Joanne Burke

Peer‐assisted learning: a novel approach to clinical skills learning for medical students

Objective  This study aimed to determine whether peer‐assisted learning (PAL) can enhance clinical examination skills training.

Peer-assisted learning in the acquisition of clinical skills: a supplementary approach to musculoskeletal system training

Background: This study evaluates whether peer-assisted learning (PAL) can be used to improve students’ clinical examination skills. Methods: Four year 4 students trained in PAL techniques and musculoskeletal (MSS) examination used the Gait, Arms, Legs and Spine (GALS) system in a five-week student selected module. These students then recruited and trained 28 second-year trainees. Trainees were evaluated using pre/post confidence questionnaires (100 mm visual analogue scale), a course experience questionnaire (five-point Likert scales) and end-of-year objective structured clinical examination (OSCE) scores. Results: Baseline data from the experimental group were no different from a separate control group, but after training a statistically significant difference in confidence levels was observed in all parts of GALS, <38 to >73 (p < 0.0001). Course experience questionnaires demonstrated benefits in all parameters including communication skills and group work with all students recommending PAL training. In end-of-year OSCE 93% of PAL-trained students passed the MSS examination station compared with 67% for those participating in the standard curriculum alone (p < 0.0001). Examination results for other clinical skill stations showed no difference in performance between the two groups. Conclusions: This study shows that PAL is a useful adjunct to MSS training, and could be incorporated into medical curricula to enhance clinical skills.

Undergraduate rheumatology: can peer-assisted learning by medical students deliver equivalent training to that provided by specialist staff?

OBJECTIVE This study addressed whether medical students using peer-assisted learning (PAL) can deliver training comparable with didactic teaching provided by a specialist. METHODS Twelve senior students were trained in PAL and the gait, arms, legs, spine (GALS) screening technique for musculoskeletal system (MSS) examination. The students recruited and trained 45 year-2 students in the use of GALS. Nineteen students were recruited by a physiotherapist for GALS training tutorials. Trainee responses were compared by analysis of pre/post training confidence (using 100 mm visual analogue scale), course experience questionnaires (using a 5-point Likert scale) including free text comments, and in end of year examinations. RESULTS Trainee confidence increased after PAL training from 3.7 to 89.9 (P < 0.0001). There were no significant differences in confidence levels from student trainees after PAL when compared with expert-led teaching. Results from course experience questionnaires demonstrated benefits in all parameters investigated with all students recommending PAL training. No differences between PAL and expert-led training were observed. Free-text comments showed that PAL-trained students perceived that this learning technique has potential to be applied to other areas of training, an observation not raised by expert-trained students. Examination results revealed that PAL-trained and expert-tutored students were respectively, 1.4 and 1.3 times more likely to pass the MSS examination, when compared with students undertaking standard training (P < 0.002 and P = 0.0001, respectively). CONCLUSION PAL is a useful adjunct to musculoskeletal clinical skills training. Students using PAL techniques offered a comparable level of training with that provided by an expert.

Temporal differences in the expression of mRNA for IL‐10 and IFN‐γ in the brains and spleens of C57BL/10 mice infected with Toxoplasma gondii

C57BL/10 Sc Sn (B10) mice infected orally with Toxo‐plasma gondii tissue cysts were killed at regular intervals up to day 116 post infection (p.i.) and their brains excised. These were used either to count the total number of cysts in the brain, for RNA purification or histopathological studies. Mortality levels in a parallel group of T. gondii infected B10 mice were also monitored and regular plasma samples taken to measure specific antibody production. Seventy per cent of mice died within the first 35 days of infection. Thereafter deaths were infrequent. Inflammation in the brain was apparent from day 10 onwards and by day 25 there was widespread astrocyte activation, perivascular cuffing, meningitis and extensive encephalitis. Total cyst numbers increased rapidly from day 15 to day 35 when they peaked. By day 60, however, cyst numbers had dropped dramatically and this decrease continued through to day 116. Using the polymerase chain reaction mRNA transcripts for IFN‐γ were detected from the first time point sampled, day 25 p.i., until the end of the study. Transcripts for IL‐10, an inhibitor of IFN‐γ production, release and activity, were not detected until day 70. The predominant antibody detected against T. gondii was IgG2a but not IgG1. Significantly transcripts for IFN‐γ were found in the spleens of infected but not noninfected animals. Our results suggest that an inflammatory response associated with IFN‐γ production in B10 mice eventually controls T. gondii infection. After the cyst burden has dropped dramatically transcripts for IL‐10 are detected in the brain, perhaps to suppress inflammation, and limit pathology.

Can training in musculoskeletal examination skills be effectively delivered by undergraduate students as part of the standard curriculum

OBJECTIVES There is a need to improve competence of musculoskeletal system (MSS) examination in medical students and junior doctors. Peer-assisted learning (PAL) is a technique whereby students learn from and with each other. This study aimed to determine whether PAL can be integrated into standard undergraduate medical curricula to improve MSS examination using the gait, arms, legs, spine (GALS) screening tool. METHODS Fifty final-year students (trainers) were trained using GALS for MSS examination while attending a standard clinical medical attachment at Glasgow Royal Infirmary. These students delivered GALS training to a further 159 students (trainees). Pre/post-confidence questionnaire (100-mm visual analogue scale) and written feedback were obtained. Final Objective Structured Clinical Examination (OSCE) scores from an MSS station were compared with a control group of 229 students randomized to other hospitals for the standard MSS training. RESULTS Analysis of completed trainer questionnaires (30/50) showed increased confidence in all parts of GALS after training [<47 (19) cf. >88 (12); P < 0.005]. Similarly, confidence in trainees (136/159) who answered the questionnaire increased [<43 (19) cf. >85 (15); P < 0.005]. Written comments highlighted that students would recommend PAL. OSCE results showed 84% (192/229) of students in the control group passed the MSS station, with 87% (139/159) of trainees (P = 0.3) and 100% (50/50) of trainers (P < 0.01). CONCLUSIONS MSS examination skills are improved by integrating PAL into the undergraduate medical curriculum, with student confidence being increased, and higher OSCE scores.

Major acute phase response of haptoglobin and serum amyloid-P following experimental infection of mice with Trypanosoma brucei brucei

Investigation of the pathophysiological role of the systemic cytokines, including interleukin-1, interleukin-6 and tumour necrosis factor α, in the host response to infection with African trypanosomes is hampered by the low and transient concentrations of these cytokines in plasma. One of the actions of these cytokines is the stimulation of hepatocyte production of acute phase proteins such as serum amyloid-P and haptoglobin. These acute phase proteins are more stable in the circulation than the cytokines and can be measured as a means of assessing the systemic cytokine response in the trypanosome-infected host. The plasma concentrations of serum amyloid-P and haptoglobin were measured in an experimental mouse model of Trypanosoma brucei brucei infection. Both serum amyloid-P and haptoglobin, increased markedly following infection. Peak concentrations of serum amyloid-P at 125 μg/ml and haptoglobin at 2 g/l were attained 10 to 12 days after infection. Thereafter, serum amyloid-P concentration decreased to approximately 40 μg/ml while the haptoglobin concentration remained elevated at approximately 1.5 g/l. The reactions of the serum amyloid-P and haptoglobin following experimental Trypanosoma brucei brucei infection in mice demonstrate that a major acute phase response has occurred indicating that the systemic cytokine network has been activated. Further studies are required to identify whether the response is stimulated by the parasite or indirectly by tissue damage.

The role of the polyamine inhibitor eflornithine in the neuropathogenesis of experimental murine African trypanosomiasis

The treatment of late‐stage human African trypanosomiasis is complicated by a post‐treatment reactive encephalopathy, also referred to as a ‘reactive arsenical encephalopathy’, that may be fatal. This study used a well established experimental mouse system to assess the use of the trypanostatic drug, eflornithine, in the management of this post‐treatment reaction. Female CD‐1 mice infected with an eflornithine‐resistant trypanosome stabilate and treated with the trypanocidal compound diminazene aceturate on or after day 21 post‐infection develop a reactive encephalopathy and relapsing parasitaemia. If these animals are re‐treated with diminazene aceturate, a severe encephalopathy develops histologically comparable with that of human cases and characterized by a severe meningoencephalitis and astrogliosis. Histopathological and immunocytochemical examination shows that administration of eflornithine before or after the development of this reactive encephalopathy prevented or ameliorated the inflammatory reaction. Since an eflornithine resistant stabilate was used, this effect appears to be independent of the drugs trypanostatic action and illustrates an important, previously unrecognized, pharmacological property of eflornithine. Consideration can now be given to the use of eflornithine for the management of human trypanosomiasis cases, even where trypanosome resistance to eflornithine exists.

A multi-professional UK wide survey of undergraduate continence education†‡

Findings from national audits and enquiries continue to report that care for patients with continence problems is often substandard and inadequate education is often cited as one of the probable causes. These factors combined with the forecasted increase in the number of people with incontinence prompted us to undertake a survey of all UK Higher Education Institutes (HEIs) to establish the amount of undergraduate continence education within relevant healthcare programs—medical, adult nursing, mental health nursing, learning disabilities nursing, childrens nursing, midwifery, physiotherapy, and occupational therapy.

Secondary bacterial infection in plasma endotoxin levels and the acute-phase response of mice infected with Trypanosoma brucei brucei.

Murine Trypanosoma brucei brucei infection leads to elevated plasma endotoxin‐like activity levels not related to parasitaemia levels accompanied by the development of acute‐phase response and increased plasma levels of serum amyloid P (SAP) and haptoglobin (Hp). To determine the source of the endotoxin‐like activity and role of secondary bacterial infection in the pathogenesis of trypanosomosis, infected mice were treated with the antibiotic ciprofloxacin. Plasma endotoxin‐like activity levels, irrespective of treatment, were elevated three‐ to fourfold, beginning 7 days after infection. Plasma protein concentrations increased markedly following infection from 7 days after infection (DAI). Peak Hp and SAP concentrations in ciprofloxacin‐treated and ‐untreated infected mice were attained 7 and 14 DAI, respectively. Thereafter, both protein levels gradually declined until the end of the experiment, but Hp levels for non‐treated mice declined up to 21 DAI and thereafter significantly increased on 28 and 35 DAI. Whole‐trypanosome lysate and the membrane‐enriched fraction demonstrated endotoxin‐like activity, with the former having higher levels. The results suggest that the endotoxin‐like activity in trypanosome fractions and plasma of infected mice is due to the trypanosome. Further elevation of haptoglobin during the late stages of infection in non‐treated mice suggests the involvement of secondary bacterial infection.

Lipopolysaccharide binding protein in the acute phase response of experimental murine Trypanosoma brucei brucei infection

Cellular responses to lipopolysaccharide (LPS) are enhanced by LPS-binding protein (LBP). The present study investigated the acute phase response of LBP during Trypanosoma brucei brucei infection in mice. Mean plasma concentrations of LBP increased two-fold by the seventh day following infection, but decreased to intermediate levels by the 14th day. There were no significant differences in LBP concentrations of infected/antibiotic-treated and infected/untreated mice. At 35 days post-infection, the infected mice were treated with the anti-trypanosomal diminazine aceturate (Berenil). LBP levels of the mice then decreased to pre-infection levels within one-week. This demonstrated that LBP is an acute phase protein during murine trypanosomosis. Furthermore, opportunistic secondary bacterial infection during trypanosomosis did not seem to play an important role in the changes in plasma LBP levels. We speculate that the marked concomitant increases in plasma LBP and endotoxin-like activity following murine trypanosome infection might play an important role in the pathogenesis of trypanosomosis.