Charlotte Burford

Hepatic Steatosis—a complex interaction of germs, genes and grub.

Non-alcoholic fatty liver disease (NAFLD) has a prevalence of 7–10% among children in the developed world, making it the most common cause of chronic liver disease in this population. Its prevalence is rising concomitant with the rise in obesity. NAFLD incorporates a spectrum of liver abnormalities, ranging from simple steatosis, to, non-alcoholic steatohepatitis (NASH), involving various degrees of inflammation, ballooning and fibrosis. NASH may evolve into cirrhosis, accounting for its place as the second most common listing indication for adult liver transplantation (LT) in the United States. It is vital to intervene in the paediatric population to avert this outcome. Dietary and lifestyle management in NAFLD remains commonplace, but poor compliance hinders this otherwise effective strategy. Pharmacological therapies, such as insulin sensitizers, antioxidants and hepato-protective agents, have shown mixed results and varying side effect profiles. There remains a desire to identify other interventional strategies. Given increasing focus on the gut-liver axis, the gut microbiome (GM) is emerging as the new kid on the block, with revolutionary potential for hepatological conditions, including NAFLD. We therefore, welcome Stanislawski et al.’s large crosssectional study on the role of GM in paediatric fatty liver. The authors selected magnetic resonance imaging to evaluate steatosis in a paediatric population cohort (n= 107), in which one-quarter were born to gestational diabetic mothers. GM was evaluated in this cohort using stool samples. The study highlights the technical challenges in the recruitment of asymptomatic children; with less than half of all children approached being able to provide a suitable stool specimen. The authors demonstrated a negative association of GM biodiversity with hepatic fat fraction (HFF). Qualitatively, genera, including Bilophila, Paraprevotella, Oscillospira and Bacteroides, are correlated with HFF. The authors defined NAFLD, based on HFF ≥ 5%, in 8 children (7.8%). However, as highlighted in our recent review, caution must be exercised when labelling children with ‘NAFLD’, based on hepatic steatosis only, given that steatosis can be a sign of other diseases. Also, as steatosis per se, is not an accurate prognostic factor for disease outcome, clinical applicability of the study remains uncertain. Lipopolysaccharide (LPS), the main component of gram-negative bacteria, through activation of toll-like receptor 4 (TLR-4) propagates an inflammatory signalling cascade, which can contribute to insulin resistance and TNF-α mediated fibroinflammatory processes within the liver. The intricate interplay between the microbiome and the immune system, will likely play a role in NAFLD, with increased LPS concentrations being reported in NASH children. Future researchers should consider routinely evaluating the microbiome in steatosis, in combination with inflammatory and fibrotic biomarkers, to understand the microbiome in the context of disease pathogenesis. Increased intestinal permeability (IP), and small intestinal bacterial overgrowth (SIBO), have been consistently described in paediatric obesity, with increasing evidence to suggest their potential involvement in fatty liver phenotypes. Although altered GM composition, known as dysbiosis, is described, inconsistent results across studies exist. Initially, a decreased abundance of Bacteroidetes and increased Firmicutes, in obesity, was found at a phylum level. However, subsequent studies have shown different, and often, opposite results. Similarly, in paediatrics, contradictory results at phylum, genus and species level exist, not only between disease and healthy states, but also within disease states. In addition to differences in study populations (e.g. obesity, NAFLD, NASH, and in this study, hepatic steatosis), the inherent complexities and limitations in conducting any GM study will largely contribute to inter-study variation. Antimicrobials, medications, diet, age, genetics and ethnicity can all influence GM. An ideal microbiome study would account for all of these, which is, understandably, challenging. We commend Stanislawski et al., for their efforts to account for diet. Dietary analysis, is particular relevant in GM-NAFLD studies, due to the bidirectional influence of diet on both GM, and NAFLD. As an example, a high fructose diet, is associated with hepatic steatosis, and, has also been correlated with SIBO and increased LPS. Stanislawski et al. used food questionnaire tools to demonstrate a weak association between mono-saturated fat, carbohydrates and HFF, but the effect on GM was difficult to establish. Dietary assessment, although technically challenging, should be attempted in any GM-NAFLD study, in order to elucidate the complex relationship between GM, diet and NAFLD. Antimicrobials can have a significant effect on the microbiome; the Human Microbiome Project excludes cases exposed to antimicrobials within six months of stool sampling, whilst others suggest the microbiome never reaches its preantimicrobial state. In addition, commonly used medications, such as, histamine receptor antagonists and proton pump inhibitors, and of particular interest in NAFLD, metformin, can also alter the microbiome. Hence, relevant medications should be incorporated into the study design of microbiome projects. In addition to differences in study populations (e.g. obesity, NAFLD, NASH and in this study, hepatic steatosis), the inherent complexities and limitations in conducting any GM study, such

Designing undergraduate neurosurgical e-learning: medical students’ perspective

Dear Editor,We were interested to read the recent article by Knight etxa0al.1 about the utility of neurosurgical sessions to students at a London-based university. The authors identified understandin...

Factors influencing interest in the brain-related sciences in a UK cohort

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Mental Wellbeing Impact Assessment (MWIA) in the workplace

Purpose The Mental Wellbeing Impact Assessment (MWIA) is an evidence-based tool that guides decision makers, such as policy makers and service managers, about the potential impacts of a new programme or policy change. It was initially used in urban regeneration but has subsequently been used in housing, children’s centres and education. The purpose of this paper is to report, for the first time, on the strengths and weaknesses of using the MWIA in the workplace. Design/methodology/approach Feedback was collected from staff who participated in stakeholder workshops as part of the MWIA process at two different public sector organisations. Findings The MWIA can be used as an effective workplace assessment tool and is valuable as both a diagnostic tool and as an intervention in its own right. The MWIA generates tailored action plans focussed on addressing the organisation or team-specific issues. The weaknesses of the MWIA in the workplace are mainly focussed around management cooperation and commitment to the process which should be screened for prior to engaging in the full stakeholder workshop. Originality/value This is the first report of MWIA’s use in the workplace but suggests that it is a useful tool which can be used to support workplace wellbeing, especially in relation to a policy or organisational change. Further studies should be carried out to fully understand the impact of the MWIA in the workplace.

Sexism in the dissection room: A medical student perspective: Letter to the Editor

We write in response to the recent article on sexism within anatomy by Morgan et al. (2016). We thank the authors for investigating this important and topical issue, particularly through assessment of sexism that may occur in consultations and textbooks, as well as sexism in anatomical terminology. However, we would like to note that teaching in the dissection room is one of the most important part of anatomy education (Sugand et al., 2010), and this area was not fully explored in the article. Sexism in the dissection room can have a significant impact on the overall anatomical education experience, and has proved off-putting for medical students we have spoken to. Our own experiences correspond to the conclusion of the article that “for both professional anatomists and medical students, levels of awareness of gender awareness and their relevance in medical education are lower than expected.” In response to quotes that demonstrate this point in the article, such as by a male anatomy demonstrator describing “rabid feminists (. . .) doing themselves and society a disservice” we would respond with this report from a female medical student about a dissection room session: “I was told in front of a group of male colleagues that my tweezer technique would only be effective in a job ‘plucking eyebrows at the weekend.’ I was also told on another occasion ‘put some effort into it, don’t be such a girl.’” Whether deliberate or not, such comments caused the student to feel uncomfortable in the dissection room, negatively affecting her educational experience. Another female medical student told us of an incident where a group who had spent the term dissecting a woman were diverted to another group’s male cadaver, as the female genitalia were “boring—nothing to see there.” The female external genitalia and uterus were not examined at all, yet extensive examination time was devoted to the testicles, penis, and spermatic cord. The student felt this missed an important opportunity for clinically relevant teaching and learning, particularly as examination of external genitalia is infrequently performed during most medical school placements. These examples clearly emphasise that, whatever the intention, sexism in the dissection room can strongly influence the educational experience and, in these examples, perhaps dissuade students from the surgical or pathological specialities, or decrease confidence when interacting with female patients relative to male patients. We fully agree with the recommendation of the article that in order to reduce the effects of sexism in anatomy education, a culture of awareness of equality and diversity issues must be encouraged. This can be achieved through education in gender issues, both for teaching staff and to be embedded in courses such as the anatomy course; to promote diverse role models, and to further develop reflective practice beyond the gender binary to encompass non-binary identities. Medical students should be included in discussion of ways to address these issues going forward.

How does the publication fate of abstracts presented at the Society of British Neurological Surgeons meetings differ five years on

We read with great interest the article published in the British Journal of Neurosurgery entitled ‘Publication fate of abstracts presented at the Society of British Neurological Surgeons meetings’. This paper looked at the publication rate for abstracts presented at the SBNS Spring and Autumn meetings from 2001–2005. They considered a number of factors such as publication rate (36.6%) and average time to publication (22 months). We set out to investigate the same over the subsequent 5-yearperiod (2006–2010) to provide a comparison. Similar to the authors of the 2015 paper, we cross-referenced the titles and names of authors from abstracts published in SBNS proceedings with Pubmed and Google Scholar. A total of 620 abstracts were presented during this period at nine different meetings. This represents a 25.5% increase in the number of abstracts presented over the preceding 5 years (2000–2005). We found 213 of these abstracts had been published resulting in a publication rate of 34.4%. This figure is similar, but slightly lower than that reported by Jamjoom and colleagues. It is possible that this is because some of the abstracts are yet to be published. However, we have performed this analysis six years after the most recent conference included (2010) which is well beyond the average publication time (22 months) reported by Jamjoom et al. In addition, in our cohort we found the average time to publications was 24 months. The range was from 1 month and up to 127 months. The highest time to publication was for the RESCUEICP trial which was first presented in 2006, when the trial was just beginning, and was published in 2016. Excluding this paper, the longest time to publication would have been 78 months. Twenty of the abstracts were published prior to presentation. We also looked at some of the other factors considered by Jamjoom et al. in their original paper. For example, the number of citations in our cohort ranged from 0 to 346 (median1⁄4 21, mean1⁄4 36). We report a median that is very close to the 22 reported by Jamjoom et al., although the maximum number of citations is lower. This could be partly explained by the time difference between our analysis (6 years after the last conference in our series) and the Jamjoom analysis (10 years after the last conference in their series). Ponce and Lozano reviewed the most highly cited works in neurosurgery in 2010, and found the number of citations in the top 100 most cited papers in neurosurgery ranged from 287 to 1515. We found 15 papers had over 100 citations and 4 papers had over 250 citations which supports the high quality of papers presented at SBNS conferences. We also looked at the institution and country the authors were based in and found that 86.7% were based in the UK. Other countries with institutions represented at the SBNS meetings included: Australia, Canada, Denmark, France, Germany, Greece, Italy and the USA. 6.1% of abstracts were from multicentre collaborations. As it may be logistically more difficult for abstracts from international research groups to be presented in the UK, abstracts from UK research groups dominate the proceedings. We also looked at the most commonly chosen journals for publication. We found the top three journals were the British Journal of Neurosurgery (24.4%), the Journal of Neurosurgery (7.50%) and Neurosurgery (6.57%). These were the same three journals, and at similar rates, reported by Jamjoom et al. The median impact factor of all the journals was 2.126 (0.25–59.57). In our cohort, the most common field of interest for publications was ‘Spinal’ (17.4%) followed by neurovascular (13.1%). Neurovascular was found to be the most common by Jamjoom and colleagues (26%) with only 7% being categorised as ‘Spinal’. Publications were categorised according to the session in which they were presented at the SBNS. If it was not clear then the publication was categorised according to our interpretation. Our findings support a growing trend in spinal surgery research. In conclusion, we found a very similar pattern of publication of SBNS presentations between 2000–2005 and 2006–2010. The number of abstracts presented had, however, increased but the similar publication rate, time to publication and number of citations all suggest that the quality of work presented has remained high.