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Background Driven by increased prevalence of type 2 diabetes and ageing populations, wounds affect millions of people each year, but monitoring and treatment remain limited. Glucocorticoid (stress hormones) activation by the enzyme 11β‐hydroxysteroid dehydrogenase type 1 (11β‐HSD1) also impairs healing. We recently reported that 11β‐HSD1 inhibition with oral AZD4017 improves acute wound healing by manual 2D optical coherence tomography (OCT), although this method is subjective and labour‐intensive. Objectives Here, we aimed to develop an automated method of 3D OCT for rapid identification and quantification of multiple wound morphologies. Methods We analysed 204 3D OCT scans of 3 mm punch biopsies representing 24 480 2D wound image frames. A u‐net method was used for image segmentation into 4 key wound morphologies: early granulation tissue, late granulation tissue, neo‐epidermis, and blood clot. U‐net training was conducted with 0.2% of available frames, with a mini‐batch accuracy of 86%. The trained model was applied to compare segment area (per frame) and volume (per scan) at days 2 and 7 post‐wounding and in AZD4017 compared to placebo. Results Automated OCT distinguished wound tissue morphologies, quantifying their volumetric transition during healing, and correlating with corresponding manual measurements. Further, AZD4017 improved epidermal re‐epithelialisation (by manual OCT) with a corresponding trend towards increased neo‐epidermis volume (by automated OCT). Conclusion Machine learning and OCT can quantify wound healing for automated, non‐invasive monitoring in real‐time. This sensitive and reproducible new approach offers a step‐change in wound healing research, paving the way for further development in chronic wounds. Development of novel clinical interventions to improve skin biomechanical properties, for example, AZD4017 for wound healing, is hampered by the lack of reliable objective imaging modalities. Here, we combined machine learning and optical coherence tomography (OCT) to develop an automated wound imaging tool able to quantify multiple acute wound morphologies in 3D. Our novel, automated method (validated against manual 2D wound re‐epithelialisation OCT outputs) was more sensitive, reproducible, objective, and comprehensive than conventional wound imaging. Application of this unbiased and robust imaging tool to clinical trial OCT outputs also corroborated our finding that AZD4017 may improve wound healing in type 2 diabetes.

Background The Recorded Consultation Assessment (RCA) was developed rapidly during the COVID-19 pandemic to replace the Clinical Skills Assessment (CSA) for UK general practice licensing. Our aim was to evaluate examiner perceptions of the RCA. Methods We employed a cross-sectional design using a questionnaire survey of RCA examiners with attitudinal (relating to examiners thoughts and perceptions of the RCA) and free text response options. We conducted statistical descriptive and factor analysis of quantitative data with qualitative thematic analysis of free text responses. Results Overall, 182 of 260 (70%) examiners completed the questionnaire. Responders felt that consultations submitted were representative of the work of a typical GP during the pandemic and provided a good sample across the curriculum. They were also generally positive about the logistic, advisory and other support provided as well as the digital platform. Despite responders generally agreeing there was sufficient information available in video or audio consultations to judge candidates’ data gathering, clinical management, and interpersonal skills, they were less confident about their ability to make judgments of candidates’ performance compared with the CSA. The qualitative analysis of free text responses detailed the problems of case selection and content, explained examiners’ difficulties when making judgments, and detailed the generally positive views about support, training and information technology. Responders also provided helpful recommendations for improving the assessment. Conclusion The RCA was considered by examiners to be feasible and broadly acceptable, although they experienced challenges from candidate case selection, case content and judgments leading to suggested areas for improvement.

Pulmonary arterial hypertension (PAH) is an unmet clinical need. The lack of models of human disease is a key obstacle to drug development. We present a biomimetic model of pulmonary arterial endothelial-smooth muscle cell interactions in PAH, combining natural and induced bone morphogenetic protein receptor 2 (BMPR2) dysfunction with hypoxia to induce smooth muscle activation and proliferation, which is responsive to drug treatment. BMPR2- and oxygenation-specific changes in endothelial and smooth muscle gene expression, consistent with observations made in genomic and biochemical studies of PAH, enable insights into underlying disease pathways and mechanisms of drug response. The model captures key changes in the pulmonary endothelial phenotype that are essential for the induction of SMC remodelling, including a BMPR2-SOX17-prostacyclin signalling axis and offers an easily accessible approach for researchers to study pulmonary vascular remodelling and advance drug development in PAH. A biomimetic inducible model of pulmonary arterial hypertension (PAH) is presented, combining natural and induced BMPR2 dysfunction with hypoxia in lung endothelial cells and blood-derived PAH cells to induce smooth muscle activation & proliferation.

Background Standard setting is one of the most contentious topics in educational measurement. Commonly-used methods all have well reported limitations. To date, there is not conclusive evidence suggesting which standard setting method yields the highest validity. Methods The method described and piloted in this study asked expert judges to estimate the scores on a real MCQ examination that they consider indicated a clear pass, clear fail, and pass mark for the examination as a whole. The mean and SD of the judges responses to these estimates, Z scores and confidence intervals were used to derive the cut-score and the confidence in it. Results In this example the new method’s cut-score was higher than the judges’ estimate. The method also yielded estimates of statistical error which determine the range of the acceptable cut-score and the estimated level of confidence one may have in the accuracy of that cut-score. Conclusions This new standard-setting method offers some advances, and possibly advantages, in that the decisions being asked of judges are based on firmer constructs, and it takes into account variation among judges.

The Recorded Consultation Assessment (RCA) was developed rapidly during the COVID-19 pandemic to replace the Clinical Skills Assessment (CSA) for UK general practice licensing. Our aim was to evaluate examiner perceptions of the RCA. We employed a cross-sectional design using a questionnaire survey of RCA examiners with attitudinal (relating to examiners thoughts and perceptions of the RCA) and free text response options. We conducted statistical descriptive and factor analysis of quantitative data with qualitative thematic analysis of free text responses. Overall, 182 of 260 (70%) examiners completed the questionnaire. Responders felt that consultations submitted were representative of the work of a typical GP during the pandemic and provided a good sample across the curriculum. They were also generally positive about the logistic, advisory and other support provided as well as the digital platform. Despite responders generally agreeing there was sufficient information available in video or audio consultations to judge candidates' data gathering, clinical management, and interpersonal skills, they were less confident about their ability to make judgments of candidates' performance compared with the CSA. The qualitative analysis of free text responses detailed the problems of case selection and content, explained examiners' difficulties when making judgments, and detailed the generally positive views about support, training and information technology. Responders also provided helpful recommendations for improving the assessment. The RCA was considered by examiners to be feasible and broadly acceptable, although they experienced challenges from candidate case selection, case content and judgments leading to suggested areas for improvement.

This paper discusses the advantages of progress testing. A utopia is described where medical schools would work together to develop and administer progress testing. This would lead to a significant reduction of cost, an increase in the quality of measurement and phenomenal feedback to learner and school. Progress testing would also provide more freedom and resources for more creative in-school assessment. It would be an educationally attractive alternative for the creation of cognitive licensing exams. A utopia is always far away in the future, but by formulating a vision for that future we may engage in discussions on how to get there.

Common gulls drop cockles onto hard sand to open them. Gulls dropped cockles 2.9 ± 0.36 times to open them, from a mean height of 24.68 ± 1.74 m. Drop heights decreased significantly during a dropping sequence. Opened cockles had a mean shell-length of 32.22 ± 0.59 mm, which was similar to the size of available cockles. An economic model showed that gulls should drop cockles of average size twice from a mean height of 31.22 m to maximise their net rate of energy gain. The model showed that intake rates were similar for two-drop strategies with a mean drop height of 31.22 m, irrespective of the distribution of drop heights within the sequence, provided the first drop was less than the height at which cockles reached terminal velocity. The combination of number of drops and drop heights varied between cockle sizes, but model results were general - the optimum economic dropping strategy for a given size consisted of a number of drops from a constant height. Model predictions were, therefore, significantly different from observed behaviour. A risk of kleptoparasitism was added to the economic model by assuming gulls lost their cockle to a parasite if it was dropped above a threshold height immediately prior to opening. This showed that the number of drops in a sequence increased and mean drop height decreased compared with the average economic optimum. Drop heights within a sequence were also predicted to decrease in the presence of kleptoparasitism because the final drop was constrained to be lower than the height at which kleptoparasitism occurs. Previous drops in the sequence have to be increased in height as a result to ensure the cockle experiences sufficient impact energy to open. The inclusion of a risk of kleptoparasitism, therefore, increased the correspondence between model predictions and observed behaviour. The role of kleptoparasitism in decision making by gulls in the wild is discussed.

A suggestion of racial discrimination in a professional licensing examination is a serious matter. 1 We are surprised to see it in the paper in the BMJ by Esmail and Roberts 2 when the corresponding GMC report using the same data explicitly states that the same authors found no bias in the clinical skills assessment (CSA) of the examination for membership of the Royal College of General Practitioners (MRCGP). Table 1 shows that black and minority ethnic (BME) candidates who are international medical graduates (IMG) and/or from the European Economic Area (EEA) also seem to do less well than white IMG/EEA candidates in the GMC's Professional and Linguistic Assessment Board (PLAB) part 2 examination. 2 Table 4 indicates several factors that may partially account for the differences in CSA pass rates for non-UK graduates. 2 Clinical medicine scores in the applied knowledge test (AKT), the \"understanding score\" of the English language capability test (IELTS), and the PLAB communication domain all score significantly as factors potentially influencing failure at first attempt. Competing interests: KH and AR are British Asians with UK qualifications; KH, AF, AR, and SR are MRCGP clinical leads; BL and BI are COGPED leads. 1 Kmietowicz Z. Study raises concerns over racial discrimination in MRCGP exam.