Clinical Acumen Research Articles

What Matters Most? How to Find Joy at Work in Post-Acute and Long-Term Care

What Matters Most? How to Find Joy at Work in Post-Acute and Long-Term Care

Ischemic burden or anatomic burden: which non-invasive testing in stable patients with suspected coronary artery disease?

Guidance on the diagnostic approach to coronary artery disease has diverged as the increasing complexity of atherosclerotic clinicopathologic correlations has been revealed. Foundational concepts linking stenosis, the ischaemic cascade and prognosis have been re-evaluated in light of the underwhelming results from the percutaneous revascularization of stenotic vessels. These studies have revealed ischaemia to be an important marker for cardiovascular outcomes, but likely separate from the causal pathway of hard clinical events. Instead, observations from non-invasive anatomical imaging have redefined risk, shifting the focus away from discrete lesions towards total atherosclerotic burden, and with it elevating the role of computed tomography in contemporary diagnostic pathways. As it currently stands, functional and anatomical approaches provide complementary information; stress testing continues to provide guidance for potential revascularization in current guidelines, yet anatomical testing may additionally identify individuals likely to benefit from preventive therapy. While guidelines attempt to keep pace with the advancing technology and expanding literature, clinicians are left to apply clinical acumen to decide on a vast and confusing array of investigative options. This review will deal with strenghts and limitations of the current approach to the diagnosis of coronary artery disease, providing the rationale for both functional and anatomical approaches.

Carbon monoxide as a clinical marker of hemolysis.

Carbon monoxide (CO)-based tests have precisely measured hemolysis for over 40 years. End-tidal CO was the primary marker in clinical hematology research, followed by carboxyhemoglobin. Quantification of CO reflects heme oxygenases degrading heme in a 1:1 stoichiometric ratio, making CO a direct marker of hemolysis. CO in alveolar air can be quantified using gas chromatography, whose high resolution allows detecting mild and moderate levels of hemolysis. CO can be elevated in active bleeding, resorbing hematoma, and smoking. Clinical acumen and other markers remain necessary to diagnose the cause of hemolysis. CO-based tests constitute an opportunity for bench-to-bedside technology transfer.

Students' Leadership Development During a High-fidelity Military Medical Field Practicum.

Leadership development is a cornerstone aspect of military medical education. Operation Bushmaster, a medical field practicum (MFP) conducted by the USU, tests fourth-year medical students' clinical skills and leadership acumen in an operational environment. No studies have examined students' perceptions of their own leadership development during this MFP. Therefore, this study explored leadership development from the students' perspectives. Using a qualitative phenomenological design, we analyzed the reflection papers of 166 military medical students who participated in Operation Bushmaster during the fall of 2021. Our research team coded and categorized the data. Once defined, these categories served as the themes in this study. Three central themes were expressed: (1) the importance of direct and decisive communication, (2) unit cohesion and interpersonal relationships enhance the team's ability to adapt, and (3) followership quality determines leadership outcomes. The students' leadership ability was maximized by established relationships within their unit and well-practiced communication, and a decreased propensity for followership negatively affected leadership. Overall, Operation Bushmaster increased students' appreciation of the importance of leadership development and overall enhanced their leadership outlook as a future military medical officer. This study provided an introspective vantage from military medical students pertaining to their own leadership development, as participants described how the challenging environment of a military MFP challenged them to hone and develop their leadership skills. As a result, the participants gained a greater appreciation of continued leadership development and realization of their future roles and responsibilities within the military health care system.

In Memoriam: Michael R. Nihill, MBBS (1936-2023).

On February 10, 2023, Dr Michael Nihill passed away peacefully at the age of 87 years. Those who were lucky enough to know him knew he was truly one of a kind.Born in 1936 in Haberfield, Australia, Dr Nihill completed his medical degree, internship, and pediatric residency in Sydney and then traveled to London, England, to work as a postgraduate student in internal medicine. Reflecting on this piece of his history, he once reported in typical fashion, “I took a job as the doctor on a cargo ship—at 10 cents a month—but I got free passage. It was there in London that I became interested in pediatric cardiology and decided to come to the States for further training.” In 1968, Dr Nihill started a fellowship in pediatric cardiology at Texas Children's Hospital in Houston, Texas. After completing his training, he returned to Australia in 1971 for a short spell before finally settling in Houston, where he stayed until his retirement from Texas Children's Hospital in 2017.Dr Nihill made an enormous impact in Houston while working side by side with some of the legends in the field, including Drs Daniel McNamara, Denton Cooley, Charles Mullins, Timothy Bricker, Charles Fraser Jr, James Willerson, and Robert Hall. Dr Nihill's dedication to teaching and his impeccable skills in physical examination and cardiac catheterization were unmatched.During his 46 years at Texas Children's Hospital, Dr Nihill cared for thousands of children and was recognized as a master clinician. His exceptional physical examination acumen was second to none, as he started in pediatric cardiology in the era before the widespread use of echocardiography. In addition, Dr Nihill's technical skills and creativity in the cardiac catheterization laboratory were phenomenal, as he worked alongside Dr Charles Mullins, a true pioneer in the use of cardiac catheterization for diagnosing and treating congenital heart disease. Furthermore, the trainee (ranging from the medical student to the resident and the pediatric cardiology fellow) who was fortunate enough to be taught by Dr Nihill benefitted from his comprehensive, classic, “patient-centric” style. Using this approach, he emphasized the importance of performing the physical examination, reviewing patient data, and having a thoughtful discussion about the differential diagnosis and possible treatment options.Dr Nihill's legacy lives on in the teaching of cardiology fellows. He was known for softly uttering his “Nihill-isms” in that unmistakable Australian lilt, accompanied by a wry smile. One of his favorites was to stop at a door and say, “Age before beauty,” while allowing the fellows to enter through the door first. The echocardiographers were amused by his frequent use of the term “echo-schmecho” on rounds, highlighting his true identity as an interventionalist. Another of Dr Nihill's favorite witticisms was, “To cath is to cure.”Dr Nihill was a truly unique figure who had a tremendous impact on his patients' lives and in whose light we basked while we had him. What differentiated him from all others was not just his exceptional clinical acumen, catheterization skills, or cardiology knowledge, but his kindness, warmth, and remarkable humanity. We celebrate his legacy and his wonderful, well-lived life.Dr Michael Nihill is survived by his wife of 57 years, Ilsa Nihill; his daughter Amanda; his sister and brother, Caroline and John; and his grandchildren, Thomas and Ella. His daughter Alisen passed away in July 2022.

Developing a Curriculum for Functional Neurological Disorder in Neurology Training (P2-2.005)

<h3>Objective:</h3> To put forward a case for why a functional neurological disorder (FND) curriculum is needed and to provide guidance on curricular content and teaching methods. <h3>Background:</h3> FND is commonly encountered by neurologists, with a growing body of evidence-based treatments operationalized over the past two decades. There remains a large gap in neurology education regarding FND, with little to no formal teaching over the course of medical education, and many practicing neurologists do not feel as though they have good knowledge of FND. <h3>Design/Methods:</h3> We included multidisciplinary and interdisciplinary expert consensus from FND care providers across neurology, psychiatry, social work, physical therapy, and psychology to develop a framework for the development of an FND curriculum for neurology residents. <h3>Results:</h3> Key curricular content regarding FND should include: Medical knowledge regarding pathophysiology and neuropsychological etiological factors, diagnostic criteria, approach to adjunctive diagnostic testing, and principles underlying treatment modalities (rehabilitative and psychological therapies). Clinical skills including being able to perform a psychiatric and social history, specific exam maneuvers to determine rule-in diagnostic features, and formulation of a multidisciplinary treatment and longitudinal care plan. Communication and collaboration skills including effectively conveying an FND diagnosis, educating the patient/family around diagnosis and management including addressing diagnostic doubt, and a thorough understanding of all care team member roles and ability to work together towards care optimization. Methods for teaching this curricular content should include didactic sessions, clinical exposure, and access to supplementary content resources for self-guided learning. Methods for evaluation of curricular content should be linked to Accreditation Council for Graduate Medical Education milestones and include written evaluation, direct clinical observation, and standardized skill assessment through use of standardized or simulated patients. <h3>Conclusions:</h3> A dedicated FND curriculum to appropriately train residents is needed, and should aim to provide knowledge, clinical acumen, communication skills, and effective use of team-based collaboration. <b>Disclosure:</b> Dr. Finkelstein has received personal compensation in the range of $500-$4,999 for serving as a Speaker at Annual Fall Meeting with Massachusetts Neurologic Association. Dr. O’Neal has received personal compensation for serving as an employee of Best Doctors. Dr. O’Neal has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Crico malpractice company. Dr. O’Neal has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Crico malpractice company. Dr. O’Neal has received publishing royalties from a publication relating to health care. Dr. Baslet has received publishing royalties from a publication relating to health care. Dr. Dworetzky has received publishing royalties from a publication relating to health care. Ms. Godena has nothing to disclose. Mrs. Maggio has nothing to disclose. Dr. Millstein has nothing to disclose. Dr. Milligan has nothing to disclose. Dr. Perez has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Wiley: Brain and Behavior. The institution of Dr. Perez has received research support from NIH. The institution of Dr. Perez has received research support from Sidney R. Baer Jr. Foundation. Dr. Perez has received publishing royalties from a publication relating to health care.

P086 Service evaluation of ultrasound use in patients with juvenile idiopathic arthritis in a UK tertiary paediatric rheumatology centre, as the first step towards developing an evidence-based guideline

Abstract Background/Aims Some studies have shown that ultrasound can be more sensitive than clinical examination in detection of synovitis and improves diagnostic accuracy when clinical examination is in doubt. This study aimed to review if ultrasound results correlate with the clinical impression in patients with juvenile idiopathic arthritis (JIA) and determine if imaging helps to change management and assist in the optimisation of radiology resources, by improving our knowledge of when ultrasound is suitable. Methods We designed a retrospective study to review cases of JIA aged 1-18 years who have had an ultrasound requested from clinic between September 2021 - April 2022. Patients were excluded from study if; diagnosis was uncertain, new patients with JIA and patients with arthritis as part of a systemic inflammatory disorder. Data was collected from the radiology database and electronic patient record (MEDITECH). Results A total of 40 patients matched eligibility criteria with ultrasound performed on average 4 weeks after request. 13 (32.5%) male and 27 (67.5%) female with an average age of 11.7 years (3 -18 years). Of these patients 16 (40%) failed to demonstrate any active clinical signs of arthritis or tenosynovitis in clinic. The most common reasons for scan in this cohort included parental concern (43.75%) and difficulty of examination (12.5%). Other reasons included: patient reporting pain or morning stiffness in the absence of clinical signs during the consult. In these patients 13 (81.25%) were normal and 3 (18.75%) demonstrated chronic changes. Ultrasound in these patients did not lead to any change in treatment. 22 (55%) of patients demonstrated clinical signs of arthritis in clinic. 7 (31.2%) of these demonstrated active arthritis or tenosynovitis and subsequently had treatment changes in the form of a steroid injection (n = 5) or change in systemic medication (n = 5). Of those that had clinical signs but no active arthritis on ultrasound, 8 (36.4%) scans were found to be non-diagnostic / demonstrated chronic synovial thickening and 7 scans were normal (32%). 2 (5%) patients were seen in virtual clinic and not examined; both had a normal scan. Small joints of the ankles (26%) and hands (23%) are the most common joints scanned. Conclusion The use of ultrasound demonstrates benefit when clinical findings are present, and the scan allows clinicians to differentiate between active synovitis, tenosynovitis and chronic damage. In patients whose clinical examination does not show signs of inflammation, there is less evidence in this study for the use of ultrasound, and we should trust our clinical acumen. Disclosure L.A. Stead: None. N. Malde: None. L. McCann: None. N. Barnes: None. C. Landes: None. K. Gargh: None.

Type of Health Care Experience Impact on PA Education Association End of Rotation Exam Scores.

The physician assistant (PA) profession is based on previous healthcare experience (HCE), yet few studies have examined the influence of HCE on outcomes. This exploratory study examined possible differences between type of HCE and End of Rotation scores as a surrogate for clinical acumen and medical knowledge. Participants included consecutive classes of PA students (2017-2020) from a single public institution (N = 196). Self-reported HCE was used to classify students into HCE groups: group 1, lower decision-making professions; and group 2, higher decision-making professions. Group 1 (n = 124) and group 2 (n = 72) had no significant difference in the 7 individual End of Rotation exam scores and HCE ( p =.163 to .907). A correlation was found between average End of Rotation exam score and PANCE scores ( r =.80, p ≤ .001). The impact of HCE during the clinical year of education and its influence on noncognitive attributes, such as communication skills and professionalism, is not known. HCE might have a role in hard to measure noncognitive, nonquantifiable qualities.

The Outcome of COVID-19 Patients with Moderate to Severe Disease: A Single Institution Study

Objective: To determine the outcome of COVID-19 positive patients with moderate to severe disease.Study Design: A cross-sectional study.Place and Duration of Study: This study was conducted at the Department of Medicine of Combined Military Hospital, Malir Karachi, Pakistan, from 1st Jun 2020 to 31st Jul 2020.Materials and Methods: Total 67 SARS-CoV-2 positive cases, including males and females, were studied. All patients were admitted with presenting complaints such as fever, cough, arthralgia, or shortness of breath. Investigations including complete blood count, serum ferritin, quantitative CRP, liver function tests, renal function tests, blood sugar fasting, and random chest radiographs and ECG were performed. Critical patients were admitted to COVID ITC and managed with high-flow oxygen and assisted ventilation. Patients with moderate disease were admitted to a high-dependency unit and managed with oxygen, intravenous dexamethasone, intravenous antibiotics, anticoagulants, and antiviral therapy patients accordingly. Supportive treatments, including zinc, vitamin C and vitamin D, were given to all patients.Results: Out of total 67 patients, 56 were suffering from comorbidities. Eighteen patients have died. Forty-nine patients have recovered with uneventful recovery.Conclusion: All over the world advanced age and comorbidities such as hypertension, diabetes, asthma, chronic obstructive pulmonary disorder, and chronic kidney disease remain a major health hazard for an increased likelihood of adverse clinical outcomes in patients with COVID-19 infections outcomes. Early diagnosis and prompt treatment of moderate to severe COVID-19 cases could only be possible with good clinical acumen to prevent a catastrophic outcome.

Practicing Confidence: An Autoethnographic Exploration of the First Years as Physicians

Phenomenon : Every year is heralded with a cohort of newly-minted medical school graduates. Through intense residency training and supervision, these learners gradually develop self-assurance in their newfound skills and ways of practice. What remains unknown, however, is how this confidence develops and on what it is founded. This study sought to provide an insider view of this evolution from the frontline experiences of resident doctors. Approach : Using an analytic collaborative autoethnographic approach, two resident physicians (Internal Medicine; Pediatrics) documented 73 real-time stories on their emerging sense of confidence over their first two years of residency. A thematic analysis of narrative reflections was conducted iteratively in partnership with a staff physician and a medical education researcher, allowing for rich, multi-perspective input. Reflections were analyzed and coded thematically and the various perspectives on data interpretation were negotiated by consensus discussion. Findings : In the personal stories and experiences shared, we take you through our own journey and development of confidence, which we have come to appreciate as a layered and often non-linear process. Key moments include fears in the face of the unknown; the shame of failures (real or perceived); the bits of courage gained by everyday and mundane successes; and the emergence of our personal sense of growth and physicianship. Insights : Through this work, we – as two Canadian resident physicians – have ventured to describe a longitudinal trajectory of confidence from the ground up. Although we enter residency with the label of ‘physician,’ our clinical acumen remains in its infancy. We graduate from residency still as physicians, but decidedly different in terms of our knowledge, attitudes, and skills. We sought to capitalize on the vulnerability and authenticity inherent in autoethnography to enrich our collective understanding of confidence acquisition in the resident physician and its implications for the practice of medicine.

“Look Both Ways When You Cross the Street” – A Reporting Sine Qua Non

We discuss an interesting case of a 67 years old female patient with an abdominal lump leading to a reporting dilemma among female genital tract lesions in which even though clinical acumen, radiological findings and gross examination of the resected specimen pointed towards a certain malignant provisional diagnosis, actually turned out to be a rare benign entity of Aggressive Angiomyxoma when seen under the microscope and proved on immunohistochemistry, pressing upon the importance of correlation of all the findings (clinical, radiological, gross and microscopy) while making a diagnosis. We also press upon the gravity of proper communication between the reporting pathologist and treating physician for the best possible patient management.

Mpox Masquerading as Secondary Syphilis.

Mpox is a great masquerader requiring emergency nurse practitioners to rely on their clinical acumen to accurately diagnose and treat this public health emergency. The disease is nearly indistinguishable from other pox viruses and similar in presentation to several viral and bacterial infections associated with enanthems and exanthems. The most recent outbreak disproportionally affects men who have sex with men, particularly those individuals with HIV. Early recognition and intervention are key; however, clinicians' lack of knowledge, limited access to testing, and unfamiliarity with appropriate medications and vaccines historically reserved for smallpox create a barrier to treatment. Emergency nurse practitioners must gain an understanding of this disease to provide the care and anticipatory guidance to prevent associated morbidity, mortality, and spread of mpox.

DIFFERENTIAL DIAGNOSIS OF RIGHT ILIAC FOSSA MASS AND THEIR MANAGEMENT

Background: Right iliac fossa mass is a common clinical entity encountered in routine surgical practice. The mass arises from different anatomical structures with varied aetiologies that require a high clinical suspicion in its management. The reason being that the mass may range from being benign to most aggressively malignant lesion which encompasses various specialities of surgery like genitourinary, vascular, gynaecological and colorectal surgery. This was a prospective observational study conducted betw Methods: een October 2021 and September 2022 in Silchar Medical College and Hospital, Silchar, Assam. 45 cases were studied after detailed history and physical examination, relevant investigations were done, and different surgical procedures done were noted and histopathological examination of resected specimens was done. In this series Results: out of 45 patients studied, 35 patients (77.5%) were diagnosed to have appendicular mass, 05 cases (11%) appendicular abscess, 02 cases (4.5%) ileocaecal TB, 02 cases (4.5%) psoas abscess, 01 cases (2.5%) Ca Caecum. Most commonly encountered in 3rd decade followed by 4th decade of life with male predominance. RIF mass is a challenging clinical sce Conclusions: nario for the surgeons. Keeping in mind the various differential diagnosis with good clinical acumen supported by appropriate investigations, patients with RIF mass can be managed appropriately either by conservative or surgical management.

Appendicitis – Is a Clinical Diagnosis Enough?

Appendicitis has always been considered a clinical diagnosis wherein the surgeon’s clinical acumen and laboratory investigations take priority over the radiological imaging. However, an atypical presentation of appendicitis can occur due to the varying location of the appendix which may result in delayed diagnosis and complications. In such cases radiological imaging such as contrast enhanced computerized tomography helps in the diagnosis. We report two cases of subhepatic appendicitis with different clinical findings.

Securing the Airway in a Patient with Massive neck Swelling, Emergency Tracheostomy: A Technical Note.

To describe the technical aspects of emergency tracheostomy in a case of extensive neck swelling with a challenging airway. We report a case of difficult tracheostomy in a patient with a huge neck swelling causing obscured anatomical landmarks in significant stridor. A literature review was performed to identify similar cases or techniques. Emergency tracheostomy was successfully executed with the help of clinical acumen, imaging findings and intra-operative ultrasound usage. We describe a safe and effective technique of emergency tracheostomy in patients with huge neck swelling and obscured anatomical landmarks. Collaboration of surgeon with the anaesthesia service is of paramount importance in dealing with challenging airways.

Cavitatory necrotising pneumonia with extrapulmonary multi-systemic involvement — a rare presentation of macrolide-resistant Mycoplasma pneumoniae

BackgroundMycoplasma pneumoniae is one of the leading causes of community-acquired pneumonia. Due to its microbiological variation, clinical presentations of mycoplasma infections are atypical and diverse. Multiple pulmonary and extrapulmonary manifestations of Mycoplasma pneumoniae have been documented. Among pulmonary, common manifestations are fever, malaise, lymphadenopathy, pneumonia, upper respiratory tract infections, sinusitis, etc. Necrotising pneumonia leading to cavitation as a manifestation is rather an uncommon presentation.Case presentationWe are reporting a rare case of a 5-year-old female child who presented with bilateral haemorrhagic pleural effusion and necrotising pneumonia with cavitation along with extrapulmonary manifestation in the form of maculo-papular rash, Coombs-positive haemolytic anaemia and serositis. The child was started on azithromycin and symptomatic management, but she did not respond to it; she had clinical worsening and evidence of radiological necrotising pneumonia. The child was treated as macrolide-resistant mycoplasma pneumonia with levofloxacin, steroids and rigorous physiotherapy.ConclusionsAccurate clinical acumen along with timely radiological imaging is the need of the hour for early diagnosis of macrolide-resistant mycoplasma pneumonia (MRMP). This case also emphasises role of fluoroquinolones and steroids in treatment of macrolide-resistant mycoplasma pneumonia.

Frailty of paediatric sepsis tools.

Journal of Paediatrics and Child HealthEarly View Heads UpFree Access Frailty of paediatric sepsis tools First published: 16 February 2023 https://doi.org/10.1111/jpc.16379 edited by Craig Mellis (craig.mellis@sydney.edu.au) AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Sepsis screening tools were introduced to facilitate early recognition of sepsis in children. The tools, based on physiological parameters, are known to have a low positive predictive value. In their study in The Journal of Paediatrics and Child Health, Damian Roland and colleagues analyse trends in physiological parameters in acute care settings. This study has important implications in revealing the frailty of sepsis tools when applied to a population of unwell children especially in those under 5 with labile physiological responses. The study (Fig 1) shows that the specificity of heart and respiratory rate is particularly low in children under 5 and increases with age.1 A large proportion of children who trigger as suspected sepsis are under 5 and may be overtreated resulting in poor antimicrobial stewardship. Underestimation of sepsis/serious illness in children can also occur secondary to sepsis fatigue. Fig. 1Open in figure viewerPowerPoint 5th to 95th centile of the study and APLS for heart and respiratory rate. We may need to accept that the perfect screening tool for paediatric sepsis is unlikely to exist. While there has been a drive to implement sepsis screening tools in acute care settings for children, the physiological parameters on which they are based need revision as unwell children, with self-limiting disease, often present with abnormal observations. Clinical acumen remains key. Reference 1Brennan L, Heal C, Brown S, Roland D, Rowland AG. Time to change the reference ranges of children's physiological observations in emergency care? A prospective study. J. Paediatr. Child Health 2023 (Epub ahead of print). https://doi.org/10.1111/jpc.16328. Reviewer: Caroline Ponmani, caroline.ponmani@nhs.net, Department of Paediatric Emergency Medicine, Barking Havering and Redbridge University Trust, London UK Early ViewOnline Version of Record before inclusion in an issue FiguresReferencesRelatedInformation

Urology boot camp for medical students: Using virtual technology to enhance undergraduate education.

The study aims to describe the methodology of converting the urology boot camp for medical students into a virtual course with key take home points for a successful conversion and to present quantitative and qualitative data demonstrating the impact of the boot camp on improving delegates' knowledge and clinical acumen. The face-to-face boot camp was converted to a virtual format employing a variety of techniques including; utilizing an online platform to deliver live screened lectures, using online polling software to foster an interactive learning environment and displaying pre-recorded videos to teach practical skills. Validated Multiple Choice Questionnaires (MCQs) were used prior to and after the course. This enabled the assessment of delegates' knowledge of urology according to the national undergraduate curriculum, and paired t tests were used to quantify the level of improvement. Thematic analysis was carried out on post-course delegate feedback to identify highlights of the course and ways of improving future iterations. In total, 131 delegates took part in the pilot virtual course. Of these, 105 delegates completed the pre- and post-course MCQs. There was a statistically significant improvement in the assessment following the course (p= <0.001) with mean score increasing from 47.5% pre-course to 65.8% post-course. All delegates who attended the most recent implementation of the virtual course (n= 31) felt it improved their knowledge and confidence in urology. Twenty delegates (64.5%) felt that it prepared them for both final year medical school examinations and working as a foundation year doctor. Positive themes in feedback were identified, which included the interactive nature of the course, the quality of teaching, the level and content of information provided and the high yield, concise organization of the teaching schedule. Using virtual technology and innovative educational frameworks, we have demonstrated the successful conversion of the urology boot camp for medical students to a virtual format. At a national level, with support from the British Association of Urological Surgeons, the face-to-face component of the course will continue to run in parallel with the virtual course with the aim of standardizing and improving UK undergraduate urological education. The virtual course has been implemented on an international scale, and this has already shown promising results.

Co-epidemics: implications of COVID-19 outbreak associated with human immune-deficiency virus, tuberculosis and Lassa fever in a low resource economy-a call for proactive measures

As the global struggle to combat the quadruple burden of COVID-19, human immunodeficiency virus, tuberculosis and Lassa fever continues to increase, Sub-Saharan Africa has been the most affected region, especially Nigeria. There is a close interaction between these four diseases and a clear understanding of each of these diseases is very crucial. People living with chronic medical conditions such as HIV, TB and Lassa fever are more likely to experience poor outcomes from COVID-19 even though there are still some unknown facts as regards the burden of COVID-19 on patients with TB, Lassa fever and HIV in our low-middle–income nation. This study was conducted to review different researches on COVID-19 associated with HIV, TB and Lassa fever co-infections, to understand the interactions between them and its implications on clinical investigations and health management in high burden countries of COVID-19, especially Nigeria. The research was designed to accommodate research and reports from different geopolitical zones of Nigeria where the diseases has been reported and centering on Ondo State reports. This was done using search engines, with reference to valid studies from academic sources like ResearchGate, PubMed and Google Scholar. We also evaluated various related titles, abstracts and full reports for eligibility. Ondo state was the centre of study as it is one of the states with high prevalence of Lassa fever, TB, HIV and COVID-19 co-infections in Nigeria. Structured diagnostic algorithms and clinical management are suggested to improve COVID-19/HIV/TB/Lassa fever or COVID-19/Lassa fever co-infection outcomes. With low quality of health care facilities for laboratory diagnosis of COVID-19 and Lassa fever, reliance on clinical acumen and high index of suspicion may be the only process that health professionals may rely upon to make early diagnosis.

Demystifying Partial Tears of the Anterior Cruciate Ligament: A Review of Current Diagnostic and Management Strategies

Partial tears of anterior cruciate ligament (ACL) are a diagnostic and management challenge. There is ongoing discussion and debate about the ideal management of a partial tear with “ala carte” options available in the current literature. Findings can remain occult on imaging studies, necessitating more efficient clinical examination and acumen to identify patients requiring surgical intervention. The authors through this literature review provide an overview on partial tears of ACL including the background anatomy, pathology, clinical diagnosis, imaging finding, and surgical techniques. The literature is critically probed and tabulated for effortless assessment. The objective is to help the orthopedic surgeon decide the optimal course for a suspected partial ACL tear. The authors do not aim to provide a guideline but rather present an inventory of available options and approaches for managing partial ACL tear. This review is a comprehensive amalgamation of the heterogeneity in the present literature.