Introduction: Malawi is one of the world's poorest countries with very limited healthcare spending and a lack of post-graduate training for healthcare workers, including in critical illness management. Critical illness simulation courses have been shown to be an effective training tool and form a key part of training for healthcare professionals in the developed world. However, these courses can be difficult and costly to set. We therefore developed an affordable and simple to run programme for use in a regional hospital in Malawi.Methods: We delivered a series of lectures alongside a simulation course based around critical illness management, including cardio-pulmonary-resuscitation. The course was taught by a visiting physician who trained a local clinical officer to continue running the course in the future. Feedback on candidate confidence in managing acutely unwell patients was collected before and after the course.Results: All staff in the unit attended the course. Median candidate confidence across all seven assessed areas increased significantly.Conclusions: Despite the basic equipment used in our course, we received very positive feedback and feel that this highlights that significant improvements in staff skillset, and therefore patient outcomes, can be achieved using a relatively simple and low cost intervention that can also easily be continued by local members of staff, ensuring sustainability. Introduction of similar courses in other resource poor settings may help improve patient outcomes without the significant financial outlay and lack of future-proofing seen with many healthcare initiatives that are deployed, and are often unsuccessful, in the developing world.

This study reports the views of second year medical students from 6 Universities on the value or not of deferring entry to medical school in order to take a 'Gap Year' obtained from an anonymous questionnaire. Data were analysed using Fisher's exact test to produce a two tailed P value, with significance defined as p <0.05. A total of 184 questionnaires returned, 79 from gap year students and 105 non gap year students. Nearly all who had taken a gap year (77/79) would advise current school leavers to take one, compared to only 48/105 who had not (p <0.0001). A similar difference was observed between the two groups when asked if they thought a gap year helped students become more mature (78/79 v 46/105, p <0.0001). Similarly, gap year students were significantly more likely to consider that a gap year made it easier for them to make friends (70/79 v 26/105, p <0.0001). There was no significant difference between the two groups in finding it difficult to settle into work at University (31/79 v 36/105, p=0.5373). This study shows overwhelming support for deferring entry to medical school and taking a gap year from those students who took one, and nearly half of those students who did not. Medical school entrance committees should re-consider their advice to students who wish to defer entry in order to take a 'gap year'.

Case report - Introduction Scleritis is severe vision-threatening scleral inflammation, commonly presenting with a red, painful eye and can be classified using the Watson system. Posterior scleritis may present with associated anterior uveitis in many cases. Steroid therapy is often successful initially; however, further immunomodulation is usually required to control subsequent episodes which can be challenging. We present an 18-year-old, Caucasian girl with a left eye, sight-threatening, steroid-dependent posterior uveitis who required escalation of treatment to tocilizumab before inflammation could be suppressed. Case report - Case description Our patient was diagnosed elsewhere with ulcerative colitis at the age of 12 and subsequently developed recurrent episodes of uveitis and scleritis which could be controlled with topical steroids. At the age of 16 she presented with an inflammatory arthritis and was treated with intravenous methylprednisolone before commencing sulfasalazine therapy. Due to persistent systemic and ophthalmic inflammation she was changed to adalimumab; however, this was also unsuccessful and methotrexate was added. By the age of 18 she had been steroid-dependent for 2 years and could not reduce daily prednisolone below 15mg without a deterioration in her left eye posterior scleritis with visual acuity compromise including episodes of complete visual loss causing high levels of anxiety. Due to the pain and deterioration in vision she struggled with her studies and school attendance, and withdrew from her passion for competitive sailing. With ongoing sight-threatening inflammatory changes she was referred for further tertiary assessment in 2019. During the following 4 months treatment was escalated rapidly. Methotrexate dose was increased, and adalimumab frequency reduced to weekly. There was a limited response, with further episodes of sight deterioration as a result of flares in inflammation. Response to tocilizumab treatment was seen after only two doses with good control of scleritis by 3 months of treatment when steroids were successfully weaned and stopped. Over 18 months of tocilizumab therapy the patient has only required one course of topical steroids for mild ocular inflammation which resolved without any other treatment required. She has successfully completed her degree, can complete daily gym training sessions and participate in regular sailing competitions. Case report - Discussion Posterior scleritis is the most common scleritis in children and can be associated with anterior uveitis, concurrent anterior scleritis, disc swelling or retinal striae. Posterior scleritis has a higher rate of complications therefore is treated aggressively. Refractory cases such as this require biologic therapy and rituximab is often used. Despite the preference of two adult eye units for treatment with rituximab the rationale for tocilizumab included; recent high quality studies showing successful treatment of inflammatory bowel disease, its known benefit for anterior uveitis and case studies in adults with posterior scleritis. Tocilizumab is a recombinant monoclonal antibody that causes a blockade of interleukin-6 receptors. It is currently only approved by the Food and Drug Administration (FDA) for use in children with polyarticular or systemic onset Juvenile Idiopathic Arthritis (JIA). Our patient had a very positive experience with this drug, no side effects and rapid clinical improvement seen. As a result her quality of life and mental health improved quickly. Case report - Key learning points This is a case of refractory, sight-threatening, steroid-dependent posterior scleritis on a background of inflammatory bowel disease and arthritis. As a result of this case our team reviewed current literature from other paediatric populations and adults with scleritis, informing the clinical decision to proceed with tocilizumab after control was unsuccessful with previous agents. The remarkable response demonstrated for our patient highlights the value tocilizumab can offer to the treatment options for similar refractory cases. This adds to the growing positive data published surrounding tocilizumab in children but further studies in paediatric populations are required to evaluate this in greater detail.

Case report - Introduction Major advances in medical and therapy management of inflammatory arthritis has been associated with marked improvement in outcomes. We present a very unusual case of a young boy with destructive and incapacitating arthritis of knees, feet and ankles refractory to such management. He is now wheelchair dependent. We have evidence of reversal of bone loss after treatment. However, synovitis and joint destruction has left few surgical options with above knee amputation considered to have the best long-term functional outcome. Case report - Case description Age five, he had persistent pain and swelling of the right knee after a minor fall. In the emergency department a sclerotic, lucent area was highlighted on X-ray. Neoplasia was ruled out and the changes were felt to be a result of erosive arthropathy. By the time of rheumatology referral, symptoms progressed to significant bilateral knee effusions with left ankle inflammation. All three joints underwent steroid injections which had a good response, but unfortunately this was short-lived and they were repeated. A synovial biopsy was sent to exclude other pathologies and loose bone fragments were removed from both knees. Biopsy confirmed chronic inflammation and methotrexate was commenced. Unfortunately, there was minimal response. Over the next 5 years he trialled etanercept, infliximab, tocilizumab, pamidronate, azathioprine and abatacept. His destructive arthritis of the knees, ankles and feet continued to progress with relentless bone loss and associated osteochondritis dissecans (OCD). Opinions from five other tertiary rheumatology units worldwide, three radiology departments and four orthopaedic units were sought. Unable to control the synovitis and in the presence of complete loss of the lateral femoral condyle we elected to refocus our attention to bone integrity and preparation for definitive surgery. This included the use of denosumab. Serial radiology showed reversal of some bone loss over 2 years but surgical teams could not identify intervention to optimise weight-bearing capacity. Mobility deteriorated to leave our patient wheelchair dependent outside, using crutches or his knees to move around inside. Further surgical consideration has indicated the best long-term will be associated with above knee amputations. Case report - Discussion Our team are aware of one less severe case in a 13-year-old male in Oxford that stabilised after 5 years, allowing definitive treatment with bilateral knee replacement followed by excellent recovery with full mobility. None of the international centres we contacted reported a case as severe as ours. From discussions with our paediatric and adult orthopaedic colleagues, the only comparable patients they have seen this level of bony knee destruction in has been uncontrolled haemophilia patients. However, the damage is not seen at such a young age which affects the surgical options due to ongoing growth in childhood and adolescence. This caused us to question; why was our patient so severely affected? Would a different treatment course have been feasible? And would this have changed the outcome? Despite trial of many immunomodulatory agents, both those routinely used for arthritis and those used in treatment resistance, the persistent inflammation and destruction progressed. As a result he developed persistent and problematic OCD. OCD is considered a relatively common diagnosis that can occur in adults and children of unclear aetiology. A small subchondral bone fragment becomes loose in the joint space as a result of disrupted blood supply. OCD seems to be more common in males and is often managed conservatively. In children, the knee is the most commonly affected joint and inflammation is hypothesised as a possible cause which we will elaborate on in our presentation. For cases requiring surgical intervention this is normally localised drilling, fixation or bone grafts; however, most cases only affect one site, with one loose fragment which was very different from our patient. Case report - Key learning points From this case we have been reminded that each patient follows a different clinical course and response to medications is difficult to predict. We have gained experience managing difficult inflammatory arthritis-related OCD working closely with our orthopaedic colleagues. Although we managed to control the destructive inflammatory process this did not reverse the damage to the patient’s joints and we have been left with no choice but to progress to surgical treatment options. By sharing this case we hope to learn from any similar experiences or challenges faced by other clinical teams to help inform our practice for any other cases in the future.

AimWe present a case study of the development of a structured, holistic, multidisciplinary prescribing teaching program for medical students in our paediatric department. The aim was to integrate theory and practise into one multidisciplinary delivered teaching session.MethodPrescribing is an area that medical students consistently report as challenging with poor teaching and minimal paediatric specific prescribing teaching as an undergraduate. After collaboration with our pharmacist colleagues the agreed objective was to design a teaching session run by doctors and pharmacists together in order to more accurately simulate paediatric prescribing in clinical practice for the inpatient environment. The method was based on Blooms Taxonomy,1 starting with a pharmacist delivering teaching on the theory of paediatric prescribing. Following this, junior doctors delivered case based prescribing scenarios to allow assimilation and application of theory. At the end of the 150 minute session feedback was collected from both session facilitators and students. These were evaluated to allow for revision and improvement of the session.ResultsBoth facilitators and students very enthusiastically received the session with phrases such as ‘amazing session thank- you!’ added to the feedback forms. Feedback was gathered from 32 students over the first 8-week cycle of the project. The majority of students stated that prior to this session they had little or no paediatric prescribing teaching. When asked the question ‘how prepared do you feel for prescribing in paediatrics?’ and asked to rank themselves from 1 (not at all) to 5 (very well) the average improved from 1.44 pre session to 3.55 post session. The feedback was consistent between sessions demonstrating no significant variation between facilitators. This highlights that the standardised, formal structure of the session allows it to be delivered by pharmacists and doctors of different grades and levels of experience without changing the success of the session for the students.ConclusionThis project demonstrates that there is a significant gap in undergraduate teaching on prescribing, especially paediatric prescribing. This teaching session is low cost, produces similar feedback despite variation in facilitators between sessions, and is easily transferable to multiple inpatient areas. Our students demonstrated that after one teaching session they felt more prepared for prescribing in paediatrics and following the feedback changes have been made to the session and ongoing feedback has further improved. We propose that this style of teaching session could be used across the country for both adult and paediatric prescribing undergraduate teaching sessions. We aim to compare our session with other universities approaches to prescribing teaching and establish whether this is a national area that requires focused educational attention.ReferenceBloom BS. Taxonomy of educational objectives: The classification of educational goals 1956.