Performance in candidates declaring versus those not declaring dyslexia in a licensing clinical examination

CONTEXT High-stakes medical examinations seek to be fair to all candidates, including an increasing proportion of trainee doctors with specific learning differences. We aimed to investigate the performance of doctors declaring dyslexia in the clinical skills assessment (CSA), an objective structured clinical examination for licensing UK general practitioners. METHODS We employed a cross-sectional design using performance and attribute data from candidates taking the CSA between 2010 and 2017. We compared candidates who declared dyslexia (‘early’ before their first attempt or ‘late’ after failing at least once) with those who did not, using multivariable negative binomial regression investigating the effect of declaring dyslexia on passing the CSA, accounting for relevant factors previously associated with performance, including number of attempts, initial score, sex, place of primary medical qualification and ethnicity. RESULTS Of 20 879 CSA candidates, 598 (2.9%) declared that they had dyslexia. Candidates declaring dyslexia were more likely to be male (47.3% versus 7.8%; p < 0.001) and to have a non-UK primary medical qualification (26.9% versus 22.4%; p < 0.01), but were no different in ethnicity compared with those who never declared dyslexia. Candidates who declared dyslexia late were significantly more likely to fail compared with those candidates who declared dyslexia early (40.6% versus 9.2%; p < 0.001) and were more likely to have a non-UK medical qualification (79.3% versus 15.6%; p < 0.001) or come from a minority ethnic group (84.9% versus 39.2%; p < 0.001). The chance of passing was lower for candidates declaring dyslexia compared to those who never declared dyslexia and lower in those declaring late (incident rate ratio [IRR], 0.82; 95% confidence interval [CI], 0.70–0.96) compared with those declaring early (IRR, 0.95; 95% CI, 0.93–0.97). CONCLUSIONS A small proportion of candidates declaring dyslexia were less likely to pass the CSA, particularly if dyslexia was declared late. Further investigation of potential causes and solutions is needed

How is performance at selection to general practice related to performance at the endpoint of GP training?

Background The selection process for entry to speciality training for general practice (GP) in the UK was changed in 2016. Doctors scoring above an agreed threshold in the computer-marked Multi-Specialty Recruitment Assessment (MSRA) were deemed appointable on that score alone and were offered a direct pathway (DP) to training, exempting them from further assessment at the final Selection Centre (SC). The SC was subsequently suspended in response to the COVID-19 pandemic and has yet to be reinstated. We aimed to evaluate the relationship between performance at selection and outcomes of GP training at licensing, to reassess the threshold score in MSRA used to bypass the SC, and to estimate the incremental predictive value of the SC after MSRA. Methods We used a longitudinal design linking selection, licensing and demographic data from doctors applying to enter GP specialty training in 2016. MSRA scores were divided into 12 score bands and SC scores into seven score bands to better identify MSRA or SC scores that corresponded to dffering GP performance on licensing assessments. Multivariable logistic regression models were used to establish the predictive validity of the MSRA scores and score bands for passing or failing the Membership of the Royal College of General Practitioners (MRCGP) licensing assessments including the Applied Knowledge Test (AKT), Clinical Skills Assessment (CSA) or Recorded Consultation Assessment (RCA), Workplace Based Assessment - Annual Review of Competence Progression (WPBA-ARCP), and performance overall. The model adjusted for sex, ethnicity, country of qualification, and declared disability. Receiver Operating Characteristic (ROC) curves of MSRA scores against performance outcomes were constructed to determine the optimal MSRA threshold scores for achieving licensing. Results We included 3338 doctors who entered specialty training for general practice in 2016 of different sex (female 63.81% vs male 36.19%), ethnicity (White British 53.95%, minority ethnic 43.04% or mixed 3.01%), country of qualification (UK 76.76%, non-UK 23.24%), and declared disability (disability declared 11.98%, no disability declared 88.02%). MSRA scores or score bands were highly predictive for all assessments of GP training outcome (AKT, CSA, RCA, and WPBA-ARCP). Lower SC score bands were predictive of lower pass rates on summative assessments and /or ARCP outcomes 2, 3, or 4. Adding SC scores did not change the predictive validity of the MSRA, and therefore the SC did not add further information to MSRA scores. An MSRA threshold of 500 (or, more precisely, 497) was optimal for correctly identifying pass/fail rates on the AKT, RCA, and CSA within the study period, and only standard outcomes on WPBA-ARCP. Thirty-five percent of candidates in the lowest two MSRA Bands (i.e., scores below 420) had at least one developmental outcome (2, 3) or outcome 4. Ethnicity did not reduce the chance of passing GP licensing tests once sex, place of primary medical qualification, declared disability and MSRA scores were taken into account. Conclusion MSRA scores predict licensing outcomes for AKT, CSA, RCA, and WPBA-ARCP within five years of starting training. The optimal MSRA threshold score for predicting an uncomplicated training pathway to licensing was around 500 in this large cohort. The SC added little to the predictive validity of the MSRA. Doctors scoring below this threshold may need additional support during training to maximise their chances of achieving licensing

The effect of specific learning difficulties on general practice written and clinical assessments

Background Substantial numbers of medical students and doctors have specific learning difficulties (SpLDs) and failure to accommodate their needs can disadvantage them academically. Evidence about how SpLDs affect performance during postgraduate general practice (GP) specialty training across the different licencing assessments is lacking. We aimed to investigate the performance of doctors with SpLDs across the range of licencing assessments. Methods We adopted the social model of disability as a conceptual framework arguing that problems of disability are societal and that barriers that restrict life choices for people with disabilities need to be addressed. We used a longitudinal design linking Multi-Specialty Assessment (MSRA) records from 2016 and 2017 with their Applied Knowledge Test (AKT), Clinical Skills Assessment (CSA), Recorded Consultation Assessment (RCA) and Workplace Based Assessment (WPBA) outcomes up to 2021. Multivariable logistic regression models accounting for prior attainment and demographics were used to determine the SpLD doctors' likelihood of passing licencing assessments. Results The sample included 2070 doctors, with 214 (10.34%) declaring a SpLD. Candidates declaring a SpLD were significantly less likely to pass the CSA (OR 0.43, 95% CI 0.26, 0.71, p = 0.001) but not the AKT (OR 0.96, 95% CI 0.44, 2.09, p = 0.913) or RCA (OR 0.81, 95% CI 0.35, 1.85, p = 0.615). Importantly, they were significantly more likely to have difficulties with WPBA (OR 0.28, 95% CI 0.20, 0.40, p < 0.001). When looking at licencing tests subdomains, doctors with SpLD performed significantly less well on the CSA Interpersonal Skills (B = −0.70, 95% CI −1.2, −0.19, p = 0.007) and the RCA Clinical Management Skills (B = −1.68, 95% CI −3.24, −0.13, p = 0.034). Conclusions Candidates with SpLDs encounter difficulties in multiple domains of the licencing tests and during their training. More adjustments tailored to their needs should be put in place for the applied clinical skills tests and during their training

Respiratory pathogen colonisation of dental plaque, the lower airways and endotracheal tube biofilms during mechanical ventilation

Purpose In mechanically ventilated patients, the endotracheal tube is an essential interface between the patient and ventilator, but inadvertently, it also facilitates the development of ventilator-associated pneumonia (VAP) by subverting pulmonary host defenses. A number of investigations suggest that bacteria colonizing the oral cavity may be important in the etiology of VAP. The present study evaluated microbial changes that occurred in dental plaque and lower airways of 107 critically ill mechanically ventilated patients. Materials and Methods Dental plaque and lower airways fluid was collected during the course of mechanical ventilation, with additional samples of dental plaque obtained during the entirety of patients' hospital stay. Results A “microbial shift” occurred in dental plaque, with colonization by potential VAP pathogens, namely, Staphylococcus aureus and Pseudomonas aeruginosa in 35 patients. Post-extubation analyses revealed that 70% and 55% of patients whose dental plaque included S aureus and P aeruginosa, respectively, reverted back to having a predominantly normal oral microbiota. Respiratory pathogens were also isolated from the lower airways and within the endotracheal tube biofilms. Conclusions To the best of our knowledge, this is the largest study to date exploring oral microbial changes during both mechanical ventilation and after recovery from critical illness. Based on these findings, it was apparent that during mechanical ventilation, dental plaque represents a source of potential VAP pathogens

Comparison of foam swabs and toothbrushes as oral hygiene interventions in mechanically ventilated patients: a randomised split mouth study

Abstract Introduction During critical illness, dental plaque may serve as a reservoir of respiratory pathogens. This study compared the effectiveness of toothbrushing with a small-headed toothbrush or a foam-headed swab in mechanically ventilated patients. Methods This was a randomised, assessor-blinded, split-mouth trial, performed at a single critical care unit. Adult, orally intubated patients with >20 teeth, where >24 hours of mechanical ventilation was expected were included. Teeth were cleaned 12-hourly using a foam swab or toothbrush (each randomly assigned to one side of the mouth). Cleaning efficacy was based on plaque scores, gingival index and microbial plaque counts. Results High initial plaque (mean=2.1 (SD 0.45)) and gingival (mean=2.0 (SD 0.54)) scores were recorded for 21 patients. A significant reduction compared with initial plaque index occurred using both toothbrushes (mean change=−1.26, 95% CI −1.57 to −0.95; p<0.001) and foam swabs (mean change=−1.28, 95% CI −1.54 to −1.01; p<0.001). There was significant reduction in gingival index over time using toothbrushes (mean change=−0.92; 95% CI −1.19 to −0.64; p<0.001) and foam swabs (mean change=−0.85; 95% CI −1.10 to −0.61; p<0.001). Differences between cleaning methods were not statistically significant (p=0.12 for change in gingival index; p=0.24 for change in plaque index). There was no significant change in bacterial dental plaque counts between toothbrushing (mean change 3.7×104 colony-forming units (CFUs); minimum to maximum (−2.5×1010 CFUs, 8.7×107 CFUs)) and foam swabs (mean change 9×104 CFUs; minimum to maximum (−3.1×1010 CFUs, 3.0×107 CFUs)). Conclusions Patients admitted to adult intensive care had poor oral health, which improved after brushing with a toothbrush or foam swab. Both interventions were equally effective at removing plaque and reducing gingival inflammation. Trial registration number NCT01154257; Pre-results

Academic performance of ethnic minority versus White doctors in the MRCGP assessment 2016-2021: cross sectional study

Background: Differential attainment has previously been suggested as being due to subjective bias due to racial discrimination in clinical skills assessments. Aim: To investigate differential attainment all UK general practice (GP) licensing tests comparing ethnic minority and White doctors. Design and Setting: Observational study of UK doctors in GP specialty training. Methods: We analysed data from doctors’ selection in 2016 to end of GP training, linking selection, licensing and demographic data to develop multivariable logistic regression models identifying predictors of pass rates for each assessment. Results: We included 3429 doctors entering GP specialty training in 2016, with doctors of different sex (female 63.81% vs male 36.19%), ethnicity (White British 53.95%, minority ethnic 43.04%, mixed 3.01%), country of qualification (UK 76.76%, non-UK 23.24%), and declared disability (disability declared 11.98%, not declared 88.02%). Multi-Specialty Recruitment Assessment scores (MSRA) were highly predictive for GP training end-point assessments including the Applied Knowledge Test (AKT), Clinical Skills Assessment (CSA), Recorded Consultation Assessment (RCA), and Workplace Based Assessment - Annual Review of Competency Progression (WPBA-ARCP). Ethnic minority doctors did significantly better compared to White British doctors in the AKT (OR 2.05, 95% CI 1.03, 4.10, p=0.042). There were no significant differences on other assessments: CSA (OR 0.72, 95% CI 0.43, 1.20, p=0.201), RCA (OR 0.48, 95% CI 0.18, 1.32, p=0.156), or WPBA-ARCP (OR 0.70, 95% CI 0.49, 1.01, p=0.057). Conclusion: Ethnicity did not reduce the chance of passing GP licensing tests once sex, place of primary medical qualification, declared disability and MSRA scores were accounted for

Changes in multimorbidity burden over a 3–5 year period among people with HIV

Introduction: As people living with HIV age, the increasing burden of multimorbidity poses a significant health challenge. The aims of this study were to identify common patterns of multimorbidity and examine changes in their burden, as well as their associations with risk factors, over a 3–5 year period in people with HIV, enrolled in the Pharmacokinetic and clinical Observations in PeoPle over fiftY (POPPY) study.Methods: Common multimorbidity patterns were identified in POPPY participants with HIV using principal component analysis, based on Somers’ D statistic. Multimorbidity burden scores were calculated for each participant/pattern at study entry/follow-up and were standardised relative to the mean in the sample at baseline (scores &gt;0 thus reflect a greater number of comorbidities relative to the mean). Two multivariable linear regression models were fitted to examine the associations between risk factors and burden z-scores at baseline and change in z-scores over a 3–5 year period.Results: Five patterns were identified among the 1073 POPPY participants with HIV {median age [interquartile range (IQR)], 52 (47–59) years; 85% male and 84% white}: Cardiovascular diseases (CVDs), Sexually transmitted diseases (STDs), Neurometabolic, Cancer and Mental-gastro-joint. The multivariable linear regression showed that older age, behavioural factors (i.e., body mass index (BMI), history of injection drug use, current recreational drug use and sex between men), and HIV-specific factors (i.e., duration since HIV diagnosis and a prior AIDS diagnosis) were associated with higher multimorbidity burden at baseline. However, only three of the factors (age, BMI and duration since HIV diagnosis) were significantly associated with an increase in burden across specific patterns over time.Discussion: Key modifiable and non-modifiable factors contributing to an increase in burden of multimorbidity were identified. Our findings may inform the development of more targeted interventions and guidelines to effectively prevent and manage the rising burden of multimorbidity in people with HIV

The Changing Face of Neolithic and Bronze Age Ireland: A Big Data Approach to the Settlement and Burial Records

This paper synthesizes and analyses the spatial and temporal patterns of archaeological sites in Ireland spanning the Neolithic period and the Bronze Age transition (4300-1900 cal BC). Included are a large number of unpublished, newly discovered sites excavated through development-led projects. Data were also sourced from national archives, published excavation reports and on-line databases. Software tools were developed to deal with the varying nature and resolution of these datasets, allowing chronology to be considered in the analysis to a degree that is usually not possible in prehistoric studies. Summed radiocarbon probabilities are used to examine the dataset using context- and sample-sensitive approaches. Visualisations of spatial and chronological data illustrate the expansion of Early Neolithic settlement, followed by an apparent attenuation of all settlement activity. The Late Neolithic and Chalcolithic periods are characterised by a resurgence and diversification of activity. To assess the significance of these observations, Irish radiocarbon data are compared to an idealized model derived from North American data. Even after taking various considerations into account, human population increases can be suggested to have occurred during the Early and Late Neolithic periods. Gaps and biases in the data are discussed and priorities for future work are identified

The Changing Landscape for Stroke\ua0Prevention in AF: Findings From the GLORIA-AF Registry Phase 2

Background GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non\u2013vitamin K antagonist oral anticoagulant (NOAC), became available. Objectives This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase&nbsp;1. Methods During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients\u2019 baseline characteristics. Atrial fibrillation&nbsp;disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics. Results Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patients were from Europe (47.1%), North America (22.5%), Asia (20.3%), Latin America (6.0%), and the Middle East/Africa (4.0%). Most had high stroke risk (CHA2DS2-VASc [Congestive heart failure, Hypertension, Age&nbsp; 6575 years, Diabetes mellitus, previous Stroke, Vascular disease, Age 65 to 74 years, Sex category] score&nbsp; 652; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc&nbsp;= 1). Overall, 79.9% received oral anticoagulants, of whom 47.6% received NOAC and 32.3% vitamin K antagonists (VKA); 12.1% received antiplatelet agents; 7.8% received no antithrombotic treatment. For comparison, the proportion of phase 1 patients (of N&nbsp;= 1,063 all eligible) prescribed VKA was 32.8%, acetylsalicylic acid 41.7%, and no therapy 20.2%. In Europe in phase 2, treatment with NOAC was more common than VKA (52.3% and 37.8%, respectively); 6.0% of patients received antiplatelet treatment; and 3.8% received no antithrombotic treatment. In North America, 52.1%, 26.2%, and 14.0% of patients received NOAC, VKA, and antiplatelet drugs, respectively; 7.5% received no antithrombotic treatment. NOAC use was less common in Asia (27.7%), where 27.5% of patients received VKA, 25.0% antiplatelet drugs, and 19.8% no antithrombotic treatment. Conclusions The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in&nbsp;Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in&nbsp;Asia&nbsp;and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701