David Hope

Restrictive versus liberal transfusion strategies for older mechanically ventilated critically ill patients: a randomized pilot trial.

Objectives:To compare hemoglobin concentration (Hb), RBC use, and patient outcomes when restrictive or liberal blood transfusion strategies are used to treat anemic (Hb ⩽ 90 g/L) critically ill patients of age ≥ 55 years requiring ≥ 4 days of mechanical ventilation in ICU. Design:Parallel-group randomized multicenter pilot trial. Setting:Six ICUs in the United Kingdom participated between August 2009 and December 2010. Patients:One hundred patients (51 restrictive and 49 liberal groups). Interventions:Patients were randomized to a restrictive (Hb trigger, 70 g/L; target, 71–90 g/L) or liberal (90 g/L; target, 91–110 g/L) transfusion strategy for 14 days or the remainder of ICU stay, whichever was longest. Measurements and Main Results:Baseline comorbidity rates and illness severity were high, notably for ischemic heart disease (32%). The Hb difference among groups was 13.8 g/L (95% CI, 11.5–16.0 g/L); p < 0.0001); mean Hb during intervention was 81.9 (SD, 5.1) versus 95.7 (6.3) g/L; 21.6% fewer patients in the restrictive group were transfused postrandomization (p < 0.001) and received a median 1 (95% CI, 1–2; p = 0.002) fewer RBC units. Protocol compliance was high. No major differences in organ dysfunction, duration of ventilation, infections, or cardiovascular complications were observed during intensive care and hospital follow-up. Mortality at 180 days postrandomization trended toward higher rates in the liberal group (55%) than in the restrictive group (37%); relative risk was 0.68 (95% CI, 0.44–1.05; p = 0.073). This trend remained in a survival model adjusted for age, gender, ischemic heart disease, Acute Physiology and Chronic Health Evaluation II score, and total non-neurologic Sequential Organ Failure Assessment score at baseline (hazard ratio, 0.54 [95% CI, 0.28–1.03]; p = 0.061). Conclusions:A large trial of transfusion strategies in older mechanically ventilated patients is feasible. This pilot trial found a nonsignificant trend toward lower mortality with restrictive transfusion practice.

Symmetry of the face in old age reflects childhood social status

The association of socioeconomic status (SES) with a range of lifecourse outcomes is robust, but the causes of these associations are not well understood. Research on the developmental origins of health and disease has led to the hypothesis that early developmental disturbance might permanently affect the lifecourse, accounting for some of the burden of chronic diseases such as coronary heart disease. Here we assessed developmental disturbance using bodily and facial symmetry and examined its association with socioeconomic status (SES) in childhood, and attained status at midlife. Symmetry was measured at ages 83 (facial symmetry) and 87 (bodily symmetry) in a sample of 292 individuals from the Lothian Birth Cohort 1921 (LBC1921). Structural equation models indicated that poorer SES during early development was significantly associated with lower facial symmetry (standardized path coefficient -.25, p=.03). By contrast, midlife SES was not significantly associated with symmetry. The relationship was stronger in men (-.44, p=.03) than in women (-.12, p=.37), and the effect sizes were significantly different in magnitude (p=.004). These findings suggest that SES in early life (but not later in life) is associated with developmental disturbances. Facial symmetry appears to provide an effective record of early perturbations, whereas bodily symmetry seems relatively imperturbable. As bodily and facial symmetries were sensitive to different influences, they should not be treated as interchangeable. However, markers of childhood disturbance remain many decades later, suggesting that early development may account in part for associations between SES and health through the lifecourse. Future research should clarify which elements of the environment cause these perturbations.

Examiners are most lenient at the start of a two-day OSCE

Abstract Background: OSCEs can be both reliable and valid but are subject to sources of error. Examiners become more hawkish as their experience grows, and recent research suggests that in clinical contexts, examiners are influenced by the ability of recently observed candidates. In OSCEs, where examiners test many candidates over a short space of time, this may introduce bias that does not reflect a candidate’s true ability. Aims: Test whether examiners marked more or less stringently as time elapsed in a summative OSCE, and evaluate the practical impact of this bias. Methods: We measured changes in examiner stringency in a 13 station OSCE sat by 278 third year MBChB students over the course of two days. Results: Examiners were most lenient at the start of the OSCE in the clinical section (β = −0.14, p = 0.018) but not in the online section where student answers were machine marked (β = −0.003, p = 0.965). Conclusions: The change in marks was likely caused by increased examiner stringency over time derived from a combination of growing experience and exposure to an increasing number of successful candidates. The need for better training and for reviewing standards during the OSCE is discussed.

Bodily symmetry increases across human childhood.

BACKGROUND Although bodily symmetry is widely used in studies of fitness and individual differences, little is known about how symmetry changes across development, especially in childhood. AIMS To test how, if at all, bodily symmetry changes across childhood. STUDY DESIGN We measured bodily symmetry via digital images of the hands. Participants provided information on their age. We ran polynomial regression models testing for associations between age and symmetry. SUBJECTS 887 children attending a public science event aged between 4 and 15 years old. OUTCOME MEASURES Mean asymmetry for the eight traits (an average of the asymmetry scores for the lengths and widths of digits 2 to 5). RESULTS Symmetry increases in childhood and we found that this period of development is best described by a nonlinear function. CONCLUSION Symmetry may be under active control, increasing with time as the organism approaches an optimal state, prior to a subsequent decline in symmetry during senescence. The causes and consequences of this contrasting pattern of developmental improvement in symmetry and reversal in old age should be studied in more detail.

More Symmetrical Children Have Faster and More Consistent Choice Reaction Times

Greater cognitive ability in childhood is associated with increased longevity, and speedier reaction time (RT) might account for much of this linkage. Greater bodily symmetry is linked to both higher cognitive test scores and faster RTs. It is possible, then, that differences in bodily system integrity indexed by symmetry may underlie the associations of RT and intelligence with increased longevity. However, RT and symmetry have seldom been examined in the same study, and never in children. Here, in 2 large samples aged 4 to 15 (combined n = 856), we found that more symmetrical children had significantly faster mean choice RT and less variability in RT. These associations of faster and less variable RT with greater symmetry early in life raise the possibility that the determinants of longevity in part originate in processes influencing bodily system integrity early in the life-course.

Report of the MEDINE2 Bachelor of Medicine (Bologna First Cycle) Tuning Project

Abstract Background: European Higher Education institutions are expected to adopt a three-cycle system of Bachelor, Master and Doctor degrees as part of the Bologna Process. Tuning methodology was previously used by the MEDINE Thematic Network to gain consensus on core learning outcomes (LO) for primary medical degrees (Master of Medicine) across Europe. Aims: The current study, undertaken by the MEDINE2 Thematic Network, sought to explore stakeholder opinions on core LO for Bachelor of Medicine degrees. Method: Key stakeholders were invited to indicate, on a Likert scale, to what extent they thought students should have achieved each of the Master of Medicine LO upon successful completion of the first three years of university education in medicine (Bachelor of Medicine). Results: There were 560 responses to the online survey, representing medical students, academics, graduates, employers, patients, and virtually all EU countries. There was broad consensus between respondents that all LO previously defined for primary medical degrees should be achieved to some extent by the end of the first three years. Conclusions: The findings promote integration of undergraduate medical curricula, and also offer a common framework and terminology for discussing what a European Bachelor of Medicine graduate can and cannot do, promoting mobility, graduate employability and patient safety.

The Age of BLood Evaluation (ABLE) randomised controlled trial: description of the UK-funded arm of the international trial, the UK cost-utility analysis and secondary analyses exploring factors associated with health-related quality of life and health-care costs during the 12-month follow-up.

BACKGROUND At present, red blood cells (RBCs) are stored for up to 42 days prior to transfusion. The relative effectiveness and safety of different RBC storage times prior to transfusion is uncertain. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of transfusing fresher RBCs (stored for ≤ 7 days) compared with current standard-aged RBCs in critically ill patients requiring blood transfusions. DESIGN The international Age of BLood Evaluation (ABLE) trial was a multicentre, randomised, blinded trial undertaken in Canada, the UK, the Netherlands and France. The UK trial was funded to contribute patients to the international trial and undertake a UK-specific health economic evaluation. SETTING Twenty intensive care units (ICUs) in the UK, as part of 64 international centres. PARTICIPANTS Critically ill patients aged ≥ 18 years (≥ 16 years in Scotland) expected to require mechanical ventilation for ≥ 48 hours and requiring a first RBC transfusion during the first 7 days in the ICU. INTERVENTIONS All decisions to transfuse RBCs were made by clinicians. One patient group received exclusively fresh RBCs stored for ≤ 7 days whenever transfusion was required from randomisation until hospital discharge. The other group received standard-issue RBCs throughout their hospital stay. MAIN OUTCOME MEASURES The primary outcome was 90-day mortality. Secondary outcomes included development of organ dysfunction, new thrombosis, infections and transfusion reactions. The primary economic evaluation was a cost-utility analysis. RESULTS The international trial took place between March 2009 and October 2014 (UK recruitment took place between January 2012 and October 2014). In total, 1211 patients were assigned to receive fresh blood and 1219 patients to receive standard-aged blood. RBCs were stored for a mean of 6.1 days [standard deviation (SD) ± 4.9 days] in the group allocated to receive fresh blood and 22.0 days (SD ± 8.4 days) in the group allocated to receive standard-aged blood. Patients received a mean of 4.3 RBC units (SD ± 5.2 RBC units) and 4.3 RBC units (SD ± 5.5 RBC units) in the groups receiving fresh blood and standard-aged blood, respectively. At 90 days, 37.0% of patients in the group allocated to receive fresh blood and 35.3% of patients in the group allocated to receive standard-aged blood had died {absolute risk difference 1.7% [95% confidence interval (CI) -2.1% to 5.5%]}. There were no between-group differences in any secondary outcomes. The UK cohort comprised 359 patients randomised and followed up for 12 months for the cost-utility analysis. UK patients had similar characteristics and outcomes to the international cohort. Mean total costs per patient were £32,346 (95% CI £29,306 to £35,385) in the group allocated to receive fresh blood and £33,353 (95% CI £29,729 to £36,978) in the group allocated to receive standard-aged blood. Approximately 85% of the total costs were incurred during the index hospital admission. There were no significant cost differences between the two groups [mean incremental costs for those receiving fresh vs. standard-aged blood: -£231 (95% CI -£4876 to £4415)], nor were there significant differences in outcomes (mean difference in quality-adjusted life-years -0.010, 95% CI -0.078 to 0.057). LIMITATIONS Adverse effects from the exclusive use of older RBCs compared with standard or fresh RBCs cannot be excluded. CONCLUSIONS The use of RBCs aged ≤ 7 days confers no clinical or economic benefit in critically ill patients compared with standard-aged RBCs. FUTURE WORK Future studies should address the safety of RBCs near the end of the current permitted storage age. TRIAL REGISTRATION Current Controlled Trials ISRCTN44878718. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 62. See the NIHR Journals Library website for further project information. The international ABLE trial was also supported by peer-reviewed grants from the Canadian Institutes of Health Research (177453), Fonds de Recherche du Québec - Santé (24460), the French Ministry of Health Programme Hospitalier de Recherche Clinique (12.07, 2011) and by funding from Établissement Français du Sang and Sanquin Blood Supply.

Conducting quantitative educational research: a short guide for clinical teachers.

Report the key background information, the population, the sample, the procedure, the key tests, the results of the tests, associated effect sizes and conclusions. It is often useful to highlight novel methodologies or differences between your results and past research.

Academic performance remains predictive over a five year medical degree

ABSTRACT Considerable efforts have been made to predict success in medical degrees. Much of the work has focused on failing students, so little is known about performance stability in medical students who pass and become doctors. If we can predict performance, we can better plan interventions and set standards. We tested the predictive capability of first year assessment on final year assessment marks in 314 graduating medical students. A linear regression model showed around half the variance in final year performance is explained by first year performance despite the very different nature of early assessment. Marks at graduation can be predicted with some accuracy using only first year results. With this information, we can better anticipate student performance and set defensible passing standards. Either first and final year assessment measures the same underlying attributes (cognitive ability, conscientiousness), first year assessment provides an absolutely critical foundation for graduation, or both.

Using differential item functioning to evaluate potential bias in a high stakes postgraduate knowledge based assessment

BackgroundFairness is a critical component of defensible assessment. Candidates should perform according to ability without influence from background characteristics such as ethnicity or sex. However, performance differs by candidate background in many assessment environments. Many potential causes of such differences exist, and examinations must be routinely analysed to ensure they do not present inappropriate progression barriers for any candidate group. By analysing the individual questions of an examination through techniques such as Differential Item Functioning (DIF), we can test whether a subset of unfair questions explains group-level differences. Such items can then be revised or removed.MethodsWe used DIF to investigate fairness for 13,694 candidates sitting a major international summative postgraduate examination in internal medicine. We compared (a) ethnically white UK graduates against ethnically non-white UK graduates and (b) male UK graduates against female UK graduates. DIF was used to test 2773 questions across 14 sittings.ResultsAcross 2773 questions eight (0.29%) showed notable DIF after correcting for multiple comparisons: seven medium effects and one large effect. Blinded analysis of these questions by a panel of clinician assessors identified no plausible explanations for the differences. These questions were removed from the question bank and we present them here to share knowledge of questions with DIF. These questions did not significantly impact the overall performance of the cohort. Group-level differences in performance between the groups we studied in this examination cannot be explained by a subset of unfair questions.ConclusionsDIF helps explore fairness in assessment at the question level. This is especially important in high-stakes assessment where a small number of unfair questions may adversely impact the passing rates of some groups. However, very few questions exhibited notable DIF so differences in passing rates for the groups we studied cannot be explained by unfairness at the question level.