Is there a difference in clinical skills gained between healthcare professionals of high- and low and middle-income countries with online simulation-based learning?

Background: Healthcare professionals in low- and middle-income countries (LMICs) compared with those in high-income countries (HICs) face unequal clinical learning opportunities, caused by barriers such as cost, time, and accessibility. Simulation via Instant Messaging - Birmingham Advance (SIMBA) overcomes these barriers, acting as a free virtual simulation-based model which supports clinicians’ professional development. The study compared the impact of SIMBA in LMICs and HICs. Method: Sixteen SIMBA sessions were conducted between May 2020 and October 2021. Participants solved anonymised real-life clinical scenarios by interacting with moderators over WhatsApp. Participants completed pre- and post- SIMBA surveys; responses were grouped into HICs and LMICs using the 2022 World Bank Report. Participants’ performance, perceptions, and improvements in core competencies were compared using the Chi-square test. Thematic analysis of open-ended questions was also performed. Findings: 462 participants (29.7% from LMICs, n137) completed both the pre- and postSIMBA surveys. Participants from HICs showed better knowledge on patient management (p=.01), whereas participants from LMICs reported higher improvement in professionalism (p=.02). Both groups reported similar gains in patient care (p=.28), systems-based practice (p=.052), practice-based learning (p=.15), communication skills (p=.22), application to practice (p=.266), engagement (p=.197), and overall quality of the session (p=.101). In thematic analysis, strengths of SIMBA included providing individualised, structured, and engaging sessions. Conclusions: Healthcare professionals from both LMICs and HICs improved in their competencies, illustrating that SIMBA produces equivalent teaching experiences. Furthermore, SIMBA’s virtual nature enables international accessibility and potential for global scalability. This model could steer future standardised education policy development in LMICs

A novel lysosome-related gene signature coupled with gleason score for prognosis prediction in prostate cancer

Background: Prostate cancer (PCa) is highly heterogeneous, which makes it difficult to precisely distinguish the clinical stages and histological grades of tumor lesions, thereby leading to large amounts of under- and over-treatment. Thus, we expect the development of novel prediction approaches for the prevention of inadequate therapies. The emerging evidence demonstrates the pivotal role of lysosome-related mechanisms in the prognosis of PCa. In this study, we aimed to identify a lysosome-related prognostic predictor in PCa for future therapies.Methods: The PCa samples involved in this study were gathered from The Cancer Genome Atlas database (TCGA) (n = 552) and cBioPortal database (n = 82). During screening, we categorized PCa patients into two immune groups based on median ssGSEA scores. Then, the Gleason score and lysosome-related genes were included and screened out by using a univariate Cox regression analysis and the least absolute shrinkage and selection operation (LASSO) analysis. Following further analysis, the probability of progression free interval (PFI) was modeled by using unadjusted Kaplan–Meier estimation curves and a multivariable Cox regression analysis. A receiver operating characteristic (ROC) curve, nomogram and calibration curve were used to examine the predictive value of this model in discriminating progression events from non-events. The model was trained and repeatedly validated by creating a training set (n = 400), an internal validation set (n = 100) and an external validation (n = 82) from the cohort.Results: Following grouping by ssGSEA score, the Gleason score and two LRGs—neutrophil cytosolic factor 1 (NCF1) and gamma-interferon-inducible lysosomal thiol reductase (IFI30)—were screened out to differentiate patients with or without progression (1-year AUC = 0.787; 3-year AUC = 0.798; 5-year AUC = 0.772; 10-year AUC = 0.832). Patients with a higher risk showed poorer outcomes (p < 0.0001) and a higher cumulative hazard (p < 0.0001). Besides this, our risk model combined LRGs with the Gleason score and presented a more accurate prediction of PCa prognosis than the Gleason score alone. In three validation sets, our model still achieved high prediction rates.Conclusion: In conclusion, this novel lysosome-related gene signature, coupled with the Gleason score, works well in PCa for prognosis prediction

Effect of COVID-19 on the clinical course of diabetic ketoacidosis (DKA) in people with type 1 and type 2 diabetes

Objective COVID-19 in people with diabetes is associated with a disproportionately worse prognosis. DKA is an acute complication of diabetes with a mortality rate of approximately 0.67%. Little is known about the natural history of DKA in the presence of COVID-19. This study aimed to explore the effects of COVID-19 on presentation, clinical course and outcome in patients presenting with DKA. Design Retrospective cohort study. Methods All patients treated for DKA between 1 March 2020 and 30 May 2020 were included. Patients were categorised as COVID-positive or COVID-negative based on the swab test. A pre-COVID group was established using data from 01 March 2019 to 30 May 2019 as external control. Data regarding demographics, diabetes type, pH, bicarbonate, lactate, glucose, DKA duration, complications and outcome were collected. Results A total of 88 DKA episodes were included in this study. There was no significant difference in the severity or duration of DKA between the three groups. COVID-positive T1DM were more hyperglycaemic on admission compared to COVID-negative and pre-COVID patients. There was an over representation of T2DM in COVID-positive patients with DKA than in pre-COVID or COVID-negative groups. Conclusion COVID-19 appears to influence the natural history of DKA differently in T1DM and T2DM. Patients with T1DM and COVID-19 presented with more hyperglycaemia (60 mmol/L (35.9–60.0) vs 31.4 mmol/L (28.0–39.1) vs 24 mmol/L (20.2–33.75), respectively). Patients with T2DM were unusually presenting in DKA when infected with COVID-19 with greater ICU need and higher mortality rates. A collaborative, multi-centre study is needed to provide more definitive results

Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis.

OBJECTIVE: To determine the clinical manifestations, risk factors, and maternal and perinatal outcomes in pregnant and recently pregnant women with suspected or confirmed coronavirus disease 2019 (covid-19). DESIGN: Living systematic review and meta-analysis. DATA SOURCES: Medline, Embase, Cochrane database, WHO COVID-19 database, China National Knowledge Infrastructure (CNKI), and Wanfang databases from 1 December 2019 to 26 June 2020, along with preprint servers, social media, and reference lists. STUDY SELECTION: Cohort studies reporting the rates, clinical manifestations (symptoms, laboratory and radiological findings), risk factors, and maternal and perinatal outcomes in pregnant and recently pregnant women with suspected or confirmed covid-19. DATA EXTRACTION: At least two researchers independently extracted the data and assessed study quality. Random effects meta-analysis was performed, with estimates pooled as odds ratios and proportions with 95% confidence intervals. All analyses will be updated regularly. RESULTS: 77 studies were included. Overall, 10% (95% confidence interval 7% to14%; 28 studies, 11 432 women) of pregnant and recently pregnant women attending or admitted to hospital for any reason were diagnosed as having suspected or confirmed covid-19. The most common clinical manifestations of covid-19 in pregnancy were fever (40%) and cough (39%). Compared with non-pregnant women of reproductive age, pregnant and recently pregnant women with covid-19 were less likely to report symptoms of fever (odds ratio 0.43, 95% confidence interval 0.22 to 0.85; I2=74%; 5 studies; 80 521 women) and myalgia (0.48, 0.45 to 0.51; I2=0%; 3 studies; 80 409 women) and were more likely to need admission to an intensive care unit (1.62, 1.33 to 1.96; I2=0%) and invasive ventilation (1.88, 1.36 to 2.60; I2=0%; 4 studies, 91 606 women). 73 pregnant women (0.1%, 26 studies, 11 580 women) with confirmed covid-19 died from any cause. Increased maternal age (1.78, 1.25 to 2.55; I2=9%; 4 studies; 1058 women), high body mass index (2.38, 1.67 to 3.39; I2=0%; 3 studies; 877 women), chronic hypertension (2.0, 1.14 to 3.48; I2=0%; 2 studies; 858 women), and pre-existing diabetes (2.51, 1.31 to 4.80; I2=12%; 2 studies; 858 women) were associated with severe covid-19 in pregnancy. Pre-existing maternal comorbidity was a risk factor for admission to an intensive care unit (4.21, 1.06 to 16.72; I2=0%; 2 studies; 320 women) and invasive ventilation (4.48, 1.40 to 14.37; I2=0%; 2 studies; 313 women). Spontaneous preterm birth rate was 6% (95% confidence interval 3% to 9%; I2=55%; 10 studies; 870 women) in women with covid-19. The odds of any preterm birth (3.01, 95% confidence interval 1.16 to 7.85; I2=1%; 2 studies; 339 women) was high in pregnant women with covid-19 compared with those without the disease. A quarter of all neonates born to mothers with covid-19 were admitted to the neonatal unit (25%) and were at increased risk of admission (odds ratio 3.13, 95% confidence interval 2.05 to 4.78, I2=not estimable; 1 study, 1121 neonates) than those born to mothers without covid-19. CONCLUSION: Pregnant and recently pregnant women are less likely to manifest covid-19 related symptoms of fever and myalgia than non-pregnant women of reproductive age and are potentially more likely to need intensive care treatment for covid-19. Pre-existing comorbidities, high maternal age, and high body mass index seem to be risk factors for severe covid-19. Preterm birth rates are high in pregnant women with covid-19 than in pregnant women without the disease. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020178076. READERS' NOTE: This article is a living systematic review that will be updated to reflect emerging evidence. Updates may occur for up to two years from the date of original publication

Clinical and biochemical profile of 786 sequential episodes of diabetic ketoacidosis in adults with type 1 and type 2 diabetes mellitus.

INTRODUCTION We explored the clinical and biochemical differences in demographics, presentation and management of diabetic ketoacidosis (DKA) in adults with type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODS \ud This observational study included all episodes of DKA from April 2014 to September 2020 in a UK tertiary care hospital. Data were collected on diabetes type, demographics, biochemical and clinical features at presentation, and DKA management. RESULTS From 786 consecutive DKA, 583 (75.9%) type 1 diabetes and 185 (24.1%) type 2 diabetes episodes were included in the final analysis. Those with type 2 diabetes were older and had more ethnic minority representation than those with type 1 diabetes. Intercurrent illness (39.8%) and suboptimal compliance (26.8%) were the two most common precipitating causes of DKA in both cohorts. Severity of DKA as assessed by pH, glucose and lactate at presentation was similar in both groups. Total insulin requirements and total DKA duration were the same (type 1 diabetes 13.9 units (9.1-21.9); type 2 diabetes 13.9 units (7.7-21.1); p=0.4638). However, people with type 2 diabetes had significantly longer hospital stay (type 1 diabetes: 3.0 days (1.7-6.1); type 2 diabetes: 11.0 days (5.0-23.1); p<0.0001). CONCLUSIONS In this population, a quarter of DKA episodes occurred in people with type 2 diabetes. DKA in type 2 diabetes presents at an older age and with greater representation from ethnic minorities. However, severity of presentation and DKA duration are similar in both type 1 and type 2 diabetes, suggesting that the same clinical management protocol is equally effective. People with type 2 diabetes have longer hospital admission

Meta-analysis of prognostic factors of overall survival in patients undergoing oesophagectomy for oesophageal cancer.

INTRODUCTION Currently, the American Joint Commission on Cancer (AJCC) staging system is used for prognostication for oesophageal cancer. However, several prognostically important factors have been reported but not incorporated. This meta-analysis aimed to characterize the impact of preoperative, operative, and oncological factors on the prognosis of patients undergoing curative resection for oesophageal cancer. METHODS This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling to determine pooled univariable hazard ratios (HRs). The study was prospectively registered with the PROSPERO database (Registration: CRD42018157966). RESULTS One-hundred and seventy-one articles including 73,629 patients were assessed quantitatively. Of the 122 factors associated with survival, 39 were significant on pooled analysis. Of these. the strongly associated prognostic factors were 'pathological' T stage (HR: 2.07, CI95%: 1.77-2.43, P < 0.001), 'pathological' N stage (HR: 2.24, CI95%: 1.95-2.59, P < 0.001), perineural invasion (HR: 1.54, CI95%: 1.36-1.74, P < 0.001), circumferential resection margin (HR: 2.17, CI95%: 1.82-2.59, P < 0.001), poor tumor grade (HR: 1.53, CI95%: 1.34-1.74, P < 0.001), and high neutrophil:lymphocyte ratio (HR: 1.47, CI95%: 1.30-1.66, P < 0.001). CONCLUSION Several tumor biological variables not included in the AJCC 8th edition classification can impact on overall survival. Incorporation and validation of these factors into prognostic models and next edition of the AJCC system will enable personalized approach to prognostication and treatment

SIMBA: using Kolb's learning theory in simulation-based learning to improve participants' confidence.

BACKGROUND Simulation via Instant Messaging- Birmingham Advance (SIMBA) delivers simulation-based learning (SBL) through WhatsApp® and Zoom® based on Kolb's experiential learning theory. This study describes how Kolb's theory was implemented in practice during SIMBA adrenal session. METHODS SIMBA adrenal session was conducted for healthcare professionals and replicated Kolb's 4-stage cycle: (a) concrete experience-online simulation of real-life clinical scenarios, (b) reflective observation-discussion and Q&A following simulation, (c) abstract conceptualisation-post-session MCQs, and (d) active experimentation-intentions to implement the acquired knowledge in future practice. Participants' self-reported confidence levels for simulated and non-simulated cases pre- and post-SIMBA were analysed using Wilcoxon Signed-Rank test. Key takeaway and feedback were assessed quantitatively and qualitatively in a thematic analysis. RESULTS Thirty-three participants were included in the analysis. A Wilcoxon signed-rank test showed that the SIMBA session elicited a statistically significant change in participants' self-reported confidence in their approach to Cushing's syndrome (Z = 3.873, p = 0.0001) and adrenocortical carcinoma (Z = 3.970, p < 0.0001). 93.9% (n = 31/33) and 84.8% (n = 28/33) strongly agreed/agreed the topics were applicable to their clinical practice and accommodated their personal learning style, respectively. 81.8% (n = 27/33) reported increase in knowledge on patient management, and 75.8% (n = 25/33) anticipated implementing learning points in their practice. CONCLUSIONS SIMBA effectively adopts Kolb's theory to provide best possible experience to learners, highlighting the advantages of utilising social media platforms for SBL in medical education. The ability to conduct SIMBA sessions at modest cost internationally paves way to engage more healthcare professionals worldwide

Differences in presentation, severity and management of DKA in type 1 and type 2 diabetes during the COVID-19 pandemic

Introduction: COVID-19 infection in people with diabetes is associated with a disproportionately increased risk of complications and mortality.1 Diabetic ketoacidosis (DKA) is an acute complication of diabetes.2,3 Little is known about DKA in the presence of COVID-19 infection. This study aimed to explore the effects of COVID-19 infection on presentation, clinical course and outcome in patients presenting with DKA. Methods: This retrospective cohort study included all patients treated for DKA between 1 March and 30 May 2020 at University Hospitals Birmingham. Patients were categorised as COVID-positive or negative based on PCR swab test. A pre-COVID group was established as external control. Data regarding demographics, diabetes type, admission pH, bicarbonate, lactate, glucose, serum electrolytes, urea, creatinine, time to resolution of acidosis and ketosis, complications and outcome were collected. DKA onset was defined as the presence of hyperglycaemia (serum glucose >11 mmol/L), ketosis (serum ketones >3 mmol/L or urine ketone >+++) and metabolic acidosis (pH 7.3 or bicarbonate >15 mmol/L) as per national guidelines in the UK.4 Results: A total of 88 episodes were included in the final analysis (20 COVID-positive, 31 COVID-negative, 37 pre-COVID). These were further sub-classified into type 1 (five COVID-positive, two COVID-negative, 29 pre-COVID) and type 2 diabetes (15 COVID-positive, two COVID-negative, eight pre-COVID). There was no significant difference in the severity of DKA at presentation (median for COVID positive, COVID negative and pre-COVID groups): pH (7.15 vs 7.2 vs 7.2), bicarbonate (11.4 mmol/L vs 11 mmol/L vs 13.3 mmol/L), glucose (25.85 mmol/L vs 30.9 mmol/L vs 29.1 mmol/L), lactate (2.7 mmol/L vs 3.2 mmol/L vs 2.8 mmol/L), serum osmolality (314.6 mmol/L vs 323.1 mmol/L vs 316.2 mmol/L). There was also no significant difference between the groups for the duration of DKA (from the time of admission to resolution of DKA: 12.5 hours vs 14.9 hours vs 17.9 hours for COVID-positive, COVID-negative and pre-COVID groups, respectively; Fig 1). COVID-positive patients with type 1 diabetes were more hyperglycaemic on admission compared to COVID-negative and pre-COVID patients. There was a significantly higher incidence of type 2 diabetes in COVID-positive patients than in pre-COVID or COVID-negative groups. COVID-negative patients had more episodes of hypokalaemia and hyperkalaemia during DKA compared to other two groups. There was no significant difference between the number of episodes of hypokalaemia in the COVID-positive compared to the pre-COVID group. In patients with type 2 diabetes, hypokalaemia was more common in COVID-negative patients. Conclusion: COVID infection appears to influence the natural history of DKA differently in type 1 and type 2 diabetes. Infection was associated with increased hyperglycaemia in type I diabetes and greater acidosis on presentation with DKA. People with type 2 diabetes were presenting unusually in DKA when infected with COVID. These patients also had higher mortality rates. There is need for a multi-centre approach to conduct larger cohort studies in this area