Joseph M. Norris

Is acupuncture beneficial in the treatment of Bell's palsy?: Best Evidence Topic (BET)

A best evidence topic in facial nerve surgery was written according to a structured protocol. The question addressed was: in [patients with Bells palsy], does [acupuncture] improve [facial nerve function and/or pain]? A total of 43 papers were identified using the reported search protocol, of which three articles represented the best available evidence to answer the clinical question. Two of these articles were review papers and together encompassed 13 primary articles. Publication details, type of study, patients studied, outcomes and results are tabulated. The two level 1 articles concluded that before firm conclusions can be drawn, better designed trials are required in order to establish whether acupuncture confers any benefit to patients with Bells palsy. The level 2 randomised controlled trial (RCT) suggested that two methods of acupuncture were associated with significant improvements in pain in Bells palsy, although the trial was poorly controlled and had risk of bias. Therefore, the clinical bottom line is that until well designed trials are able to clearly demonstrate a role for acupuncture in Bells palsy, its efficacy should be considered to remain unproven.

Surgical management of chronic subdural haematoma: One hole or two?

A best evidence topic in neurosurgery was written according to a structured protocol. The question addressed was: In patients undergoing craniostomy for the evacuation of chronic subdural haematoma, does the use of two burr-holes compared to one burr-hole improve clinical outcomes? A total of 238 papers were identified using the reported search protocol. Four of these articles represented the best evidence to answer the clinical question. The authors, date and country of publication, study type, patient group, outcomes and key results of these papers have been represented in a table. Three out of four studies showed that there was no significant difference in prevalence or rate of haematoma recurrence between two burr-hole craniostomy or one burr-hole craniostomy. Two studies demonstrated shorter hospital stay with two burr-hole craniostomy. Furthermore, one study showed increased rates of wound infection with one burr-hole craniostomy. Therefore, the clinical bottom line is that performing either two burr-hole craniostomy or one burr-hole craniostomy does not provide specific differences in patient outcome improvement following surgery for chronic subdural haematoma, however further research is required owing to the flawed methodology of existing studies.

Medical grade honey in the management of chronic venous leg ulcers

A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was: In patients with chronic venous leg ulcers (CVLU), does the use of medical grade honey as compared to standard wound therapy improve clinical outcomes? A total of 299 papers were identified using the search protocol described, of which five represented the best evidence available to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Two randomised controlled trials arrived at contradictory conclusions: one showing better outcomes for CVLU healing with use of honey over standard wound therapy and the other showing equivalent outcomes but more adverse effects. A third randomised controlled trial showed a non-significant reduction in bacterial colonisation of CVLU with honey compared to standard therapy. Two further studies--a prospective cohort study and a case series--supported the use of honey, but these were of lower grade evidence and had numerous methodological faults. Therefore, the clinical bottom line is that there is no conclusive evidence that honey improves outcome in patients with CVLU, and until more robust trials are conducted, its benefit should be considered unproven.

Surgical versus endovascular management of thrombosed autogenous arteriovenous fistulae

A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was: In patients undergoing haemodialysis with thrombosed autogenous arteriovenous fistulae, does surgical management as compared to endovascular management improve clinical outcomes? A total of 130 papers were identified using the search protocol described, of which four represented the best evidence available to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Three of the four studies demonstrated no significant difference between the initial success rates of surgical or endovascular management. However, one study illustrated that hybrid surgery (a combination of endovascular and surgical techniques) significantly improved initial success rates, shortened hospital stays and decreased total monetary costs. Furthermore, three studies showed that subsequent fistula patency rates were significantly higher when surgical management was instigated. Nevertheless, one study suggested that surgery worsened subsequent patency rates and that in fact surgical patients were more likely to require temporary dialysis catheters than endovascular patients. Therefore, the clinical bottom line is that with careful patient and fistula selection, surgery provides a number of benefits over endovascular management of thrombosed autogenous arteriovenous fistulae, particularly in the medium to long term. However, further appropriately powered and randomised Level 1 studies are necessary to clarifying this important issue.

Comparison of 640-Slice Multidetector Computed Tomography Versus 32-Slice MDCT for Imaging of the Osteo-odonto-keratoprosthesis Lamina.

Purpose: To investigate the efficacy of 640-slice multidetector computed tomography (MDCT) for detecting osteo-odonto laminar resorption in the osteo-odonto-keratoprosthesis (OOKP) compared with the current standard 32-slice MDCT. Methods: Explanted OOKP laminae and bone–dentine fragments were scanned using 640-slice MDCT (Aquilion ONE; Toshiba) and 32-slice MDCT (LightSpeed Pro32; GE Healthcare). Pertinent comparisons including image quality, radiation dose, and scanning parameters were made. Results: Benefits of 640-slice MDCT over 32-slice MDCT were shown. Key comparisons of 640-slice MDCT versus 32-slice MDCT included the following: percentage difference and correlation coefficient between radiological and anatomical measurements, 1.35% versus 3.67% and 0.9961 versus 0.9882, respectively; dose–length product, 63.50 versus 70.26; rotation time, 0.175 seconds versus 1.000 seconds; and detector coverage width, 16 cm versus 2 cm. Conclusions: Resorption of the osteo-odonto lamina after OOKP surgery can result in potentially sight-threatening complications, hence it warrants regular monitoring and timely intervention. MDCT remains the gold standard for radiological assessment of laminar resorption, which facilitates detection of subtle laminar changes earlier than the onset of clinical signs, thus indicating when preemptive measures can be taken. The 640-slice MDCT exhibits several advantages over traditional 32-slice MDCT. However, such benefits may not offset cost implications, except in rare cases, such as in young patients who might undergo years of radiation exposure.

The Transference of a Successful Strategy to the Care of Stroke Patients

In the United Kingdom, stroke is the second greatest cause of mortality, the single greatest cause of significant morbidity, and the cause of 4–6% of the total National Health Service (NHS) annual expenditure (1,2). Thus, any improvement in the care of stroke patients would reduce the healthcare burden on the population significantly. At the heart of any improvement of care should be research and utilization of evidence-based practice. All UK adult cardiac surgical patients have their details registered in a national database and the impact of this has been staggering (3). There has been a reduction in mortality, morbidity, and the numbers of operations on patients who were previously believed to be ‘dangerous’ without any scientific rationale. This whole project has resulted in anecdotally maintained misconceptions being replaced with evidence-based practice. The transference of this idea to stroke medicine could have similar results. A greater data set would allow for advanced understanding of stroke care, helping to dispel spurious anecdotal beliefs, while conclusively identifying true risk factors and their impact on treatment. There are several parallels between adult cardiac surgery and stroke patients, namely: • the majority of the patient population is elderly • the cases of non-elderly pathology are rare • the time-critical nature of the work, and • the presence of comorbidity is higher than in other patient groups Stroke is an exigent problem in an aging population. Improvement in stroke management will follow the placement of large volume, high-quality evidence at the heart of patient care. In the stroke service, this will advance shortand long-term outcomes for all patients and ensure maximum efficiency of service provision across the whole country.

Defining Surgical Role Models and Their Influence on Career Choice

Dear Editor, We read with great interest Ravindra and Fitzgerald’s article on the effect of role models on choosing to pursue a surgical career [1]. Their questionnaire-based study lucidly demonstrates the strong influence of role models and they make pertinent observations regarding the need to encourage surgical interest. Choosing whether to enter a surgical specialty is a significant decision and it is crucial that the influencing factors are considered fully. Whilst role models are undoubtedly important, we propose that lack of early exposure to certain surgical disciplines may dissuade potential applicants from applying to surgical training. Role models can have a persuasive effect on choosing a surgical career and which branch is pursued; however, they usually arise sporadically from chance allocation to surgical firms during medical school. In the UK, application to core surgical training occurs during the second postgraduate year. This decision to commit to surgery is based largely on surgical experience in medical school and surgical postgraduate internships. But at this early stage, is this enough? Experience as an undergraduate is crucial in determining the career choice of the young doctor, equal to any effect role models may have [2]. What little time may be spent on surgery in foundation/internship posts will likely involve much ward administration, providing less time to ‘‘explore’’ the speciality than during medical school. However, undergraduate surgical experience is far from comprehensive and often there is a paucity of exposure to many of the more niche surgical specialties such as oromaxillofacial and cardiothoracic surgery. Indeed, the strong influence of role models may even be warped by the brief undergraduate/intern experience: a positive role model may well persuade one to pursue his/her specialty, whilst a negative one (e.g., a clash of personalities) may taint the speciality forever. There is little time to establish a balanced view; therefore, one’s decision is not truly informed. In addition to formative experiences, fortuitous allocation to productive and engaging surgical firms that actively involve students in audits and research may actually bolster the portfolios of a few lucky students with publications. Furthermore, these types of firms are also more likely to provide positive role models. Finally, it is impossible for undergraduates to fully appreciate the ramifications of becoming a senior surgeon in a particular speciality, in which they will spend the majority of their career. Students who identify role models are also more likely to discuss potential lifestyle implications—some of the most influential factors when considering a surgical career [3]. With these issues in mind, it is of paramount importance to maximise surgical exposure during the undergraduate period, allowing all surgical specialities to be experienced. Undergraduate surgical conferences and events may provide an effective method of compensating for the brevity of exposure in each field. Moreover, the abundance of keen and helpful senior surgeons at these events represents a prime bank of potential role models. M. D. Smith J. M. Norris D. R. McGowan (&) Brighton and Sussex Medical School, BSMS Teaching Building, University of Sussex Campus, Brighton, East Sussex BN1 9PX, UK e-mail: d.mcgowan1@uni.bsms.ac.uk

PubMed fever: A disease sweeping medical students?

article reported about it in Malaysia settings. This study aimed to evaluate its psychometric properties in a sample of Malaysian medical students. It was designed to answer a few questions: (1) Is DREEM a valid and reliable tool to measure educational climate in the studied population?, (2) What is the best fit model of DREEM in the studied population? (3) Does internal consistency vary across years of study? The author carried out a cross-sectional study on 656 medical students. A total of 511 (77.9%) medical students completely responded to the DREEM: 156 (30.5%) first year, 196 (38.4%) third year and 159 (31.1%) fifth year. Majority of them were female (61.1%). Confirmatory factor analysis (CFA) and reliability analysis were analysed by SPSS version 18 and AMOS 19 to assess the construct validity and internal consistency. The CFA showed that the proposed five-factor structure of the original DREEM was not fit as all the goodness of fit indices did not signify for model fit. This finding consistent with previous studies reported that its construct validity was not well supported by the empirical data (Jakobsson et al. 2011). On further CFA, the author found that the five-factor structure of DREEM with 17 items (i.e. the shortened DREEM) was fit as all the indices signify for model fit. Cronbach’s alpha values across years of study for the subscales of both DREEM versions ranged between 0.53 and 0.82. Our study did not support the proposed five-factor structure of DREEM. The shortened version demonstrated a better fit with the proposed model and was found to be as reliable as the original version across years of study. Continued research is required to verify and maximize psychometric credentials of the DREEM across institutions and nationalities.

Situational judgement tests for medical students: really the best way to determine your future?

Final year of medical school represents a period of intense anguish for students in the United Kingdom (UK). In addition to pressure that examinations exert, students must also spend time applying for their first job to the Foundation Programme. Infamously, this system has been fraught with complications since its inception in 2005. From the debacle of Modernising Medical Careers and the negative ramifications that this had on student applications, to the 2007 scandal in which hundreds of students’ confidential details were inadvertently leaked; the entire scheme has been surrounded by controversy (Day 2007). There has been a significant new addition to the process for final year students applying in 2012 – the Situational Judgement Test (SJT). We perceive this as a concerning change to an already complicated procedure and that a brief discussion is highly pertinent. SJTs are a well-validated and highly regarded method of assessing applicants’ ability and prowess at analysing situations and determining most appropriate courses of action (Koczwara et al. 2012). They are used in a range of different fields outside of medicine, but within healthcare, their assessment in application to general practice is most prominent. SJTs are not used routinely in undergraduate education and have never been used as a selection tool for the Foundation Programme. As of 2012, SJTs will form 50% of the application process for final year medical students, and as such, will play an enormous role in determining students’ immediate future: greater than the medical degree itself, performance throughout medical school, publications, presentations, posters or prizes. We find this fact somewhat alarming. As applicant numbers continue to soar, we must strive for optimal methods of evaluation and aim to evolve our assessment tools; often, this will warrant introduction of new examinations, but this must be done with utmost care. An informal pilot scheme was run to gauge final year medical students’ reactions to the SJT and some positive feedback was received. Whether those who genuinely take the test will share these feelings shall emerge in early 2013. Hopefully, the UK Foundation Programme Office’s bold decision to introduce the SJT into the tumultuous process of appointing junior doctors shall transpire to be a success story – but only time will tell. In the meantime, we urge UK medical schools to offer support, advice and preparation for their students approaching this enigmatic examination, in what must be a tremendously nerve-wracking period of their education.

The homogenisation of medical students: A necessary evil?

reported they ‘‘thought differently’’ about sexual orientation, sexual lifestyle choices and TOP, respectively. Students reporting being more comfortable when dealing with differing sexual orientations, behaviours and TOP were 133 (63%), 155 (73.5%) and 130 (61.6%), respectively. In view of these positive results, the teaching session is now permanent within Edinburgh’s undergraduate curriculum. This technique could be considered by other sexual health departments struggling to deliver experiential learning to students.