Emma C. Alexander

Quality improvement initiatives for hospitalised small and sick newborns in low- and middle-income countries: a systematic review

BackgroundAn estimated 2.6 million newborns died in 2016; over 98.5% of deaths occurred in low- and middle-income countries (LMICs). Neonates born preterm and small for gestational age are particularly at risk given the high incidence of infectious complications, cardiopulmonary, and neurodevelopmental disorders in this group. Quality improvement (QI) initiatives can reduce the burden of mortality and morbidity for hospitalised newborns in these settings. We undertook a systematic review to synthesise evidence from LMICs on QI approaches used, outcome measures employed to estimate effects, and the nature of implementation challenges.MethodsWe searched Medline, EMBASE, WHO Global Health Library, Cochrane Library, WHO ICTRP, and ClinicalTrials.gov and scanned the references of identified studies and systematic reviews. Searches covered January 2000 until April 2017. Search terms were “quality improvement”, “newborns”, “hospitalised”, and their derivatives. Studies were excluded if they took place in high-income countries, did not include QI interventions, or did not include small and sick hospitalised newborns. Cochrane Risk of Bias tools were used to quality appraise the studies.ResultsFrom 8110 results, 28 studies were included, covering 23 LMICs and 65,642 participants. Most interventions were meso level (district and clinic level); fewer were micro (patient-provider level) or macro (above district level). In-service training was the most common intervention subtype; service organisation and distribution of referencing materials were also frequently identified. The most commonly assessed outcome was mortality, followed by length of admission, sepsis rates, and infection rates. Key barriers to implementation of quality improvement initiatives included overburdened staff and lack of sufficient equipment.ConclusionsThe frequency of meso level, single centre, and educational interventions suggests that these interventions may be easier for programme planners to implement. The success of some interventions in reducing morbidity and mortality rates suggests that QI approaches have a high potential for benefit to newborns. Going forward, there are opportunities to strengthen the focus of QI initiatives and to develop improved, larger-scale, collaborative research into implementation of quality improvement initiatives for this high-risk group.Trial registrationPROSPERO CRD42017055459.

Rethinking neoadjuvant chemotherapy for breast cancer

As evidence questioning the rationale behind neoadjuvant chemotherapy in breast cancer grows, Jayant Vaidya and colleagues say we must reconsider the current treatment options

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

Graduate-entry medicine: a worthwhile innovation

Graduate-entry medicine: a worthwhile innovation Ten years ago in the JRSM, Calvert et al. described the academic performance of graduate-entry medical students exceeding the performance of mainstream students in their cohort. We write as graduateentry students who are concerned that access to medicine is narrowing for students such as ourselves. In recent years, four-year graduate-entry courses have closed or narrowed requirements to exclude individuals with non-scientific backgrounds. King’s College London accepted their last arts graduates in 2015. St George’s halved places on its programme in 2014. Leicester, Bristol and Imperial closed their four-year courses altogether. This is occurring in anticipation of future constraints on recruitment. The 2013 UK Shape of Training Review advised: ‘Full registration should happen at point of graduation from medical school.’ This threatens the eligibility of graduate-entry courses, where the first Foundation Programme year counts as the fifth year of medical study; current European Parliament guidance states qualifying medical degrees require five years of study. Universities have responded to this uncertainty by narrowing their intakes. This is disappointing given the clear case for graduate-entry programmes. Graduates facilitate peer-topeer learning – many have worked as healthcare assistants, nurses or pharmacists, and can provide clinical skills teaching to students without such a background. Arts graduates can teach on relevant areas such as critical appraisal, history and philosophy: knowledge that is vital for a well-rounded doctor. Graduate-entry courses increase the diversity of a historically middle-class profession and graduates are more likely to pick careers in General Practice, which fits with current UK health policy priorities. Theoretically, five-year undergraduate courses are open to graduates, but are financially punitive because they do not allow those with prior degrees to receive a student loan. New avenues should be explored to ensure that able and talented graduates from diverse backgrounds are not blocked out of the profession for financial or technical reasons. Declarations Competing Interests: None declared.

Systematic review of infant and young child complementary feeding practices in South Asian families: the Pakistan perspective

Objective Suboptimal nutrition among children remains a problem among South Asian (SA) families. Appropriate complementary feeding (CF) practices can greatly reduce this risk. Thus, we undertook a systematic review of studies assessing CF (timing, dietary diversity, meal frequency and influencing factors) in children aged <2 years in Pakistan. Design Searches between January 2000 and June 2016 in MEDLINE, EMBASE, Global Health, Web of Science, OVID Maternity & Infant Care, CINAHL, Cochrane Library, BanglaJOL, POPLINE and WHO Global Health Library. Eligibility criteria: primary research on CF practices in SA children aged 0–2 years and/or their families. Search terms: ‘children’, ‘feeding’ and ‘Asians’ with their derivatives. Two researchers undertook study selection, data extraction and quality appraisal (EPPI-Centre Weight of Evidence). Results From 45 712 results, seventeen studies were included. Despite adopting the WHO Infant and Young Child Feeding guidelines, suboptimal CF was found in all studies. Nine of fifteen studies assessing timing recorded CF introduced between 6 and 9 months. Five of nine observed dietary diversity across four of seven food groups; and two of four, minimum meal frequency in over 50 % of participants. Influencing factors included lack of CF knowledge, low maternal education, socio-economic status and cultural beliefs. Conclusions This is the first systematic review to evaluate CF practices in Pakistan. Campaigns to change health and nutrition behaviour are needed to meet the substantial unmet needs of these children.

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

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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.