Review: Epicardio Simulation v1.5 (Trial)

EDIT:

After writing this review, I got my hands on the full version. So this review continues here.

Epicardio offer a 60% discount to full-time students

Download for Windows/OSX:

  • Trial (Free)
  • Paid (£149-£215)

Developer: Epicardio.ltd

Studying ECG can be one hell of a mountain to climb, especially when you’re at the novice level of cardiac education. Due to how vital it is, it’s imperative that you can not only make the distinction between Mobitz II AV Block and sinus arrhythmia, but also understand the intricacies of the cardiac conduction behind them, and all of the other rhythm abnormalities. Learning these things like the back of your hand is one thing, but combining all that knowledge is, at times, overwhelming. So after 12 months of scouring the internet, trying to find a decent cardiac anatomy and 12-lead ECG simulation tool, I was over the moon to stumble upon Epicardio Simulation; a cardiac electrophysiology tutorial application, developed by Epicardio ltd.

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The program is available in 3 main forms; Epicardio ECG, ECG and Pacing, and 3-day trial. As I don’t have £149 kicking around (the price of the basic ECGcentric offering), I can’t review the full version and all of its features, but the 3 day trial version (which is £0), is well within my price range. Thus, I shall only be commenting on the features with which I have been able to sample.

Thankfully, the collection of features available to trial version users is still extensive, so I have lots to cover, and perhaps I’ll spring for the full version when funds allow. The question is: does the trial impress enough to warrant the large expense? Let’s investigate further:

Almost as soon as you open Epicardio, the vibrant display hits you; a large, anatomically accurate heart fills most of the screen as colourful depolarisation waves travel across the atria, and down through the ventricles. The live single lead ECG tracks with concordance, and the right hand menu buttons are nicely presented and clearly display exactly what they do.

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Depolarisation mechanics can be viewed through the heart as a whole, or each section on its own. Atria, ventricles, bundle branches and coronaries, can all be viewed independently whilst depolarisation occurs, so it’s possible to learn how the various components of the cardiac system operate during each cycle.

Further structural overlays can be added, in the form of the vena cava, thoracic cage and a translucent torso, further adding to the ability to understand the heart’s positioning in humans.

The electrical readout on the lower region of the screen comes with the option of cycling through all 12 leads on the standard ECG, individually, but as well the real time single lead ECG, users can also activate a live 12-lead, which again updates in real time with each cardiac cycle. This mode itself allows for different viewing styles, including the layout presented on most standard ECG printouts, which is perfect for students. It also features all the subtle morphology differences and minor, unavoidable muscle tremors that one would find on a real ECG recording. Calipers are a welcome feature, too, and they work well in Epicardio, allowing for measurements that students will definitely have to become proficient in throughout training.

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Further customisation options are numerous; the colours of the depolarisation waves are changeable, as is the colour of the backdrop. Rather than simply offering pre-set rhythms, Epicardio allows you to manually alter heart rate, and, possibly more importantly, AV delay, so it’s possible to visibly alter the depolarisation wave on the beating heart in the centre of the screen, and see the  live trace display a prolonged PR interval.

A most welcome feature is the electrode view option. A click on this button brings up a moving image of the heart within the thorax, and the standard precordial electrode sites. These electrodes can be moved anywhere and the real-time result displayed on the recorded trace, so it’s rather nice to be able to explore the difference in the voltage/time graph that occurs with electrode misplacement.

A defibrillator option allows you to shock the heart, although this was of limited use to me, as I did not have access to the fibrillatory rhythms that come with the paid version, but the artificial pacemaker below it allows the user to alter pacing pulses and observe the changes on the ECG.

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My issues with Epicardio range from those that exist simply because the version I tried is restricted, to those that are nought but minor niggles, so I shall focus on those minor niggles, as oppose to content I simply have not paid to access.

The ECG trace, whilst being incredibly customisable, would feel much more authentic if it were set against a proportional image of standard ECG paper; being able to view the trace against the background most students will see throughout studies would be a great primer in the early days of study, and considering the trace speed is adjustable, I was disappointed it wasn’t a feature.

The option buttons look lovely, offer genuine function and, once you’ve been through the tutorial and played around with them, make perfect sense. It would perhaps be helpful if a brief explanation appeared when the mouse pointer was placed over each one, however, as it was a struggle remembering what the more vague options actually did, especially for the first few hours of using the program.

However, as I stated, these are only minor gripes. Epicardio is a wonderful and genuinely fun bit of software to use. I’ve got a feel for how beneficial having this in the beginning of my studies would have been. The layout, options, functionality and simplicity of using Epicardio are all near-perfect, so I can’t wait to get a hold of the full version, complete with pacemaker-specific options. If you have a spare weekend, then follow the link at the top of the page, and download the free trial. If you have a spare £149/£215, then follow the same link and download the full version, as if it’s provides even 50% more features than the demo, I can be certain it’s worth it.

I will review the full version as soon as I can.

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Ajmaline Provocation in Suspected Brugada

Today, I was present during a Brugada provocation test using ajmaline, a class 1a antiarrhythmic drug much like class 1c drug, flecainide, in that it acts as a Na channel blocker. As its action lengthens the action potential phase 0, in non-pacemaker myocytes, it induces bradycardia, and encourages the transient Brugada rhythm to present itself.

Indications for the test are outlined here, and the procedure itself, is a relatively simple one;

  • Ajmaline is prepared at a total dose of 1mg/kg-1
  • 12 lead ECG is applied to the patient
    • V1 and V2 should be positioned on IC3 or IC2
    • The ECG should be viewable in real time, as well as be printable
  • Intravenous Ajmaline is administered in a 10mg bolus, every 2 minutes
    • Fractions should be administered slowly over 1 minute
  • ECG should be printed after each dose

Indications for terminating the test are as follows:

  • Ajmaline dosage is completely administered
  • Typical Brugada criteria present on the ECG
    • ST coving present in more than 1 right precordial lead
    • J point elevation greater than 2mm
  • Incidence of:
    • PVCs
    • AV Block (2nd° or 3rd°)
    • VT
    • Sinus arrest

During the test, the patient indicated that the initial 10mg was very unpleasant, and caused “a horrible feeling” at the back of her throat. She did say that this initial bolus was the worst, however, and that subsequent injections were bearable, by comparison. Towards the end of the test, i.e., one injection from termination, the patient indicated that her lips had become almost completely numb.

The test, in this case, was negative, and the patient’s ECG showed no changes to suggest Brugada at any point throughout the procedure.

Ajmaline is unlicensed in the UK, but this is not indicative of its level of safety, rather it is because it is manufactured in Germany, and imported to trusts in this country. Curious as to why ajmaline was being used, I asked the nurse practitioner who was on hand to implement the test, who informed me why the trust opted to use ajmaline as oppose to flecainide, when both seemingly do the same thing. She cited the time taken for each pharmaceutical agent to leave the patient after the test; in the event of a negative outcome, ajmaline allows a patient to be discharged safely in around 3 hours, whereas flecainide takes a great deal longer to be removed.

Not knowing the costs associated with each drug, I decided to look for other reasons as to why an imported medication is used in this provocative study, and discovered research by Wolpert et al  published in 2005, that tested ajmaline and flecainide against each other in a blind trial.

22 patients for whom a diagnosis of Brugada was already known, underwent IV flecainide and ajmaline testing, and the results were then studied by 3 physicians who were unaware of the drug being used in provocation.

The results for flecainide showed

  • Significant ST changes in 15/22 of the patients tested (68%)
  • Mean V1 amplitude of 0.19mV
  • Mean V2 amplitude of 0.31mV
  • Mean V3 amplitude of 0.1mV

The results for ajmaline showed

  • Significant ST changes in 22/22 of the patients tested
  • Mean V1 amplitude of 0.22mV
  • Mean V2 amplitude of 0.39mV
  • Mean V3 amplitude of 0.1mV

It is important to note, that whilst these results show a more favourable outcome when using ajmaline over flecainide, in provocative studies, this research is limited in that, despite being a blinded study, it was not a randomised trial and was not repeated. Nevertheless, it does suggest that provocative studies using flecainide may not successfully unmask Brugada syndrome in patients, and its longer life within the patient may favour the use of ajmaline in investigations.

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Teaching

I’m not sure how many students know this, but once you’re qualified and working within a trust, a part of your job description denotes the expectation that you teach those who come after you, regardless of your job title or profession. Those mentors and staff that answer your questions whilst you’re on placement don’t get paid more for doing so and, for the most part, they don’t have special teaching roles. They do it to help and inspire you, and others, into being the best healthcare professionals that you can be, and one day, you’ll do that too.

I had my first taste of this, last week, when myself, fellow TSP writer OliGS and another student, along with two qualified physiologists, gave tech demonstrations, took Q&A’s and generally outlined the profession to a large group of medically-inclined 6th Form students. Oli had the joy of lying still and having successive Echo exams performed on him, but myself and the third student gave some ECG and BP demonstrations to small, rotating groups of young adults. They engaged a lot more than I initially thought they would, given that it was a hot day and the session was scheduled directly after lunch, but with a bit of cajoling, they performed simple 3-lead exams on one another, and took each other’s blood pressure. We answered all of the usual questions…

“Will this hurt?”

“Are you allowed to tell me if this shows I’m going to die”

“Will this electrocute me?”

…which aren’t entirely dissimilar to those put to us by patients, so it actually meant giving the same spiel, in response.

It was nerve-wracking, speaking candidly about your studies to strangers, especially when you don’t know at what level they are, with regards to cardiovascular anatomy, and when boring them is the last thing you want to do, so ensuring we spoke with enthusiasm was paramount. Perhaps unsurprisingly, only a couple of the students actually knew that HCS existed, so that added more of an incline to the mountain it felt we had to climb, but I’d happily do it again, as even one converted student feels like a victory, considering it was the first time I’d done anything like this. They seemed genuinely intrigued by diagnostics, and, after the aforementioned questions, asked some really challenging things about our role in wider healthcare, as well as about the equipment and techniques themselves. It’s odd to know that young students aren’t informed of all of the opportunities available them when they enter higher education, and it highlights the need for more publicity surrounding the scientific careers present in the process of patient care.

It’s difficult to know how to publicise this vein of science and healthcare, but there has to be a way; the disciplines and specialisms within it are at the forefront of diagnostic medicine and research, and are a truly rewarding endeavour for those willing to persevere through the sometimes unforgiving education pathways. If I’m invited back next year, I hope to convey some of that sentiment to the next batch of hopefuls, as, like me, they won’t look back once they start.

Thanks.

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Coronary Artery Bypass Graft and Mitral Valve Repair

I had the rather marvellous opportunity today; spending a day in cardiac theatres and, under the guidance and tutelage of two cardiac surgeons and an anaesthetist, learning the processes and methodologies behind CABG and MV repair.

I arrived at the Bristol Royal Infirmary surgical centre at 7:45am and was quickly changed into some scrubs and inducted into the OR’s team: three surgeons, two anaesthetists, one perfusionist and a selection of nurses both scrub, and regular. It was clear to me that each of these individuals knew one another well, just by the way they talked to each other; everyone seemed at ease with the rest of their colleagues. It turns out, I was right. Many of them knew each other from other hospitals, university or simply having been mentored by each other during training. This camaraderie bled into the surgery, as each team member knew not only their role, but that of the others, also, so equipment was passed over or set up without being requested, making for a seamless procedure.

The patient was, until the last year or so, a very fit and active 79y/o, who had suffered from AF for at least 10 years, and had developed a stenosed left anterior descending coronary artery as a result. In addition, echo had shown a severe mitral regurgitation due to valvular prolapse. The procedure would attempt to bypass the LAD using the left internal mammary artery (LIMA), as shown below.

LIMA bypass graft
Figure 1: The left internal mammary artery (shown in situ on the right) is relocated from the chest wall to bypass the stenosed section of the LAD.

The plan was to perform the bypass graft, and then set about repairing the damaged mitral valve.

 

After the patient’s ID and contraindicators had been checked, the anaethetists set about carefully monitoring their respiratory and cardiovascular function as the GA took effect. The ECG, arterial and venous pressure traces were available on lots of screens around the rooms, as whilst they must be monitored all of the time, it becomes particularly important to keep an eye on the given values as the heart is both stopped and re-started.

Interestingly, I noticed a pattern in conversation with each patient throughout the day, as the anaesthetic was administered. The patient was asked to think of their favourite place and the team then asked where that place was. Each time, this was met with silence, but just to make sure, the patient was always asked if they were warm enough. When no answer was forthcoming, they were wheeled into the theatre room proper.

Not everyone on the team was scrubbed up and sterilised, as obviously some would not be required to touch the patient, and others would be required to fetch replacement equipment should it be needed. This created a “sterile field” around the operating table, so only sterile members of staff were permitted within it.

After 1 hour and a whole heap of sterile gowns and drapes were applied over the patient, with only a small window showing the surgical site, the operation began.

Step 1 required access to the thoracic cavity. In case of blood splatter, masks fitted with facial protection were supplied to myself and the other team members who would be in the direct vicinity of the patient when the chest was opened.

Full Face Mask

An incision was made as illustrated below. This is known as a median sternotomy, and extends from the sternal notch to the xyphoid process. In order to progress past the sternum, an oscillating saw is used to cut throught it. There is a surprising amount of finesse involved in this stage, despite how much pressure is required and as a result, how brutal it appears.

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The incision is deepened and cauterised until it travels through the pericardium, so as to allow access to the heart and, after the bleeding vessels around the wound are cauterised, a finochietto retractor is used to hold the sternum open. During this time, the LIMA is found and carefully removed from the chest wall. It is then held in an accessible place with forceps, to be used later.

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Lung and cardiac function is transfered to a cardiopulmonary bypass machine, which allows both the heart and lungs to be stopped/emptied, allowing even greater access to the heart due to the lack of lung obstruction, and intricate work to be perfomed whilst the heart is not beating.

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The cardiopulmonary bypass apparatus purifies the blood that passes through it from the patient via cannulas placed in the heart and pumps it back, thereby doing the work of the heart and lungs. The heart is fed nutrients at the same time, so as to keep it healthy for the extended period of inactivity. This method of on-pump surgery is known to be incredibly safe- between 1 and 2% of high risk patients will suffer adverse effects as a result of the treatment, and surgical teams are well versed in assessing this via risk factors.

Once the LAD has been correctly identified, an incision is made, creating an opening that roughly matches the size of the end of the LIMA, and the two are stitched together using sutures made of polypropylene,which are no thicker than a human hair, yet can withstand the pressure that would be required to rupture a healthy vessel. To test the suture site, blood is passed through the vessel, and in the event of any gaps in the connection, this blood will be seen outside of the join, which can then be further secured as necessary.

The process, whilst quick to document, was a long one, as each step of the technique was scrutinised carefully before considered complete. In addition, each stitch required at least two people directly, to exact it; one to add the suture, and the rest to support the structures surrounding it.

The second stage of this case was the mitral valve repair, which was in itself a multi-stepped procedure. It is possible to repair a damaged mitral valve using less invasive, keyhole methods, but due to the need for a bypass graft, this wasn’t an option this time.

After gaining access to the valve itself, via an incision in the left atrium, the condition of the valve leaflets is assessed. This particular patient’s posterior leaflet had a prolapsing middle scallop, which meant that the below procedure was necessary to repair it.

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The process off attaching the ring was a long one, involving a lot of organisation and intricate knotting. The sutures are applied to both the ring and the valve, the latter is then gently pushed down the threads and into place. These suture strings are then tied off and cut.

temporary_1464194828160.pngOnce this has been completed, the valve integrity and functionality was tested by flushing water through the heart. In this case, the valve was still slightly prolapsing, as the water flushed through the valve in an unwanted quantity. The entire process, then, was considered from the beginning, and the valve only said to be repaired, when the regurgitation seen through the valve was minimal.

When performing the annuloplasty removed the surplus anterior leaflet, it took with it a tendineae chordeae, so in order to stabilise it further, an artificial heart string (made of Gore-Tex) was attached to the leaflet and papillary muscle.

A final transesophageal echo was performed, to assess the level of air still present in the heart, and to then assess the function of the repaired mitral valve, and after all of this was successfully accomplished, the long task to gently remove all of the cannulas that were used to bypass the cardiopulmonary system were begun to be removed. Each chamber was sutured in sequence, and the corresponding section of the perfusion apparatus turned off. All of this time, the anaesthetist monitored the patient’s drug infusions and every member of the team monitored pressure and ECG traces. This was still going on whilst the SpR set about cauterising vessels and wiring the sternum before pulling it back together. None of this section of the procedure involved any real finesse; pulling the wires taut so as to close the chest cavity is a test of strength. Each pull caused the patient to move for the first time since coming into the theatre, so I guess that was why it was the only section of the surgery that almost made me wince (something the theatre lead noticed and laughed about). Once it was done, the multiple layers of sutures were applied to seal the surface wound and the patient was taken to recovery.

In all honesty, the most difficult part for me, was in standing for so long. This was echoed by the surgeons, who said that they always felt backed up by their colleagues, so they felt confident that the procedure itself would go well, but standing, often in an unnatural position for so six hours at a time played havoc with their backs and legs. The anaesthetists, being required fully at the beginning and the end of the surgery, spent a great deal of time sat waiting, save for occasionally changing an infusion as and when required. The people working solidly were the surgeons and the scrub nurse, but even the surgeons swapped roles, observed one another without participating, and even took breaks periodically. None of this diminishes any one role, however; each member of the team was required, be it constantly or otherwise, and when one was needed, it took a single word for everyone in the room to know what was required, and by whom. Despite the procedure itself being amazing, it was the mechanical and seamless nature of the professionals in the room that was the most astounding part of the day.

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Introduction to Pacing

Exams are over, coursework is in, and I’ve FINALLY got some time to devote to TSP, so I’ll endeavour to post updates with the same level of regularity as I did a few moths ago. It’s been a while since I added anything other than study pages, so it’s proving difficult to get back into the swing of reflective writing. I shall try to be clear, however.

The first week of my 15 week placement has been an interesting and challenging one. I’ve been in pacing clinics (the third of which allowed me to have some hands-on experience), tape clinics and have analysed my first full 24 hour ECG recording, so the amount of information I’ve absorbed has been of a high volume in a short space of time.

I’m not going to comment on tape analysis or clinics just yet, as I’m yet to have my completed work assessed, so I’ll wait until I’ve gained some feedback on my current performance. Pacing, however, is extracurricular, so I’ll glady share my experience.

Pacing checks were very fun; during eight or so hours of lingering/observation, I was gradually allowed to do a bit more with regards to clinical practice; analysing lead outputs and EGM readings, setting up programming equipment and learning my way around each box-specific bit of software, etc.

The majority of patients that came into the clinic were annual follow-ups, and six week post-insertion assessments, wherein the overestimated pacing parameters are altered so as to preserve battery life, and due to their nature, each was simply a case of checking each value and adjusting accordingly, meaning each 15 or 20 minute consult went off without a hitch, and I got a feel for the regular procedure and could have some of the physics explained to me. It also allowed my tutors to ask me questions and test me a bit.

The third and final clinic, however, allowed me to assume the role of primary (under strict supervision, of course) and perform threshold tests on my patient. It’s amazing how quickly it’s possible to forget everything you’ve spent the last few days learning, when it comes to actually doing it; the sudden pressure of being thrown into practical learning caused my mind to go completely blank, but with a bit of time, I settled into the role and things started to make sense as I was doing them. There’s a really overwhelming feeling of resposibility when you’re charged with manually increasing or decreasing your patient’s heart rate during threshold tests, and in addition, spotting the loss of atrial capture is, in most cases, far more difficult that that of ventricular capture. It was an exillerating experience, though, and I really felt like I had accomlished something at the end of the clinic. In three days I felt like I could quantify my progression, so the first week has left me feeling excited for the rest of the placement block.

Until this week, I’d never considered pacing as a future specialism – I was focussed on echo –  but getting some real exposure has shown me how much I could enjoy a future in the discipline. I can’t wait to do more.

I’ll write more about my own research into pacing as I do it, so keep an eye out for that.

Thanks!

 

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Review: Acadoodle

Acadoodle.comonline

Price: $99/ £66 per annum (approx)

Authors: Dr John Ryan, Dr John Seery

Acadoodle is a subscription-based online resource for ECG training that boasts a large selection of video tutorials which can be viewed individually, or as part of a tested course. The ECG Teacher sections are the primary focus of this review, but other courses such as blood gas analysis are available, however.

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Produced by Drs John Seery and John Ryan, I found these courses to compliment my study, and even when I wasn’t watching them directly, I found myself letting them play in the background as I read a textbook, or went over my lecture notes.

The videos themselves are well produced and make understanding the ECG and its subsequent analysis much easier. The animations are slick and the narration is clear, concise and full of all the pertinent diagnostic information you will require.

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Each area of study is tailored to a specific area of electrocardiogram diagnostics, so each playlist/module flows from one video to the next. In addition, the flow of the modules themselves makes sense, and the learning curve increases in a logical order and as such, each section follows on from the one that precedes it in a manner that doesn’t overload you with information before you’re ready.

A small selection of the videos are available on YouTube, so if you wished to try before you buy, then searching for “Acadoodle” would throw up some of the more basic tutorials for you to have a look at. I noticed that these YouTube videos are also embedded in the Acadoodle site proper, giving rise to a sometimes noticeable drop in picture quality, on occasion.

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It’s nearly impossible to fault the content and structure, as these videos have helped me immeasurably throughout the last six or seven months, but it is an expensive purchase for anyone, let alone students, especially when you consider that almost all of the content is in some way available via lectures or found in other, similar video courses on YouTube. In that respect, despite the quality of the content, I find it hard to recommend Acadoodle to physiology students who are considering purchasing a personal subscription, but for lecturers or professional bodies and universities, it should prove to be a valuable asset when clarifying concepts to a class full of students.

That isn’t to say that a student purchasing a subscription wouldn’t get a lot out of Acadoodle; it’s certainly worth it, it’s just expensive at a time when disposeable income is generally spent on textbooks or… food and shelter. If splitting £66 is something that you and a few peers feel is possible, then I highly recommend it, as the website can be used from multiple PCs with little to no issue.

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Synap: Beta Test Update

Synap is an upcoming revision tool that is driven by students. The platform enables students to create their own multiple choice questions and upload them, then download those created by others. It’s possible to “follow” other users, as you would someone on Twitter or, incidentally, this site (you can do that in the sidebar of this page…), and take any quiz that they have created. Image upload and basic editing is supported, so quizzes for physiology, such as ECG arrhythmia or echocardiography quizzes are more than possible, and are one of the reasons I decided to get involved with the whole thing. In addition, the app tracks your progress and structures your revision for you, based on your course and modules.

I’ve spent the last week or so beta testing the Synap web platform or, more specifically, I’ve been taking tests and creating basic ECG quizzes to help bug test and check functionality.

The platform, as I’ve mentioned, is currently in closed beta and only present on the web, so without having an app and a larger number of users I cannot comment on it fully, but as it stands, the processes involved in creating a profile and quiz are incredibly simple; adding and annotating images is a cinch, and a complete question only requires the user to add a correct answer and a few wrong ones. Whilst I encountered a few bugs initially, the feedback I provided was swiftly taken on board and the problems were remedied overnight. Taking quizzes is incredibly simple, and all you need to do is click “take quiz” (shockingly), then select your answers and have them marked. You can take these as many times as you like, too, and if the creator has provided any, feedback will be available for each individual question.

My only concern is the reliance on the quiz-maker supplying the correct information. I’ve taken a quiz wherein the correct answer was the only one that was possible to be correct (think “What has tusks and a trunk? 1) Elephant 2)Belephant 3)Your hamster”) yet I was still told my answer was wrong. This is a closed beta, though and that’s what these processes are for. I know it hasn’t escaped the attention of the developers, so we shall see how it is dealt with.

To break all of this down and show you what I know for sure so far, have a look at this (incomplete) features list:

  • MCQs:
    • Image/annotation upload
    • Correct answer & up to 5 incorrect
    • Optional feedback for test-taker
    • Optional link to external learning resource
    • Test result calculation
    • Obtainable achievements
    • Personalised revision quizzes sent to you
  • Community links based on:
    • Course/Discipline
    • Cohort
    • Institution

I’ll add to this list the more familiar I become with the platform.

Omair and James, its creators, and the rest of the Synap team hope that this app will enable students nationwide to help each other and revise together, and it’s a pleasure for me to be involved, even if it’s only in a small way, currently. I’ll continue to post updates as things progress.

For more info, visit @Synap on twitter.

Thanks

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