Standard setting in Australian medical schools

Background: Standard setting of assessment is critical in quality assurance of medical programs. The aims of this study were to identify and compare the impact of methods used to establish the passing standard by the 13 medical schools who participated in the 2014 Australian Medical Schools Assessment Collaboration (AMSAC). Methods: A survey was conducted to identify the standard setting procedures used by participating schools. Schools standard setting data was collated for the 49 multiple choice items used for benchmarking by AMSAC in 2014. Analyses were conducted for nine schools by their method of standard setting and key characteristics of 28 panel members from four schools. Results: Substantial differences were identified between AMSAC schools that participated in the study, in both the standard setting methods and how particular techniques were implemented. The correlation between the item standard settings data by school ranged from − 0.116 to 0.632. A trend was identified for panel members to underestimate the difficulty level of hard items and overestimate the difficulty level of easy items for all methods. The median derived cut-score standard across schools was 55% for the 49 benchmarking questions. Although, no significant differences were found according to panel member standard setting experience or clinicians versus scientists, panel members with a high curriculum engagement generally had significantly lower expectations of borderline candidates (p = 0.044). Conclusion: This study used a robust assessment framework to demonstrate that several standard setting techniques are used by Australian medical schools, which in some cases use different techniques for different stages of their program. The implementation of the most common method, the Modified Angoff standard setting approach was found to vary markedly. The method of standard setting used had an impact on the distribution of expected minimally competent student performance by item and overall, with the passing standard varying by up to 10%. This difference can be attributed to the method of standard setting because the ASMSAC items have been shown over time to have consistent performance levels reflecting similar cohort ability. There is a need for more consistency in the method of standard setting used by medical schools in Australia

Magnetic resonance imaging detects placental hypoxia and acidosis in mouse models of perturbed pregnancies

Endothelial dysfunction as a result of dysregulation of anti-angiogenic molecules secreted by the placenta leads to the maternal hypertensive response characteristic of the pregnancy complication of preeclampsia. Structural abnormalities in the placenta have been proposed to result in altered placental perfusion, placental oxidative stress, cellular damage and inflammation and the release of anti-angiogenic compounds into the maternal circulation. The exact link between these factors is unclear. Here we show, using Magnetic Resonance Imaging as a tool to examine placental changes in mouse models of perturbed pregnancies, that T2 contrast between distinct regions of the placenta is abolished at complete loss of blood flow. Alterations in T2 (spin-spin or transverse) relaxation times are explained as a consequence of hypoxia and acidosis within the tissue. Similar changes are observed in perturbed pregnancies, indicating that acidosis as well as hypoxia may be a feature of pregnancy complications such as preeclampsia and may play a prominent role in the signalling pathways that lead to the increased secretion of anti-angiogenic compounds

Perceptions of preparedness for the first medical clerkship : a systematic review and synthesis

Background: The transition from university-based to clerkship-based education can be challenging. Medical schools have introduced strategies to ease the transition, but there has been no systematic review synthesizing the evidence on the perceptions of preparedness of medical students for their first clerkship to support these interventions. This study therefore aimed to (1) identify and synthesize the published evidence on medical students’ perceptions of preparedness for their first clerkship, and (2) identify factors that may impact on preparedness for clerkship, to better inform interventions aimed at easing this transition. Methods: Electronic databases (Medline, Journals@Ovid, CINAHL, ERIC, Web of Science, Embase) were searched without restriction and secondary searching of reference lists of included studies was also conducted. Included studies used quantitative or qualitative methodologies, involved medical students and addressed student/supervisor perceptions of preparedness for first clerkship. The first clerkship was defined as the first truly immersive educational experience during which the majority of learning was vocational and self-directed, as per the MeSH term ‘clinical clerkship’ and associated definition. Using an inductive thematic synthesis approach, 2 researchers independently extracted data, coded text (from results and discussion sections), and identified themes related to preparedness. Any disagreements were resolved by discussion and findings were then narratively synthesized. Results: The initial search identified 1214 papers. After removing duplicates and assessing abstracts and full articles against the inclusion criteria, 8 articles were included in the review. In general, the body of evidence was of sound methodological quality. Ten themes relating to perceptions of preparedness of medical students for their first clerkship were identified; competence, disconnection, links to the future, uncertainty, part of the team, time/workload, adjustment, curriculum, prior life experiences and learning. Conclusions: Eight of the ten themes related to perceptions of preparedness are potentially amenable to curricula strategies to improve the transition experience. The evidence supports clinical skills refreshers, clarification of roles and expectations, demystification of healthcare hierarchy and assessment processes and student-student handovers. Evidence also supports preclinical educational strategies such as enhancing content contextualization, further opportunities for the application of knowledge and skills, and constructive alignment of assessment tasks and pedagogical aims

Additional file 1: of Perceptions of preparedness for the first medical clerkship: a systematic review and synthesis

PRISMA Checklist. (DOC 63 kb

Comparison of sampling methods for international normalized ratio monitoring in haemodialysis patients (INRHaemo study)

Background: Haemorrhagic and thrombotic complications are common in dialysis patients on warfarin; thus, accurate international normalized ratio (INR) monitoring is critical. For expediency and patient comfort, blood sampling from the haemodialysis access or circuit is commonly performed. Point-of-care (POC) INR machines allow both peripheral vein preservation and rapid results, yet are not validated in the haemodialysis population. Methods: A prospective cohort study in haemodialysis patients taking warfarin was undertaken. Three paired samples were drawn over a single session: peripheral blood INR, POC INR, and dialysis INR. Agreement using Bland-Altman analysis and correlation coefficients between the peripheral blood INR, haemodialysis INR, and POC INR were calculated. Inappropriate dosing decisions based on haemodialysis or POC INR were quantified. Results: Amongst 34 patients, agreement between the dialysis INR and peripheral blood INR was high, with the haemodialysis INR differing from the peripheral INR by <±0.2, 85.2% of the time. Correlation between the 2 methods was high (r = 0.914; p < 0.001). POC INR differed from peripheral INR values by <±0.2, 67.6% of the time, with less agreement at higher INR values. Dosing decisions were incongruent between the dialysis and peripheral INR in 6%, whilst the POC and peripheral INR disagreed in 26%. Conclusions: There was good agreement and correlation between the peripheral blood, haemodialysis access/circuit, and POC INR values. POC INR was less reliable at higher values, and dosing decisions differed from the peripheral INR in a quarter of cases

Placental regulation of inflammation and hypoxia after TNF-α infusion in mice

Problem: Increased levels of inflammatory cytokines are demonstrated in the serum of women with pre-eclampsia. TNF-α infusion in animal models induces proteinuric hypertension similar to human pre-eclampsia. The effect of TNF-α on regulation of the immune and hypoxic pathways in the developing placenta and their relationship with experimental pre-eclampsia remains unexamined. Method of Study: TNF-α was infused into pregnant mice, and the effects on maternal hypertension, proteinuria, circulating levels of sFlt-1 and corresponding placental changes in molecules responding to inflammation (TLR-3 and TLR-4) and hypoxia (HIF-1α) were examined. Results: TNF-α infusion resulted in maternal hypertension and proteinuria. Molecular changes in the placenta involved upregulation of TLR-3, TLR-4 and HIF-1α. Serum levels of sFlt-1 were high in pregnant animals, but not further upregulated by TNF-α infusion. Conclusion: A role for maladaptive regulation of TLR and HIF-1α induced by an imbalance in inflammatory cytokines is implicated in the pathogenesis of pre-eclampsia

Variability in mRNA expression of fms-like tyrosine kinase-1 variants in normal and preeclamptic placenta

Background: Preeclampsia is a complication of pregnancy characterised by gestational hypertension and proteinuria and is a leading cause of morbidity and mortality in both mothers and infants. Certain anti-angiogenic factors have long been implicated in the pathogenesis of preeclampsia and the placental expression of factors such as soluble fms-like tyrosine kinase-1 (sFLT-1) are often reported in studies of normal and diseased placentae. Despite evidence showing significant differences in placental gene expression by collection site, many studies fail to provide sufficient details on sample selection and collection. Findings: With ourselves and others investigating and reporting on the expression of FLT-1 variants and other genes in the placenta of normotensive and preeclamptic patients, we felt it prudent to examine the variation in expression of FLT-1 variants across human placenta. We examined the differential expression of FLT-1 variants in samples obtained from 12 sites on normal and preeclamptic placentae and found expression to be highly variable between sites. We therefore developed an algorithim to calculate the mean expression for any number of these sites collected and in any combination. The coefficient of variation for all combinations of sites was then used to determine the minimum number of sites required to reduce coefficient of variation to below an acceptable 10%. We found that 10 and 11 sites had to be sampled in the normal and preeclamptic placentae respectively to ensure a representative expression pattern for all FLT-1 variants for an individual placenta. Conclusions: These findings demonstrate significant variation in expression levels of several commonly investigated genes across sites in both normal and preeclamptic placenta. This highlights both the importance of adequate sampling of human placenta for expression studies and the effective communication of sample selection and collection methods, for data interpretation and to ensure the reproducibility and reliability of results and conclusions drawn

Magnetic resonance imaging measurements of T2 relaxation times within contrasting regions of murine placenta is dependent upon blood flow

Introduction: It has been postulated that reduced placental perfusion as a result of abnormal placental implantation is the initiating event that leads to the maternal symptoms of preeclampsia. To be able to directly measure blood flow and perfusion in the placenta in experimental models of preeclampsia would provide valuable insight into the structural abnormalities of this syndrome. Magnetic resonance imaging (MRI) offers visualization of anatomy and analysis of changes in tissue morphology and function including blood flow and perfusion. The major source of image contrast in MRI comes from the variation in relaxation times between tissues. Previously, human placenta has appeared as fairly homogeneous in studies of T1 and T2 relaxation times, with no internal morphology apparent. Objectives: The aim of this study was to investigate, using much higher field strengths (11.7 Tesla) and much higher resolution than have been used previously, whether structural inhomogeneities in the placenta can be discerned by T2 mapping and whether T2 mapping is capable of detecting structural abnormalities that may affect blood flow in a preeclamptic placenta

Application of Cytoscape to the analysis of diagrams of mechanisms underlying patient problems

In problem based learning (PBL) tutorials in a medical context, students solve authentic patient problems with the educational aim to develop their reasoning capacity. A key activity to facilitate development of their reasoning capacity in a tutorial is the construction of diagrams of mechanisms that explain patient problems. These diagrams are networks of discrete elements (such as headache) of patient problems. Analysis of these diagrams may yield insights into students’ reasoning styles. To achieve this aim, we employed an application called Cytoscape, which is capable of visualising and analysing networks, to study these diagrams. In this preliminary study, we showed that Cytoscape can be used to analyze these diagrams of mechanisms produced in PBL tutorials. We found that students tend to reason in a hierarchical manner. Parameters are also defined that can be used to identify incorrect and missing links in their reasoning processes

Morphological differences in murine placenta detected by magnetic resonance imaging measurements of T2 relaxation times in mouse models of preeclampsia

Introduction: We have demonstrated that morphologically distinct regions of the murine placenta can be detected by magnetic resonance imaging (MRI), with image contrast arising from the variation in T2 relaxation times between regions and dependent upon blood flow. Previous studies of human placenta by other groups have shown a homogeneous tissue with correlation of relaxation times with gestational age and a trend for shorter relaxation times in pregnancies complicated by preeclampsia and fetal growth restriction. The ability to detect morphological changes and alterations in blood flow in experimental models of preeclampsia would be a significant boost in understanding the relationship between abnormal placental implantation, reduced placental perfusion, inflammatory cytokines, angiogenic molecules and other factors that may play a role in the syndrome. Objectives: The aim of this study was to investigate whether morphological changes or abnormalities can be detected by T2 mapping in the placenta of mice subject to two experimental models of preeclampsia (reduced uterine perfusion pressure (RUPP) model and TNF-a induced model)