Tzu-Chieh Yu

Medical students-as-teachers: a systematic review of peer-assisted teaching during medical school

Introduction International interest in peer-teaching and peer-assisted learning (PAL) during undergraduate medical programs has grown in recent years, reflected both in literature and in practice. There, remains however, a distinct lack of objective clarity and consensus on the true effectiveness of peer-teaching and its short- and long-term impacts on learning outcomes and clinical practice. Objective To summarize and critically appraise evidence presented on peer-teaching effectiveness and its impact on objective learning outcomes of medical students. Method A literature search was conducted in four electronic databases. Titles and abstracts were screened and selection was based on strict eligibility criteria after examining full-texts. Two reviewers used a standard review and analysis framework to independently extract data from each study. Discrepancies in opinions were resolved by discussion in consultation with other reviewers. Adapted models of “Kirkpatrick’s Levels of Learning” were used to grade the impact size of study outcomes. Results From 127 potential titles, 41 were obtained as full-texts, and 19 selected after close examination and group deliberation. Fifteen studies focused on student-learner outcomes and four on student-teacher learning outcomes. Ten studies utilized randomized allocation and the majority of study participants were self-selected volunteers. Written examinations and observed clinical evaluations were common study outcome assessments. Eleven studies provided student-teachers with formal teacher training. Overall, results suggest that peer-teaching, in highly selective contexts, achieves short-term learner outcomes that are comparable with those produced by faculty-based teaching. Furthermore, peer-teaching has beneficial effects on student-teacher learning outcomes. Conclusions Peer-teaching in undergraduate medical programs is comparable to conventional teaching when utilized in selected contexts. There is evidence to suggest that participating student-teachers benefit academically and professionally. Long-term effects of peer-teaching during medical school remain poorly understood and future research should aim to address this.

A systematic review of resident-as-teacher programmes

Context  Residents in all disciplines serve as clinical teachers for medical students. Since the 1970s, there has been increasing evidence to demonstrate that residents wish to teach and that they respond positively to formal teacher training. Effective resident‐as‐teacher (RaT) programmes have resulted in improved resident teaching skills. Current evidence, however, is not clear about the specific features of an effective RaT programme.

Randomized clinical trial of goal‐directed fluid therapy within an enhanced recovery protocol for elective colectomy

Goal‐directed fluid therapy (GDFT) has been compared with liberal fluid administration in non‐optimized perioperative settings. It is not known whether GDFT is of value within an enhanced recovery protocol incorporating fluid restriction. This study evaluated GDFT under these circumstances in patients undergoing elective colectomy.

Preoperative Glucocorticoid Use in Major Abdominal Surgery Systematic Review and Meta-Analysis of Randomized Trials

Objective: To determine the clinical safety and efficacy of preoperative glucocorticoid (GC) administration in major abdominal surgery with regards to short term outcomes. Background: Previous randomized controlled trials (RCTs) in major abdominal surgery have displayed conflicting results regarding the short-term benefits of preoperative GC administration. Importantly, the safety of this intervention has not been conclusively determined. Methods: A systematic review and quantitative meta-analysis was conducted of all RCTs exploring preoperative GC administration in major abdominal surgery for the endpoints of complications, hospital length of stay (LOS) and serum IL-6 on postoperative day one. Subset analyses by procedure were planned “a priori.” Results: Eleven RCTs of moderate quality, comprising 439 patients in total, were included in the final analysis. Preoperative GC use decreased complications (OR = 0.37; 95% CI, 0.21–0.64; P < 0.01), LOS (mean = 1.97 days; 95% CI, −3.33 to −0.61; P = 0.01), and serum IL-6 (mean: −55 pg/mL; 95% CI, −82.30 to −27.91; P < 0.01). Preoperative GCs decreased complications in hepatic resection (OR = 0.28; 95% CI, 0.14–0.55; P < 0.01) and mean LOS (mean LOS: −2.66; 95% CI, −5.01 to −0.32; P = 0.03). GCs reduced mean LOS in patients undergoing colorectal surgery (mean LOS: −0.98; 95% CI, −1.67 to −0.27; P = 0.01). There was no difference in complication rates (OR: 0.45; 95% CI, 0.16–1.32; P = 0.15) or anastomotic leaks specifically. Conclusions: Preoperative administration of GCs decreases complications and LOS after major abdominal surgery as a likely consequence of attenuating the postsurgical inflammatory response. There is no evidence of increased complications in colorectal surgery.

Systematic review of breast cancer biology in developing countries (part 1): Africa, the middle East, eastern europe, Mexico, the Caribbean and South america.

There has been no systematic appraisal of ethnicity-based variations in breast cancer (BC) biology amongst women from developing countries. A qualitative systematic review was conducted of breast cancer size, stage, grade, histological type, extra-mammary involvement, hormone receptor status as well as patient demographics. This review includes patients from Africa, the Middle East, Eastern Europe, Mexico, the Caribbean and South America. BC in these regions present at an earlier age with large aggressive tumours. Distant metastases are frequently present at the time of diagnosis. African women have a higher frequency of triple negative tumours. Over half of Middle Eastern women have lymph node involvement at the time of diagnosis. Despite experiencing a lower incidence compared to the Ashkenazi Jewish population, Palestinian women have poorer five-year survival outcomes. The majority of women from Mexico and South America have stage two or three disease whilst over sixty percent of women from Eastern Europe have either stage one or stage two disease. The biological characteristics of BC in the Caribbean cannot be fully assessed due to a paucity of data from the region. BC amongst the developing world is characterised by an early peak age of onset with aggressive biological characteristics. Strategies that improve breast cancer awareness, address amenable risk factors and improve early detection are essential.

Systematic Review of Breast Cancer Biology in Developing Countries (Part 2): Asian Subcontinent and South East Asia

There has been no systematic appraisal of ethnicity-based variations in breast cancer (BC) biology amongst women from developing countries. A qualitative systematic review was conducted of breast cancer size, stage, grade, histological type, extra-mammary involvement, hormone receptor status as well as patient demographics. This review includes patients from Africa, the Middle East, Eastern Europe, Mexico, the Caribbean and South America. BC in these regions present at an earlier age with large aggressive tumours. Distant metastases are frequently present at the time of diagnosis. African women have a higher frequency of triple negative tumours. Over half of Middle Eastern women have lymph node involvement at the time of diagnosis. Despite experiencing a lower incidence compared to the Ashkenazi Jewish population, Palestinian women have poorer five-year survival outcomes. The majority of women from Mexico and South America have stage two or three disease whilst over sixty percent of women from Eastern Europe have either stage one or stage two disease. The biological characteristics of BC in the Caribbean cannot be fully assessed due to a paucity of data from the region. BC amongst the developing world is characterised by an early peak age of onset with aggressive biological characteristics. Strategies that improve breast cancer awareness, address amenable risk factors and improve early detection are essential.

Warm, Humidified Carbon Dioxide Gas Insufflation for Laparoscopic Appendicectomy in Children: A Double-blinded Randomized Controlled Trial

Objective:To investigate clinical benefits of warm, humidified carbon dioxide (CO2) insufflation for acute laparoscopic appendicectomy on postoperative pain and recovery in children (age 8–14 years). Background:Conventional CO2 insufflation leads to desiccation-related peritoneal inflammation and injury, which is preventable with warm, humidified CO2 gas. We hypothesized that reduced peritoneal desiccation would improve patient-centered outcomes in children after laparoscopic appendicectomy. Method:A double-blinded, randomized controlled trial was conducted. Intervention group participants received warm (37°C), humidified (98% relative humidity) CO2 gas insufflation, whereas control participants received standard room temperature (20°C) gas with 0% relative humidity. Perioperative analgesia and anesthesia were standardized. Postoperative opiate usage was converted to morphine equivalent daily dosages (MEDD) for comparison, and pain intensity at rest and on moving was rated by participants using visual analog scales. Postoperative recovery and return to normal activities was assessed using a questionnaire on day 10. Results:Between February 2010 and March 2011, a total of 190 participants were randomized. Both intervention and control groups were matched at baseline. Postoperative MEDD and pain scores were also similar. There were no differences in postoperative recovery parameters. Conclusions:Warm, humidified CO2 insufflation for acute laparoscopic appendicectomy has no short-term clinical benefits on postoperative outcomes in pediatric patients (ClinicalTrials.gov trial identifying code: NCT01027455).

The relationship between academic assessment and psychological distress among medical students: a systematic review

A systematic review was conducted to determine the relationship between academic assessment and medical student psychological distress with the aim of informing assessment practices. A systematic literature search of six electronic databases (Medline, Medline IN PROCESS, PubMed, EMBASE, Psychinfo, ERIC) from 1991 to May 2014 was completed. Articles focusing on academic assessment and its relation to stress or anxiety of medical students were included. From 3,986 potential titles, 82 full-text articles were assessed for eligibility, and 23 studies met review inclusion criteria. Studies focused on assessment stress or anxiety, and assessment performance. Consistent among the studies was the finding that assessment invokes stress or anxiety, perhaps more so for female medical students. A relationship may exist between assessment stress or anxiety and impaired performance. Significant risks of bias were common in study methodologies. There is evidence to suggest academic assessment is associated with psychological distress among medical students. However, differences in the types of measures used by researchers limited our ability to draw conclusions about which methods of assessment invoke greater distress. More rigorous study designs and the use of standardized measures are required. Future research should consider differences in students’ perceived significance of assessments, the psychological effects of constant exposure to assessment, and the role of assessment in preparing students for clinical practice.

Factors Influencing Intentions of Female Medical Students to Pursue a Surgical Career

abstracts for potentially relevant articles and these wereobtained in full text for closer inspection. The final selec-tion of articles was based on the following criteria:1. Published in English after 1990.2. Study results not duplicated in earlier publications.3. A significant proportion of study participants (>60%)were students enrolled in a medical program.4. Study results identified factors that influence studentintentions to pursue a career in surgery, and in partic-ular, general surgery. Studies that focused on interestin surgical specialties were included, given that thisalways included general surgery, but those that focusedon only 1 surgical subspecialty other than generalsurgery (eg, orthopaedics, urology, cardiothoracic,vascular) were excluded. No standard definitions wereapplied to the terms surgery and surgical specialties.5. If participants included women and men, study inves-tigators analyzed the data by sex to identify sex-specificfactors and draw separate conclusions about womenand men.Data management techniquesData extractionA standardized data extraction and critical appraisalinstrument was constructed by the investigators usingan electronic spreadsheet (Microsoft Excel Mac OS X2008, Microsoft Corporation) for the purpose of thisreview and included the following sections andcomponents:1. Study introduction: research objectives and rationale.2. Study context: study setting, details of study partici-pants, description of medical program.3. Study methods and materials: study design, participantrecruitment and sampling, study duration and follow-up, method(s) of data collection, psychometric proper-ties of data collection instruments, resources used, anddata analysis.4. Study results: main study findings, measures of func-tional significance (effect size, proportion of variance),attendance and drop-out rates.5. Discussion of study results: significance and practicalimplications of study findings, study strengths andlimitations, guidance on future research topics.6. Study conclusions.7. Appraisal for risks of bias: recruitment or selectionbias, data analysis and interpretation bias, incompleteand selective reporting bias, other sources of bias.Each selected article was analyzed independently by atleast 2 investigators (TY, AJ, and MC) and data wereextracted using the instrument described above.Data analysisDiscrepancies in opinions between 2 investigators wereidentified and final consensus was reached through face-to-face discussions and mediation by the other investiga-tors. The investigators analyzed study methodologies,defined common themes from study findings, and triedto find chronologic patterns in their occurrence. Selectedstudies were divided into 2 groups: those published beforeand during the year 2000 and those published after 2000.Career-influencing factors directly reported by studentparticipants were differentiated from factors that wereidentified indirectly through means such as data correla-tion and association analysis.

Use of Statins in Adhesive Small Bowel Obstruction

BACKGROUND Adhesive small bowel obstruction (ASBO) causes considerable morbidity and may require surgical intervention. The role of statins in adhesion prevention is of increasing interest, though no investigation of its impact on ASBO and operative rates has been conducted. This study investigates the impact of statin use on operative rates in ASBO. METHODS A retrospective review of all patients with ASBO within our institution from January 1997 to December 2007 was conducted. Demographic data, potential confounders, and treatment received (conservative/operative) were recorded. Statistical significance was determined using the two-tailed Fishers exact test for categorical data and the Mann-Whitney U test for continuous data. Univariate and logistic regression were conducted to control for potential known confounders. RESULTS There were 419 cases of ASBO with 253 (60.4%) females. The median age of diagnosis was 62 (15-93) years and the median ASA score was 2 (1-4). Forty-nine (11.7%) patients required operative management, the median day-stay was three (1-154) d and 151 (36%) patients were taking statins. On univariate analysis, statin use was associated with decreased operative rates (P = 0.02). The relative risk was 0.46 with an absolute risk reduction of 7.9% (95% CI: 2.1%-13.7%). The number needed to treat was 13 (NNT = 13; 95% CI: 7.3-46.8). Statin use was associated with decreased operative rates using a logistic regression model (P = 0.04). CONCLUSION Statin use is independently associated with decreased operative rates in ASBO.