Simulation can offer a sustainable contribution to clinical education in osteopathy

Background: Clinical education forms a substantial component of health professional education. Increased cohorts in Australian osteopathic education have led to consideration of alternatives to traditional placements to ensure adequate clinical exposure and learning opportunities. Simulated learning offers a new avenue for sustainable clinical education. The aim of the study was to explore whether directed observation of simulated scenarios, as part replacement of clinical hours, could provide an equivalent learning experience as measured by performance in an objective structured clinical examination (OSCE).Methods:The year 3 osteopathy cohort were invited to participate in replacement of 50% of their clinical placement hours with online facilitated, video-based simulation exercises (intervention). Competency was assessed by an OSCE at the end of the teaching period. Inferential statistics were used to explore any differences between the control and intervention groups as a post-test control design.Results:The funding model allowed ten learners to participate in the intervention, with sixty-six in the control group. Only one OSCE item was significantly different between groups, that being technique selection (p = 0.038, d = 0.72) in favour of the intervention group, although this may be a type 1 error. Grade point average was moderately positively correlated with the manual therapy technique station total score (r = 0.35, p r = 0.17, p = 0.132).Conclusions:The current study provides support for further investigation into part replacement of clinical placements with directed observation of simulated scenarios in osteopathy

Nucleoporin Mediated Nuclear Positioning and Silencing of HMR

The organization of chromatin domains in the nucleus is an important factor in gene regulation. In eukaryotic nuclei, transcriptionally silenced chromatin clusters at the nuclear periphery while transcriptionally poised chromatin resides in the nuclear interior. Recent studies suggest that nuclear pore proteins (NUPs) recruit loci to nuclear pores to aid in insulation of genes from silencing and during gene activation. We investigated the role of NUPs at a native yeast insulator and show that while NUPs localize to the native tDNA insulator adjacent to the silenced HMR domain, loss of pore proteins does not compromise insulation. Surprisingly we find that NUPs contribute to silencing at HMR and are able to restore silencing to a silencing-defective HMR allele when tethered to the locus. We show that the perinuclear positioning of heterochromatin is important for the NUP-mediated silencing effect and find that loss of NUPs result in decreased localization of HMR to the nuclear periphery. We also show that loss of telomeric tethering pathways does not eliminate NUP localization to HMR, suggesting that NUPs may mediate an independent pathway for HMR association with the nuclear periphery. We propose that localization of NUPs to the tDNA insulator at HMR helps maintain the intranuclear position of the silent locus, which in turn contributes to the fidelity of silencing at HMR

Home and Online Management and Evaluation of Blood Pressure (HOME BP) using a digital intervention in poorly controlled hypertension: randomised controlled trial

Objective: The HOME BP (Home and Online Management and Evaluation of Blood Pressure) trial aimed to test a digital intervention for hypertension management in primary care by combining self-monitoring of blood pressure with guided self-management. Design: Unmasked randomised controlled trial with automated ascertainment of primary endpoint. Setting: 76 general practices in the United Kingdom. Participants: 622 people with treated but poorly controlled hypertension (>140/90 mm Hg) and access to the internet. Interventions: Participants were randomised by using a minimisation algorithm to self-monitoring of blood pressure with a digital intervention (305 participants) or usual care (routine hypertension care, with appointments and drug changes made at the discretion of the general practitioner; 317 participants). The digital intervention provided feedback of blood pressure results to patients and professionals with optional lifestyle advice and motivational support. Target blood pressure for hypertension, diabetes, and people aged 80 or older followed UK national guidelines. Main outcome measures: The primary outcome was the difference in systolic blood pressure (mean of second and third readings) after one year, adjusted for baseline blood pressure, blood pressure target, age, and practice, with multiple imputation for missing values. Results: After one year, data were available from 552 participants (88.6%) with imputation for the remaining 70 participants (11.4%). Mean blood pressure dropped from 151.7/86.4 to 138.4/80.2 mm Hg in the intervention group and from 151.6/85.3 to 141.8/79.8 mm Hg in the usual care group, giving a mean difference in systolic blood pressure of −3.4 mm Hg (95% confidence interval −6.1 to −0.8 mm Hg) and a mean difference in diastolic blood pressure of −0.5 mm Hg (−1.9 to 0.9 mm Hg). Results were comparable in the complete case analysis and adverse effects were similar between groups. Within trial costs showed an incremental cost effectiveness ratio of £11 ($15, €12; 95% confidence interval £6 to £29) per mm Hg reduction. Conclusions: The HOME BP digital intervention for the management of hypertension by using self-monitored blood pressure led to better control of systolic blood pressure after one year than usual care, with low incremental costs. Implementation in primary care will require integration into clinical workflows and consideration of people who are digitally excluded. Trial registration: ISRCTN13790648

"It's not an acting job ... don't underestimate what a simulated patient does" : a qualitative study exploring the perspectives of simulated patients in health professions education

Introduction: Simulated patients (SPs) are individuals who have learned to realistically portray patient roles in health professional education. Program recommendations are increasing for simulation programs, and as key stakeholders, SPs' perspectives seem underrepresented. The aim of the study was to explore the experiences, perspectives, and practices of SPs to gain insights on topics of importance to SPs and inform program recommendations. Methods: An interpretivist research paradigm and qualitative design were adopted. Eighteen SPs participated in 2 focus groups that were audio recorded, transcribed, and deidentified. Three researchers completed inductive thematic analysis. Institutional ethical approval was obtained. Results: Three themes represented the different elements of SP practice: becoming and being a SP, preparing for a SP role, and performing a SP role. Simulated patients identify as educated specialists with unique responsibilities and attributes. Simulated patients are committed to representing the perspectives of real patients, while simultaneously supporting learners and educators. Simulated patients can feel unprepared to perform a role but have innovated responsive strategies. Conclusions: Simulated patients considered 3 primary aspects to their practice and shared ways that they might be well supported. Simulated patients represent a community of practice, characterized by mutual engagement, joint enterprise, and a shared repertoire. Ongoing SP input in SP programs may benefit SPs and lead to higher-quality educational experiences for learners