Heterotopic ossification is a condition affecting an appreciable minority of critical care patients; it can have long-lasting effects on recovery and return to functional status. Ectopic bone forms in soft tissues near the large joints, causing pain, swelling, limitation of movement and ultimate disability. X-ray changes may be delayed for several weeks after the diagnosis is clinically suspected. Magnetic resonance imaging may be more sensitive for detecting early changes, yielding positive results several weeks before Xrays. However it is not clear that diagnosing the process early will influence long-term patient outcome, because no effective treatments are available.Currently only a small minority of long-stay intensive care patients are followed up by the critical care service, and thus there is no 'bridge' between the critical and rehabilitation phases of illness. Recent studies have demonstrated that survivors suffer long-term consequences that can have a marked impact on their recovery and quality of life for years after discharge, and a current paper highlights a specific physical issue: heterotopic ossification (HO) [1].Return to normal functional status is often slow, with different rates of physical and psychological improvement [2][3][4]. Lack of understanding and experience of possible long-term sequelae of critical illness may hinder patient recovery further because access to the full range of services required in the rehabilitative phase may not be provided.HO is a recognised condition in critical care patients, causing significant long-term morbidity in up to 5% patients after a prolonged stay [5]. The condition is not widely recognised and may evade diagnosis, yet it may be a major cause of impaired mobility and pain in the months after discharge [5]. The condition has been described in patients with head or spinal cord injury, pancreatitis and acute respiratory distress syndrome (ARDS), although any sedated patient is vulnerable [6,7].The presentation is non-specific, with pain, swelling, fever and decreased joint mobility -common signs that may be frequently overlooked. Furthermore, presentation may be obscured by sedation or muscle relaxants.Argyropoulou and colleagues [1] describe a series of 11 patients who developed HO of the knee during prolonged critical care stay; head injury was the cause for admission in most cases. They report early 'lacy' changes in the vastus medialis and lateralis muscles on magnetic resonance imaging (MRI) (T1-weighted and short TI inversion recovery (STIR) images) and homogeneous high signal changes in the medial portion of the vastus medialis. The authors report that MRI changes occurred very rapidly after clinical suspicion of the diagnosis, but X-ray changes were delayed for a further 23 days. On follow-up MRI scanning, the medial portion of the vastus medialis had developed heterogeneous changes suggestive of HO in all cases. X-rays at this time showed calcification in the same position. This delay in X-ray presentation is plausible, because substan...
Purpose Undergraduate clinical placements have the potential for significant improvement. Previous research has shown the growing value of clinical teaching fellows (CTFs) within medical education. Changing traditional placements to a model whereby CTFs have defined roles and lead the majority of teaching can positively reinvent undergraduate clinical teaching. We wanted to see how a structured teaching programme delivered by CTFs could affect student experience and personal development within a large associate teaching hospital. We consider how such a model could be implemented and explore the opportunities for CTFs to develop in personal and professional capacities. Methods A mixed methods study was organised to assess student experience of a CTF-led placement. A novel structured teaching programme was delivered by 14 CTFs, who provided or were involved with the majority of teaching for all medical students. Thematic analysis was conducted on focus groups with 48 final year medical students from Queen Mary University of London following completion of their clinical placements. The same students were asked to complete an anonymous survey from which results were analysed using modified 5-point Likert scales. Results Eight themes were identified from the focus groups. Students appreciated the increased individualisation, relevance and variety of teaching and the ability to record progress. Other perceived effects were higher teacher to student ratios, more learning opportunities and increased familiarity and reliability with CTFs. Of the students surveyed, 96% felt their overall placement experience was very good in comparison to previous placements elsewhere. Survey results supported focus group themes and demonstrated perceived growth in students’ personal development. Conclusion Placement models where CTFs lead most teaching can improve medical undergraduate experience and training. A move towards CTF-delivered teaching can be of financial benefit to hospital trusts whilst allowing time for junior doctors to explore different clinical specialities and hone their teaching skills.
Summary A patient with the toxic shock syndrome presented with conjugate deviation of downgaze and impaired ocular movement. Focal neurological signs are rare in this syndrome and disordered eye movement has not been previously reported.
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