The role of percutaneous vertebroplasty in spinal metastasis

Despite the widespread use of percutaneous vertebroplasty for myeloma and spinal metastases, the evidence of its safety, efficacy and cost to the health service is based mainly on retrospective studies with short and incomplete follow up. The aims of this thesis were to: (1) Perform a systematic review to examine the safety and efficacy of vertebroplasty in malignancy, and to determine factors that may be associated with an increased risk of complications or reduced efficacy; (2) To assess the outcome and complication rate of percutaneous vertebroplasty in a large cohort of consecutive patients with myeloma and spinal metastases treated over 9 year period and (3) To ascertain prospectively the health service cost of vertebroplasty on a cohort of consecutive patients with spinal metastases. Results: Thirty studies were included in the review, of which 8 were prospective. Most report performing the procedure under local anaesthesic and continuous fluoroscopic screening, and only two centres reported treating more than four vertebrae per session. Five deaths were attributable to vertebroplasty, with a further 19 patients suffering a serious complication related to the procedure. There is some evidence to suggest that the complication rate may be related to the higher cement volume used, although the data is not robust enough for meta-analysis. Pain reduction ranged between 47-87%, similar to results for osteoporosis. There is no correlation between pain reduction and cement volume.   In our second study, 128 patients underwent percutaneous vertebroplasty for myeloma (n=41) or spinal metastasis (n=87) over a 9 year period. VAS scores fell from 7.75 +/- 1.88 pre-vertebroplasty to 4.77 +/- 2.69 post vertebroplasty (p=0.001). RDQ scores improved from 18.55 +/- 4.79 to 13..5 +/- 6.96 (p=0.001). Complications were recorded in three patients : cement extension to vena cava (n=1), local haematoma (n=1) and loss of sensation over T1 dermatome (n=1). The Kaplan-Meier estimate of 5 year survival post-vertebroplasty was 40% for patients with myeloma and 25% for those with metastases. In our final study, the majority of the procedures were performed on an outpatient basis (8/11). The median duration of the procedure was 60 minutes (range 40-80 mins) with a further 60 minutes spent in the recovery room (10-230 mins). Personnel involved included a consultant radiologist, a radiology registrar, four nurses and two radiographers. The average cost of vertebroplasty per patient, including consumables, capital equipment, hotel/clinic costs and staffing, was £2213.25 (95% CI £729.95). The mean EQ -5D utility scores increased from 0.421 pre-treatment to 0.5979 post-treatment (p=0.047). The visual analogue scale (VAS) of perceived health improved from a mean to 41.88 to 63.75 (p=0.00537). Conclusion: Percutaneous vertebroplasty is safe and effective when performed under local anaesthetic. There is good evidence that pain and disability are improved and this effect appears to persist for the duration of the patient’s life. Its cost to the health service is acceptable and in line with that of other palliative procedures

The role of radiology in medical student education

Introduction: Radiologists have been espousing the merit of Radiology in teaching medical students for almost a hundred years. Yet, despite all the above, the role of radiology in medical student education is poorly defined and understood. With technological advances in CT, MRI, ultrasound and interventional radiology, Radiology not only details human anatomy and pathology, but is central to the practice of modern clinical medicine. The aims of this thesis were to (1) Perform a literature review of the role of radiology in teaching medical students and its evolution through time. (2) Assess the current role of Radiologists in undergraduate medical education. (3) Evaluate and quantify the hours allocated to Radiology teaching in medical schools and to determine if they can fulfil the requirements expected of Clinician Teachers of other disciplines and the upcoming GMC Medical Licensing Assessment. (4) Examine how frequently radiologic images features in summative assessments in Medical Schools. (5) Determine if small group teaching in Radiology impacted Anatomy scores in summative end of year assessment. (6) Explore the potential role of Radiology in teaching Clinical Reasoning to Medical Students. Methods: MEDLINE (Ovid), Embase (Ovid), the Cochrane Database of Systematic Reviews and CENTRAL (Wiley Interscience) and the Education Resources Information Centre and British Education Index (EBSCOhost) databases were searched up to 2018 for relevant articles for the literature review to evaluate the role of Radiology in undergraduate medical education. A national online survey of Consultant Radiologists was performed in November 2019. Raw data from Analysis of Teaching of Medical Schools survey (2020) was evaluated to determine the hours allocated to radiology. A survey evaluating what University Lead Clinician Teachers consider essential Radiology knowledge for medical students was performed in 2020. Data (up to 2019) from all Scottish medical schools’ summative written and clinical assessments was collected and analysed to determine how frequently Radiologic images appeared in written and OSCE examinations. Anonymised end of year summative total and anatomy scores over 5 years were retrospectively collected and analysed to determine if small group teaching improved Anatomy scores. Interactive online learning resource was produced together with a student. The materials were built around radiology images, to teach students’ clinical reasoning as well as the central role of radiology in acute clinical scenarios through gamification of learning. Results: 377 records were included in the review spanning 1925 – 2019. There was a 100 fold increase in rate of publication over time. The vast majority (60%) of publications were expositions (“how we teach”) and surveys, with few truly experimental articles. Radiology was involved in both clinical (63%) and pre-clinical (Anatomy) teaching, but almost half of Anatomic Radiology teaching was conducted without a Radiologist’s input. Compulsory Radiology blocks / clerkships were offered infrequently (35%). 102 responses were collected from the online survey, representing 34% of Consultant Radiologists in Scotland. All agreed Radiology should be taught to medical students, with over 70% currently teaching. The most common barrier cited to teaching was the lack of time, with 76% of those who do not teach expressing a desire to do so. Median time spent teaching medical students was 10 hours/year. Medical students in Scottish Universities were allocated 59 hours in Radiology (0.3%) out of a total 19,325 hours of time tabled teaching. Hospital based radiology teaching was variable and ranged from 0 – 31 hours. Almost half (15/31) of University Lead Clinician Teachers felt there was insufficient radiology teaching in their specialty. Of the 30 conditions included in the GMC MLA under Clinical Imaging, 13 were cited as important by Clinician Teacher, while 23 other conditions listed by them were not included in the GMC MLA. 10, 534 MCQ and 1083 OSCE stations were included in the evaluation of Radiologic inclusion in medical schools. There was a wide variation in the number, type and timing of assessments across Scottish medical schools. There were significant differences in the number of OSCE stations and the number of MCQs set over the study period (p<0.001). Radiologic images were used on average 0.6 times (0 – 1.1) in each OSCE examination and 2.4 times (range 0.1 -3.7) for written assessments. Student numbers ranged 238-290 per year. Mean Anatomy scores ranged 62-74%, compared to mean Total examination score of 62-65%. Anatomy scores were significantly higher than Total examination scores for the study period of 2017 and 2018 [68.97 (17.32) vs 63.12(11.51) and 73.77 (17.85) vs 64.99 (10.31); p< 0.001]. Combined Anatomy scores 2017 and 2018 were significantly higher than base line years 2015 and 2016, difference of 5.50 (95% C.I 3.31-7.70; p<0.0001). No significant difference in Anatomy and Total scores was observed at baseline and post intervention years (2015, 2016 and 2019). Radiology online learning resource has been popular and extremely well received by students. Feedback comments include : “Good thinking about how the history/presentation can change when different or new factors were added into consideration”; “Good systematic approach to learning”; “Relevant to real cases + ILOs”; “Easy to know where to improve”. Adding a student voice to the making of the material made it more relevant and student- centric. Conclusion: Given the importance of Radiology in modern medicine, it is not surprising to find that it permeates all aspects of the medical student education and assessment. However, the hours allocated to teaching Radiology by medical schools are clearly insufficient to meet the expectations of both Clinician Teachers and the GMC. Innovative solutions combined with resource and faculty development is required to meet the need of the medical student. Collaboration between Universities, Health Boards and Radiologists is required if this is to be achieved

Radiology for medical students (1925-2018): an overview

Objective: Radiology has been espoused as an excellent tool for educating medical students since 1925. Advances in technology and PACS mean it has never been easier to demonstrate living anatomy and clinical pathology in exquisite detail to students. The aim of this study was to provide an overview of radiologic publications related to teaching medical students and its evolution through time. Methods: A literature search was performed from inception to November 2018. The search strategies used both text words and relevant indexing related to “radiology”, “medical students” and “curriculum”. Results: 3589 records were identified of which 377 were included. There was a 100 fold increase in rate of publication over time—most were expository or surveys (60%), with few truly experimental articles. Radiology was used in clinical teaching (67%) and anatomy (33%). Almost half of radiologic anatomy teaching was conducted without the input of a Radiologist. Compulsory clinical clerkships/blocks in radiology was offered infrequently (35%). Female first authorship had increased in the last decade (47%). Conclusion: There is a significant increase in articles published on the role of radiology in medical student teaching in the last decade. Research in this area is required in order to investigate the role of radiology in improving the modern medical students’ education

Radiology for medical students: do we teach enough? A national study

Objective: A recent study has shown that the averaged time tabled teaching for a medical student across 5 years in the UK was 4629 hours. Radiology has been demonstrated to be an excellent teaching source, yet the number of hours allocated to this has never been calculated. The aims of this study were to evaluate and quantify the hours allocated to radiology teaching in Scottish Medical Schools and to evaluate if they can fulfil requirements expected from other Clinical disciplines and the upcoming General Medical Council Medical Licensing Assessment (GMC MLA). Methods: Data pertaining to timetabled teaching for Radiology in Scottish Universities were obtained from the authors of the Analysis of Teaching of Medical Schools (AToMS) survey. In addition, University Lead Clinician Teachers were surveyed on the radiological investigations and skills medical students should have at graduation. Results: Medical students in Scottish Universities were allocated 59 h in Radiology (0.3%) out of a total 19,325 h of timetabled teaching. Hospital-based teaching was variable and ranged from 0 to 31 h. Almost half (15 of 31) of Clinician Teachers felt that there was insufficient radiology teaching in their specialty. Thirteen of 30 conditions included in the GMC MLA were listed by Clinician Teachers, while 23 others not listed by the GMC were considered important and cited by them. Conclusion: This study demonstrates that medical students do not receive enough radiology teaching. This needs to be addressed by Universities in collaboration with the NHS in an effort to bring up this up to line with other developed countries and prepare students for the GMC MLA. Advances in knowledge: (1) There is insufficient time allocated in Medical Students’ curriculum to Radiology. (2) Radiology teaching in medical schools fall short of University Lead Clinician Teachers’ and GMC expectations of medical students at graduation

Radiology and the medical student: do increased hours of teaching translate to more radiologists?

Objectives: The UK has a shortage of Radiologists to meet the increasing demand for radiologic examinations. To encourage more medical students to consider Radiology as a career, increased exposure at undergraduate level has been advocated. The aim of this study was to evaluate if formal Radiology teaching hours at medical school had any association with the number of qualified Radiologists joining the General Medical Council Specialist Register. Methods: Total number of doctors joining the GMC Specialist Register as Clinical Radiologists, and those with a primary medical qualifications awarded in Scotland, was obtained from the GMC (2010–2020). Graduate numbers from all 4 Scottish Medical Schools (2000–2011) were also obtained. Hours of Radiology teaching for medical schools in Scotland were obtained from validated AToMS study. Results: Two hundred and twenty three (6.6%) of 3347 Radiologists added to the GMC Specialist Register between 2010 and 2020 received their primary medical qualification (PMQ) from Scottish Universities. The number of Radiologists from Scottish Universities joining the GMC specialist register was 2.6% of the total number of Scottish Medical Graduates. There was no association between the number of hours (Range 1–30) Radiology was taught to medical students and the number that joined the specialist register as Radiologists (p = 0.54 chi square trend). Conclusion: Increased exposure to Radiology teaching does not influence medical students’ decision to take up Radiology as a career. While continued Radiology exposure remains important, other strategies are required in both the short and long term to ensure radiology services are maintained without detriment to patients

Implications of Change/Stability Patterns in Children’s Non-symbolic and Symbolic Magnitude Judgment Abilities Over One Year: A Latent Transition Analysis

Non-symbolic magnitude abilities are often claimed to support the acquisition of symbolic magnitude abilities, which, in turn, are claimed to support emerging math abilities. However, not all studies find links between non-symbolic and symbolic magnitude abilities, or between them and math ability. To investigate possible reasons for these different findings, recent research has analyzed differences in non-symbolic/symbolic magnitude abilities using latent class modeling and has identified four different magnitude ability profiles residing within the general magnitude ability distribution that were differentially related to cognitive and math abilities. These findings may help explain the different patterns of findings observed in previous research. To further investigate this possibility, we (1) attempted to replicate earlier findings, (2) determine whether magnitude ability profiles remained stable or changed over 1 year; and (3) assessed the degree to which stability/change in profiles were related to cognitive and math abilities. We used latent transition analysis to investigate stability/changes in non-symbolic and symbolic magnitude abilities of 109 5- to 6-year olds twice in 1 year. At Time 1 and 2, non-symbolic and symbolic magnitude abilities, number transcoding and single-digit addition abilities were assessed. Visuospatial working memory (VSWM), naming numbers, non-verbal IQ, basic RT was also assessed at Time 1. Analysis showed stability in one profile and changes in the three others over 1 year. VSWM and naming numbers predicted profile membership at Time 1 and 2, and profile membership predicted math abilities at both time points. The findings confirm the existence of four different non-symbolic–symbolic magnitude ability profiles; we suggest the changes over time in them potentially reflect deficit, delay, and normal math developmental pathways

Medical student assessments-frequency of radiological images used : a national study

Assessments are a key part of life for medical students at University. We know there is variation in these assessments across Universities. The aims of this study were to expatiate summative assessments in Scottish Medical Schools and to examine how frequently radiological images feature in them. All Scottish medical schools were invited to participate in the study. Data on objective structured clinical examinations (OSCEs; 5 years) and written assessments (3 years) were retrospectively collected for each university and results were collated. Each University was randomly assigned a letter from A to E and anonymised for data presentation. 10,534 multiple choice questions (MCQ) and 1083 OSCE stations were included in this study. There was wide variation in the number, type and timing of assessments across Scottish medical schools. There were highly significant differences in the number of OSCE stations and the number of MCQs set over the study period ( <0.0001). Radiological images were used on average 0.6 times (range 0-1.1) in each OSCE examination and 2.4 times (range 0.1-3.7) for written assessments. In this detailed study, we demonstrated significant differences in medical student assessments across Scottish Universities. Given the importance of Radiology in modern medicine, the frequency and differences in which radiological images were used in assessments across Universities should be addressed. This is the first national longitudinal study to quantify the role of radiological images in summative Medical Student Assessments. Great variability exists in the extent and how (clinical versus written assessments) radiological images are used to assess Scottish medical students. Radiological images are used infrequently in clinical assessments, but are present in every written assessment. These findings could help inform medical schools and academic radiologists as they prepare medical students for the imminent unified medical licensing examination, where Clinical Imaging is a subject with one of the highest number of associated conditions examinable. [Abstract copyright: © 2020 The Authors. Published by the British Institute of Radiology.]Publisher PDFPeer reviewe

Deficiency of Th17 cells in hyper IgE syndrome due to mutations in STAT3

Hyper–immunoglobulin E syndrome (HIES) is a primary immune deficiency characterized by abnormal and devastating susceptibility to a narrow spectrum of infections, most commonly Staphylococcus aureus and Candida albicans. Recent investigations have identified mutations in STAT3 in the majority of HIES patients studied. Despite the identification of the genetic cause of HIES, the mechanisms underlying the pathological features of this disease remain to be elucidated. Here, we demonstrate a failure of CD4+ T cells harboring heterozygous STAT3 mutations to generate interleukin 17–secreting (i.e., T helper [Th]17) cells in vivo and in vitro due to a failure to express sufficient levels of the Th17-specific transcriptional regulator retinoid-related orphan receptor γt. Because Th17 cells are enriched for cells with specificities against fungal antigens, our results may explain the pattern of infection susceptibility characteristic of patients with HIES. Furthermore, they underscore the importance of Th17 responses in normal host defense against the common pathogens S. aureus and C. albicans

Mal-positioned nasogastric feeding tubes : are medical students safe to identify them?

OBJECTIVES: Nasogastric tube (NGT) placement is listed against Clinical Imaging in the upcoming Medical Licensing Assessment-compulsory for every graduating UK medical student from 2025. This study aims to establish the ability of medical students to correctly identify the position of an NGT on Chest X-ray (CXR) and to evaluate a learning tool to improve student outcome in this area. METHODS: Fourth-year (MB4) and fifth-year (MB5) medical students were invited to view 20 CXRs with 14 correctly sited and 6 mal-positioned NGT. MB5 students (Intervention) were exposed to an online interactive learning tool, with MB4 students kept as control. One week later, both groups of students were invited to view 20 more CXRs for NGT placement. RESULTS: Only 12 (4.8%) of 249 MB5 students and 5 (3.1%) of 161 MB4 students correctly identified all the NGTs on CXRs. The number of students misidentifying 1 or more mal-positioned NGT as "safe to feed" was 129 (51.8%) for MB5 and 76 (47.2%) for MB4 students. This improved significantly (P < .001) following exposure to the learning tool with 58% scoring all CXRs correctly, while 28% scored 1 or more mal-positioned NGT incorrectly. Students struggled to determine if the NGT tip had adequately passed into the stomach. However, they failed to identify an NG tube in the lung ("never event") in just one out of 1,108 opportunities. CONCLUSION: Medical students' ability to determine if the NGT was in the stomach remains suboptimal despite exposure to over 60 CXRs. Feeding NGT should be formally reported before use. ADVANCES IN KNOWLEDGE: This is the first attempt at quantifying graduating medical students', and by inference junior doctors', competence in safely identifying misplaced nasogastric feeding tubes. An online, experiential learning resource significantly improved their ability