoretical framework of this work, beginning with the main metabolic characteristics that globally describe cancer as well as the families and mechanisms of action of drugs used in chemotherapy. The drugs used nowadays to treat OS are also presented, together with the Palladium(II) complex with spermine, Pd2Spm, potentially active against cancer. Then, the global strategy for cell metabolomics is explained and the state of the art of metabolomic studies that analyze the effect of anticancer agents in cells is presented. In Chapter 2, the fundamentals of the analytical techniques used in this work, namely for biological assays, NMR spectroscopy and multivariate and statistical analysis of the results are described. A detailed description of the experimental procedures adopted throughout this work is given in Chapter 3. The biological and analytical reproducibility of the metabolic profile of MG-63 cells by high resolution magic angle spinning (HRMAS) NMR is evaluated in Chapter 4. The metabolic impact of several factors (cellular integrity, spinning rate, temperature, time and acquisition parameters) on the 1H HRMAS NMR spectral profile and quality is analysed, enabling the definition of the best acquisition parameters for further experiments. The metabolic consequences of increasing number of passages in MG-63 cells as well as the duration of storage are also investigated. Chapter 5 describes the metabolic impact of drugs conventionally used in OS chemotherapy, through NMR metabolomics studies of lysed cells and aqueous extracts analysis. The results show that MG-63 cells treated with cisplatin (cDDP) undergo a strong up-regulation of lipid contents, alterations in phospholipid constituents (choline compounds) and biomarkers of DNA degradation, all associated with cell death by apoptosis. Cells exposed to doxorubicin (DOX) or methotrexate (MTX) showed much slighter metabolic changes, without any relevant alteration in lipid contents. However, metabolic changes associated with altered Krebs cycle, oxidative stress and nucleotides metabolism were detected and were tentatively interpreted at the light of the known mechanisms of action of these drugs. The metabolic impact of the exposure of MG-63 cells and osteoblasts to cDDP and the Pd2Spm complex is described in Chapter 6. Results show that, despite the ability of the two agents to bind DNA, the metabolic consequences that arise from exposure to them are distinct, namely in what concerns to variation in lipid contents (absent for Pd2Spm). Apoptosis detection assays showed that, differently from what was seen for MG-63 cells treated with cDDP, the decreased number of living cells upon exposure to Pd2Spm was not due to cell death by apoptosis or necrosis. Moreover, the latter agent induces more marked alterations in osteoblasts than in cancer cells, while the opposite seemed to occur upon cDDP exposure. Nevertheless, the results from MG-63 cells exposure to combination regimens with cDDP- or Pd2Spm-based cocktails, described in Chapter 7, revealed that, in combination, the two agents induce similar metabolic responses, arising from synergy mechanisms between the tested drugs. Finally, the main conclusions of this thesis are summarized in Chapter 8, and future perspectives in the light of this work are presented.

Implementation of a service quality strategy: application to the Algarve hotel industry

Tese dout., Doctor of Philisophy, Sheffield Hallam University, 2001

Quantitative evaluation of three reconfiguration strategies on FPGAs: a case study

Reconfigurable computing is becoming an important new alternative for implementing computations. Field programmable gate arrays (FPGAs) are the ideal integrated circuit technology to experiment with the potential benefits of using different strategies of circuit specialization by reconfiguration. The final form of the reconfiguration strategy is often non-trivial to determine. Consequently, in this paper, we examine strategies for reconfiguration and, based on our experience, propose general guidelines for the tradeoffs using an area-time metric called functional density. Three experiments are set up to explore different reconfiguration strategies for FPGAs applied to a systolic implementation of a scalar quantizer used as a case study. Quantitative results for each experiment are given. The regular nature of the example means that the results can be generalized to a wide class of industry-relevant problems based on arrays.

Community empowerment or a strategy of containment? Evaluating neighbourhood governance in the city of Westminster

The longstanding emphasis on the neighbourhood as a scale for intervention and action has given rise to a variety of forms of governance with a number of different rationales. The predominant rationales about the purpose of neighbourhood governance are encapsulated in a fourfold typology developed by Lowndes and Sullivan (2008). This article sets out to test this approach by drawing on an evaluation of neighbourhood initiatives in the City of Westminster which were delivered through a third sector organisation, the Paddington Development Trust. ‘Insider’ perspectives gathered at city and neighbourhood levels regarding the infrastructure for neighbourhood management are discussed and evaluated in the light of these rationales. The conclusions, while broadly reflecting Lowndes and Sullivan and a follow-up study of Manchester, suggest that in Westminster the civic and economic rationales tend to predominate. However, the Westminster approach is contingent on the prevailing ethos and funding regimes at central and local levels and remains relatively detached from mainstream services. While community empowerment is an important part of the policy rhetoric, it is argued that in practice a ‘strategy of containment’ operates whereby residents in the neighbourhoods have relatively little control over targets and resources and that new governance mechanisms can be relatively easily de-coupled when required. In retrospect, co-production might have been a more effective model for neighbourhood governance, not least given its fit with policy direction.

A quantitative evaluation of three hand drying methods and the potential for dissemination of virus particles into the environment

The importance of hand hygiene in reducing the spread of pathogens has been long established and this has been highlighted recently in initiatives such as the NHS’s ‘clean your hands’ campaign. However, much of the focus on hand hygiene has concerned effective hand washing; there has been less emphasis on hand drying and its role in hygienic practices. This study aimed to compare three hand drying methods namely paper towels, a warm air dryer and a jet air dryer for their relative ability to disseminate virus particles into the washroom environment during hand drying. A bacteriophage model was used to compare these methods; hands were artificially contaminated with MS2 phage and dried using each device. Both air sampling and contact plates were assessed and a plaque assay was used to quantify virus dissemination. Samples were collected at set times, heights, angles and distances around each device. Both air sampling and contact plate results indicated that the jet air dryer produced significantly more virus dispersal than either paper towels or the warm air dryer in terms of quantity, distance travelled and the time spent circulating in the air around the device and potentially in the washroom environment.

Evaluation of solubility and partition properties of ampicillin-based ionic liquids

In order to overcome the problems associated with low water solubility, and consequently low bioavailability of active pharmaceutical ingredients (APIs), herein we explore a modular ionic liquid synthetic strategy for improved APIs. Ionic liquids containing l-ampicillin as active pharmaceutical ingredient anion were prepared using the methodology developed in our previous work, using organic cations selected from substituted ammonium, phosphonium, pyridinium and methylimidazolium salts, with the intent of enhancing the solubility and bioavailability of l-ampicillin forms. In order to evaluate important properties of the synthesized API-ILs, the water solubility at 25 °C and 37 °C (body temperature) as well as octanol–water partition coefficients (Kow's) and HDPC micelles partition at 25 °C were measured. Critical micelle concentrations (CMC's) in water at 25 °C and 37 °C of the pharmaceutical ionic liquids bearing cations with surfactant properties were also determined from ionic conductivity measurements.

Planning and implementing a new assessment strategy using an e-learning platform

One of the most difficult issues of e-Learning is the students’ assessment. Being this an outstanding task regarding theoretical topics, it becomes even more challenging when the topics under evaluation are practical. ISCAP’s Information Systems Department is composed of about twenty teachers who have been for several years using an e-learning environment (at the moment Moodle 2.3) combined with traditional assessment. They are now planning and implementing a new e-learning assessment strategy. This effort was undertaken in order to evaluate a practical topic (the use of spreadsheets to solve management problems) common to shared courses of several undergraduate degree programs. The same team group is already experienced in the assessment of theoretical information systems topics using the b-learning platform. Therefore, this project works as an extension to previous experiences being the team aware of the additional difficulties due to the practical nature of the topics. This paper describes this project and presents two cycles of the action research methodology, used to conduct the research. The first cycle goal was to produce a database of questions. When it was implemented in order to be used with a pilot group of students, several problems were identified. Subsequently, the second cycle consisted in solving the identified problems preparing the database and all the players to a broader scope implementation. For each cycle, all the phases, its drawbacks and achievements are described. This paper suits all those who are or are planning to be in the process of shifting their assessment strategy from a traditional to one supported by an e-learning platform.