King's College London Research Articles

62O_PR Non-adherence to adjuvant endocrine treatment and its determinants among early stage breast cancer patients

Background Non-adherence to adjuvant endocrine treatment (ET) among breast cancer patients has been associated with worse prognosis. We sought to identify factors affecting non-adherence to ET, taking into account determinants at baseline and followup. Methods From linkage between Swedish national registers, we identified all women diagnosed with stage I-III, ER-positive breast cancer in Stockholm-Gotland, Uppsala- O€rebroand NorthernSwedenbetween 2006 and 2009.A total of 4,413 women who had at least one dispensation of tamoxifen or aromatase inhibitors (AIs) and 5 years of follow-up were included in the analysis. A medical possession ratio (MPR) of < 80% was used to define non-adherents. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of non-adherence to ET. Results During follow-up, 1,131 (25.6%) women became non-adherents. The following determinants of non-adherence were identified: age, marital status, region of diagnosis, private hospital, tumour size, lymph node metastasis, tumour grade, HER2 status, type of surgery, adjuvant chemotherapy, type of ET, pre-diagnostic hormone replacement therapy, the use of symptom-relieving drugs at baseline and during follow-up, baseline scores and any increase in Charlson co-morbidity index (CCI). In multivariable analysis, non-adherence was only associated with younger age (OR: 0.67; 95%CI: 0.50- 0.90and0.66; 0.48-0.92 forage50-65 and65+ comparedto < 50, respectively), marital status(OR:1.40;95%CI:1.23-1.60forsingle/divorced/widowedcomparedtomarried women),socioeconomicstatus(OR:1.17;95%CI:1.00-1.37and1.60;1.16-2.21for white collar and being unemployed compared to blue collar workers, respectively), and pre-diagnostic use ofhormone replacementtherapy(OR: 1.57; 95%CI: 1.28-1.93). Conclusions Our study identifies socioeconomic subgroups with increased risk ofnon- adherence that may be of use when measures for improving adherence are tested. Women with pre-diagnosticuseofHRT mayrepresentabiologicalsubsetwith a disposition for side effects from ET. Legal entity responsible for the study King's College London Funding King's College London Disclosure All authors have declared no conflicts ofinterest.

54P Circulating prostate-specific antigen and telomere length in a nationally representative sample of men without history of prostate cancer

Background We investigated the association of prostate-specific antigen (PSA) with leukocyte telomere length, which may be altered in preclinical prostate malignancies. Methods This study was based on the 2001-2002 USA National Health and Nutrition ExaminationSurvey(NHANES). Asubsampleof1,127 menaged40-85yearswithout prior history of prostate cancer who provided informed consent and blood samples were selected. Leukocyte telomere length (LTL) relative to standard DNA reference (T/S ratio) was quantified by polymerase chain reaction (PCR). Survey-weighted multivariable linear regression was performed to examine T/S ratio across quintiles of total and free PSA and free-to-total PSA ratio (%fPSA). A sensitivityanalysis was performed by excluding men dying from prostate cancer during follow-up through to 31 December 2006. Stratification analyses were carried out to assess any effect modification by age group, race, body mass index (BMI) and levels of C-reactive protein (CRP), a marker of inflammation. Results Higher total PSA levels were associated to longer LTL, with approximately 8% increase in log-transformed T/S ratio (95% confidence interval [CI]: 2-13%) among men in the highest quintile of total PSA compared to the lowest in the fully adjusted model (Ptrend —0.01). No significant association was found for free PSA or %fPSA, although nonlinearity between all PSA measures and T/S ratio was indicated. Similar results were found after excluding men who died from prostate cancer during follow-up. We also found the associations between total PSA and T/S ratio to be strongest among non-Hispanic blacks, non-obese men (BMI <30 kg/m2), and those with low CRP. However, a significant interaction was only found between total PSA and race/ethnicity (P interaction— 0.01). Conclusions Total PSA levels were strongly associated to leukocyte telomere length, particularly among non-Hispanic blacks. Our findings support a potential link between PSA and specific mechanisms contributing to prostate cancer development. Legal entity responsible for the study King's College London Funding PILAR Research and Education Foundation Disclosure All authors have declared no conflicts ofinterest.

Research round-up

Suzanne Sargent, Lecturer in Hepatology at King's College London, provides a brief overview of recently published, liver-related nursing and health articles

Book Reviews

Shaun Hargreaves Heap of King's College London reviews “Prisoners of Reason: Game Theory and Neoliberal Political Economy,” by S. M. Amadae. The Econlit abstract of this book begins: “Considers classical liberal capitalism's commitment to the no-harm principle and its recognition of individual human dignity in comparison to neoliberalism's view of life as a ceaseless, predatory struggle codified in noncooperative game theory. Presents the case that strategic rationality informs the strand of postmodern neoliberal subjectivity and agency operative in advanced capitalism, explores the canonical set of findings that characterize neoliberal theory, and explains how the political theory consistent with strategic rationality marks a break with classical liberalism.”

Cell scientist to watch – Brian Stramer

ABSTRACT Brian Stramer completed his undergraduate degree at the University of Rochester in Rochester, NY, and then moved to pursue his PhD at Tufts University in Boston, MA. He then crossed the Atlantic to work in the laboratory of Paul Martin as a US/UK Royal Society Fellow at the University of Bristol, UK. Before becoming a lecturer and a group leader at King's College London in 2008, Brian was also a lecturer of Veterinary Basic Sciences at the Royal Veterinary College in London. In 2015, Brian received a Wellcome Trust Investigator Award, which he will use to continue his research on the regulation of contact inhibition of locomotion and its roles in animal physiology.

Global health partnership for student peer-to-peer psychiatry e-learning: Lessons learned.

BackgroundGlobal ‘twinning’ relationships between healthcare organizations and institutions in low and high-resource settings have created growing opportunities for e-health partnerships which capitalize upon expanding information technology resources worldwide. E-learning approaches to medical education are increasingly popular but remain under-investigated, whilst a new emphasis on global health teaching has coincided with university budget cuts in many high income countries.ResultsKing’s Somaliland Partnership (KSP) is a paired institutional partnership health link, supported by Tropical Health and Education Trust (THET), which works to strengthen the healthcare system and improve access to care through mutual exchange of skills, knowledge and experience between Somaliland and King’s Health Partners, UK. Aqoon, meaning knowledge in Somali, is a peer-to-peer global mental health e-learning partnership between medical students at King’s College London (KCL) and Hargeisa and Amoud Universities, Somaliland. It aims to extend the benefits of KSP’s cross-cultural and global mental health education work to medical students and has reported positive results, including improved attitudes towards psychiatry in Somaliland students.ConclusionsThe process of devising, piloting, evaluating, refining, implementing, re-evaluating and again refining the Aqoon model has identified important barriers to successful partnership. This article describes lessons learned during this process, sharing principles and recommendations for readers wishing to expand their own global health link beyond qualified clinicians, to the healthcare professionals of the future.Electronic supplementary materialThe online version of this article (doi:10.1186/s12992-016-0221-5) contains supplementary material, which is available to authorized users.

Chronic liver conditions in teens linked to anxiety risk.

King's College London researchers have called for a greater focus on the mental health of young people with chronic liver conditions, after a study showed an increased risk of anxiety and depression.

A dental student's life: The dancing dentist

Kishan Sheth, 21, is a 4th year dental student at Guy's, King's and St Thomas' Dental Institute and a dance choreographer and actor in his spare time. This December he will be speaking on minimally invasive dentistry at King's College London for the London Materials Society.

The work of the British School at Athens, 2015–2016

The School's research programme in 2015 was once again extensive, including archaeological fieldwork in six sites or regions and study at a further seven, as well as the work of the Fitch Laboratory and the Knossos Research Centre (see Map 1). Other activities of the School span many other disciplines: history, anthropology, philosophy and the fine arts, including music, for example, represented by a successful conference held in May in Athens in collaboration with the Athens Conservatoire and Kings College London on music and identity (Fig. 1a). Research, of course, demands publication and, as noted last year, the School has now overhauled its publication arrangements. In addition to the Annual of the BSA and Archaeological Reports, we continue to collaborate with the French School on AGOnline (http://chronique.efa.gr/index.php/); our Supplements series also continues, as a vehicle for the publication of BSA fieldwork projects. The inaugural volume in the new Ashgate (now Routledge) series, British School at Athens Modern Greek and Byzantine Studies, appeared in December 2015 (Couroucli and Marinov 2015) (Fig. 1b). Two further volumes in this series will appear in 2016 and the first publication in the new Cambridge University Press series, British School at Athens Studies in Greek Antiquity, will appear in late 2016 (Kiriatzi and Knappett forthcoming).

Evaluating the educational environment of an international animal model-based wet lab course for undergraduate students.

BackgroundEssential Skills in the management of Surgical Cases – ESMSC is an International Combined Applied Surgical Science and Wet Lab course aimed at the undergraduate level. ESMSC combines interactive basic science workshops and case-based learning, with basic surgical training modules (BST) on Ex Vivo and In Vivo swine model. In Vivo Dissections include more advanced modules i.e. Abdominal Anatomy Dissections and Cardiac Transplant.AimTo evaluate the educational environment of a novel course, as well as to compare Medical students' perceptions across various groups.Materials and Methods83 Delegates from King's College London (KCL) and several Hellenic Medical Schools attended the ESMSC course. The DREEM inventory was distributed upon completion of the modules.ResultsThe mean overall score for DREEM inventory was 148.05/200(99–196, SD = 17.90). Cronbach's Alpha value was 0.818, indicating good internal consistency of the data. Year 3/4 Students have a significantly positive “Perception of Learning”, when compared to Year 5/6 (36.43 vs. 33.75, p = 0.017). KCL Students have a more positive view of the course compared to their Greek counterparts (155.19 vs. 145.62/200, p = 0.034). No statistical significant difference was noted when comparing male vs. female students (p > 0.05).ConclusionsStudents seem to positively rate the ESMSC educational environment. Junior as well as KCL students appear to be more enthusiastic. Further research should focus on the optimal strategy for early involvement and motivation of various students' groups in BST.

Self and identity over time: dementia.

Here, the author revisits the discussion on the impact of dementia on experiences of self and identity over time that formed part of the workshop session on Mental Disorder and Selfhood at Kings College London, September 1, 2015. Dementia is described as being synonymous with loss, but this, in the author's view, is due to conscious and unconscious focus on the later stages of the illness that undermine all our abilities to think about and use the intervening years. Those years can deliver remarkable insights into the capacity to navigate fragmented identities. They can also remind us vividly of the importance of a relational, interactive quality to identity and the degree to which aspects of our selves and identities reside and thrive in the minds of others.

Crisis, Revolution and Hegemonic Transition: The American Civil War and Emancipation in Marx'sCapital

Crisis, Revolution and Hegemonic Transition: The American Civil War and Emancipation in Marx's CapitalLucia PradellaLucia PradellaDepartment of European and International Studies, King's College London, Virginia Woolf Building, 22 Kingsway, London WC2B 6NR, United Kingdom. [email protected]Search for more papers by this authorPublished Online:September 2016https://doi.org/10.1521/siso.2016.80.4.454PDFPDF PLUS ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations About Previous article Next article FiguresReferencesRelatedDetails Cited byCited by1. The Abstract Slave: Anti-Blackness and Marx's MethodOnline publication date: 29 November 2019. Go to citation Crossref Google Scholar Volume 80Issue 4Oct 2016 Information© 2016 by S & S Quarterly, Inc.PDF download

A survey of undergraduate orthodontic teaching and factors affecting pursuit of postgraduate training.

Background Undergraduate orthodontic teaching has been focused on developing an understanding of occlusal development in an effort to equip practitioners to make appropriate referrals for specialist-delivered care. However, there is a growing interest among general dentists in delivering more specialised treatments, including short-term orthodontic alignment. This study aimed to assess the levels of knowledge of occlusal problems among final year undergraduate dental students, as well as their interest in various orthodontics techniques and training.Methods A 36-item electronic questionnaire was sent to all final year undergraduate students in four dental institutes in the UK (Barts and the London, Kings College London, Cardiff and Dundee). The questionnaire explored satisfaction with undergraduate orthodontic teaching; students' perception of knowledge, based on General Dental Council learning outcomes; perceptions of the need for specialist involvement in the management of dental problems; interest in further training in orthodontics; and potential barriers to undertaking specialist training.Results The overall response rate was 66% (239/362). The majority of students (84.1%) were aware of GDC guidance in terms of undergraduate teaching. Students reported a preference for case-based and practical teaching sessions in orthodontics, with less interest in lectures or problem-based learning approaches. A high percentage were interested in further teaching in interceptive orthodontics (60.3%) and fixed appliance therapy (55.7%). Further training including specialist orthodontic training (36.4%), Invisalign (59%) and Six Month Smiles (41%) courses appealed to undergraduates. Levels of student debt, course fees and geographical issues were seen as potential barriers to formal, specialist training pathways.Conclusions Satisfaction with undergraduate orthodontic teaching is high and interest in further training, including specialist training pathways, continues to be high. While short-term orthodontics is not taught at undergraduate level, there appears to be an appetite to undertake alternatives to conventional orthodontics among dental students.

In This Issue

HomeCirculation ResearchVol. 119, No. 7In This Issue Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBIn This Issue Ruth Williams Ruth WilliamsRuth Williams Search for more papers by this author Originally published16 Sep 2016https://doi.org/10.1161/RES.0000000000000122Circulation Research. 2016;119:773Macrophage Expansion in Chronic Heart Failure (p 853)Download figureDownload PowerPointMacrophages accumulating in the heart after an infarction come from local and peripheral sources, report Sager et al.After a heart attack, myocardial remodeling results in altered structure and reduced function. These muscular changes are accompanied by inflammation, with the numbers of monocytes and macrophages in the heart increasing significantly. While these immune cells are necessary for wound healing, they can cause tissue damage if the inflammation is not resolved quickly. To learn more about the origins of the expanded monocyte and macrophage population in mouse hearts after infarction, Sager and colleagues performed fate mapping experiments. They found evidence for both proliferation of resident heart macrophages and recruitment of circulating monocytes—with the latter accounting for approximately one third of the expanded monocyte and macrophage population. To investigate whether reducing the numbers of recruited monocytes might lessen tissue damage, the team used nanoparticle delivery of silencing RNAs to suppress the expression of adhesion molecules (required for monocyte exit from the circulation) in the cardiac endothelium of the mice. They found that this procedure diminished remodeling and prevented the decline in left ventricle function. Together, the results indicate that minimizing monocyte infiltration after infarction could improve functional recovery.Isoproterenol-Induced Myocyte Injury (p 865)Download figureDownload PowerPointA recently described cardiac regeneration model may not be what it seems, suggest Wallner et al.In recent years, cardiac stem cells (CSCs) have received considerable attention for their potential to promote the recovery of injured hearts. But while some reports indicate that CSC form myocytes, others suggest that there is minimal transdifferentiation of CSCs into adult cardiac myocytes. Georgina Ellison of Kings College London and colleagues have reported that, following a high-dose injection of isoproterenol, which kills ≈10% of cardiac myocytes in mice, CSCs can rapidly—within a couple of months—replace the dead cells. Given the utility of such a model for studying CSC-driven cardiac myocyte regeneration, Wallner and colleagues decided to validate these findings. They found that while injection of isoproterenol (at an equivalent dose to that used by Ellison) certainly damaged myocytes, it tended not to kill the cells. Moreover, by fate mapping experiments, Wallner and coworkers showed that the proportion of CSC-derived cells did not increase in the hearts of isoproterenol-treated animals, suggesting that the myocytes simply recovered from injury rather than being replaced. Based on these findings, the authors concluded that isoproterenol injection is not a reliable model for CSC-driven cardiac regeneration.Inhaled Nitrite Improves Hemodynamics in HFpEF (p 880)Download figureDownload PowerPointPatients suffering from heart failure with preserved ejection fraction may benefit from a new treatment strategy, say Borlaug et al.Approximately half the patients suffering from heart failure (HF) do not show a reduction in the ejection fraction (EF) of the heart. Known as heart failure with preserved ejection fraction (HFpEF), the condition is characterized by shortness of breath, elevated cardiac filling pressure, and pulmonary hypertension. Because of its vasodillatory effects, injection of nitrite—which converts to NO in the body—has been investigated as a potential treatment for HFpEF. Encouragingly, the treatment has been shown to temporarily improve symptoms: reducing cardiac filling pressure and hypertension. However, frequent injections are undesirable as a long-term treatment regimen. Borlaug and colleagues, therefore, investigated whether administering nitrite via inhalation might offer a less invasive alternative. In a randomized, double-blind, placebo-controlled trial, 26 HFpEF patients were treated with either nebulized sodium nitrite or saline (placebo). The effects of nebulized sodium nitrite were similar to those observed with nitrite injection and led to a temporary reduction in ventricular filling pressures and pulmonary artery pressures, both at rest and during exercise. These promising preliminary results now set the stage for longer-term studies using regular sodium nitrite inhalation for amelioration of HFpEF symptoms. Previous Back to top Next FiguresReferencesRelatedDetails September 16, 2016Vol 119, Issue 7 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/RES.0000000000000122 Originally publishedSeptember 16, 2016 PDF download Advertisement

Bibliometric profile of the global scientific research on autism spectrum disorders.

BackgroundAutism spectrum disorders (ASD) are a group conditions classified as neuro-developmental disorders. Research activity on ASD is important for all countries since such disorders have both social and health consequences. The objective of this study was to analyze research output on ASD during the period 2005–2014.MethodsAll articles relevant to ASD plus all articles published in autism journals were retrieved using Scopus database. VOSviewer software was used to create density and network visualization maps. Bibliometric indicators were investigated by analyzing annual research output, languages, countries, institutions, journals, title terms, highly cited articles, and co-authorship relations.ResultsA progressive annual growth of ASD research was observed from 2005 to 2014. During this period, a total of 18,490 articles were retrieved. The majority of these articles was published in Journal of Autism and Developmental Disorders with 48,416 citations and an average citation of 23.59 citations per article. The countries that published the largest number of articles were the United States (US) (n = 8594; 46.48 %), United Kingdom (n = 2430; 13.14 %) and Canada (n = 1077; 5.8 %). International collaborations produced 30.18 % of the articles published by top 10 productive countries. King’s College London (UK) ranked first in number of publications and total citations. The top 10 list of productive institutions was dominated by US academic and research institutions. More than half of the highly cited articles were in the field of molecular genetics. Articles with more than 50 citations were published mainly by authors from USA, UK and Canada.ConclusionsThere is a worldwide growth of publications on ASD led by countries in Northern America and Europe. Retrieved articles were published in a wide range of journals. Molecular genetics of ASD is the primary hot topic on ASD. For some leading countries, intra country collaboration is dominant.

Decisional support for young people who self-harm: protocol for a feasibility trial.

IntroductionSelf-harm is common in adolescents, and it is the strongest predictor of suicide. Young people who self-harm are often unsure of how and where to get help. Decision aids (DAs) have been shown to help with decisional conflict where there is uncertainty around different options. We have developed an online DA to support young people in help-seeking for self-harm. A feasibility trial will examine the acceptability of the online intervention and the ability to recruit and follow-up participants within a school setting.Methods and analysisIn this parallel arm, single-blind feasibility trial, 60 participants aged 12–18 years who have self-harmed in the past 12 months, will be randomised to either (1) a group receiving the online DA or (2) a control group receiving general information about feelings and emotions. Both groups will complete measures assessing decision-making and help-seeking behaviour. The school counsellor will be notified of any participants who have been randomised to ensure safeguarding for the young person. Participants in both groups will be followed up at 4 weeks, and the measures will be repeated. Qualitative interviews will be conducted with a subset of participants to explore their views and experiences of the DA and of participation in the study.Ethics and disseminationEthical approval was granted by King's College London (KCL) College Research Ethics Committee. Results of this study will help to clarify if we can recruit and administer an online decisional support intervention within a school setting for young people who self-harm. The study will inform the design and implementation of a larger randomised controlled trial to test the effectiveness of the DA. Dissemination of the study findings will target publication in peer-reviewed journals of general and special interest. The funder will be sent a report outlining the major findings of the study.Trial registration numberISRCTN11230559.

Documenting attacks on health workers and facilities in armed conflicts.

During armed conflicts, international humanitarian law (which regulates the conduct of parties engaged in war) protects health-care workers and health facilities, the wounded and the sick. In the first half of 2016, however, the international medical charity Medecins Sans Frontieres (MSF) reported several attacks on health facilities and workers in Afghanistan, the Central African Republic, South Sudan, the Syrian Arab Republic and Yemen. (1) These events have attracted media attention to a phenomenon of contemporary armed conflict that has important ramifications for the health, humanitarian, legal and security sectors. (2) In December 2015, the Stockholm Peace Research Institute and the Conflict and Health Research Group at King's College London convened a workshop in London on Eliminating violence against health workers: from theory to practice. Participants from MSF, the International Committee of the Red Cross (ICRC), Medical Aid for Palestinians and academic organizations discussed current trends in violence against health workers and attacks on health facilities, presented research findings and highlighted key debates and research gaps in evidence. Some important lessons can be drawn from ICRC's Health Care in Danger campaign, MSF's Medical Care Under Fire campaign, as well as other organizations such as Physicians for Human Rights, which has recently documented mass atrocities in the Syrian Arab Republic as well as the impact of the Syrian conflict on the health sector. (3-5) There is a perception Of an increase in the number of health workers being killed and facilities being accidentally destroyed (so-called collateral damage) or deliberated targeted during armed conflicts. Comprehensive databases have been set up by independent research organizations to record major incidents of violence against aid workers, such as the Aid Worker Security Database of Humanitarian Outcomes and the Security in Numbers Database from Insecurity Insight. (6) However, even these do not currently provide health-specific data. The absence of baseline and routine data relating to attacks on health workers and health facilities makes it difficult to identify actual rising trends. Most of the available data sources do not capture violence on local health workers, who seem to bear the brunt of most attacks. Data disaggregated by sex are also lacking. (6) Box 1 Key needs for documenting attacks on health workers and health facilities in armed conflicts * Analysis of trends of attacks on patients and health-care workers, facilities and transport during armed conflict and other violent incidents. * Collection of systematic routine data, prospective and retrospective, which are disaggregated by sex. * Examination of the context of each conflict to understand the dynamics and motives for attacks. * Disaggregation of data on humanitarian databases to distinguish between types of aid workers, including local and international health-care workers. * Public availability of anonymized data collected by humanitarian organizations to support a global response on prevention and accountability. * Assessment of open threats and impact on health facilities and health-care personnel by security staff both before deployment and immediately after conflict. * Systematic analysis of the immediate and longer-term impact of violence on the providers of health care. These gaps in the evidence seem incongruous in an era of increasingly accessible and globalized data. Yet there are many factors that inhibit systematic data collection: poor or non-existent data collection by those in the field (for a variety of reasons ranging from security risks to insufficient research capacity); bias in data collection; insufficient research funding for the topic; and a lack of developed method. Some efforts have been made to monitor and study attacks (both quantitatively and qualitatively), particularly by the ICRC and MSF. However, multidisciplinary, collaborative, long-term retrospective and prospective studies are absent--often for valid reasons. …

Stanley Gregory

Stanley Gregory

Weather, climate and health

Weather, climate and health

Fostering Dental Students’ Academic Achievements and Reflection Skills Through Clinical Peer Assessment and Feedback

Peer assessment is increasingly being encouraged to enhance dental students' learning. The aim of this study was to evaluate the educational impact in terms of academic achievements and reflective thinking of a formative prospective peer assessment and feedback protocol. Volunteer final-year dental students at King's College London Dental Institute, UK, received training on peer assessment, peer feedback, and self-reflection. At the beginning (baseline) and end (resultant) of the 2012-13 academic year, 86 students (55% of the year group) completed a reflection questionnaire (RQ). Sixty-eight of those students used a modified Direct Observation of Procedural Skills (DOPS) as a framework for peer assessment and peer feedback during a complete academic year. End-of-year, high-stakes examination grades and RQ scores from the participants and nonparticipants were statistically compared. The participants completed 576 peer DOPS. Those 22 students who peer assessed each other ≥10 times exhibited highly statistically significant differences and powerful positive effect sizes in their high-stakes exam grades (p=0.0001, d=0.74) and critical reflection skills (p=0.005, d=1.41) when compared to those who did not assess one another. Furthermore, only the same 22 students showed a statistically significant increase and positive effect size in their critical reflection skills from baseline to resultant (p=0.003, d=1.04). The results of this study suggest that the protocol used has the potential to impact dental students' academic and reflection skills, provided it is practiced in ten or more peer encounters and ensuring peer feedback is provided followed by self-reflection.