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The authors describe their personal experience of responding to changing perceptions of best practice and the expanding evidence base, in relation to assessment and feedback in dental education. Changes at a particular dental school over the years are described, along with a more general outlook, culminating in suggestions for future directions. Key points Assessment in dental education has changed considerably in the past 20-30 years, at least partially driven by developments in assessment theory and consequent concerns about the validity of traditional approaches. Objective assessment methods have gained considerable popularity, with apparently good reason. However, these approaches do not always allow authentic assessment of real-world clinical practice. Workplace-based assessments have been adapted for use in undergraduate settings. Such methods require the acceptance and management of expert judgement. They also require sophisticated approaches to the interpretation of large datasets. Properly implemented, they can facilitate defensible progress decisions but their role in supporting development is equally important.

The role of the dental therapist has evolved over the course of the past 70 years, both in the UK and across the globe. The General Dental Council's Scope of practice guidance sets out the skills and abilities of each of the professional roles within the dental team, including the dental therapist. Scope of practice of the multidisciplinary team remains poorly understood, to the detriment of teamworking. The dental profession is under pressure and the development of a flexible and appropriately trained skill mix might help us adapt to meet the oral health needs of the population, while leveraging a sustainable workforce. In 2019, the School of Dentistry at the University of Liverpool introduced a novel ‘centennial curriculum', designed to fully integrate the interprofessional training requirements of dentists and dental therapists, following application via two distinct routes of entry. Challenges have arisen and addressing these has required a culture of openness and honesty regarding the complexities of shared care and scope of practice. Key points Scope of practice of the multidisciplinary team remains poorly understood, to the detriment of teamworking. NHS England's workforce plan aims to have the right number of staff, with the right skills and competencies, in the right place, at the right time, to deliver services that provide the best possible patient care and meet demand, within an affordable budget. For this, the profession is required to have a flexible and appropriately trained skill mix. The NHS needs to develop healthcare professionals who can adapt to meet the oral health needs of the population while leveraging a sustainable workforce. In 2019, the School of Dentistry at the University of Liverpool introduced a novel ‘centennial curriculum' designed to fully integrate the interprofessional training of dentists and dental therapists. We discuss the challenges we have faced and how these have been addressed.

A primary aim of dental schools is to produce competent and caring independent professionals, capable of developing themselves and serving the needs of their patients through reflective practice and self-regulated continuous learning. The General Dental Council has also explicitly recognised the importance of self-regulated learning, and other associated behaviours, in the new The safe practitioner framework. However, traditional learning designs focus on the development of academic and clinical skills, and assume that psychosocial skills, which support self-regulated learning and enable the management of personal challenging circumstances, are already present. Unfortunately, data suggest that the psychosocial skills in many students currently entering healthcare programmes are relatively underdeveloped, impacting upon their approaches to learning and their mental health, and potentially, patient safety. Therefore, there is a need to support students in their psychosocial development. This development starts with teachers understanding the societal, academic and environmental circumstances that their current students have experienced, followed by the consideration of the importance of psychosocial skills within their dental education. This paper discusses these matters and suggests a psychosocial sub-curriculum along with a suggested framework for its implementation. Key points Discusses the need for an introduction of a psychosocial curriculum within dental education to address the needs of the current generation of dental students and meet the General Dental Council's required outcomes. Proposes a syllabus and organisation of subjects to allow dental education providers to facilitate monitoring of satisfactory student development in this area. Considers the change to The safe practitioner framework as an opportunity to develop key behaviours that can support learning, personal well being, and good long-term mental health.

Cardiogenic shock is associated with a high risk for morbidity and mortality. The impact of gender on treatment and outcomes is poorly defined. This study aimed to evaluate whether gender influences the clinical management and outcomes of patients with prehospital cardiogenic shock. Consecutive adult patients with cardiogenic shock who were transferred to hospital by emergency medical services (EMS) between January 1, 2015 and June 30, 2019 in Victoria, Australia were included. Data were obtained from individually linked ambulance, hospital, and state death index datasets. The primary outcome assessed was 30-day mortality, stratified by patient gender. Propensity score matching was performed for risk adjustment. Over the study period a total of 3,465 patients were identified and 1,389 patients (40.1%) were women. Propensity score matching yielded 1,330 matched pairs with no differences observed in baseline characteristics, including age, initial vital signs, pre-existing co-morbidities, etiology of shock, and prehospital interventions. In the matched cohort, women had higher rates of 30-day mortality (44.7% vs 39.2%, p = 0.009), underwent less coronary angiography (18.3% vs 27.2%, p <0.001), and revascularization with percutaneous coronary intervention (8.9% vs 14.2%, p <0.001), compared with men. In conclusion, in this large population-based study, women with cardiogenic shock who were transferred by EMS to hospital had significantly worse survival outcomes and reduced rates of invasive cardiac interventions compared to men. These data underscore the urgent need for targeted public health measures to redress gender differences in outcomes and variation with clinical care for patients with cardiogenic shock.

Introduction Concerns regarding the preparedness of dental graduates often focus on the number of procedures undertaken before qualification.Aims To assess the validity of numerical requirements in determining whether a student has sufficient competency to graduate.Materials and methods In total, 50,821 observations of student activity while on the restorative clinic, for two integrated student cohorts (n = 139), were continuously recorded using the LiftUpp system from their third year to graduation. Analysis of data determined the most frequent type, location and difficulty of the direct restorations provided.Results Four groups of students, categorised by the total number of restorations they provided, were identified. Those with the most restorations (70+) had a statistically significantly greater experience in restoring different tooth surfaces, in different quadrants, on different patients than those with the least (40-49). However, increased numbers did not correlate with increasing difficulty, suggesting that students simply became more adept at easier procedures.Discussion Using a derived measure of 'consistency', it was observed that increased performance consistency was not correlated with greater overall experience. Furthermore, only 4% of students were 100% consistent in their performance in their final year.Conclusions These data suggest that a 'numerical requirements' approach cannot be used, in isolation, as a valid measure of the competency of an individual. Further work is needed to validate consistency as a holistic measurement to characterise the performance of graduates.Key pointsThe numerical requirement approach alone should not be used to make valid judgements over the competency of a dental student to undertake direct restorations.Consistency as a holistic measure of performance may be more suitable to assess the set of skills required.Students are not usually 100% consistent in their performance by graduation.

Rheumatoid arthritis (RA) is the most common inflammatory arthritis and is associated with increased risk of cardiovascular events and mortality. Evidence regarding outcomes following PCI is limited. This study aimed to assess differences in outcomes following percutaneous coronary intervention (PCI) between patients with and without RA. The Melbourne Interventional Group PCI registry (2005 to 2018) was used to identify 756 patients with RA. Outcomes were compared with the remaining cohort (n = 38,579). Patients with RA were older, more often female, with higher rates of hypertension, previous stroke, peripheral vascular disease, obstructive sleep apnea, chronic lung disease, myocardial infarction, and renal impairment, whereas rates of dyslipidemia and current smoking were lower, all p <0.05. Lesions in patients with RA were more frequently complex (ACC/AHA type B2/C), requiring longer stents, with higher rates of no reflow, all p <0.05. Risk of long-term mortality, adjusted for potential confounders, was higher for patients with RA (hazard ratio 1.53, 95% confidence interval 1.30 to 1.80; median follow-up 5.0 years), whereas 30-day outcomes including mortality, major adverse cardiovascular events, bleeding, stroke, myocardial infarction, coronary artery bypass surgery, and target vessel revascularization were similar. In subgroup analysis, patients with RA and lower BMI (Pfor interaction < 0.001) and/or acute coronary syndromes (Pfor interaction = 0.05) had disproportionately higher risk of long-term mortality compared with patients without RA. In conclusion, patients with RA who underwent PCI had more co-morbidities and longer, complex coronary lesions. Risk of short-term adverse outcomes was similar, whereas risk of long-term mortality was higher, especially among patients with acute coronary syndromes and lower body mass index.

The COVID-19 pandemic, and the subsequent lockdown, had a significant and disproportionate impact on subjects that required the development of clinical technical skills due to the lack of access to simulation classrooms and patients. To directly address this impact, we developed a conceptual framework for the design and implementation of a progressive simulation approach from the perspective of a teacher. This conceptual framework integrates and draws from key theories of simulation design, curriculum integration, learner motivation, and considerations of the facets of good assessment, including modern approach validity. We used the conceptual framework to inform and develop a progressive simulation design to support the development of essential intra-oral suturing skills outside of the classroom, at home, while still being able to provide external feedback as if learners were in the classroom or clinic. Moreover, the approach described significantly extended the available opportunities for deliberate practice, assisting with the automation of essential skills and aiming to better support learner development during face-to-face patient opportunities. Although further work is needed, we believe that our conceptual framework could be applied to any situation where progressive simulation is seen as beneficial, especially if there are elements of key skills that could initially be developed using a simple take-home simulator.

•Outcomes of overweight and obese patients were compared with normal weight patients.•Overweight BMI was independently associated with reduced mortality post-TAVI.•Obese patients were found to be more frail than normal weight patients. Transcatheter aortic valve implantation (TAVI) is emerging as the default strategy for older patients with severe, symptomatic, and trileaflet aortic stenosis. Increased body-mass index (BMI) is associated with a protective effect in patients undergoing percutaneous coronary intervention. We assessed whether elevated BMI was associated with a similar association in TAVI. We evaluated prospectively collected data from 634 patients who underwent TAVI at 2 centers from August 2008 to April 2019. Patients were stratified as normal weight (BMI 18.5 to 24.9 kg/m2, n = 214), overweight (25 to 29.9 kg/m2, n = 234), and obese (>30 kg/m2, n = 185). Outcomes were reported according to VARC-2 criteria. Mortality was assessed using Cox proportional hazards regression analysis (median follow-up 2 years). Kaplan-Meier analysis was used to estimate cumulative mortality. Baseline differences were seen in age (85 vs 84 vs 82, p <0.001), STS-PROM score (4.3 vs 3.4 vs 3.6, p <0.001), sex (50% vs 36% vs 55% female, p <0.001), clinical frailty score (p = 0.02), diabetes (21% vs 29% vs 40%, p <0.001), and presence of chronic obstructive pulmonary disease (COPD) (13% vs 13% vs 23%, p = 0.009). On multivariable analysis there was no mortality difference between normal and obese patients (hazard ratio [HR] 0.70, confidence interval [CI] 0.46 to 1.1 p = 0.11), however overweight patients had significantly lower mortality (HR 0.56 CI 0.38 to 0.85, p = 0.006). Variables independently associated with increased mortality were increasing age, male sex, COPD, previous balloon valvuloplasty, and higher STS-PROM. In conclusion, overweight patients have lower long-term mortality when compared with normal weight and obese patients undergoing TAVI.

Purpose During the COVID-19 pandemic, widespread public health measures were implemented to control community transmission. The association between these measures and health-related quality of life (HRQOL) among patients following percutaneous coronary intervention has not been studied. Methods We included consecutive patients undergoing percutaneous coronary intervention (PCI) in the state-wide Victorian Cardiac Outcomes Registry between 1/3/2020 and 30/9/2020 (COVID-19 period; n  = 5024), with a historical control group from the identical period one year prior (control period; n  = 5041). HRQOL assessment was performed via telephone follow-up 30 days following PCI using the 3-level EQ-5D questionnaire and Australian-specific index values. Results Baseline characteristics were similar between groups, but during the COVID-19 period indication for PCI was more common for acute coronary syndromes. No patients undergoing PCI were infected with COVID-19 at the time of their procedure. EQ-5D visual analogue score (VAS), index score, and individual components were higher at 30 days following PCI during the COVID-19 period (all P  < 0.01). In multivariable analysis, the COVID-19 period was independently associated with higher VAS and index scores. No differences were observed between regions or stage of restrictions in categorical analysis. Similarly, in subgroup analysis, no significant interactions were observed. Conclusion Measures of HRQOL following PCI were higher during the COVID-19 pandemic compared to the previous year. These data suggest that challenging community circumstances may not always be associated with poor patient quality of life.

The practice of pretreatment with oral P2Y12 inhibitors in non-ST elevation acute coronary syndromes (NSTEACS) remains common; however, its association with improved cardiovascular outcomes is unclear. To assess the association between oral P2Y12 inhibitor pretreatment and cardiovascular and bleeding outcomes in patients with NSTEACS. On March 20, 2021, PubMed, MEDLINE, Embase, Scopus, Web of Science, Science Direct, clinicaltrials.gov, and the Cochrane Central Register for Controlled Trials were searched from database inception. Randomized clinical trials of patients with NSTEACS randomized to either oral P2Y12 inhibitor pretreatment (defined as prior to angiography) or no pretreatment (defined as following angiography, once coronary anatomy was known) among patients undergoing an invasive strategy. This study followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data on publication year, sample size, clinical characteristics, revascularization strategy, P2Y12 inhibitor type and dosage, time from pretreatment to angiography, and end point data were independently extracted by 2 authors. A random-effects model was used, including stratification by (1) P2Y12 inhibitor type, (2) revascularization strategy, and (3) access site. The primary end point was 30-day major adverse cardiac events (MACEs). Secondary end points were 30-day myocardial infarction (MI) and cardiovascular death. The primary safety end point was 30-day major bleeding (defined according to individual studies). A total of 7 trials randomizing 13 226 patients to either pretreatment (6603 patients) or no pretreatment (6623 patients) were included. The mean age of patients was 64 years and 3598 (27.2%) were female individuals. Indication for P2Y12 inhibitors was non-ST elevation myocardial infarction in 7430 patients (61.7%), radial access was used in 4295 (32.6%), and 10 945 (82.8%) underwent percutaneous coronary intervention. Pretreatment was not associated with a reduction in 30-day MACE (odds ratio [OR], 0.95; 95% CI, 0.78-1.15; I2 = 28%), 30-day MI (OR, 0.90; 95% CI, 0.72-1.12; I2 = 19%), or 30-day cardiovascular death (OR, 0.79; 95% CI, 0.49-1.27; I2 = 0%). The risk of 30-day major bleeding was increased among patients who underwent pretreatment (OR, 1.51; 95% CI, 1.16-1.97; I2 = 41%). The number needed to harm to bring about 1 major bleeding event with oral P2Y12 inhibitor pretreatment was 63 patients. In this study, pretreatment with oral P2Y12 inhibitors among patients with NSTEACS prior to angiography, compared with treatment once coronary anatomy is known, was associated with increased bleeding risk and no difference in cardiovascular outcomes. Routine pretreatment with oral P2Y12 inhibitors in patients with NSTEACS receiving an early invasive strategy is not supported by this study.