Profiling strugglers in a graduate-entry medicine course at Nottingham: a retrospective case study

Background 10-15% of students struggle at some point in their medicine course. Risk factors include weaker academic qualifications, male gender, mental illness, UK ethnic minority status, and poor study skills. Recent research on an undergraduate medicine course provided a toolkit to aid early identification of students likely to struggle, who can be targeted by established support and study interventions. The present study sought to extend this work by investigating the number and characteristics of strugglers on a graduate-entry medicine (GEM) programme. Methods A retrospective study of four GEM entry cohorts (2003–6) was carried out. All students who had demonstrated unsatisfactory progress or left prematurely were included. Any information about academic, administrative, personal, or social difficulties, were extracted from their course progress files into a customised database and examined. Results 362 students were admitted to the course, and 53 (14.6%) were identified for the study, of whom 15 (4.1%) did not complete the course. Students in the study group differed from the others in having a higher proportion of 2ii first degrees, and scoring less well on GAMSAT, an aptitude test used for admission. Within the study group, it proved possible to categorise students into the same groups previously reported (struggler throughout, pre-clinical struggler, clinical struggler, health-related struggler, borderline struggler) and to identify the majority using a number of flags for early difficulties. These flags included: missed attendance, unsatisfactory attitude or behaviour, health problems, social/family problems, failure to complete immunity status checks, and attendance at academic progress committee. Conclusions Problems encountered in a graduate-entry medicine course were comparable to those reported in a corresponding undergraduate programme. A toolkit of academic and non-academic flags of difficulty can be used for early identification of many who will struggle, and could be used to target appropriate support and interventions

A Minimal Model of Signaling Network Elucidates Cell-to-Cell Stochastic Variability in Apoptosis

Signaling networks are designed to sense an environmental stimulus and adapt to it. We propose and study a minimal model of signaling network that can sense and respond to external stimuli of varying strength in an adaptive manner. The structure of this minimal network is derived based on some simple assumptions on its differential response to external stimuli. We employ stochastic differential equations and probability distributions obtained from stochastic simulations to characterize differential signaling response in our minimal network model. We show that the proposed minimal signaling network displays two distinct types of response as the strength of the stimulus is decreased. The signaling network has a deterministic part that undergoes rapid activation by a strong stimulus in which case cell-to-cell fluctuations can be ignored. As the strength of the stimulus decreases, the stochastic part of the network begins dominating the signaling response where slow activation is observed with characteristic large cell-to-cell stochastic variability. Interestingly, this proposed stochastic signaling network can capture some of the essential signaling behaviors of a complex apoptotic cell death signaling network that has been studied through experiments and large-scale computer simulations. Thus we claim that the proposed signaling network is an appropriate minimal model of apoptosis signaling. Elucidating the fundamental design principles of complex cellular signaling pathways such as apoptosis signaling remains a challenging task. We demonstrate how our proposed minimal model can help elucidate the effect of a specific apoptotic inhibitor Bcl-2 on apoptotic signaling in a cell-type independent manner. We also discuss the implications of our study in elucidating the adaptive strategy of cell death signaling pathways.Comment: 9 pages, 6 figure

Adjuvant TACE inhibitor treatment improves the outcome of TLR2(-/- )mice with experimental pneumococcal meningitis

BACKGROUND: Streptococcus (S.) pneumoniae meningitis has a high lethality despite antibiotic treatment. Inflammation is a major pathogenetic factor, which is unresponsive to antibiotics. Therefore adjunctive therapies with antiinflammatory compounds have been developed. TNF484 is a TNF-alpha converting enzyme (TACE) inhibitor and has been found efficacious in experimental meningitis. Toll-like receptor 2 (TLR2) contributes to host response in pneumococcal meningitis by enhancing bacterial clearing and downmodulating inflammation. In this study, TNF484 was applied in mice, which lacked TLR2 and exhibited a strong meningeal inflammation. METHODS: 10(3 )CFU S. pneumoniae serotype 3 was inoculated subarachnoidally into C57BL/6 wild type (wt) mice or TLR2(-/-), CD14(-/- )and CD14(-/-)/TLR2(-/- )mice. Severity of disease and survival was followed over 9 days. Response to antibiotics (80 mg/kg ceftriaxone i.p. for 5 days) and/or TACE inhibitor treatment (1 mg/kg s.c. twice daily for 4 days) was evaluated. Animals were sacrificed after 12, 24, and 48 h for analysis of bacterial load in cerebrospinal fluid (CSF) and brain and for TNF and leukocyte measurements in CSF. RESULTS: TLR2(-/- )mice were significantly sicker than the other mouse strains 24 h after infection. All knockout mice showed higher disease severity after 48 h and died earlier than wt mice. TNF release into CSF was significantly more elevated in TLR2(-/- )than in the other strains after 24 h. Brain bacterial numbers were significantly higher in all knockout than wt mice after 24 h. Modulation of outcome by antibiotic and TACE inhibitor treatment was evaluated. With antibiotic therapy all wt, CD14(-/- )and TLR2(-/-)/CD14(-/- )mice, but only 79% of TLR2(-/- )mice, were rescued. TACE inhibitor treatment alone did not rescue, but prolonged survival in wt mice, and in TLR2(-/- )and CD14(-/- )mice to the values observed in untreated wt mice. By combined antibiotic and TACE inhibitor treatment 95% of TLR2(-/- )mice were rescued. CONCLUSION: During pneumococcal meningitis strong inflammation in TLR2-deficiency was associated with incomplete responsiveness to antibiotics and complete response to combined antibiotic and TACE inhibitor treatment. TACE inhibitor treatment offers a promising adjuvant therapeutic strategy in pneumococcal meningitis

Medical students' personal experience of high-stakes failure:case studies using interpretative phenomenological analysis

Abstract (provisional): Background Failing a high-stakes assessment at medical school is a major event for those who go through the experience. Students who fail at medical school may be more likely to struggle in professional practice, therefore helping individuals overcome problems and respond appropriately is important. There is little understanding about what factors influence how individuals experience failure or make sense of the failing experience in remediation. The aim of this study was to investigate the complexity surrounding the failure experience from the student’s perspective using interpretative phenomenological analysis (IPA). Methods The accounts of 3 medical students who had failed final re-sit exams, were subjected to in-depth analysis using IPA methodology. IPA was used to analyse each transcript case-by-case allowing the researcher to make sense of the participant’s subjective world. The analysis process allowed the complexity surrounding the failure to be highlighted, alongside a narrative describing how students made sense of the experience. Results The circumstances surrounding students as they approached assessment and experienced failure at finals were a complex interaction between academic problems, personal problems (specifically finance and relationships), strained relationships with friends, family or faculty, and various mental health problems. Each student experienced multi-dimensional issues, each with their own individual combination of problems, but experienced remediation as a one-dimensional intervention with focus only on improving performance in written exams. What these students needed to be included was help with clinical skills, plus social and emotional support. Fear of termination of the their course was a barrier to open communication with staff. Conclusions These students’ experience of failure was complex. The experience of remediation is influenced by the way in which students make sense of failing. Generic remediation programmes may fail to meet the needs of students for whom personal, social and mental health issues are a part of the picture

Tolerance to bronchodilation during treatment with long-acting beta-agonists, a randomised controlled trial

BACKGROUND: Regular use of beta-agonists leads to tolerance to their bronchodilator effects. This can be demonstrated by measuring the response to beta-agonist following bronchoconstriction using methacholine. However most studies have demonstrated tolerance after a period of beta-agonist withdrawal, which is not typical of their use in clinical practice. This study assessed tolerance to the bronchodilator action of salbutamol during ongoing treatment with long-acting beta-agonist. METHODS: Random-order, double-blind, placebo-controlled, crossover trial. After 1 week without beta-agonists, 13 asthmatic subjects inhaled formoterol 12 μg twice daily or matching placebo for 1 week. Eight hours after the first and last doses subjects inhaled methacholine to produce a 20% fall in FEV(1). Salbutamol 100, 200 and 400 μg (cumulative dose) was then given at 5-minute intervals and FEV(1 )was measured 5 minutes after each dose. After a 1 week washout subjects crossed over to the other treatment. Unscheduled use of beta-agonists was not allowed during the study. The main outcome variable was the area under the salbutamol response curve. RESULTS: The analysis showed a significant time by treatment interaction indicating that the response to salbutamol fell during formoterol therapy compared to placebo. After 1 week of formoterol the area under the salbutamol response curve was 48% (95% confidence interval 28 to 68%) lower than placebo. This reduction in response remained significant when the analyses were adjusted for changes in the pre-challenge FEV(1 )and dose of methacholine given (p = 0.001). CONCLUSION: The bronchodilator response to salbutamol is significantly reduced in patients taking formoterol. Clinically relevant tolerance to rescue beta-agonist treatment is likely to occur in patients treated with long-acting beta-agonists

Patients experiences of Polymyalgia Rheumatica: a Qualitative Literature Synthesis Review

Background Qualitative research is needed to better understand the concepts of remission and relapse in Polymyalgia Rheumatica (PMR). Remission, relapse, and disease activity have been defined heterogeneously in clinical studies which exclude the patient view leading to a discrepancy between physician and patient perspectives when evaluating disease activity. Aims The present work is part of a project of the PMR Working Group of Outcome Measures in Rheumatology (OMERACT), which is a global, volunteer-driven, non-profit research group aiming to improve outcome measures in rheumatic diseases. We carried out a synthesis of findings from multiple qualitative studies to provide a range and depth of meanings, experiences, and perspectives of participants across health-care contexts to explore the patient perspectives of disease activity in PMR. Methods A professional librarian carried out systematic search of the qualitative research literature across Ovid (Medline), EMBASE and CINAHL to identify studies of interest. Research synthesis was carried out in accordance with the ENTERQ criteria by three researchers with qualitative research experience. Results The search was carried out from each of the database point of inception to 19/10/2023. Review of abstracts, and hand searching reference lists of manuscripts identified 12 studies of interest. There were three main over-arching ideas identified within the published work: 1. Pathway to diagnosis, 2. Managing uncertainty and 3. Challenges to everyday life. Within these three over-arching ideas there were sub-themes identified within the conceptual scaffold which were underpinned with the expression of self and control. The domain of pathway diagnosis included making sense of the condition, normalisation of symptoms and struggles navigating care systems. Within the domain of manging uncertainty where the concepts of self and illness and the positive and negative effects of steroids. The Challenges to everyday life domain comprised day to day living, adaptation and psycho-social burden of disease. Conclusion This research synthesis of qualitative work on PMR has identified three over-arching domains providing a rich narrative of lived experience which point to why discrepancies exist within current physician-focused definitions of remission and relapse. Disclosure Nonspecific to this study

Emergence of Variability in Isogenic Escherichia coli Populations Infected by a Filamentous Virus

The spread of epidemics not only depends on the average number of parasites produced per host, but also on the existence of highly infectious individuals. It is widely accepted that infectiousness depends on genetic and environmental determinants. However, even in clonal populations of host and viruses growing in homogeneous conditions, high variability can exist. Here we show that Escherichia coli cells commonly display high differentials in viral burst size, and address the kinetics of emergence of such variability with the non-lytic filamentous virus M13. By single-cell imaging of a virally-encoded fluorescent reporter, we monitor the viral charge distribution in infected bacterial populations at different time following infection. A mathematical model assuming autocatalytic virus replication and inheritance of bacterial growth rates quantitatively reproduces the experimental distributions, demonstrating that deterministic amplification of small host inhomogeneities is a mechanism sufficient to explain large and highly skewed distributions. This mechanism of amplification is general and may occur whenever a parasite has an initial phase of exponential growth within its host. Moreover, it naturally reproduces the shift towards higher virulence when the host is experimenting poor conditions, as observed commonly in host-parasite systems

The AURORA pilot study for molecular screening of patients with advanced breast cancer–a study of the breast international group

Several studies have demonstrated the feasibility of molecular screening of tumour samples for matching patients with cancer to targeted therapies. However, most of them have been carried out at institutional or national level. Herein, we report on the pilot phase of AURORA (NCT02102165), a European multinational collaborative molecular screening initiative for advanced breast cancer patients. Forty-one patients were prospectively enroled at four participating centres across Europe. Metastatic tumours were biopsied and profiled using an Ion Torrent sequencing platform at a central facility. Sequencing results were obtained for 63% of the patients in real-time with variable turnaround time stemming from delays between patient consent and biopsy. At least one clinically actionable mutation was identified in 73% of patients. We used the Illumina sequencing technology for orthogonal validation and achieved an average of 66% concordance of substitution calls per patient. Additionally, copy number aberrations inferred from the Ion Torrent sequencing were compared to single nucleotide polymorphism arrays and found to be 59% concordant on average. Although this study demonstrates that powerful next generation genomic techniques are logistically ready for international molecular screening programs in routine clinical settings, technical challenges remain to be addressed in order to ensure the accuracy and clinical utility of the genomic data.info:eu-repo/semantics/publishe

Influence of Different Application of Lubricants on Wear and Pre-existing Rolling Contact Fatigue Cracks of Rail Materials

Rolling contact fatigue (RCF) of rail can be a significant problem affecting safety and maintenance. Rail materials have been optimized to reduce it, but not enough is known about how friction management products applied to the rail affect crack growth. This study presents experimental results carried out to explore the influence of different lubricants and application orders on wear and pre-existing RCF cracks in rail materials. The results indicate that the types or properties of lubricants have a vital role in the wear rate and fatigue crack growth characteristics of rail materials after conditioning with 5000 dry cycles to initiate cracks. Using a different application order of two lubricants has a significant influence on the crack growth angles in the rail rollers