John Hanrahan

Developing a novel international undergraduate surgical masterclass during a financial crisis: our 4-year experience

Background Essential Skills in the Management of Surgical Cases (ESMSC) is a novel 3-day international undergraduate surgical masterclass. Its current curriculum (Cores integrated for Research—Ci4R) is built on a tetracore, multiclustered architecture combining high-fidelity and low-fidelity simulation-based learning (SBL), with applied and basic science case-based workshops, and non-technical skills modules. We aimed to report our experience in setting up ESMSC during the global financial crisis. Methods We report the evolution of our curriculum’s methodology and summarised the research outcomes related to the objective performance improvement of delegates, the educational environment of the course and the use of mixed-fidelity SBL. Feedback from the last three series of the course was prospectively collected and analysed using univariate statistics on IBM SPSS V.23. Results 311 medical students across the European Union (EU) were selected from a competitive pool of 1280 applicants during seven series of the course between 2014 and 2017. During this period, curriculum 14 s evolved to the final Ci4R version, which integrates a tetracore structure combining 32 stations of in vivo, ex vivo and dry lab SBL with small group teaching workshops. Ci4R was positively perceived across different educational background students (p>0.05 for any comparison). Conclusions ESMSC is considered an innovative and effective multidisciplinary teaching model by delegates, where it improves delegates objective performance in basic surgical skills. Our experience demonstrates provision of high-quality and free surgical education during a financial crisis, which evolved through a dynamic feedback mechanism. The prospective recording and subsequent analysis of curriculum evolution provides a blueprint to direct development of effective surgical education courses that can be adapted to local needs.

O1.2 PERIPHERAL INFLAMMATORY MARKERS ARE PREDICTIVE OF CLINICAL CHARACTERISTICS AND OUTCOME IN PSYCHOSIS

Abstract Background Dysregulation of the immune system represents an important vulnerability factor for schizophrenia. A rise in peripheral inflammatory markers has previously been demonstrated in psychosis; however, its significance remains uncertain. Characterising this relationship aids our understanding of the role of immunological factors in psychosis, as well as potentially identifying candidate biomarkers to guide diagnosis, treatment and prognosis. Whilst specialized inflammatory marker assays have been found to be associated with outcome and treatment, these tests are not typically available in clinical practice. We sought to establish whether routine inflammatory markers are associated with clinical characteristics and outcomes in patients with schizophrenia and related disorders. Methods A multi-site cohort study of patients admitted to an acute psychiatric ward between January 2013 and December 2016 within a large Mental Health Trust was undertaken. Cases were identified from an electronic database containing full clinical records. Inclusion criteria were patients aged 18 and 65 years with a discharge diagnosis of schizophrenia, or related disorder and a routine blood test within 3 days of admission. Exclusion criteria were diagnoses of drug-induced psychosis, organic brain disorder, or admission during the perinatal period. Pro-inflammatory (white blood cell total and differential count, C-reactive protein) and anti-inflammatory markers (albumin) recorded during the admission were extracted. Clinical characteristics were based upon the Health of the Nation Outcome Scale, a 12-item clinician rated tool contemporaneously rated at admission and discharge. Results A total of 968 patients met the inclusion criteria. 309 patients were female and mean age was 38 years. The most frequent ethnicities were White, Black African, Black Other and Black Caribbean and the commonest diagnoses were schizophrenia, unspecified non-organic psychosis and schizoaffective disorder. Mean interval from admission to admission blood test was 0.8 days. Patients with affective psychosis had a significantly higher white cell count, monocyte count and lymphocyte count than patients with non-affective psychosis on admission. Furthermore, among patients with affective psychosis, a partial correlation controlling for age, body mass index, blood pressure, physical health and smoking status found a significant association between symptom severity and monocyte count. There was a highly significant association between both neutrophil count and white cell count with hallucinatory symptoms. There was also a highly significant positive association between C-reactive protein and self-injurious behaviour, replicating recently published findings in smaller samples. There was a significant reduction in overall psychiatric symptoms over the course of admission, which was significantly associated with admission monocyte count. A partial correlation found white cell count and neutrophil count at admission were associated with reductions in hallucinatory symptoms. Eosinophil count was significantly associated with admission length. Discussion In a large cohort of patients admitted due to psychotic disorder, pro-inflammatory markers were associated with affective psychosis and overall symptom severity, and predicted admission length and reduction in symptom severity. The study supports an association between immune dysregulation and psychosis. Furthermore, the study highlights the role of routinely and inexpensively measured peripheral inflammatory markers as potential diagnostic and prognostic biomarkers in psychosis.

Posterior fossa arachnoid cyst causing torticollis and gastro-oesophageal reflux in an infant

IntroductionArachnoid cysts (ACs) account for a small proportion of all intracranial lesions. They are often incidental but can become symptomatic and even cause a threat to life. Symptoms are usually due to direct compression of neural elements and/or raised intracranial pressure.Case reportWe report the case of an infant with an enlarging posterior fossa arachnoid cyst (PFAC) causing torticollis and gastro-oesophageal reflux (GOR), the combination of which had been previously unreported in this context. Endoscopic fenestration and cyst decompression were followed by complete resolution of the symptoms. We discuss the possible mechanisms of torticollis and GOR in this context.

Developing a novel framework for non-technical skills learning strategies for undergraduates: a systematic review

Objectives There is substantial lack of guidance when it comes to the implementation of non-technical skills (NTS) in undergraduate medical education. This review aimed to identify and critically evaluate published literature on learning strategies for NTS in undergraduate medical education and to derive a training framework targeted towards standardizing future training interventions. Methods A systematic review of the MEDLINE database was performed using a prospective protocol following PRISMA guidelines. Studies evaluating undergraduate medical students exposed to NTS interventions, which measured subjective or objective outcomes in selected attributes, were included. Results Initial systematic search yielded a total of 5079 articles, out of which 68 fulfilled the inclusion criteria. A total of 24 NTS were identified, with communication skills being the most commonly reported skill evaluated (n = 37). A variety of educational tools were used (n = 32), noteworthy being the use of simulated patients. Great heterogeneity was also observed in measured outcomes and methods of assessment. A ‘triad of outcomes’ in NTS training was devised (knowledge, skill performance and attitude towards skills) and used for classification of all reported outcomes. Extracted data were used to design a non-technical skill training framework. Conclusions The existing literature describes a plethora of NTS interventions in undergraduate medical education, with varied outcomes and assessments. We hereby propose the ‘NTS Training Framework’, in an attempt to coordinate future research and catalyze the identification of an ideal NTS course structure to form tomorrows physicians.

Increasing motivation and engagement in neurosurgery for medical students through practical simulation-based learning

Background Simulation-based learning (SBL) is an essential adjunct to modern surgical education. Our study aimed to evaluate the educational benefit and motivational impact of a pilot practical neurosurgical module. Materials and methods 38 clinical medical students from several EU Medical Schools attended an international surgical course focused on teaching and learning basic surgical skills. We designed a pilot neurosurgical workshop instructing students to insert an intracranial pressure bolt using an ex vivo pig model. Each delegate was assessed by two consultant neurosurgeons using a validated assessment tool. Structured questionnaires were distributed on completion of the module. Results Delegate performance increased (p < 0.001) with no difference in performance improvement across year of study (p = 0.676) or medical school (p = 0.647). All delegates perceived this workshop as a potential addition to their education (median 5/5, IQR = 0), and indicated that the course provided motivational value towards a neurosurgical career (median 4/5, IQR = 1), with no difference seen between year of study or medical school (p > 0.05). Conclusion Our pilot neurosurgical workshop demonstrated the educational value of practical SBL learning for motivating students towards a surgical career. Homogeneous views across year of study and medical school underline the value of developing a unified strategy to develop and standardise undergraduate surgical teaching with a practical focus.

Hands train the brain—what is the role of hand tremor and anxiety in undergraduate microsurgical skills?

IntroductionPhysiological hand tremor occurs naturally, due to oscillations of the upper extremities. Tremor can be exacerbated by stress and anxiety, interfering with fine motor tasks and potentially impact on surgical performance, particularly in microsurgery. We investigated the link between tremor, anxiety and performance in a neurosurgical module as part of an international surgical course.MethodsEssential Skills in the Management of Surgical Cases (ESMSC) course recruits medical students from European Union (EU) medical schools. Students are asked to suture the dura mater in an ex vivo swine model, of which the first suture completed was assessed. Questionnaires were distributed before and after the module, eliciting tremor risk factors, self-perception of tremor and anxiety. Johnson O’Connor dexterity pad was used to objectively measure dexterity. Direct Observation of Procedural Skills (DOPS) was used to assess skills-based performance. Anxiety was assessed using the Westside Test Anxiety Scale (WTAS). Tremor was evaluated by four qualified neurosurgeons.ResultsForty delegates participated in the study. Overall performance decreased with greater subjective perception of anxiety (p = 0.032, rho = − 0.392). Although increasing scores for tremor at rest and overall WTAS score were associated with decreased performance, this was not statistically significant (p > 0.05). Tremor at rest did not affect dexterity (p = 0.876, rho = − 0.027).ConclusionsPhysiological tremor did not affect student performance and microsurgical dexterity in a simulation-based environment. Self-perception of anxiety affected performance in this module, suggesting that more confident students perform better in a simulated neurosurgical setting.

24 Is it feasible to use routine clinical records to investigate biomarkers in schizophrenia and related disorders

Objective There is interest in identifying reliable prognostic biomarkers in schizophrenia and related disorders. Serum inflammatory markers, such as white cell count and C-reactive protein (CRP), have been shown to be elevated during psychotic episodes; however, their pathogenic role is uncertain. There is limited data relating to their variability in clinical practice and relationship to clinical outcome. We have sought to investigate whether routine clinical case records contain the necessary data to further understand the relationship between serum inflammatory markers and prognosis. Method This is a retrospective case note review of patients admitted to an inner city female acute psychiatry ward. Cases were identified by reviewing electronic ward round records. Patients included had a diagnosis of non-affective, non-drug induced psychosis (schizophrenia, acute and transient psychotic disorder, persistent delusional disorder, schizotypal disorder and nonorganic psychosis) and had received a routine admission blood test. Exclusion criteria included pregnancy, significant recreational drug use prior to admission, clinical evidence of infection or history of inflammatory or haematological disease. Results A total of 20 patients met the inclusion criteria between April 2015 and October 2016. Mean age was 43 years (SD=15) and the most common ethnicities were White British (23%), Mixed Ethnicity (23%), and Caribbean (23%). The majority of cases were detained under the Mental Health Act (68%) and had previously been treated with antipsychotic medication (94%). Mean admission duration was 38 days (SD=30) and average time from admission to routine admission blood test was 4 days (SD=3 days). Admission duration was moderately positively correlated with white cell count (r=0.41, n=20, p=0.07), platelet count (r=0.40, n=20, p=0.08) and albumin (r=0.42, n=20, p=0.07). Admission duration was weakly correlated with neutrophil count (r=0.27, n=20, p=0.24) and CRP (r=−0.22, n=20, p=0.35). When patients split according to those above and below the median admission length, patients with longer admissions had significantly higher platelet count (p<0.05) only. Conclusion This small retrospective review suggests that in routine clinical case practice information is collected which could be used to explore the role of inflammatory markers as prognostic biomarkers in patients with schizophrenia and related disorders. Despite our extremely small sample we have found a positive correlation between platelet count and admission length. However this needs to be considered in the presence of multiple confounders. Use of electronic patient databases may be helpful in extending the sample to formally establish any prognostic relationships.

How does the publication fate of abstracts presented at the Society of British Neurological Surgeons meetings differ five years on

We read with great interest the article published in the British Journal of Neurosurgery entitled ‘Publication fate of abstracts presented at the Society of British Neurological Surgeons meetings’. This paper looked at the publication rate for abstracts presented at the SBNS Spring and Autumn meetings from 2001–2005. They considered a number of factors such as publication rate (36.6%) and average time to publication (22 months). We set out to investigate the same over the subsequent 5-yearperiod (2006–2010) to provide a comparison. Similar to the authors of the 2015 paper, we cross-referenced the titles and names of authors from abstracts published in SBNS proceedings with Pubmed and Google Scholar. A total of 620 abstracts were presented during this period at nine different meetings. This represents a 25.5% increase in the number of abstracts presented over the preceding 5 years (2000–2005). We found 213 of these abstracts had been published resulting in a publication rate of 34.4%. This figure is similar, but slightly lower than that reported by Jamjoom and colleagues. It is possible that this is because some of the abstracts are yet to be published. However, we have performed this analysis six years after the most recent conference included (2010) which is well beyond the average publication time (22 months) reported by Jamjoom et al. In addition, in our cohort we found the average time to publications was 24 months. The range was from 1 month and up to 127 months. The highest time to publication was for the RESCUEICP trial which was first presented in 2006, when the trial was just beginning, and was published in 2016. Excluding this paper, the longest time to publication would have been 78 months. Twenty of the abstracts were published prior to presentation. We also looked at some of the other factors considered by Jamjoom et al. in their original paper. For example, the number of citations in our cohort ranged from 0 to 346 (median1⁄4 21, mean1⁄4 36). We report a median that is very close to the 22 reported by Jamjoom et al., although the maximum number of citations is lower. This could be partly explained by the time difference between our analysis (6 years after the last conference in our series) and the Jamjoom analysis (10 years after the last conference in their series). Ponce and Lozano reviewed the most highly cited works in neurosurgery in 2010, and found the number of citations in the top 100 most cited papers in neurosurgery ranged from 287 to 1515. We found 15 papers had over 100 citations and 4 papers had over 250 citations which supports the high quality of papers presented at SBNS conferences. We also looked at the institution and country the authors were based in and found that 86.7% were based in the UK. Other countries with institutions represented at the SBNS meetings included: Australia, Canada, Denmark, France, Germany, Greece, Italy and the USA. 6.1% of abstracts were from multicentre collaborations. As it may be logistically more difficult for abstracts from international research groups to be presented in the UK, abstracts from UK research groups dominate the proceedings. We also looked at the most commonly chosen journals for publication. We found the top three journals were the British Journal of Neurosurgery (24.4%), the Journal of Neurosurgery (7.50%) and Neurosurgery (6.57%). These were the same three journals, and at similar rates, reported by Jamjoom et al. The median impact factor of all the journals was 2.126 (0.25–59.57). In our cohort, the most common field of interest for publications was ‘Spinal’ (17.4%) followed by neurovascular (13.1%). Neurovascular was found to be the most common by Jamjoom and colleagues (26%) with only 7% being categorised as ‘Spinal’. Publications were categorised according to the session in which they were presented at the SBNS. If it was not clear then the publication was categorised according to our interpretation. Our findings support a growing trend in spinal surgery research. In conclusion, we found a very similar pattern of publication of SBNS presentations between 2000–2005 and 2006–2010. The number of abstracts presented had, however, increased but the similar publication rate, time to publication and number of citations all suggest that the quality of work presented has remained high.