Simulated sessions are widely used within medical education. Despite the potential benefits of simulated learning, it suffers from a narrow scope of practice; acute, emergency presentations and procedural skills. There is less research for its utility in sub-acute and chronic disease management. To develop expertise in medical practice, learners require sufficient foundational knowledge to facilitate more complex behaviours [1]. Within ward environments, lack of foundational knowledge in both ‘hard’ (knowledge) skills, and ‘soft’ (organizational) skills can limit learners’ potential for development. Considering legitimate peripheral participation theory, learners require ‘enculturing’ into an institution to develop ‘soft’ skills. Examples of ‘soft’ skills include understanding problem solving approaches, language, values and norms of the profession [2]. To design and assess the educational impact of simulated ward round teaching sessions on medical students in semi-acute settings, focussing on ‘enculturing’ skills. This was a prospective study. We created a ward round-based simulation session, with six simulated patient scenarios, designed for clinical placement level medical students. Ten students were included in the study. We utilized an induction exercise to familiarize students with medical documentation, a simulated ward round, and a consolidation exercise reviewing discharge paperwork and prescriptions. A simulated patient was present in each scenario, with a member of faculty facilitating. Simulated ward round entries, nursing handover queries and investigations were provided to students. Scenarios were 20 minutes; with objectives to produce ward round documentation and generate holistic clinical management decisions. Students participated in a ‘board round’, which served as a forum for station specific feedback. Enculturing values were assessed via a 40-point, knowledge based formative assessment, covering the main themes of the session: appropriate documentation, medical abbreviations, and clinical decision-making. Assessment was administered both pre- and post-session. Qualitative feedback of the session was obtained from learners to identify themes for further development. There was a significant improvement in knowledge following the session (see Results of pre- and post-intervention knowledge assessment Our results demonstrate an increased sense of empowerment in the study population. Simulated practice can be used effectively to enhance learning in sub-acute medical situations. Enculturing skills were particularly enhanced; promoting future learning through orientation within zones of legitimate peripheral participation. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

The ‘Sepsis Six’ bundle was promoted as a deliverable tool outside of the critical care settings, but there is very little data available on the progress and change of sepsis care outside the critical care environment in the UK. Our aim was to compare the yearly prevalence, outcome and the Sepsis Six bundle compliance in patients at risk of mortality from sepsis in non-intensive care environments. Patients with a National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled into four yearly 24-h point prevalence studies, carried out in fourteen hospitals across Wales from 2016 to 2019. We followed up patients to 30 days between 2016–2019 and to 90 days between 2017 and 2019. Out of the 26,947 patients screened 1651 fulfilled inclusion criteria and were recruited. The full ‘Sepsis Six’ care bundle was completed on 223 (14.0%) occasions, with no significant difference between the years. On 190 (11.5%) occasions none of the bundle elements were completed. There was no significant correlation between bundle element compliance, NEWS or year of study. One hundred and seventy (10.7%) patients were seen by critical care outreach; the ‘Sepsis Six’ bundle was completed significantly more often in this group (54/170, 32.0%) than for patients who were not reviewed by critical care outreach (168/1385, 11.6%; p < 0.0001). Overall survival to 30 days was 81.7% (1349/1651), with a mean survival time of 26.5 days (95% CI 26.1–26.9) with no difference between each year of study. 90-day survival for years 2017–2019 was 74.7% (949/1271), with no difference between the years. In multivariate regression we identified older age, heart failure, recent chemotherapy, higher frailty score and do not attempt cardiopulmonary resuscitation orders as significantly associated with increased 30-day mortality. Our data suggests that despite efforts to increase sepsis awareness within the NHS, there is poor compliance with the sepsis care bundles and no change in the high mortality over the study period. Further research is needed to determine which time-sensitive ward-based interventions can reduce mortality in patients with sepsis and how can these results be embedded to routine clinical practice. Trial registration Defining Sepsis on the Wards ISRCTN 86502304 https://doi.org/10.1186/ISRCTN86502304 prospectively registered 09/05/2016.

Background To evaluate the role of combined MRI and mammogram follow-up in patients with previous 'mammographically occult' breast cancer. Methods Between 2011 and 2016, examinations of all patients undergoing routine surveillance following previous 'mammogram occult' breast cancer were evaluated. Patients had both MRI and mammograms on the same day with an interval of 12-18 months between consecutive pairs. Total number of recalls on both imaging modalities and the outcome of those recalls was recorded. There were six median examinations per patient. Results There were a total of 325 examinations of 54 patients. There were 96 mammograms/MRI pairs and 87 lone MRI and 46 lone mammograms. There were a total of 26 recalls in 21 patients. MRI had specificity (95% CI) of 89.99 (85.67 to 93.11) compared to mammograms 96.27 (92.53 to 98.25). The diagnostic OR with 95% CI was 19.40 (3.70 to 101.57) vs 6.72 (1.43 to 31.58) of mammograms and MRI, respectively. Three of seven cancers presented symptomatically. Conclusions MRI surveillance leads to higher recalls and false positives compared to mammograms in this specific subgroup of high-risk patients. Large proportion of cancers presented symptomatically, stressing the importance of remaining vigilant of breast symptoms despite imaging surveillance.

Recent description of the microbiology of sepsis on the wards or information on the real-life antibiotic choices used in sepsis is lacking. There is growing concern of the indiscriminate use of antibiotics and omission of microbiological investigations in the management of septic patients. We performed a secondary analysis of three annual 24-h point-prevalence studies on the general wards across all Welsh acute hospitals in years 2016-2018. Data were collected on patient demographics, as well as radiological, laboratory and microbiological data within 48-h of the study. We screened 19,453 patients over the three 24 h study periods and recruited 1252 patients who fulfilled the entry criteria. 775 (64.9%) patients were treated with intravenous antibiotics. Only in 33.65% (421/1252) of all recruited patients did healthcare providers obtain blood cultures; in 25.64% (321/1252) urine cultures; in 8.63% (108/1252) sputum cultures; in 6.79% (85/1252) wound cultures; in 15.25% (191/1252) other cultures. Out of the recruited patients, 59.1% (740/1252) fulfilled SEPSIS-3 criteria. Patients with SEPSIS-3 criteria were significantly more likely to receive antibiotics than the non-septic cohort (p < 0.0001). In a multivariable regression analysis increase in SOFA score, increased number of SIRS criteria and the use of the official sepsis screening tool were associated with antibiotic administration, however obtaining microbiology cultures was not. Our study shows that antibiotics prescription practice is not accompanied by microbiological investigations. A significant proportion of sepsis patients are still at risk of not receiving appropriate antibiotics treatment and microbiological investigations; this may be improved by a more thorough implementation of sepsis screening tools.