Hypothermia and stroke update

Separate discussions of course. These were presented at the Elderly Care departmental meeting in Truro.

Nice update on hypothermia and its management. Disappointed that when I went to search Osborne waves on the internet the 12 lead ECG library's discussion of the 1953 paper was not listed in the search engines. Hmm. There is more competition for ECGs online these days ... or maybe it is that other websites have more useful information. Asked a question at the meeting about bicarbonate and survival and probably sounded as though I was alive when Osborne's original paper was published. Wonder what JJ Osborne's first names were? Never did find out when I researched it earlier.

There was an interesting aspect to the presentation. It was decided to present the case because there was some uncertainty on behalf of the trainee and of the admissions staff as to what the best treatment is for hypothermia. There were no guidelines available but by using up-to-date, which is available within the Trust, they could get quite rapid access to information. It would be good to try and distil that information for a readily available and localised treatment plan for us within the admissions unit. This would be especially useful for this type of unusual condition that does not lend itself to evidence-based practice (as most publications are presumably case reports or consensus views) and is associated with a high mortality.

There was also an update on the 5th UK Stroke Forum that took place in Glasgow. Good discussion on thrombolysis and acute neurosurgery.

Students debate case reports ...

... and conclude they'd like to write some.

Just wrote a blog entry about the recent Warwick Medical School Journal Club conference at the weekend.

Case Reports in the era of Evidence-Based Medicine

Calcifications

Attended the Elderly Care departmental meeting at Truro where there was an interesting case report of Parkinson Disease diagnosed 10 years previously and who then presented with some features of Systemic Sclerosis and quite marked basal ganglia calcification on the CT.

It was an odd collection of signs and there didn't seem to be any unifying diagnosis. Fahr's disease was discussed and prompted me to find a review. (1)

There was also a discussion about when a CT brain is indicated in 'routine' Parkinson patients.

1) Manyam BV. What is and what is not 'Fahr's disease'. Parkinsonism Relat. Disord. 2005;11(2):73-80. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15734663

A possible future for CME?

Pedagogical Ecology is a lovely jargon term originally from Jaffee and used by Nada Dabbagh & Rick Reo in Back to the Future: Tracing the Roots and Learning Affordances of Social Software. In Lee MJW, McLoughlin C (Eds). Web 2.0-Based E-Learning: Applying Social Informatics for Tertiary Teaching. IGI Global; 2010.

They use it to describe a trajectory for e-learning from traditional broadcast media to social software learning environments in tertiary education. Could the same trajectory be true for Continuing Medical Education CME (though perhaps delayed by a few years)?

I've summarized it in this PowerPoint on Pedagogical Ecologies in CME.

I think it is a useful tool for exploring where our current CME activities can be placed, where our learners might be and where we may want to move to (or not).

Appraising rural clinics

Just came back from a fantastic family holiday in India organised by Janet and Peter at Brambles Art Retreat. Clare and Molly were the artists and we were the 'support team'. We stayed at the marvellous Karmi Farm which is just North West of Darjeeling and run by Andrew Pulgar-Frame and his mother Deki.

There is also a Karmi Farm Clinic staffed by a young, local man, Siroj who spoke excellent English and had worked there for 5 years. The clinic serves a population of about 3000 who live in the local area in small, humble homes of wood and corrugated steel. The clinic is supported by Nomad Travel and also extensively by Andrew.

The clinic is principally a triage and first aid centre. When we were there it was staffed by Tom and Emily from the UK on a tour of voluntary work. They could handle most things without needing to send patients on the 4 hour bumpy jeep trip to the nearest hospital.

What amazed me most was not the monk who had nearly sliced off his palm with a Kukri that Tom stitched together on and improvised operating table in open air, or Clare using her dental skills in between painting to describe to Tom and Emily how to take out a tooth using a Leatherman multi-tool, or the house visits up extreme paths through the hills, or the copious amounts of "HIT Super Strong (for sale in Sikkim only)" being drunk by all the locals. No ... it was the fact that almost all the booking, follow-up arrangements, and advice was given over the mobile phone by Siroj the local worker who was clearly trusted by the clinic's community.

In this reasonably remote and poor area of West Bengal, where the clinic sometimes lacked lignocaine and dressings, where the people walked in flip-flops for several hours to seek advice they had a local community health care worker who dealt with a community twice the size of most single-handed GP practice lists using mobile technology.

I left wondering how best to practically support such an outpost or others in similar situations in developing countries. Local, trusted, community health care workers may be providing a lot of care to some of the most vulnerable of people and often outside any formal Government health programme. What can be done to support them?

Here are some ideas:

• regular face-to-face support - this is the first thing that Siroj asked for - volunteer medics especially in the unpopular monsoon seasons
• more formalised telemedicine perhaps. Where a decision to 'have a go and stitch it' or 'send it to the local hospital' is being made then a phone-a-friend option might be most welcome. This is a highly specialised and urgent discussion which doesn't lend itself to the more convenient asynchronous technologies like social media.
• semi-automated collection of data - so that suggestions could be made (remotely) for further support or training
• local / regional networking. I know some medics in West Bengal and one whose family runs a small hospital not far from this area. Network weaving by linking them to the clinic would help. One issue that had been raised previously was the apparently high incidence of hypertension. After being there a week it seems that it may be the measurements that were probably high not the blood pressure itself - after climbing a hill your blood pressure will be high and aneroid sphygmomanometers are not as reliable as mercury ones. Perhaps a local contact could source better equipment? I found the Indian Hypertension Guidelines and emailed them to Tom - printing them out at Karmi farm is the trick.
  
• getting an experienced community health care project leader / researcher / team to conduct a 'rapid appraisal' and involving the clinic's population

Would be interested to hear some others.

TILT - microblogging your learning

Just caught up with news of this Today I Learnt That ... pilot from the TRIP database guys Jon Brassey and Chris Price.

Nice one ... and it's another 4 letter acronym beginning with 'T'!

Not to be confused with FT's tilt (note the lower case) which is a digital news site about 'tilting' markets?

TILT looks like a Web 2.0 way of microblogging your own learning especially when reading the evidence-based medicine summaries on the TRIP database. Since they have now got 10,000 registered users it would make great sense to give them some sort of simple way of tracking their reflections. Having a dedicated tool used by this particular community has advantages over, say, a more general microblogging tool such as Twitter since the learning may get mixed up with what you're eating for breakfast or which train you're on. There's the challenge too and I wonder if we may see some linking up of other online tools via fancy tagging. Hey ... the #tilt hashtag is not really widely used so I'd start posting it to reserve it!

Online vs. face-to-face learning

"Focussing on the individual learner, their needs and encouraging their reflection, is more important than fancy online tools".

Reading the report Evaluation of Evidence-Based Practices in Online Learning: A meta-analysis and review of online learning studies. U.S. Department of Education. Revised September 2010.

This is a systematic review of the literature (the principle databases were ERIC, PsycINFO, PubMed, ABI/INFORM, UMI ProQuest Digital Dissertations but manual techniques were also used) 1996 - July 2008 of studies looking for experimental or quasi-experimental studies evaluating face to face and online learning with objective measures of learning. 1132 abstracts screened, 176 studies selected of which 99 used for analysis and 77 used for narrative synthesis.

The authors concluded:

• "Few rigorous research studies of the effectiveness of online learning for K-12 students have been published." Many of the studies included in this report were from higher education such as medical training. So, even more interest from a medical education perspective.
• Face to Face plus online learning is better than online learning alone which is better than Face to Face alone. The authors warn against over-interpretation of this finding since the differences may be due to factors other than the media per se. These factors could include content, pedagogy and learning time.
• Instructor-directed learning and collaborative learning (peer to peer) were effective but individual learning was not.
• "Most of the variations in the way in which different studies implemented online learning did not affect student learning outcomes significantly." 13 different learning practices had been identified as potential sources of variation but none were found to be.
• "The effectiveness of online learning approaches appears quite broad across different content and learner types." Undergraduates, graduates and professionals all seem to benefit from online learning.

Also, they observed that studies tending to conclude the following:

• Blended and purely online learning within a single study have similar effects.
• Video and quizzes don't seem to have an influence on the amount that is learnt online.
• Learner control and reflection enhances learning.
• Guiding groups of online learners tends to influence the way the interact but not the amount they learn. Compare this with the beneficial effect of guiding individuals online.

It is great that this type of work is regularly undertaken in the US. We owe a lot to the public funding and open publication of such research.

I wonder if the conclusions here should be that online learning allows for more opportunities and time for learning, good teaching works regardless of the media used ("Effective teaching transcends course format") and focussing on the individual learner, their needs and encouraging their reflection, is more important than fancy online tools.

Diabetes education project

Started an international diabetes project yesterday for primary care physicians in four different countries. The educational intervention is based on the social learning theory Communities of Practice¹. It will be evaluated by colleagues in Canada - hopefully across the two languages - and written up early next year.

There was a lively discussion at our orientation session in Cardiff (thanks all) but all too brief. I hope the platform that we've developed will help extend the discussion.

Before the session we asked some of the GPs to send details about their current clinical practice and plugged them into Wordle to create a visual summary of the themes and issues - a technique I picked up from Bronwyn Stuckey (thanks @BronSt).



Don't know what it means but, like reading tea leaves, it helps to stimulate conversation.

Looking forward to the online discussion and perhaps the possibility of breaking out of our basecamp.

1. Etienne Wenger. Communities of practice: learning, meaning, and identity. Cambridge University Press; 1998. Associated website at: http://www.ewenger.com/theory/ .

Sharing presentations

Have a presentation next week where some of the participants can't attend in person so we will, at another time, go through the slides with them remotely but the presentation has been developed by someone else in Office 2007 .pptx format. Boo!

Whilst it is possible to share this with various web conferencing software by sharing screen displays they all rely on either Flash (DimDim), Java (Elluminate) or both. Whilst these are excellent services they can have some 'set up' issues. I'd like a much smaller barrier as this is the first meeting of the group.

I would prefer to present this using a simple interface that needs no logging in and can be used whilst talking over the telephone. i.e. Google Docs. However, Google docs works with ppt files and not pptx files. Also if I open the presentation with Open Office and save it in Office 97/2000/XP version .ppt format then Google thinks it's corrupt. Hmm I wonder who is corrupt. It couldn't be Microsoft could it trying to force people to use a new version of their Office software? (Got a copy of MS Office 2003 on a laptop so will have to go there and do a conversion I suppose. But really ... why?)

Recently seen some excellent examples of document sharing using Google Docs on the CPsquare Foundations course. I think the ability to use simple collaborative and white boarding tools with low barriers for participation is very important for engaging learners especially those who are less experienced with such online participation. Being inclusive is more important than choosing a particular technology. Something that just uses the browser without any need for plugins would be ideal.

Any suggestions for very simple whiteboard viewers?

skrbl looks good but doesn't seem to do pictures / screen shots
Google Docs Drawing seems better but would be a little clunky for a long presentation

Geeking out with a Communities of Practice Workshop

The Foundations of Communities of Practice Workshop, September 2010 course from CPSquare starts today.

http://cpsquare.org/edu/foundations/

I enrolled on the course to learn more as a current project I'm involved with includes an attempt to stimulate and support a Community of Practice among doctors who care for people with diabetes. Having read the books (http://www.ewenger.com/pub/pubbooks.htm) and the theory I felt some practical discussion and experience would be helpful.

The best way to learn about a particular learning theory is to learn about it by using it to learn about it.

Communities of Practice are not discussed widely in medicine but they clearly exist. They are far more openly promoted in other industries including local government in the UK which an old friend pointed out over the summer.

However, doctors are a strange bunch and sometimes if you tell them you want to put them into a 'community of practice' their initial response would be to say no thanks. They say that when they talk about their clinical work but in other aspects they leap into communities of practice. There are quite a few medics in the cycling group "One and All". It was very interesting listening to the informal discussions about the practice of cycling during the ride, afterwards at the cafe and later on the Facebook page. There are also strong issues about negotiation of identity. There are cycling outfits (you can imagine it) that reflect membership of the club from those on the periphery and one person was even wearing new branded socks which someone else very much wanted to have. Where next?

Anyhow, looking forward to geeking out with other CoP enthusiasts later today.

iPhone App for 24HourLondon launched

Web interface, website and iPhone App sorted.

Been working with Emma for the last few months on developing the web database that delivers the details of the venues to the iPhone App and its associated website with funky graphics designed by Corin.

http://24hourlondon.co.uk/

It has been really enjoyable - though a little challenging working with family and another developer all at a distance - and it is great to see it finally listed on the Apple Store as 24hourlondon for iPhone. Well done Emma.

Basically there is a large database of thoroughly researched late night venues. The iPhone App tells the database its geolocation and the database calculates distances and lists those venues that are nearby. Want to carry on past your normal bed time? 24 Hour London is here to help.

I get the feeling that this sort of work is currently over-priced. The development costs are quite high in comparison to the relative simplicity of the technology. I'm sure that in coming years developing applications for smartphones is going to be cheaper. The real value is in the "content" - the details of the venues that have been researched and are more reliable than simply searching the web for details that may be very out of date. Content is king ... and always was.

Now we've got the web API sorted out we'll have to do the same for Android phones.

Dermatomyositis

Lunchtime meeting in Truro on Dermatomyositis with a presentation of two cases. Excellent reminder of this condition which seems to be very popular at lunchtime meetings wherever you go.

The additional images and differential diagnosis slides were particularly good and came from DermNet NZ.

There's also a good example of how the rash appears on darker skin at BMJ Case Reports¹.

1. Tristano AG. A woman with muscles pain, weakness, and macular rash. BMJ Case Reports. 2009;2009(aug27 1):bcr0620092027-bcr0620092027. Available at: http://casereports.bmj.com/content/2009/bcr.06.2009.2027.full [Accessed May 6, 2010].

Women in Kenya are 50 times more likely to die in childbirth than in the UK.

The Lancet has published Maternal Mortality Rates for 181 countries (1).

The Guardian has also published the maternal mortality rate table in its blog.

Looking down the table with our particular interest in Kenya it looks like they have made some progress in reducing the rate in the last 20 years but very little. Even though some of the discussion in the last few days has been on why the UK has not improved or why it is "worse" than Albania it is sobering to think that women in Kenya are 50 times more likely to due during or after childbirth than women in the UK.

1. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010 Apr 9

Started a JustGiving page for Mercy Rescue Trust

After some fiddling managed to get my JustGiving page up for the Mercy Rescue Trust.

http://www.justgiving.com/DeanJenkins

Has the doubtful strapline of "sponsor us having a good time" or something like that.

Punk IPA - BrewDog Brewery

Very hoppy IPA with 6% ABV.

Pale yellow with nice foamy head. Straw, mildly fruity and light caramel nose. Quite a bite on tasting - "resinous" with a long dry bitter end like licking someone's armpit - very punk.

http://www.brewdog.com/punk_ipa.php


Transatlantic influenced IPA. How many hops can we stuff in it?

Nice but would find it hard to drink two.