Exploring correlation between early clinical skills teaching and self-reported competence of senior medical students; a cross-sectional study

Η εκπαίδευση σε συνθήκες προσομοίωσης σε συνδυασμό με την πρακτική άσκηση υπό επίβλεψη σε πραγματικούς ασθενείς, αποτελούν δύο απαραίτητα βήματα για την ασφαλή και συστηματική εκπαίδευση στις κλινικές δεξιότητες. Η οικοδόμηση της αυτοεκτίμησης των φοιτητών ιατρικής κατά τη διάρκεια των σπουδών τους είναι ζωτικής σημασίας, αλλά δεν αρκεί για να εξασφαλίσει την επιτυχή πραγματοποίηση κλινικών δεξιοτήτων. O σκοπός της μελέτης ήταν να αξιολογήσει την αυτο-αναφερόμενη ικανότητα σε βασικές κλινικές δεξιότητες φοιτητών μεγαλυτέρων ετών της ιατρικής, πριν από την αποφοίτησή τους και να διερευνήσει πιθανές συσχετίσεις με την πρώιμη εκπαίδευση κλινικών δεξιοτήτων σε συνθήκες προσομοίωσης. Μέθοδος: Πραγματοποιήσαμε μια συγχρονική μελέτη σε τελειόφοιτους φοιτητές ιατρικής ένα μήνα πριν από την αποφοίτησή τους. Καλέσαμε τους φοιτητές να κάνουν την αυτοεκτίμηση των ικανοτήτων τους σε 42 βασικές κλινικές δεξιότητες χρησιμοποιώντας ένα ανώνυμο ερωτηματολόγιο μέσω διαδικτύου. Τα δεδομένα αναλύθηκαν λαμβάνοντας υπόψη την προηγούμενη συμμετοχή των φοιτητών στο επιλεγόμενο μάθημα «Εργαστήριο Κλινικών Δεξιοτήτων» (ΕΚΔ). Αποτελέσματα: Η απαντητικότητα των τελειόφοιτων φοιτητών ιατρικής στην ηλεκτρονική μας μελέτης ήταν 24,6%. Τριάντα τέσσερις φοιτητές (38,6%) είχαν παρακολουθήσει το επιλεγόμενα μάθημα ΕΚΔ. Η παρακολούθηση του ΕΚΔ φάνηκε να επηρεάζει την αυτοεκτίμηση της ικανότητας των φοιτητών στην πραγματοποίηση των 15 δεξιοτήτων που διδάσκονται στο επιλεγόμενο μάθημα, σε σχέση με τους φοιτητές που δεν το έχουν παρακολουθήσει (p>0,05). Δεν υπήρχε στατιστικά σημαντική διαφορά μεταξύ των δύο ομάδων φοιτητών σε σχέση με τις άλλες βασικές δεξιότητες που δεν διδάχθηκαν στο ΕΚΔ. Συμπεράσματα: Τα αποτελέσματά μας δείχνουν ότι οι τελειόφοιτοι φοιτητές ιατρικής δεν αισθάνονται αρκετά ικανοί να επιτελέσουν τις βασικές κλινικές δεξιότητες που πρέπει να καλύπτει το προπτυχιακό πρόγραμμα σπουδών της ιατρικής. Η συστηματική εκπαίδευση στις κλινικές δεξιότητες στα πρώτα χρόνια των ιατρικών σπουδών πριν από την επαφή με τους ασθενούς φαίνεται να είναι αρκετή για να αλλάξει την αυτοεκτίμηση των τελειόφοιτων φοιτητών ιατρικής στην πραγματοποίηση επιλεγμένων κλινικών δεξιοτήτων.Introduction: Simulation-based teaching combined with supervised clinical practice, are the necessary steps for safe and systematic clinical skills education. Building medical students’ self-esteem during their undergraduate studies has a positive effect in their competence but is not sufficient to ensure successful clinical skills performance. The aim of the study was to assess senior medical students’ self-reported competence before graduation in basic clinical skills and explore potential correlations with early simulation-based clinical skills teaching. Methods: We conducted a cross-sectional study in final-year medical students one month before their graduation. We invited senior medical students to self-report their competence in 42 basic clinical skills using an online anonymous questionnaire. Medical students’ participation in the clinical skills lab (CSL) elective course was the main factor of analysis. Results: Senior medical students’ response rate in our electronic study was 24.6%. Thirty-four students (38.6%) have attended CSL elective course. Attending CSL seemed to influence senior medical students’ self-reported competence in performing the 15 skills taught in the elective course in comparison with students who have not attended it (p>0.05). There was no statistical difference between the two groups in regard to other basic skills that were not taught in the CSL. Conclusion: Our results indicate that senior medical students do not feel competent enough to perform basic clinical skills that the undergraduate medical curricula should cover. Systematic clinical skills teaching in early years of medical studies before patient contact seemed to be enough to change senior medical students’ self-reported competence in specific clinical skills

Prevention of orthodontic enamel demineralization: a systematic review with meta‐analyses

Aim of this systematic review was to assess the efficacy of preventive interventions against the development of white spot lesions (WSLs) during fixed appliance orthodontic treatment. Nine databases were searched without limitations in September 2018 for randomized trials. Study selection, data extraction and risk of bias assessment were done independently in duplicate. Random-effects meta-analyses of mean differences (MDs) or relative risks (RRs) with their 95% confidence intervals (CIs) were conducted, followed by sensitivity analyses, and the GRADE analysis of the evidence quality. A total of 24 papers (23 trials) were included, assessing preventive measures applied either around orthodontic brackets (21 trials; 1427 patients; mean age 14.4 years) or molar bands (2 trials; 46 patients; age/sex not reported). Active patient reminders were associated with reduced WSL incidence on patient level compared to no reminder (3 trials; 190 patients; RR: 0.4; 95% CI: 0.31-0.64; Number Needed to Treat [NNT]: 3 patients), flat surface sealants were associated with reduced WSL incidence on tooth level than no sealant (5 trials; 2784 teeth; RR: 0.8; 95% CI: 0.63-0.95; NNT: 33 teeth), and fluoride varnish was associated with reduced WSL severity on tooth level (2 trials; 1160 teeth; MD: -0.32 points; 95% CI: -0.44 to -0.21 points). However, the quality of evidence was low according to GRADE, due to risk of bias. Some evidence indicates that active patient reminders and flat surface sealants or fluoride varnish around orthodontic brackets might be associated with reduced WSL burden, but further research is needed. Keywords: adverse effects; clinical trials; dental caries; evidence-based medicine; fixed appliances; systematic review

Artificial pancreas treatment for outpatients with type 1 diabetes: systematic review and meta-analysis.

OBJECTIVE: To evaluate the efficacy and safety of artificial pancreas treatment in non-pregnant outpatients with type 1 diabetes. DESIGN: Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES: Medline, Embase, Cochrane Library, and grey literature up to 2 February 2018. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials in non-pregnant outpatients with type 1 diabetes that compared the use of any artificial pancreas system with any type of insulin based treatment. Primary outcome was proportion (%) of time that sensor glucose level was within the near normoglycaemic range (3.9-10 mmol/L). Secondary outcomes included proportion (%) of time that sensor glucose level was above 10 mmol/L or below 3.9 mmol/L, low blood glucose index overnight, mean sensor glucose level, total daily insulin needs, and glycated haemoglobin. The Cochrane Collaboration risk of bias tool was used to assess study quality. RESULTS: 40 studies (1027 participants with data for 44 comparisons) were included in the meta-analysis. 35 comparisons assessed a single hormone artificial pancreas system, whereas nine comparisons assessed a dual hormone system. Only nine studies were at low risk of bias. Proportion of time in the near normoglycaemic range (3.9-10.0 mmol/L) was significantly higher with artificial pancreas use, both overnight (weighted mean difference 15.15%, 95% confidence interval 12.21% to 18.09%) and over a 24 hour period (9.62%, 7.54% to 11.7%). Artificial pancreas systems had a favourable effect on the proportion of time with sensor glucose level above 10 mmol/L (-8.52%, -11.14% to -5.9%) or below 3.9 mmol/L (-1.49%, -1.86% to -1.11%) over 24 hours, compared with control treatment. Robustness of findings for the primary outcome was verified in sensitivity analyses, by including only trials at low risk of bias (11.64%, 9.1% to 14.18%) or trials under unsupervised, normal living conditions (10.42%, 8.63% to 12.2%). Results were consistent in a subgroup analysis both for single hormone and dual hormone artificial pancreas systems. CONCLUSIONS: Artificial pancreas systems are an efficacious and safe approach for treating outpatients with type 1 diabetes. The main limitations of current research evidence on artificial pancreas systems are related to inconsistency in outcome reporting, small sample size, and short follow-up duration of individual trials

Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).

Glycemic management in type 2 diabetes mellitus has become increasingly complex and, to some extent, controversial, with a widening array of pharmacological agents now available (1–5), mounting concerns about their potential adverse effects and new uncertainties regarding the benefits of intensive glycemic control on macrovascular complications (6–9). Many clinicians are therefore perplexed as to the optimal strategies for their patients. As a consequence, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) convened a joint task force to examine the evidence and develop recommendations for antihyperglycemic therapy in nonpregnant adults with type 2 diabetes. Several guideline documents have been developed by members of these two organizations (10) and by other societies and federations (2,11–15). However, an update was deemed necessary because of contemporary information on the benefits/risks of glycemic control, recent evidence concerning efficacy and safety of several new drug classes (16,17), the withdrawal/restriction of others, and increasing calls for a move toward more patient-centered care (18,19). This statement has been written incorporating the best available evidence and, where solid support does not exist, using the experience and insight of the writing group, incorporating an extensive review by additional experts (acknowledged below). The document refers to glycemic control; yet this clearly needs to be pursued within a multifactorial risk reduction framework. This stems from the fact that patients with type 2 diabetes are at increased risk of cardiovascular morbidity and mortality; the aggressive management of cardiovascular

Hydrotherapy (Project Hydriades)

Natural resources are being used for the maintenance of health. According to the Law 3498/2006 of the Greek Parliament the natural health spas must be validated for their therapeutic properties. The Association of Municipalities and Communities of Health Springs of Greece signed a contract with the Research Committee of the Aristotle University of Thessaloniki, Greece, in order to conduct the research programme: ‘Study for the documentation of the therapeutic properties of the thermomineral waters’. The main aim of the project is: (1) the study of biological and therapeutic parameters of the natural health sources, (2) the identification of the indications and contraindications of hydrotherapy. Aims parallel to the main ones have been also set

Albiglutide and cardiovascular outcomes in patients with type 2 diabetes and cardiovascular disease (Harmony Outcomes): a double-blind, randomised placebo-controlled trial

Background: Glucagon-like peptide 1 receptor agonists differ in chemical structure, duration of action, and in their effects on clinical outcomes. The cardiovascular effects of once-weekly albiglutide in type 2 diabetes are unknown. We aimed to determine the safety and efficacy of albiglutide in preventing cardiovascular death, myocardial infarction, or stroke. Methods: We did a double-blind, randomised, placebo-controlled trial in 610 sites across 28 countries. We randomly assigned patients aged 40 years and older with type 2 diabetes and cardiovascular disease (at a 1:1 ratio) to groups that either received a subcutaneous injection of albiglutide (30–50 mg, based on glycaemic response and tolerability) or of a matched volume of placebo once a week, in addition to their standard care. Investigators used an interactive voice or web response system to obtain treatment assignment, and patients and all study investigators were masked to their treatment allocation. We hypothesised that albiglutide would be non-inferior to placebo for the primary outcome of the first occurrence of cardiovascular death, myocardial infarction, or stroke, which was assessed in the intention-to-treat population. If non-inferiority was confirmed by an upper limit of the 95% CI for a hazard ratio of less than 1·30, closed testing for superiority was prespecified. This study is registered with ClinicalTrials.gov, number NCT02465515. Findings: Patients were screened between July 1, 2015, and Nov 24, 2016. 10 793 patients were screened and 9463 participants were enrolled and randomly assigned to groups: 4731 patients were assigned to receive albiglutide and 4732 patients to receive placebo. On Nov 8, 2017, it was determined that 611 primary endpoints and a median follow-up of at least 1·5 years had accrued, and participants returned for a final visit and discontinuation from study treatment; the last patient visit was on March 12, 2018. These 9463 patients, the intention-to-treat population, were evaluated for a median duration of 1·6 years and were assessed for the primary outcome. The primary composite outcome occurred in 338 (7%) of 4731 patients at an incidence rate of 4·6 events per 100 person-years in the albiglutide group and in 428 (9%) of 4732 patients at an incidence rate of 5·9 events per 100 person-years in the placebo group (hazard ratio 0·78, 95% CI 0·68–0·90), which indicated that albiglutide was superior to placebo (p<0·0001 for non-inferiority; p=0·0006 for superiority). The incidence of acute pancreatitis (ten patients in the albiglutide group and seven patients in the placebo group), pancreatic cancer (six patients in the albiglutide group and five patients in the placebo group), medullary thyroid carcinoma (zero patients in both groups), and other serious adverse events did not differ between the two groups. There were three (<1%) deaths in the placebo group that were assessed by investigators, who were masked to study drug assignment, to be treatment-related and two (<1%) deaths in the albiglutide group. Interpretation: In patients with type 2 diabetes and cardiovascular disease, albiglutide was superior to placebo with respect to major adverse cardiovascular events. Evidence-based glucagon-like peptide 1 receptor agonists should therefore be considered as part of a comprehensive strategy to reduce the risk of cardiovascular events in patients with type 2 diabetes. Funding: GlaxoSmithKline

Large expert-curated database for benchmarking document similarity detection in biomedical literature search

Document recommendation systems for locating relevant literature have mostly relied on methods developed a decade ago. This is largely due to the lack of a large offline gold-standard benchmark of relevant documents that cover a variety of research fields such that newly developed literature search techniques can be compared, improved and translated into practice. To overcome this bottleneck, we have established the RElevant LIterature SearcH consortium consisting of more than 1500 scientists from 84 countries, who have collectively annotated the relevance of over 180 000 PubMed-listed articles with regard to their respective seed (input) article/s. The majority of annotations were contributed by highly experienced, original authors of the seed articles. The collected data cover 76% of all unique PubMed Medical Subject Headings descriptors. No systematic biases were observed across different experience levels, research fields or time spent on annotations. More importantly, annotations of the same document pairs contributed by different scientists were highly concordant. We further show that the three representative baseline methods used to generate recommended articles for evaluation (Okapi Best Matching 25, Term Frequency-Inverse Document Frequency and PubMed Related Articles) had similar overall performances. Additionally, we found that these methods each tend to produce distinct collections of recommended articles, suggesting that a hybrid method may be required to completely capture all relevant articles. The established database server located at https://relishdb.ict.griffith.edu.au is freely available for the downloading of annotation data and the blind testing of new methods. We expect that this benchmark will be useful for stimulating the development of new powerful techniques for title and title/abstract-based search engines for relevant articles in biomedical research.Peer reviewe

The effect of hyperinsulinemia on renotobular sodium transport in single - kidney patients

The present study is about renal tubular transport of Na⁺ using the technique of constant lithium clearance periods. The study was conducted pre and post nephrectomy, in two groups of patients, insulin-sensitive and insulin-resistant, who were sorted according to the insulin-dependent glucose disposal rate (M), as it was derived from a hyperinsulinemic euglycemic insulin clamp. Renal tubular transport of Na⁺ under hyperinsulinemia was also studied. In the study participated 18 patients (14 male and 4 female). The patients underwent nephrectomy due to unilateral kidney disease. Patients with personal or familial history of arterial hypertension or diabetes were excluded. None of the subjects was receiving any medication known to interfere with renal sodium handling. The personal data of the patients are summarized in chart 4. The day before the study, 24h urine was collected and the subjects were receiving 600 mg of carbon-lithium (Milithin). The study started on 8.00 am and included: a) a basal period (40 min), and b) a hyperinsulinemia euglycemic clamp, lasting 2 hours. After the end of the basal period, insulin infusion was initiated, initially with a 100 mU/m² min rate for 5 min, then 60 mU/m² min for another 5 min, and finally 40 mU/m² min for the rest of the study. For the maintenance of euglycemia, a 20% glucose solution was infused, with variant rate, according to the level of plasma glucose, which was assessed every 5 min. For the calculation of insulin-dependent glucose disposal rate (M) we used the mean glucose infusion rate during the last 40 min of the study. According to M, patients were sorted in two groups: group A (insulin - sensitive M > 4 mg/kg BW min) and group B (insulin - resistant M 4 mg/kg ΒΣ min). Επίσης μελετήθηκε η σωληναριακή μεταφορά του Na⁺ υπό την επίδραση εξωγενώς χορηγούμενης ινσουλίνης. Στη μελέτη μας συμμετείχαν 18 ασθενείς (14 άνδρες και 4 γυναίκες). Τα άτομα αυτά υποβλήθηκαν σε νεφρεκτομή λόγω ετερόπλευρης νεφρικής νόσου. Από τη μελέτη αποκλείσθηκαν ασθενείς με ατομικό ή οικογενειακό ιστορικό αρτηριακής υπέρτασης ή σακχαρώδη διαβήτη. Κανένα από τα εξετασθέντα άτομα δε λάμβανε φάρμακα που επηρεάζουν τη νεφρική αποβολή του νατρίου. Τα γενικά χαρακτηριστικά των ασθενών φαίνονται στον πίνακα 4. Την προηγούμενη της μελέτης ημέρα γινόταν 24ωρη συλλογή ούρων και οι ασθενείς λάμβαναν 600 mg ανθρακικό λίθιο (Milithin). Η μελέτη ξεκινούσε στις 8:00 πμ και περιελάμβανε: α) τη βασική περίοδο διάρκειας 40 min, και β) την ευγλυκαιμική υπερινσουλιναιμική ΔΙΑ (δοκιμασία ινσουλινικού αποκλεισμού – hyperinsulinemic euglycemic clamp) διάρκειας 2 ωρών. Μετά το πέρας της βασικής περιόδου, άρχιζε η έγχυση ινσουλίνης, αρχικά με ρυθμό 100 mU/m²- min για πέντε λεπτά, στη συνέχεια 60 mU/m²- min για άλλα πέντε λεπτά, και τέλος 40 mU/m²- min για το υπόλοιπο τμήμα της μελέτης. Για τη διατήρηση ευγλυκαιμίας, γινόταν έγχυση διαλύματος γλυκόζης 20%, με ρυθμό ανάλογο των επιπέδων γλυκόζης πλάσματος, η οποία μετρούνταν ανά 5 λεπτά. Για τον υπολογισμό του ρυθμού ινσουλινοεξαρτώμενης κατανάλωσης γλυκόζης (Μ) χρησιμοποιήθηκε ο μέσος όρος του ρυθμού έγχυσης γλυκόζης κατά τα τελευταία δύο 20λεπτα. Με βάση αυτόν (Μ) οι μελετηθέντες χωρίσθηκαν σε 2 ομάδες: την ομάδα Α (ινσουλινοευαίσθητοι Μ > 4 mg/kg ΒΣ – min) και την ομάδα Β (ινσουλινοάντοχοι Μ 4 mg/kg ΒΣ – min). Διενεργήθηκαν συνολικά 4 περίοδοι καθάρσεων, 1 πριν και 3 κατά τη διάρκεια του ευγλυκαιμικού υπερινσουλιναιμικού clamp. Σε κάθε περίοδο γινόταν μέτρηση κρεατινίνης, λιθίου και νατρίου ούρων. Επίσης στη μέση κάθε περιόδου λαμβάνονταν δείγματα αίματος για προσδιορισμό κρεατινίνης, λιθίου, νατρίου, γλυκόζης και ινσουλίνης. Στους ασθενείς υπολογίσθηκαν: κάθαρση κρεατινίνης, λιθίου και νατρίου, κλασματική απέκκριση λιθίου και νατρίου, κλασματική εγγύς και άπω επαναρρόφηση νατρίου, απόλυτη εγγύς και άπω επαναρρόφηση νατρίου, διηθούμενο νάτριο και αποβαλλόμενο νάτριο. Η ίδια μελέτη επαναλαμβάνονταν και μετά παρέλευση χρονικού διαστήματος 6 εβδομάδων – 6 μηνών από τη νεφρεκτομή. Από την ανάλυση των αποτελεσμάτων της μελέτης είναι δυνατόν να εξάγουμε τα ακόλουθα συμπεράσματα: 1. Η έγχυση ινσουλίνης συνεπάγεται αντινατριούρηση, η οποία οφείλεται σε αύξηση της επαναρρόφησης στον άπω νεφρώνα. 2. Η αντινατριουρητική δράση της ινσουλίνης είναι χρόνο- και δοσοεξαρτώμενη, όπως προκύπτει από τα ευρήματά μας, τόσο στους ινσουλινοάντοχους όσο και στους ινσουλινοευαίσθητους ασθενείς. Συγκεκριμένα οι ινσουλινοευαίσθητοι εμφανίζουν αύξηση της άπω επαναρρόφησης Na⁺ και ταυτόχρονα ελάττωση της εγγύς 2h μετά την έγχυση. Οι ινσουλινοάντοχοι (χρόνια υπερινσουλιναιμία) εμφανίζουν περαιτέρω αύξηση στην ήδη αυξημένη άπω επαναρρόφηση (δοσοεξαρτώμενη), και ελάττωση στην ήδη ελαττωμένη εγγύς, και για το λόγο αυτό δεν είναι στατιστικά σημαντικές οι διαφορές. 3. Μετά τη νεφρεκτομή οι ασθενείς εμφανίζουν στατιστικά σημαντική αύξηση της GFR/νεφρό και ταυτόχρονα και της FENa. Σύμφωνα με τα ευρήματά μας δεν υφίστανται διαφορές μεταξύ των ινσουλινοάντοχων και ινσουλινοευαίσθητων ασθενών. Αυτό θα μπορούσε να αποδοθεί στη ελαττωμένη εγγύς επαναρρόφηση. Μετά την έγχυση ινσουλίνης η FENa δε μεταβάλλεται σε καμία από τις δύο ομάδες. Αυτό συμβαίνει παρά το γεγονός ότι αυξάνεται η κλασματική άπω επαναρρόφηση (FDRNa), και οφείλεται στην ελάττωση της κλασματικής εγγύς επαναρρόφησης (FPRNa). Αξίζει να επισημανθούν μικρές διαφορές μεταξύ των ινσουλινοευαίσθητων και των ινσουλινοάντοχων (οι ινσουλινοευαίσθητοι εμφανίζουν μεγαλύτερη αύξηση της άπω επαναρρόφησης). Όσον αφορά την εγγύς επαναρρόφηση, μολονότι μετά την έγχυση ινσουλίνης μειώνεται και στις δύο ομάδες, θα πρέπει να επισημανθεί ότι στους ινσουλινοάντοχους η εγγύς επαναρρόφηση είναι ήδη ελαττωμένη σε βασικές συνθήκες (μετά τη νεφρεκτομή). Το εύρημα αυτό ενδεχομένως υποδηλώνει μια προϋπάρχουσα ήδη αύξηση του εξωκυττάριου όγκου με συνακόλουθη ελάττωση της εγγύς επαναρρόφησης