Delivering a modified continuous objective structured clinical examination for ophthalmology residents through a hybrid online method

Since coronavirus disease 2019 was declared a global pandemic by the World Health Organization, it has become a challenging situation to continue medical education, including in Indonesia. The situation prohibited face-to-face (direct) educational activities in clinical settings, therefore also postponing examinations involving especially procedural skills. Adaptations were urgently needed to maintain the delivery of high-stake examinations to sustain the number of ophthalmology graduates and the continuation of eye health service. Objective structured clinical examination (OSCE) has been one of our widely used method to assess clinical competencies for ophthalmology residents, and is the one method that involves gatherings, close contact of examiners, examinees and patients, therefore the most difficult to adjust. Pandemic challenges brought technical changes in our delivering the OSCE to online, maximizing digital platforms of meetings, while still concerned to guarding the safety of candidates, patients and staffs. OSCE scenarios were also made as timely efficient as possible by changing continuous station models to a cascade one. The purpose of this article is to document our experience in conducting a feasible and reproducible OSCE in this pandemic era filled with limitations.

Exploring the perspectives of medical students of application on e-learning in medical education during the COVID-19 pandemic

BACKGROUND: The use of e-learning has become mandatory during the COVID-19 pandemic. However, there are many barriers to applying e-learning in medical education. OBJECTIVE: This study aimed to explore medical students’ perspectives on the application of e-learning in medical education during the COVID-19 pandemic. METHODS: This Q-methodology explorative study was conducted in Kurdistan Region of Iraq. A sample of 37 medical students was purposively selected to represent different characteristics. The students distributed 37 statements representing different aspects of e-learning in medical education into a nine-point scoring grid from “least agree” to “most agree.” RESULTS: Data analysis revealed three distinct viewpoints. The first viewpoint, complete dependence on e-learning, emphasized a preference for e-learning to continue medical education and complete the study year with a minimal return to study halls or practical/clinical sessions. The second viewpoint, opponents of applying e-learning in medical education, included a generally negative view about e-learning and its role in medical education during the COVID-19 pandemic. The third viewpoint, e-learning as a supplement to medical education, emphasized a generally positive view about e-learning and considered it a supplement to the theoretical parts of medical education during the pandemic. CONCLUSION: The three diverse viewpoints are primarily distinguished by the availability of e-learning experience and skills, availability of technology, risk perception of COVID-19, and the need for in-hospital clinical teaching. Provision of necessary facilities and training is required to strengthen the role of e-learning in medical education. A safe environment is needed for on-campus or hospital clinical teaching.

Streptococcus oralis MitraClip endocarditis following a dental procedure: a case report

Background Transcatheter edge-to-edge mitral valve repair using the MitraClip device is increasingly used for high surgical risk patients with severe mitral regurgitation (MR). Previous guidelines for infective endocarditis prophylaxis prior to dental procedures focused on high-risk patients, but without explicit recommendation for MitraClip recipients. We believe this could be the first reported case to identify Streptococcus oralis as the causative organism. Case presentation An 87-year-old male with severe MR treated with two MitraClip devices three months prior to index admission, presented with worsening malaise and intermittent chills on a background of multiple comorbid conditions. The patient had dental work a month prior to presentation, including a root canal procedure, without antibiotic prophylaxis. Vitals were significant for fever and hypotension. On physical examination, there was a holosystolic murmur at the apex radiating to the axilla, bilateral pitting edema in the lower extremities, and elevated jugular venous pulsation. A transthoracic echocardiogram showed severe MR with a possible echodensity on the mitral valve, prompting a transesophageal echocardiogram, which demonstrated a pedunculated, mobile mass on the posterior leaflet of the mitral valve. Five blood cultures grew gram positive cocci in pairs and chains, later identified as Streptococcus oralis, with minimum inhibitory concentration to penicillin 0.06 mg/L. Initial empiric antibiotics were switched to ceftriaxone 2 gr daily and subsequent blood cultures remained negative. However, the patient developed pulmonary edema and worsening hemodynamic instability requiring vasopressors. As surgical risk for re-operation was considered prohibitive, the decision was made to continue medical management and comfort-directed care. The patient died a week later. Conclusions Despite low incidence, infective endocarditis should be included in the differential among MitraClip recipients. The explicit inclusion of this growing patient population in the group requiring prophylaxis prior to dental procedures in the 2020 ACC/AHA valvular heart disease guidelines is an important step forward.

The evolution of Cuban medical diplomacy

The author examines the evolution of Cuban medical diplomacy under the governments of Raul Castro and Miguel Diaz-Canel. The author shows that the essence of the Cuban national health system, which developed after the 1959 Revolution, is its accessibility. At the time of collapse of the socialist bloc, the Cuban government managed to maintain and surpass the achieved level of development of medicine. The presence of a large number of medical specialists allows the socialist government of Cuba to organize cooperation with dozens of states around the world. Under the leadership of Castro, the export of medical goods and services has become the main source of foreign exchange earnings and a driver of economic growth, and medical diplomacy has become an important tool of soft power, which is used to form an attractive image of the state among the world community. In doing so, the government combines pragmatism, increasing the cost-effectiveness of the programs, and altruism, providing gratuitous aid to the countries most in need. The main difficulty in developing this direction in Cuba’s foreign policy is associated with the North American embargo. In 2018, the US government launched a large-scale campaign to discredit Cuban medical internationalism. This policy aims to further restrict already limited access to essential resources. The country was also negatively affected by the ‘right turn’ in the region: the neoliberal governments of several countries refused to continue medical cooperation with Cuba. At the same time, the trends of recent years indicate an imminent repetition of the shift to the left, which in the future can significantly strengthen the Cuban positions in the region. In addition, the coronavirus pandemic showed that the world community needs a rapid medical response force with Cuban missions serving as a basis thereof.

Clinical Ethics Consultation in Neurology – a case series

Background The concept of clinical ethics consultation (CECs) was implemented to provide support in ethical controversies in clinical settings and are offered in at least every second hospital in Germany. Neurological disorders often require complex decision-making. The aims of this study were to determine which situations lead to CEC in neurology and to investigate the influence of the individual patient’s wishes on the recommendation. Methods Standardised CEC protocols in the years 2011 to 2017 at the University Hospitals of Goettingen and Jena were retrospectively surveyed. The contents were categorised along existing protocol templates of CEC scenarios and subsequently paraphrased and reduced to significant meanings. Results 27 CEC scenarios which were facilitated by various professional disciplines were reviewed. Stroke was the most frequent underlying condition. Nearly all patients were not able to consent. Mostly, the relatives acted as representatives or health advocates. In 67 % of cases, a sense of conflict triggered a CEC; in 33 % a sense of uncertainty was the reason for the CEC request. In 21 CEC scenarios, a recommendation was reached in consensus with all parties involved. In 59 % of cases, a decision was made to continue medical therapy. In seven cases, the patient’s wishes led to a limitation of therapy, while in just two cases this decision was made primarily relying on the patient’s best interest. In only 13 % of cases, a valid advance directive led to respective therapeutic consequences. Conclusions CEC is feasible for consensus-finding not only in conflicts, but also in situations of therapeutic uncertainty in neurology. There is a special importance of the patient’s wishes in decision-making in neurology. However, only in a few cases were advance directives precise and specific enough to have sufficient and decisive weight in therapeutic decision-making.

Surgery for Grave’s Disease

Graves’ disease (GD) is the commonest cause of hyperthyroidism followed by toxic nodular goitre. Patients presenting as goitre with clinical features of hyperthyroidism are to be carefully evaluated with biochemically with thyroid stimulating hormone (TSH), free thyroxine (fT4) and radionuclide scan (Technitium-99/Iodine-123). Those with GD also have raised thyroid receptor stimulating antibody levels. Patients are simultaneously evaluated for eye disease and managed accordingly. Initial treatment is rendering patient euthyroid using anti thyroid drugs (ATD) and if remission does not occur either continue medical therapy or proceed for definitive therapy by radioactive iodine ablation (RAI) or surgery. In last decades there is ample literature preferring surgery as preferred definitive therapy. Surgery in thyroid disease has become safer with development of many intra-operative adjuncts but it should be performed by high volume thyroid surgeon. The procedure of choice is near total or total thyroidectomy as it avoids recurrences. Patients who are not eligible or willing for surgery can be managed with RAI.

Interventional Pulmonology and COVID-19: Experience from a Malaysian Tertiary Hospital

The ongoing pandemic of COVID-19 has presented multiple challenges to global healthcare services, dictating changes in almost every aspect of daily medical practice. Performing aerosol generating procedures (AGPs) in the field of interventional pulmonology can lead to profound formation of aerosols, leading to a high risk of infection among healthcare workers (HCWs). We share our experiences on performing AGPs in the midst of a COVID-19 pandemic by focusing on changes in AGP practices. In a pandemic, HCWs ought to adapt to the ever-changing situation and use available resources to provide the best possible healthcare to patients, ensure safety of staff, and continue medical education of future pulmonologists. Keywords: Bronchoscopy, infectious diseases, pulmonary, respiratory medicine

Risk factors for refusing to continue medical follow-up by tuberculosis patients detected in the penitentiary system of the Russian Federation

One of the essential problem sisthelack of continuity of medical follow-up and treatment of tuberculosis patients released from the penitentiary units and transferred tocivilian medical services. Mostly it is due to the fact that patients released from prisons are reluctant to continue medical follow up needed for their disease of tuberculosis or risk of its reactivation.The objective of the study: to find out the predictors of avoidance behavior in tuberculosis patients released from the penitentiary system of Russia resulting in reluctance to continue medical follow-up.Subjects and methods. During the case-control study, the information about 75 patients was investigated; those patients were detected in the penitentiary system in the period with 2014 2018 and released by the moment when the study was conducted. Ofthem, 62 referred to TB dispensary to continue follow-up and 13 didn't. The following predictors of the failure to continue medical follow-up were found out: the lackofa regular place of residence or foreign citizen ship; tuberculosis with minimal lesions and the negative result of the sputum test; clinically cured tuberculosis at the moment of release (Group III of dispensary follow-up). The regular place of residence, certain concurrent somatic conditions, and virus hepatites contributed to the willingness of patients to continue follow-up in the civilian medical system including due to tuberculosis.

The role of virtual reality in the changing landscape of surgical training

BackgroundThe current coronavirus disease 2019 pandemic has caused unprecedented challenges to surgical training across the world. With the widespread cancellations of clinical and academic activities, educators are looking to technological advancements to help ‘bridge the gap’ and continue medical education.SolutionsSimulation-based training as the ‘gold standard’ for medical education has limitations that prevent widespread adoption outside suitably resourced centres. Virtual reality has the potential to surmount these barriers, whilst fulfilling the fundamental aim of simulation-based training to provide a safe, effective and realistic learning environment.Current limitations and insights for futureThe main limitations of virtual reality technology include comfort and the restrictive power of mobile processors. There exists a clear developmental path to address these restrictions. Continued developments of the hardware and software set to deepen immersion and widen the possibilities within surgical education.ConclusionIn the post coronavirus disease 2019 educational landscape, virtual, augmented and mixed reality technology may prove invaluable in the training of the next generation of surgeons.