Workshop 47. The Future of consulting: Impact of changing practice on our cognitive load as experts and educators & insights into the novice perspective

Objectives1) To consider current & future impact of remote consulting & the covid pandemic on our cognitive load as clinical reasoning ‘experts’ 2) To consider & reflect on the insights this has provided us as clinicians & educators into the student perspective (clinical reasoning ‘novices’) & their clinical reasoning development 3) To analyse delegates’ own experiences where this & similar transformative learning experiences could be deployed to drive effective learning 4) To recognise & describe the impact on traditional curricula structures

Anthropometric characteristics and sex influence magnitude of skin cooling following exposure to whole body cryotherapy

This study explored whether anthropometric measures influence magnitude of skin cooling following exposure to whole body cryotherapy (WBC). Height, weight, body fat percentage, and lean mass were measured in 18 male and 14 female participants. Body surface area, body surface area to mass ratio, body mass index, fat-free mass index, and fat mass index were calculated. Thermal images were captured before and after WBC (-60°C for 30 seconds, -110°C for 2 minutes). Skin temperature was measured at the chest, arm, thigh, and calf. Mean skin temperature before and after WBC and change in mean skin temperature (ΔT sk) were calculated. ΔT sk was significantly greater in females (12.07 ± 1.55°C) than males (10.12 ± 1.86°C; t(30) = -3.09, P = .004). A significant relationship was observed between body fat percentage and ΔT sk in the combined dataset (P = .002, r = .516) and between fat-free mass index and ΔT sk in males (P = .005, r = .622). No other significant associations were found. Skin response of individuals to WBC appears to depend upon anthropometric variables and sex, with individuals with a higher adiposity cooling more than thinner individuals. Effects of sex and anthompometrics should be considered when designing WBC research or treatment protocols

Examining Clinical Reasoning Through a Threshold Concept Lens

Importance: While there is an extensive body of evidence examining the learning of clinical reasoning in medicine, there is limited discussion of this in the context of musculoskeletal therapies. There is a need to better understand the complexity of clinical reasoning and to consider pedagogical approaches to support students to learn this troublesome skill. This commentary aims to (1) explore the complexity of clinical reasoning for the musculoskeletal therapies; (2) review clinical reasoning for musculoskeletal therapies through the lens of Threshold Concepts; and (3) explore approaches to curriculum and pedagogy to address the troublesome nature of learning to clinically reason. Observations: Beyond the established cognitive and metacognitive processes occurring as part of clinical reasoning, there are several factors that contribute to the complexity of this skill and make the learning and mastering clinical reasoning a challenge. Clinical reasoning has been identified as a threshold concept, in adjacent disciplines. The learning of clinical reasoning is troublesome, not least because of variability, issues with authenticity and integration of learning. Educators can assist students to navigate uncertainties faced when learning clinical reasoning. Conclusion and relevance: It is recommended that educators use an integrative pedagogical approach for developing the education of clinical reasoning in musculoskeletal therapies. Case based instruction and high-fidelity simulation may offer opportunities for students to develop adaptive expertise and self-regulatory reflective skills, improving their diagnostic and therapeutic reasoning. Approaching the education of clinical reasoning with the use of a threshold concept lens and integrative pedagogical approach, can assist students in learning the troublesome skill of clinical reasoning

Building finite element models to investigate zebrafish jaw biomechanics

Skeletal morphogenesis occurs through tightly regulated cell behaviors during development; many cell types alter their behavior in response to mechanical strain. Skeletal joints are subjected to dynamic mechanical loading. Finite element analysis (FEA) is a computational method, frequently used in engineering that can predict how a material or structure will respond to mechanical input. By dividing a whole system (in this case the zebrafish jaw skeleton) into a mesh of smaller 'finite elements', FEA can be used to calculate the mechanical response of the structure to external loads. The results can be visualized in many ways including as a 'heat map' showing the position of maximum and minimum principal strains (a positive principal strain indicates tension while a negative indicates compression. The maximum and minimum refer the largest and smallest strain). These can be used to identify which regions of the jaw and therefore which cells are likely to be under particularly high tensional or compressional loads during jaw movement and can therefore be used to identify relationships between mechanical strain and cell behavior. This protocol describes the steps to generate Finite Element models from confocal image data on the musculoskeletal system, using the zebrafish lower jaw as a practical example. The protocol leads the reader through a series of steps: 1) staining of the musculoskeletal components, 2) imaging the musculoskeletal components, 3) building a 3 dimensional (3D) surface, 4) generating a mesh of Finite Elements, 5) solving the FEA and finally 6) validating the results by comparison to real displacements seen in movements of the fish jaw

Is surface roughness of direct resin composite restorations material and polisher‐dependent? A systematic review

Statement of Problem: Direct resin composite bonding offers a highly esthetic, minimally invasive option for the treatment of anterior teeth however the challenge to improve their longevity remains. Direct resin composite restorations are limited by the risk of staining which may be influenced by the final surface roughness (Ra) of composite achieved. Purpose: The purpose of this review is to investigate, using a systematic approach, whether the final surface roughness of anterior composite restorations is affected by the interaction between resin composite and polishing systems. Materials and Methods: The review was conducted by 3 independent reviewers and included articles published up to January 21, 2021. Three electronic databases were searched: Medline, Embase, and Web of Science. Studies assessing a quantitative effect of polishing methods on the Ra of direct composite resin materials published after the year 2000 and restricted to the English language were included. Results: The database search for the effect of polishing systems on composite materials retrieved 125 eligible studies. Twelve duplicate records were removed. The resulting records were screened using title and abstract leading to 38 reports which were sought for retrieval. Application of eligibility criteria led to 11 studies included in the review. Hand searching of these studies yielded no additional papers. Conclusions: There is insufficient evidence to determine whether combination of composite and polisher influences final Ra. More research is required to determine if there is an optimum combination of polisher and composite. Clinical Implications: Polishing should be completed following planned finishing procedures. The approximation to the final surface and which finishing burs to use, if any, should be considered when planning a restoration. Durafill VS predictably achieves an acceptable Ra by different polishers

Wnt16 Elicits a Protective Effect Against Fractures and Supports Bone Repair in Zebrafish

Bone homeostasis is a dynamic, multicellular process which is required throughout life to maintain bone integrity, prevent fracture and respond to skeletal damage. WNT16 has been linked to bone fragility and osteoporosis in human genome wide association studies, as well as the functional haematopoiesis of leukocytes in vivo. However, the mechanisms by which WNT16 promotes bone health and repair are not fully understood. We used CRISPR-Cas9 to generate mutant zebrafish lacking Wnt16 (wnt16-/-) to study its effect on bone dynamically. wnt16 mutants displayed variable tissue mineral density and were susceptible to spontaneous fractures and the accumulation of bone calluses at an early age. Fractures were induced in the lepidotrichia of the caudal fins of wnt16-/- and wild type (WT) zebrafish; this model was used to probe the mechanisms by which Wnt16 regulates skeletal and immune cell-dynamics in vivo. In WT fins, wnt16 expression increased significantly during the early stages for bone repair. Mineralization of bone during fracture repair was significantly delayed in wnt16 mutants compared to WT zebrafish. Surprisingly, we found no evidence that the recruitment of innate immune cells to fractures or soft callus formation was altered in wnt16 mutants. However, osteoblast recruitment was significantly delayed in wnt16 mutants post-fracture, coinciding with precocious activation of the canonical Wnt signalling pathway. In situ hybridization suggests that canonical Wnt-responsive cells within fractures are osteoblast progenitors, and that osteoblast differentiation during bone repair is coordinated by the dynamic expression of runx2a and wnt16. This study highlights zebrafish as an emerging model for functionally validating osteoporosis-associated genes and investigating fracture repair dynamically in vivo. Using this model, we demonstrate that Wnt16 protects against fracture and supports bone repair, likely by modulating canonical Wnt activity, via runx2a, to facilitate osteoblast differentiation and bone matrix deposition