Pain medicine content, teaching and assessment in medical school curricula in Australia and New Zealand

Background: The objective of pain medicine education is to provide medical students with opportunities to develop their knowledge, skills and professional attitudes that will lead to their becoming safe, capable, and compassionate medical practitioners who are able to meet the healthcare needs of persons in pain. This study was undertaken to identify and describe the delivery of pain medicine education at medical schools in Australia and New Zealand. Method: All 23 medical schools in Australia and New Zealand in 2016 were included in this study. A structured curriculum audit tool was used to obtain information on pain medicine curricula including content, delivery, teaching and assessment methods. Results: Nineteen medical schools (83%) completed the curriculum audit. Neurophysiology, clinical assessment, analgesia use and multidimensional aspects of pain medicine were covered by most medical schools. Specific learning objectives for pain medicine were not identified by 42% of medical schools. One medical school offered a dedicated pain medicine module delivered over 1 week. Pain medicine teaching was delivered at all schools by a number of different departments throughout the curriculum. Interprofessional learning (IPL) in the context of pain medicine education was not specified by any of the medical schools. The mean time allocated for pain medicine teaching over the entire medical course was just under 20 h. The objective structured clinical examination (OSCE) was used by 32% of schools to assess knowledge and skills in pain medicine. 16% of schools were unsure of whether any assessment of pain medicine education took place. Conclusion: This descriptive study provides important baseline information for pain medicine education at medical schools in Australia and New Zealand. Medical schools do not have well-documented or comprehensive pain curricula that are delivered and assessed using pedagogically-sound approaches considering the complexity of the topic, the prevalence and public health burden of pain

Systematic review of pain medicine content, teaching, and assessment in medical school curricula internationally

Introduction: Pain management is a major health care challenge in terms of the significant prevalence of pain and the negative consequences of poor management. Consequently, there have been international calls to improve pain medicine education for medical students. This systematic review examines the literature on pain medicine education at medical schools internationally, with a particular interest in studies that make reference to: a defined pain medicine curriculum, specific pain medicine learning objectives, dedicated pain education modules, core pain topics, medical specialties that teach pain medicine, elective study opportunities, hours allocated to teaching pain medicine during the curriculum, the status of pain medicine in the curriculum (compulsory or optional), as well as teaching, learning, and assessment methods. Methods: A systematic review was undertaken of relevant studies on pain medicine education for medical students published between January 1987 and May 2018 using PubMed, Medline, Excerpta Medica database (EMBASE), Education Resources Information Center (ERIC), and Google Scholar, and Best Evidence Medical Education (BEME) data bases. Results: Fourteen studies met the inclusion criteria. Evaluation of pain medicine curricula has been undertaken at 383 medical schools in Australia, New Zealand, the United States of America (USA), Canada, the United Kingdom (UK), and Europe. Pain medicine was mostly incorporated into medical courses such as anaesthesia or pharmacology, rather than presented as a dedicated pain medicine module. Ninety-six percent of medical schools in the UK and USA, and nearly 80% of medical schools in Europe had no compulsory dedicated teaching in pain medicine. On average, the median number of hours of pain content in the entire curriculum was 20 in Canada (2009), 20 in Australia and New Zealand (2018), 13 in the UK (2011), 12 in Europe (2012/2013), and 11 in the USA (2009). Neurophysiology and pharmacology pain topics were given priority by medical schools in all countries. Lectures, seminars, and case-based instruction were the teaching methods most commonly employed. When it was undertaken, medical schools mostly assessed student competency in pain medicine using written examinations rather than clinical assessments. Conclusions: This systematic review has revealed that pain medicine education at medical schools internationally does not adequately respond to societal needs in terms of the prevalence and public health impact of inadequately managed pain

Patient attitudes towards analgesia and their openness to non-pharmacological methods such as acupuncture in the emergency department

Aims: To investigate patient attitudes to analgesia, opioids and non-pharmacological analgesia including acupuncture, in the ED. Methods: ED patients with pain were surveyed regarding: pain scores, satisfaction, addiction concern, non-pharmacological methods of pain relief, and acupuncture. Data were analysed using logistic regression. Results: Of 196 adult patients, 52.8% were ‘very satisfied’ with analgesia. Most patients (84.7%) would accept non-pharmacological methods including acupuncture (68.9%) and 78.6% were not concerned about addiction. Satisfaction was associated with male gender, and ‘adequate analgesia’ but not with opioids. Conclusion: Most patients were generally satisfied with ED analgesia and were open to non-pharmacologic analgesia including acupuncture

Methodological considerations in quantification of oncological FDG PET studies

Contains fulltext : 87741.pdf (publisher's version ) (Closed access) Contains fulltext : 87741-1.pdf (postprint version ) (Open Access)PURPOSE: This review aims to provide insight into the factors that influence quantification of glucose metabolism by FDG PET images in oncology as well as their influence on repeated measures studies (i.e. treatment response assessment), offering improved understanding both for clinical practice and research. METHODS: Structural PubMed searches have been performed for the many factors affecting quantification of glucose metabolism by FDG PET. Review articles and references lists have been used to supplement the search findings. RESULTS: Biological factors such as fasting blood glucose level, FDG uptake period, FDG distribution and clearance, patient motion (breathing) and patient discomfort (stress) all influence quantification. Acquisition parameters should be adjusted to maximize the signal to noise ratio without exposing the patient to a higher than strictly necessary radiation dose. This is especially challenging in pharmacokinetic analysis, where the temporal resolution is of significant importance. The literature is reviewed on the influence of attenuation correction on parameters for glucose metabolism, the effect of motion, metal artefacts and contrast agents on quantification of CT attenuation-corrected images. Reconstruction settings (analytical versus iterative reconstruction, post-reconstruction filtering and image matrix size) all potentially influence quantification due to artefacts, noise levels and lesion size dependency. Many region of interest definitions are available, but increased complexity does not necessarily result in improved performance. Different methods for the quantification of the tissue of interest can introduce systematic and random inaccuracy. CONCLUSIONS: This review provides an up-to-date overview of the many factors that influence quantification of glucose metabolism by FDG PET.01 juli 201

High-Sugar, High-Saturated-Fat Dietary Patterns Are Not Associated with Depressive Symptoms in Middle-Aged Adults in a Prospective Study

Background: The consumption of unhealthy "Western" dietary patterns has been previously associated with depressive symptoms in different populations. Objective: We examined whether high-sugar and high-saturated-fat dietary patterns are associated with depressive symptoms over 5 y in a British cohort of men and women. Methods: We used data from the Whitehall II study in 5044 individuals (aged 35-55 y). Diet was assessed at phase 7 (2003-2004) using a validated food-frequency questionnaire. Dietary patterns were derived by using reduced rank regression with sugar, saturated fat, and total fat as response variables. The Center for Epidemiological Studies-Depression (CES-D) scale was used to assess depressive symptoms (CES-D sum score ≥16 and/or use of antidepressant medication) at phase 7 and at phase 9 (2008-2009). We applied logistic regression analyses to test the association between dietary patterns and depressive symptoms. All analyses were stratified by sex. Results: In total, 398 cases of recurrent and 295 cases of incident depressive symptoms were observed. We identified 2 dietary patterns: a combined high-sugar and high-saturated-fat (HSHF) and a high-sugar dietary pattern. No association was observed between the dietary patterns and either incidence of or recurrent depressive symptoms in men or women. For example, higher consumption of the HSHF dietary pattern was not associated with recurrent depressive symptoms in men (model 3, quartile 4: OR: 0.67; 95% CI: 0.36, 1.23; P-trend = 0.13) or in women (model 3, quartile 4: OR: 1.26; 95% CI: 0.58, 2.77; P-trend = 0.97). Conclusion: Among middle-aged men and women living in the United Kingdom, dietary patterns containing high amounts of sugar and saturated fat are not associated with new onset or recurrence of depressive symptoms

Changes in the central component of the hypothalamus-pituitary-thyroid axis in a rabbit model of prolonged critical illness

Introduction: Prolonged critically ill patients reveal low circulating thyroid hormone levels without a rise in thyroid stimulating hormone (TSH). This condition is labeled "low 3,5,3'-tri-iodothyronine (T3) syndrome" or "nonthyroidal illness syndrome (NTI)" or "euthyroid sick syndrome". Despite the low circulating and peripheral tissue thyroid hormone levels, thyrotropin releasing hormone (TRH) expression in the hypothalamus is reduced and it remains unclear which mechanism is responsible. We set out to study whether increased hypothalamic T3availability could reflect local thyrotoxicosis and explain feedback inhibition-induced suppression of the TRH gene in the context of the low T3syndrome in prolonged critical illness.Methods: Healthy rabbits were compared with prolonged critically ill, parenterally fed animals. We visualized TRH mRNA in the hypothalamus by in situ-hybridization and measured mRNA levels for the type II iodothyronine diodinase (D2), the thyroid hormone transporters monocarboxylate transporter (MCT) 8, MCT10 and organic anion co-transporting polypeptide 1C1 (OATP1C1) and the thyroid hormone receptors α (TRα) and β (TRβ) in the hypothalamus. We also measured the activity of the D2 and type III iodothyronine deiodinase (D3) enzymes.Results: In the hypothalamus of prolonged critically ill rabbits with low circulating T3 and TSH, we observed decreased TRH mRNA, increased D2 mRNA and increased MCT10 and OATP1C1 mRNA while MCT8 gene expression was unaltered as compared with healthy controls. This coincided with low hypothalamic thyroxine (T4) and low-normal T3concentrations, without a change at the thyroid hormone receptor level.Conclusions: Although expression of D2 and of the thyroid hormone transporters MCT10 and OATP1C1 were increased in the hypothalamus of prolonged critical ill animals, hypothalamic T4and T3content or thyroid hormone receptor expression were not elevated. Hence, decreased TRH gene expression, and hereby low TSH and T3 during prolonged critical illness, is not exclusively brought about by hypothalamic thyrotoxicosis, and infer other TRH suppressing factors to play a role

Microsatellite allele dose and configuration establishment (MADCE): an integrated approach for genetic studies in allopolyploids

BACKGROUND: Genetic studies in allopolyploid plants are challenging because of the presence of similar sub-genomes, which leads to multiple alleles and complex segregation ratios. In this study, we describe a novel method for establishing the exact dose and configuration of microsatellite alleles for any accession of an allopolyploid plant species. The method, named Microsatellite Allele Dose and Configuration Establishment (MADCE), can be applied to mapping populations and pedigreed (breeding) germplasm in allopolyploids. RESULTS: Two case studies are presented to demonstrate the power and robustness of the MADCE method. In the mapping case, five microsatellites were analysed. These microsatellites amplified 35 different alleles based on size. Using MADCE, we uncovered 30 highly informative segregating alleles. A conventional approach would have yielded only 19 fully informative and six partially informative alleles. Of the ten alleles that were present in all progeny (and thereby ignored or considered homozygous when using conventional approaches), six were found to segregate by dosage when analysed with MADCE. Moreover, the full allelic configuration of the mapping parents could be established, including null alleles, homozygous loci, and alleles that were present on multiple homoeologues. In the second case, 21 pedigreed cultivars were analysed using MADCE, resulting in the establishment of the full allelic configuration for all 21 cultivars and a tracing of allele flow over multiple generations. CONCLUSIONS: The procedure described in this study (MADCE) enhances the efficiency and information content of mapping studies in allopolyploids. More importantly, it is the first technique to allow the determination of the full allelic configuration in pedigreed breeding germplasm from allopolyploid plants. This enables pedigree-based marker-trait association studies the use of algorithms developed for diploid crops, and it may increase the effectiveness of LD-based association studies. The MADCE method therefore enables researchers to tackle many of the genotyping problems that arise when performing mapping, pedigree, and association studies in allopolyploids. We discuss the merits of MADCE in comparison to other marker systems in polyploids, including SNPs, and how MADCE could aid in the development of SNP markers in allopolyploids

Ethylene-mediated nitric oxide depletion pre-adapts plants to hypoxia stress

Timely perception of adverse environmental changes is critical for survival. Dynamic changes in gases are important cues for plants to sense environmental perturbations, such as submergence. In Arabidopsis thaliana, changes in oxygen and nitric oxide (NO) control the stability of ERFVII transcription factors. ERFVII proteolysis is regulated by the N-degron pathway and mediates adaptation to flooding-induced hypoxia. However, how plants detect and transduce early submergence signals remains elusive. Here we show that plants can rapidly detect submergence through passive ethylene entrapment and use this signal to pre-adapt to impending hypoxia. Ethylene can enhance ERFVII stability prior to hypoxia by increasing the NO-scavenger PHYTOGLOBIN1. This ethylene-mediated NO depletion and consequent ERFVII accumulation pre-adapts plants to survive subsequent hypoxia. Our results reveal the biological link between three gaseous signals for the regulation of flooding survival and identifies key regulatory targets for early stress perception that could be pivotal for developing flood-tolerant crops

Uptake of triiodothyronine sulfate and suppression of thyrotropin secretion in cultured anterior pituitary cells

To investigate the uptake of triiodothyronine sulfate (T3S) and its effect on thyrotropin-releasing hormone (TRH)-induced thyrotropin (TSH) secretion, anterior pituitary cells were isolated from euthyroid rats and cultured for 3 days in medium containing 10% fetal calf serum. Incubation was performed at 37°C in medium containing 0.5% bovine serum albumin (BSA). Exposure of the pituitary cells to TRH (0.1 μmol/L) for 2 hours stimulated TSH secretion by 176%. This effect was reduced by approximately 45% after a 2-hour preincubation with T3 (0.001 to 1 μmol/L). A significant inhibitory effect of T3S on TRH-induced TSH release was only observed at a concentration of 1 μmol/L. The uptake of [125I]T3 after 1 hour of incubation was reduced by 40% ± 4% (P < .001) by simultaneous addition of 10 nmol/L unlabeled T3, whereas 1 μmol/L T3S was required to obtain a reduction of the [125I]T3 uptake by 34% ± 2% (P < .001). The amount of T3 present in the unlabeled T3S preparation was 0.25% as determined by radioimmunoassay. When pituitary cells were incubated for 1 hour with [125I]T3S or [125I]T3 both 50,000 cpm/0.25 mL), the uptake of [125I]T3zS expressed as a percentage of the dose was 0.04% ± 0.02% (mean ± SE, n = 4), whereas that of [125I]T3 amounted to 3.0% ± 0.4% (n = 4). In contrast, when hepatocytes were incubated for 1 hour with [125I]T3S, the uptake amounted to 5.1% ± 0.8% (n = 9), whereas that of [125I]T3 was 22.1% ± 1.7% (n = 9). Furthermore, [125I]T3S was as rapidly deiodinated (iodide production, 14.9% ± 2.6%; n = 9) as [125I]T3 (12.1% ± 0.8%, n = 9) by hepatocytes. It is concluded that (1) T3S is poorly taken up by pituitary cells, and (2) the suppressive effect of high concentrations of T3S on TRH-induced TSH secretion and on [125I]T3 uptake can be explained by slight contamination with T3. Thus, it appears that T3S has only a minor biological effect, if any, on the pituitary