Learning from errors:Assessing final year medical students' reflection on safety improvement, five year cohort study

Abstract Background Investigation of real incidents has been consistently identified by expert reviews and student surveys as a potentially valuable teaching resource for medical students. The aim of this study was to adapt a published method to measure resident doctors’ reflection on quality improvement and evaluate this as an assessment tool for medical students. Methods The design is a cohort study. Medical students were prepared with a tutorial in team based learning format and an online Managing Incident Review course. The reliability of the modified Mayo Evaluation of Reflection on Improvement tool (mMERIT) was analysed with Generalizability G-theory. Long term sustainability of assessment of incident review with mMERIT was tested over five consecutive years. Results A total of 824 students have completed an incident review using 167 incidents from NHS Tayside’s online reporting system. In order to address the academic practice gap students were supervised by Senior Charge Nurses or Consultants on the wards where the incidents had been reported. Inter-rater reliability was considered sufficiently high to have one assessor for each student report. There was no evidence of a gradient in student marks across the academic year. Marks were significantly higher for students who used Section Questions to structure their reports compared with those who did not. In Year 1 of the study 21 (14%) of 153 mMERIT reports were graded as concern. All 21 of these students achieved the required standard on resubmission. Rates of resubmission were lower (3% to 7%) in subsequent years. Conclusions We have shown that mMERIT has high reliability with one rater. mMERIT can be used by students as part of a suite of feedback to help supplement their self-assessment on their learning needs and develop insightful practice to drive their development of quality, safety and person centred professional practice. Incident review addresses the need for workplace based learning and use of real life examples of mistakes, which has been identified by previous studies of education about patient safety in medical schools

Perivascular Expression and Potent Vasoconstrictor Effect of Dynorphin A in Cerebral Arteries

BACKGROUND: Numerous literary data indicate that dynorphin A (DYN-A) has a significant impact on cerebral circulation, especially under pathophysiological conditions, but its potential direct influence on the tone of cerebral vessels is obscure. The aim of the present study was threefold: 1) to clarify if DYN-A is present in cerebral vessels, 2) to determine if it exerts any direct effect on cerebrovascular tone, and if so, 3) to analyze the role of κ-opiate receptors in mediating the effect. METHODOLOGY/PRINCIPAL FINDINGS: Immunohistochemical analysis revealed the expression of DYN-A in perivascular nerves of rat pial arteries as well as in both rat and human intraparenchymal vessels of the cerebral cortex. In isolated rat basilar and middle cerebral arteries (BAs and MCAs) DYN-A (1-13) and DYN-A (1-17) but not DYN-A (1-8) or dynorphin B (DYN-B) induced strong vasoconstriction in micromolar concentrations. The maximal effects, compared to a reference contraction induced by 124 mM K(+), were 115±6% and 104±10% in BAs and 113±3% and 125±9% in MCAs for 10 µM of DYN-A (1-13) and DYN-A (1-17), respectively. The vasoconstrictor effects of DYN-A (1-13) could be inhibited but not abolished by both the κ-opiate receptor antagonist nor-Binaltorphimine dihydrochloride (NORBI) and blockade of G(i/o)-protein mediated signaling by pertussis toxin. Finally, des-Tyr(1) DYN-A (2-13), which reportedly fails to activate κ-opiate receptors, induced vasoconstriction of 45±11% in BAs and 50±5% in MCAs at 10 µM, which effects were resistant to NORBI. CONCLUSION/SIGNIFICANCE: DYN-A is present in rat and human cerebral perivascular nerves and induces sustained contraction of rat cerebral arteries. This vasoconstrictor effect is only partly mediated by κ-opiate receptors and heterotrimeric G(i/o)-proteins. To our knowledge our present findings are the first to indicate that DYN-A has a direct cerebral vasoconstrictor effect and that a dynorphin-induced vascular action may be, at least in part, independent of κ-opiate receptors

Pacing and Decision Making in Sport and Exercise: The Roles of Perception and Action in the Regulation of Exercise Intensity

In pursuit of optimal performance, athletes and physical exercisers alike have to make decisions about how and when to invest their energy. The process of pacing has been associated with the goal-directed regulation of exercise intensity across an exercise bout. The current review explores divergent views on understanding underlying mechanisms of decision making in pacing. Current pacing literature provides a wide range of aspects that might be involved in the determination of an athlete's pacing strategy, but lacks in explaining how perception and action are coupled in establishing behaviour. In contrast, decision-making literature rooted in the understanding that perception and action are coupled provides refreshing perspectives on explaining the mechanisms that underlie natural interactive behaviour. Contrary to the assumption of behaviour that is managed by a higher-order governor that passively constructs internal representations of the world, an ecological approach is considered. According to this approach, knowledge is rooted in the direct experience of meaningful environmental objects and events in individual environmental processes. To assist a neuropsychological explanation of decision making in exercise regulation, the relevance of the affordance competition hypothesis is explored. By considering pacing as a behavioural expression of continuous decision making, new insights on underlying mechanisms in pacing and optimal performance can be developed. © 2014 Springer International Publishing Switzerland

Minimally invasive surgery and cancer: controversies part 1

Perhaps there is no more important issue in the care of surgical patients than the appropriate use of minimally invasive surgery (MIS) for patients with cancer. Important advances in surgical technique have an impact on early perioperative morbidity, length of hospital stay, pain management, and quality of life issues, as clearly proved with MIS. However, for oncology patients, historically, the most important clinical questions have been answered in the context of prospective randomized trials. Important considerations for MIS and cancer have been addressed, such as what are the important immunologic consequences of MIS versus open surgery and what is the role of laparoscopy in the staging of gastrointestinal cancers? This review article discusses many of the key controversies in the minimally invasive treatment of cancer using the pro–con debate format

Development of a compact system for in-situ X-ray scattering studies of organic thin film deposition

We have developed a compact vacuum deposition chamber for in-situ x-ray scattering studies of organic thin film growth. The system is based on a small cylindrical chamber that can be mounted on a standard four-circle diffractometer. Incident and scattered x-rays enter and exit the chamber through a curved Be foil window that covers 200 degrees, and is sealed to the body of the chamber. The sample is mounted on a support tube with heating and cooling from liquid nitrogen temperature to >100°C. Integral to the sample stage is a multi-wire feedthrough to facilitate in-situ electrical transport characterization of organic semiconductor thin films. This is one of the novel capabilities of the system. In addition, the sample stage is mounted on a rotary vacuum feedthrough, which is mechanically coupled to the "phi" stage of the diffractometer. An effusion cell, shutter, and quartz oscillator thickness monitor are also incorporated into the system, which is pumped by a small turbomolecular pump. The system thus configured is capable of access to full reciprocal space, within the limits of the Be window. Results of initial experiments performed at the 48-pole wiggler beamline A2, at the Cornell High Energy Synchrotron Source show that in-situ x-ray scattering is sensitive to the early stages of nucleation and growth of organic semiconductor thin films

Early stages of pentacene film growth on silicon oxide

Among the various materials suitable for organic thin-film transistors (OTFTs), pentacene stands out as a model molecule, exhibiting one of the highest field effect mobilities reported so far. Understanding the growth mechanism of pentacene on dielectrics is essential for controlling film morphology and for fabricating high quality, large-grain, defect-free films. Such films will help us gain insight into the fundamentals of transport in organic films as well as enable the ultimate OTFT performance. In situ synchrotron X-ray scattering was used to probe the early stages of pentacene growth on SiO2 in real time and under conditions relevant to the fabrication of OTFTs. Reflectivity measurements reveal that a thin layer of water, initially present on the substrate, is trapped at the interface when the pentacene film is deposited. Therefore, the interface relevant for OTFTs is that between pentacene and water. Anti-Bragg oscillations, observed for the first time during organic film growth, reveal that the first monolayer of pentacene completes fully before the second one nucleates. Subsequent layers nucleate before the underlying layers complete, giving rise to the characteristic island structure observed in pentacene films used in OTFTs. A simple distributed growth model was found to adequately describe the growth mechanism. © 2004 Elsevier B.V. All rights reserved

Growth dynamics of pentacene thin films: Real-time synchrotron x-ray scattering study

Real-time synchrotron x-ray scattering in the anti-Bragg configuration was used to monitor the dynamics of pentacene film growth on inert substrates. A distributed-growth model, according to which pentacene molecules adsorbed on the nth layer can either nucleate and contribute to the growth of the (n+1) th layer or transfer downward and contribute to the growth of the nth layer, gave a good description of the data. For molecules adsorbed on the first and second layers, the probability of downward transfer was found to be dependent on the substrate, and independent of temperature within the range from 25 to 60°C. For films grown on Si O2, an Ehrlich-Schwoebel barrier of the order of 70 meV dominated downward transfer of pentacene molecules in layers away from the substrate. For films grown on an alkylated self-assembled monolayer, significant desorption of pentacene molecules from the substrate at elevated temperatures forced the growth mode toward the three-dimensional limit. © 2006 The American Physical Society

Orientation of pentacene films using surface alignment layers and its influence on thin-film transistor characteristics

We have investigated the effect of surface order on the orientation and mobility of pentacene. The surface order was created using monolayers and polymers that are normally used to align liquid crystals. Rubbed polyvinylalcohol layers were found to align approximately 27% of the pentacene grains within a 30° range. When introduced in a thin-film transistor, they were found to enhance the saturation current by a factor of 2.5. A mechanism for this enhancement is proposed. © 2001 American Institute of Physics

Structure of pentacene thin films

Grazing incidence x-ray diffraction, x-ray reflectivity and atomic force microscopy have been performed to study the structure of pentacene thin films on oxidized Si substrates from submonolayer to multilayer coverages. The volume of the unit cell in the thin film phase is almost identical to that of the bulk phase, thus the molecular packing efficiency is effectively the same in both phases. The structure forming from the first monolayer remains the same for films at least 190 Å thick. The in-plane structure of the submonolayer islands also remains unchanged within a substrate temperature range of 0< Tsub <45 °C while the island size changes by more than a factor of 4. © 2004 American Institute of Physics

Structure of a pentacene monolayer deposited on SiO<inf>2</inf>: Role of trapped interfacial water

In situ synchrotron x-ray reflectivity is used to probe the early stages of pentacene growth in real time, under conditions relevant to the fabrication of organic thin film transistors. The results reveal that there is an interfacial water layer initially present on the Si O2 substrate and that this water layer is still present at the interface after the deposition of a pentacene thin film. The thickness of the trapped interfacial water layer does not significantly change subsequent to film deposition, even after exposure to atmospheric pressure or during vacuum annealing at 70 °C. However, a water layer is observed to form on the free surface of pentacene after sufficient exposure to water vapor, and the thickness of this layer can be reduced by subsequent vacuum annealing. These observations are correlated with organic thin film transistor mobilities measured at atmospheric pressure versus under vacuum. © 2006 American Institute of Physics