Medic, Psychic & Bliss

How PACES is marked

Before the exam starts the examiners calibrate all do cases at each station. This involves agreeing on the specific areas that a candidate needs to cover in order to be awarded a ‘satisfactory’ mark. Their criteria are based on the guidance they are provided on the marksheet and also by the expectations of how a competent trainee doctor entering higher specialist training (ST3 in the UK) should perform.

PACES is marked on seven skills, A-G. Skill B, identifying physical signs, is often considered the most challenging skill to pass.

Skill A: Physical examination (stations 1, 3 and 5)
Skill B: Identifying physical signs (stations 1, 3 and 5)
Skill C: Clinical communication (stations 2, 4 and 5)
Skill D: Differential diagnosis (stations 1, 2, 3 and 5)
Skill E: Clinical judgement (all stations)
Skill F: Managing patients’ concerns (all stations)
Skill G: Maintaining patient welfare (all stations)

General tips to help you improve

If you feel that you have done badly at one station, it is important that you try and remember this will not affect your marks at the next station and that you can still pass the exam. Use the 5 minutes to concentrate on the next station and not to reflect on what went before. This can be particularly difficult at stations 1 and 3 where you have no scenario to read. Examiners realise that you may be anxious, and that this can affect performance. The more you practice, the easier you will find it to keep your anxiety under control.

Skill A: Physical Examination
You must demonstrate good technique when examining the major clinical systems (respiratory, abdomen, cardiovascular and neurological) in a thorough and methodical manner. At stations 1 and 3, you have to complete your examination in no more than 6 minutes. In station 5, you must be able to perform a focused examination of the areas relevant to the scenario you have read and the history you have obtained from the patient in front of you. You should start the examination at the same time you obtain the history.

Reasons why you may not have passed Skill A:

not examining in a systematic way
using incorrect techniques
missing out significant parts of the examination.
Reasons for being marked down:

your examination was hesitant or lacking confidence
examining in an unprofessional way
examining the patient through their clothing.

Tips to help you improve

Examine as many patients as possible, including those without clinical abnormalities.
Have your examination technique for the various systems observed by your clinical supervisor or by other more senior colleagues who can give you critical feedback.
Use a timer when you practice to make sure you know how long you have to perform each aspect of the examination.

Skill B: Identifying physical signs

You must be able to identify the key clinical signs that are present and also, and just as importantly, you must not report clinical signs that are not present. You need to be able to present these signs in a logical and clear manner to the examiners during discussion.

Unsatisfactory performance in Skill B is one of the most common reasons for not passing PACES. The ability to identify physical signs is one of the most important skills of a physician, even in the era of relatively easy access to investigations. Confidence in this skill comes with practice.

Reasons why you may not have passed Skill B:

not identifying the physical signs that were agreed to be present by the examiners during calibration
finding physical signs that were not present.

Tips to help you improve

Examine as many patients as possible, in a systematic manner, including those without abnormal clinical signs, so that you are comfortable identifying and reporting when physical signs are not present.
Discuss with your clinical supervisor, and ask your clinical colleagues to observe you examining consenting patients with clinical signs in all of the relevant systems.
Ask colleagues from a range of specialties to observe you examine consenting patients, and discuss both your examination technique and examination findings with them.

Skill C: Clinical Communication skills

Clinical communication skills are examined in a variety of ways, depending on the station. Being able to communicate clearly is essential to get an accurate history so that the underlying medical, personal and social issues can be addressed. This skill is also important for patient safety.

In station 2, you must be able to take a systematic and thorough history, identify the patient’s concerns and agree a management plan in no more than 14 minutes.

In station 4, you must be able to explain relevant clinical information in an accurate, clear, and structured manner. You are expected to lead a structured interview, yet remain flexible enough to respond to the questions and concerns of the patient or surrogate. You should spend the full 5 minutes reading the scenario to ensure that you are clear about the task you have been asked to perform.

In station 5, you are required to take a focused history based on the scenario you have been given.

Reasons why you may not have passed Skill C:

not explaining the relevant clinical information in an accurate or clear fashion
missing out important information
giving inaccurate or unclear information
using information that includes too much specialist language that the patient did not understand, or was unprofessional.

Tips to help you improve

Reflect on the comments on your marksheets and discuss them with your educational supervisor or a senior colleague.
Practice information gathering and information giving as often as possible; ask patients for their feedback as well as being observed by senior colleagues.
If English is not your first language, practice speaking English as often as possible, including the use of medical terms which you should try and convey in easy to understand terms in order to avoid the use of confusing specialist language.
Practice using the sample station 2 and 4 scenarios on the MRCP(UK) website. These are very similar to those you will encounter in the examination and are an excellent source of practice material.
Ask one of your senior colleagues to watch you taking a history or communicating with a patient or surrogate.

Skill D: Differential diagnosis

Differential diagnosis is a ‘linked’ skill, this means that if you failed to identify the physical signs present (Skill B), you will also be marked down on differential diagnosis. You must include the correct diagnosis and indicate an appropriate differential diagnosis for the patient in front of you. You should mention the most likely diagnosis first. A good differential diagnosis for the wrong signs will not be regarded as satisfactory.

Reasons why you may not have passed Skill D:

giving a poor differential diagnosis
failing to consider the right diagnosis
giving a ‘textbook’ list, rather than a list of likely diagnoses that are relevant for the patient you have just seen.

Tips to help you improve

Practice discussing the differential diagnosis for all patients you see, and ask for feedback from your colleagues.
Discuss with your clinical or educational supervisor, or with a senior colleague, and practice case-based discussions of patients.
Arrange to be observed examining patients and formulating a differential diagnosis.

Skill E: Clinical judgement

Clinical judgement is a ‘linked’ skill. If you failed to identify the physical signs (Skill B) and particularly if you fail to consider the correct diagnosis (Skill D), you will also be marked down on clinical judgement. You must be able to suggest appropriate investigations and discuss a sensible management plan for the patient you have just seen. Good management of the wrong condition will not be regarded as satisfactory.

Reasons why you may not have passed Skill E:

not seeming familiar with the correct management plan
suggesting inappropriate investigations or management for the patient
failing to identify the correct clinical signs, or to reaching the correct diagnosis which led to suggesting an incorrect management plan.

Tips to help you improve

Reflect on any feedback on the marksheets and discuss it with your clinical and educational supervisors, or with a senior colleague.
Ask senior colleagues to observe you examining as broad a range of medical patients as possible, and follow this by discussion of differential diagnosis, appropriate investigations and management.
If you feel the exam exposed some knowledge gaps, review the areas you covered in the written exams.

Skill F: Managing patient concerns

The ability to identify the patient’s main concerns is important to ensure a satisfactory consultation. All scenarios for stations 2, 4 and 5 have specific questions for the patient or surrogate to ask of the candidate. You must demonstrate that you have asked the patient/surrogate if they have any questions and then answer them accurately and sympathetically. You should ensure that the patient has understood your explanation and discussion.

Reasons why you may not have passed Skill F:

not exploring the patients’ concerns in enough detail or not addressing the concerns in a satisfactory manner
not really listening to the patient/relative
talking over the patient/relative
not checking that the patient/relative understood what you had discussed
appearing unconcerned and failing to build a rapport with the patient
running out of time to ask the patient/relative if they have any questions and to answer them.

Tips to help you improve

Review any comments on the marksheets to help you identify areas of weakness.
Reflect on where things might have gone wrong during each scenario and discuss this with your educational supervisor or a senior colleague.
When you are interacting with patients, focus on identifying their concerns, and ask for feedback on your performance.
If English is not your first language, use every opportunity to practice potential scenarios.
Use a timer during practice to ensure that you leave sufficient time to specifically ask the patient/relative if they have any questions or concerns.

Skill G: Maintaining patient welfare

Ensuring that the patient is treated with dignity and sensitivity is an essential part of safe practice, and is crucial to the doctor-patient relationship. If you have failed on Skill G, the examiners have felt you did not treat the patient with sufficient respect and sensitivity, or have failed to ensure their comfort or safety. You may have caused the patient emotional or physical discomfort that concerned the examiners. You may have been felt to make decisions that jeopardised the patient’s safety. Your marksheets may tell you the specific areas of concern.

Tips to help you improve

Reflect on any comments on the marksheet and discuss it with your educational supervisor, or with a senior colleague.
Think about how you would like your relatives to be examined or cared for.

https://youtu.be/qzDuJQdQHOQ
This is the newer format - PACES 2023.
15 minutes Consultation
Station 2 and Station 5.

This will start in Diet 3 2023 in the UK and Diet 1 2024 in Singapore

MRCP 2 PACES 2023: 15-min Patient Examination, Clinical Consultation (Stations 2 & 5) Watch this sample PACES case video (PACES 2023 format), included in Pastest's online resource. This Acromegaly patient examination is aligned to the new form...

PACES 2023
Due to the impact of the COVID-19 pandemic across all of our PACES centres in the UK and internationally, the introduction of the new PACES examination had to be delayed. We are pleased to confirm that the new format examination, now known as PACES23 will be introduced from the 3rd Diet of 2023*

The examination will still test the same clinical skills, and there will still be five stations. However, some of the encounters are changing. We will be providing more information and training materials for candidates and examiners in the lead up to introduction of PACES23. Further updates will be available here on this webpage in due course.

*PACES23 will be introduced for candidates sitting in Singapore from early 2024.

Why are we changing the examination?
Postgraduate medical education has undergone significant changes in the ten years since the current MRCP(UK) Part 2 Clinical Examination (Practical Assessment of Clinical Examination Skills), commonly known as PACES, was introduced. The new Internal Medicine Curriculum, Shape of Training and other reviews have helped us to better understand the competences required of doctors in the 21st century.

The changes to PACES are the product of a 12 month review of the examination by MRCP(UK) to ensure that it remains fair, relevant and fit for purpose. The changes build on the current format but develop some elements to make them more realistic for examiners and trainees. It now better reflects the new Internal Medicine stage 1 curriculum, developed by the JRCPTB on behalf of the Federation of the Royal Colleges of Physicians. The curriculum, implemented in August 2019, is designed to produce doctors with the generic professional and clinical capabilities needed to manage patients presenting with a wide range of general medical symptoms and conditions and holistic decisions on progress will be made for high level capabilities in practice.

What is being removed?
1. Station 2
The history-taking station was considered to be artificial with structured history-taking skills being tested in isolation and not representative of modern practice.
2. Station 4
20 minutes for a single communication and ethics encounter was felt to be rather long and in particular, the five-minute examiner/candidate interaction added little value to the overall assessment.
3. Station 5
Testing all seven skills in an integrated manner was very like real life but was very pressured in 10 minutes.

What is being introduced?
1. Communication
Two 10-minute communication encounters. These will no longer include a question and answer section with the examiners. Instead, the encounter will be judged on observation alone.
2. Consultations
Two 20-minute clinical consultations will assess candidates across all seven skills in a realistic and integrated manner. Candidates will have 15 minutes to take a structured history, examine the patient, explain the likely diagnosis and management and address any questions or concerns raised. There will then be a five minute question and answer section with the examiners.
3. Encounter sequencing across the carousel
The new carousel will alter the sequencing of the encounters through the carousel. Some stations will include physical examination and communication encounters. This will ensure that examiners at each station contribute more judgements in each of the skills for each candidate, improving the reliability of the exam.

This is best illustrated by the following diagram:
What is next?
We will be providing a comprehensive range of resources for candidates and examiners to ensure that they are prepared for the new format of PACES. These will include informative videos of the new encounters, an examiner webinar, written guidance and attendance at events and training days.

UK trainees should now start discussing with their educational supervisors when they plan to sit PACES.

ECG manifestation of AMI

FDA Approves First-in-Class Inclisiran to Lower LDL-C

Inclisiran is a small interfering RNA (siRNA) that inhibits the hepatic translation proprotein convertase subtilisin-kexin type 9 (PCSK9), thereby upregulating the number of LDL-receptors on the hepatocytes.

Mechanism of action

Inclisiran is delivered to the hepatocyte through the asialoglycoprotein receptor (ASGPR). Its antisense strand then binds to the RNA Induced Silencing complex (RISC). The combination of RISC and the antisense stand then binds PCSK9 messenger RNA (mRNA), leading to degradation of PCSK9 mRNA and less PCSK9 protein synthesis. PCSK9 directs LDL receptor (LDLR) for degradation by the lysosome. Due to less PCSK9 protein, more LDLR can be recycled to the hepatic membrane for LDL-C uptake.

Inclisiran is indicated for use atop maximally tolerated statins in adults with clinical cardiovascular disease or in patients with heterozygous familial hypercholesterolemia.

Cardiovascular Research, Volume 116, Issue 11, 1 September 2020, Pages e136–e139, https://doi.org/10.1093/cvr/cvaa212

https://www.medscape.com/viewarticle/965464?src=soc_fb_211224_mscpedt_news_endo_inclisiran&faf=1

FDA Approves First-in-Class Inclisiran to Lower LDL-C Injectable Inclisiran (Leqvio) is now indicated in the US as an adjunct to maximal statins in adults with CV disease and patients with heterozygous familial hypercholesterolemia.

Medic, Psychic & Bliss updated their website address.

Medic, Psychic & Bliss updated their business hours.

https://www.techmed.sk/zaklady-transplantacie-organov/

Základy transplantácie orgánov Základné princípy transplantačnej medicíny. Prehľad hlavných imunologických bariér pri transplantácií orgánov. Mechanizmy akútnej a chronickej rejekcie

https://www.techmed.sk/svt-odporucania/

Supraventrikulárne tachykardie (Odporúčania 2019) Preložené z odporúčaní ESH/ESC pre supraventrikulárne tachykardie

https://www.techmed.sk/arteriova-hypertenzia-odporucania/

Artériová hypertenzia (Odporúčania 2018) Preložené z odporúčaní ESH/ESC pre artériovú hypertenziu.

https://www.techmed.sk/auskultacia-srdca-ozvy-selesty/
Heart sounds and murmurs

Srdcové ozvy a šelesty - Zvukové nahrávky Zvukové nahrávky a popis každej srdcovej ozvy a šelestu. Popis a návod auskultácie (posluch) srdca pri každej ozve a šeleste. Množstvo názorných obrázkov

https://www.techmed.sk/ekg-a-arytmologia-kniha/
Arrhythmology

EKG & Arytmológia (1400 stranová kniha) EKG kniha je zadarmo. Elektrokardiogram je základné vyšetrenie. V knihe sú vysvetlené všetky arytmie (poruchy rytmu), tachykardia, bradykardia, STEMI infarkt, AV blokády, a mnohé ďalšie témy

Different cardiac arrhythmias

Review
November 9, 2021
Cardiogenic Shock After Acute Myocardial Infarction
A Review
Marc D. Samsky, MD1; David A. Morrow, MD, MPH2; Alastair G. Proudfoot, MBChB, PhD3,4,5; et al Judith S. Hochman, MD6; Holger Thiele, MD7; Sunil V. Rao, MD1
Author Affiliations
JAMA. 2021;326(18):1840-1850. doi:10.1001/jama.2021.18323

GUIDE-HF

SMART-MI

Emperor-Pooled

Emperor-Preserved

Cardiac MRI consists of using MRI to study heart anatomy,physiology, and pathology.

Advantages
In comparison to other techniques, cardiac MRI offers:
improved soft tissue definition
protocol can be tailored to likely differential diagnoses
a large number of sequences are available
dynamic imaging provides functional assessment
no ionizing radiation
MRI safety still requires consideration

Limitations
MRI is generally inferior to cardiac CT for evaluation of the coronary arteries.
Cardiac MRI can be technically challenging.

Mechanistic explanation for SGLT2-Is as the disease-modifying therapy in HFrEF

https://www.medscape.com/viewarticle/955628?src=soc_fb_210807_mscpedt_news_mdscp_clots&faf=1

New NICE Guidelines on Post-COVID Vaccine Blood Clots Rapid guidance for diagnosis and treatment of VITT will be updated as new evidence emerges.

Physician aide

AntiCoagulaTIon cOroNavirus - ACTION

AntiCoagulaTIon cOroNavirus - ACTION

The ACTION trial failed to show that therapeutic anticoagulation during COVID-19 infection was beneficial.
Among patients admitted with COVID-19 infection with elevated D-dimer, therapeutic anticoagulation was not superior to prophylactic anticoagulation. Rivaroxaban for stable patients and enoxaparin for unstable patients did not improve clinical outcomes; however, major bleeding was increased.

References:
Presented by Dr. Renato D. Lopes at the American College of Cardiology Virtual Annual Scientific Session (ACC 2021), May 16, 2021.

Total Ischemic Event Reduction with Rivaroxaban after Peripheral Arterial Revascularization in the VOYAGER PAD Trial
J Am Coll Cardiol. May 16, 2021. Epublished DOI: 10.1016/j.jacc.2021.05.003

Background
Patients with peripheral artery disease (PAD) undergoing lower extremity revascularization (LER) are at high risk of major adverse limb and cardiovascular events. VOYAGER PAD demonstrated that rivaroxaban 2.5 mg twice daily reduced first events by 15%. The benefit of rivaroxaban on total (first and subsequent) events in this population is unknown.

Objectives
To evaluate the total burden of vascular events in PAD patients after LER and the efficacy of low dose rivaroxaban on total events.

Methods
VOYAGER PAD randomized PAD patients undergoing LER to rivaroxaban 2.5 mg twice daily plus aspirin or aspirin alone. The primary endpoint was time to first event of acute limb ischemia, major amputation of a vascular cause, myocardial infarction, ischemic stroke, or CV death. The current analysis considered all events (first and subsequent) for components of the primary endpoint as well as additional vascular events including peripheral revascularizations and venous thromboembolism. Hazard ratios were estimated by marginal proportional hazards models.

Results
Among 6564 randomized there were 4714 total first and subsequent vascular events including 1614 primary endpoint events and 3100 other vascular events. Rivaroxaban reduced total primary endpoint events (HR 0.86,95% CI 0.75-0.98; p=0.02) and total vascular events (HR 0.86,95% CI 0.79-0.95; p=0.003). An estimated 4.4 primary and 12.5 vascular events/100 participants were avoided with rivaroxaban over three years.

Conclusions
Symptomatic PAD patients undergoing LER have a high total event burden which is significantly reduced with rivaroxaban. Total event reduction may be useful metric to quantify the efficacy of rivaroxaban in this setting.

Prevention of Cardiac Dysfunction During Adjuvant Breast Cancer Therapy (PRADA)
Circulation. 2021;143:00–00. DOI: 10.1161/CIRCULATIONAHA.121.054698

Anthracycline-containing adjuvant therapy for early breast cancer was associated with a decline in LVEF during extended follow-up. Candesartan during adjuvant therapy did not prevent reduction in LVEF at 2 years, but was associated with modest reduction in left ventricular end-diastolic volume and preserved global longitudinal strain. These results suggest that a broadly administered cardioprotective approach may not be required in most patients with early breast cancer without preexisting cardiovascular disease.

Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke
May 15, 2021
DOI: 10.1056/NEJMoa2101897

Background
Surgical occlusion of the left atrial appendage has been hypothesized to prevent ischemic stroke in patients with atrial fibrillation, but this has not been proved. The procedure can be performed during cardiac surgery undertaken for other reasons.
Methods
We conducted a multicenter, randomized trial involving participants with atrial fibrillation and a CHA2DS2-VASc score of at least 2 (on a scale from 0 to 9, with higher scores indicating greater risk of stroke) who were scheduled to undergo cardiac surgery for another indication. The participants were randomly assigned to undergo or not undergo occlusion of the left atrial appendage during surgery; all the participants were expected to receive usual care, including oral anticoagulation, during follow-up. The primary outcome was the occurrence of ischemic stroke (including transient ischemic attack with positive neuroimaging) or systemic embolism. The participants, research personnel, and primary care physicians (other than the surgeons) were unaware of the trial-group assignments.
Results
The primary analysis population included 2379 participants in the occlusion group and 2391 in the no-occlusion group, with a mean age of 71 years and a mean CHA2DS2-VASc score of 4.2. The participants were followed for a mean of 3.8 years. A total of 92.1% of the participants received the assigned procedure, and at 3 years, 76.8% of the participants continued to receive oral anticoagulation. Stroke or systemic embolism occurred in 114 participants (4.8%) in the occlusion group and in 168 (7.0%) in the no-occlusion group (hazard ratio, 0.67; 95% confidence interval, 0.53 to 0.85; P=0.001). The incidence of perioperative bleeding, heart failure, or death did not differ significantly between the trial groups.
Conclusions
Among participants with atrial fibrillation who had undergone cardiac surgery, most of whom continued to receive ongoing antithrombotic therapy, the risk of ischemic stroke or systemic embolism was lower with concomitant left atrial appendage occlusion performed during the surgery than without it. (Funded by the Canadian Institutes of Health Research and others; LAAOS III ClinicalTrials.gov number, NCT01561651. opens in new tab.)

How to read ECG
17 steps