Sayinthen Vivekanantham

Neuroinflammation in Parkinson's disease: role in neurodegeneration and tissue repair

Neuroinflammation in Parkinsons disease [PD] is a process that occurs alongside the loss of dopaminergic neurons, and is associated with alterations to many cell types, most notably microglia. This review examines the key evidence contributing to our understanding of the role of inflammation-mediated degeneration of the dopaminergic (DA) nigrostriatal pathway in PD. It will consider the potential role inflammation plays in tissue repair within the brain, inflammation linked gene products that are associated with sporadic Parkinsonian phenotypes (alpha-synuclein, Parkin and Nurr 1), and developing anti-inflammatory drug treatments in PD. With growing evidence supporting the key role of neuroinflammation in PD pathogenesis, new molecular targets are being found that could potentially prevent or delay nigrostriatal DA neuron loss. Hence, this creates the opportunity for disease modifying treatment, to currently what is an incurable disease.

Surgical safety checklists in developing countries

The World Health Organization Surgical Safety Checklist (WHO SSC) has demonstrated efficacy in developed and developing countries alike. Recent increases in awareness of surgical morbidity in developing countries has placed greater emphasis on strategies to improve surgical safety in resource-limited settings. The implementation of surgical safety checklists in low-income countries has specific barriers related to resources and culture. Adapting and amending existing surgical safety checklists, as well as considering factors unique to developing countries, may allow the potential of this simple intervention to be fully harnessed in a wider setting. This review will address the benefits and challenges of implementation of surgical safety checklists in developing countries. Moreover, inspiration for the original checklist is revisited to identify areas that will be of particular benefit in a resource-poor setting. Potential future strategies to encourage the implementation of checklists in these countries are also discussed.

Evaluation of an online medical teaching forum

Social media is increasingly being used for teaching and assessment. We describe the design and implementation of a Facebook© teaching forum for medical students, and evaluate its effectiveness.

Does Video Gaming Affect Orthopaedic Skills Acquisition? A Prospective Cohort-Study

Introduction Previous studies have suggested that there is a positive correlation between the extent of video gaming and efficiency of surgical skill acquisition on laparoscopic and endovascular surgical simulators amongst trainees. However, the link between video gaming and orthopaedic trauma simulation remains unexamined, in particular dynamic hip screw (DHS) stimulation. Objective To assess effect of prior video gaming experience on virtual-reality (VR) haptic-enabled DHS simulator performance. Methods 38 medical students, naïve to VR surgical simulation, were recruited and stratified relative to their video gaming exposure. Group 1 (n = 19, video-gamers) were defined as those who play more than one hour per day in the last calendar year. Group 2 (n = 19, non-gamers) were defined as those who play video games less than one hour per calendar year. Both cohorts performed five attempts on completing a VR DHS procedure and repeated the task after a week. Metrics assessed included time taken for task, simulated flouroscopy time and screw position. Median and Bonett-Price 95% confidence intervals were calculated for seven real-time objective performance metrics. Data was confirmed as non-parametric by the Kolmogorov-Smirnov test. Analysis was performed using the Mann-Whitney U test for independent data whilst the Wilcoxon signed ranked test was used for paired data. A result was deemed significant when a two-tailed p-value was less than 0.05. Results All 38 subjects completed the study. The groups were not significantly different at baseline. After ten attempts, there was no difference between Group 1 and Group 2 in any of the metrics tested. These included time taken for task, simulated fluoroscopy time, number of retries, tip-apex distance, percentage cut-out and global score. Conclusion Contrary to previous literature findings, there was no correlation between video gaming experience and gaining competency on a VR DHS simulator.

The issue of ‘informed consent’ in medical student introductions

‘Good morning! My name is John Smith and I am a medical student.’ This familiar phrase is employed by medical students the world over in a variety of formats. Despite the varying terminology, the purpose of this introduction remains to obtain ‘informed consent’ from patients. Even though the importance of informed consent is universally acknowledged by doctors, patients and students, Silver-Isenstadt and Ubel [1] found evidence for a worrying decline in the perceived importance of conveying one’s student status in medical students as they progress through medical school. This was in contrast to patients’ desires for clear communication of medical student roles and the scope of their involvement, especially in the context of invasive procedures in operating theatres under the influence of anaesthesia [1]. This calls into question the adequacy of current medical student introductions in obtaining true informed consent. Recently, Carson-Stevens et al. [2] surveyed medical students’ perceptions on the role of terminology used for introducing themselves and found that students knowingly employed varying terminology, often choosing to introduce themselves as ‘student doctors’. Students perceived this to have a dual benefit of increasing the probability of patient consent and reassuring patients of the near-professional status of the student [2]. However, Santen et al. [3] confirmed that even when informed of the medical student’s relative inexperience, 90 % of patients consented to a procedure in the emergency department although 66 % of patients did feel that they should be informed if the medical student is performing the procedure for the first time [3]. We believe that the continued use of ambiguous introductions by medical students restricts patient autonomy by withholding essential information, and this also erodes trust in the student/doctor-patient relationship. We propose that medical students approach the matter of clinical introduction by introducing themselves unambiguously as medical students, explaining their affiliation with the medical team and indicating the breadth of their experience prior to requesting consent.

Harnessing social media for medical education.

We thank Han et al. for discussing the timely issue of the online learning requirements of medical students. 1 One conclusion of the article was that social networking technologies were not deemed a suitable platform for education, despite extensive usage by clinical students. The reasons stated were twofold: fi rstly, students used the medium more for personal use; secondly, sensitive patient information should not be discussed on such an open platform. Nevertheless, we successfully established a Facebook® teaching forum for clinical medical students, ensuring patient anonymity by establishing fi rm ground rules. 2 Students particularly appreciated that our forum encouraged peertopeer learning and teaching. Han et al. ’ s study highlights that Facebook® is in the top fi ve software technologies used by medical students, with 90 per cent usage reported. 1

Should there be greater exposure to interventional radiology in the undergraduate curriculum

Medical imaging has been one of the most revolutionary innovations in medicine. Today, as health care professionals shift their focus toward more sophisticated technology and minimally invasive procedures, interventional radiology (IR) has become a rapidly expanding specialty. Despite these advances, there is a lack of doctors specializing in this field. A growing body of evidence suggests that the low number of applicants for posts may be due to poor exposure to the specialty at medical school. In this article, we outline the importance of IR in today’s health care system. Next, we evaluate the evidence that there is a lack of knowledge of IR not only among medical students in the UK but globally. We further discuss how a more effective incorporation of IR in the undergraduate curriculum can enhance medical students’ interest in the field and subsequently increase the number of doctors specializing in IR. Finally, we suggest alternative strategies to gauge medical students’ interest in IR, including teaching via e-learning and virtual reality.

How Should Surgical Safety be Taught

We thank Saturno et al. [1] for highlighting issues surrounding compliance with the World Health Organisation Surgical Safety Checklist (WHO SSC) [2]. The authors suggest that checklist compliance would ‘‘improve with overall safety culture improvement,’’ which should be ‘‘an objective that should be explicitly considered in all training programs for residents and health professions curricula.’’ We welcome this suggestion; however, we would like to raise certain points to be aware of surrounding educating medical trainees on safety checklists. Checklists may be effective as a result of our colleagues being able to scrutinize the document, similar to the Hawthorn effect discussed in the study by Saturno et al. [1]. However, no research has been carried out to determine whether tasks that are not being monitored as part of a checklist, or with low compliance, will be conducted to a compromised standard when checklists are in use. Indeed, Rydenfalt et al. [3] suggest that when checklist compliance is low (as demonstrated by Saturno et al. [1]), in combination with other safety checks being omitted because team members think they are being handled by the checklist, a false sense of safety will arise. For example, the checklist asks whether the pulse oximeter is functioning before the induction of anesthesia, but there is no specific question regarding the fluid status of the patient [2]. Perhaps the younger generation of trainees may neglect the importance of other key parameters simply because it is not on this list, especially in the acute setting. Whilst the initial WHO guidelines for safe surgery state that ‘‘checklists clarify the minimum expected steps in a complex process,’’ [4] the numerous checklists that have been created may result in the junior trainee relying on these aids. This poses the risk of trainees feeling that checklists are sufficient to assure safety, rather than a minimum standard. Currently, doctors in training are already taught and assessed on a number of guidelines and protocols. Although we agree that careful implementation of these guidelines can improve medical safety by means of reduced complication rates, [2] we fear that being taught about more checklists in the clinical setting may introduce challenges in usage. Indeed, ‘checklist fatigue’—where the overuse of checklists results in reduced overall compliance—is increasingly recognized in clinical contexts [5]. We believe the study by Saturno et al. [1] clearly highlights that education on medical safety must increase; however, in the context of checklists we should reinforce that they are a minimum standard rather than the benchmark. If the emphasis of safety education is focused on checklists, then trainees may not equip themselves with the necessary skills and knowledge to approach novel clinical scenarios with confidence. We welcome further teaching on the importance of checklists in the surgical safety curriculum; however, as the low compliance in the study by Saturno et al. [1] demonstrates, we believe that future educators must emphasize the rationale behind checklists, and stress that checklists are only one component in improving the culture of patient safety.

The global burden of surgical disease: Past, present and future

The global burden of disease (GBD) study was the first, and remains the only, comprehensive attempt at quantifying disease burden worldwide. The initial GBD study in 1992 highlighted the burden of various diseases, and risk factors of disease, many of which remain poorly addressed. This study introduced a new metric, disability adjusted life years (DALYs), through which it became possible to calculate time lost through premature death and time lived with disability. Many of the disease groups identified in the GBD study (including malignancies and musculoskeletal disorders) are amenable to surgical correction and constitute a considerable proportion of the GBD. Revisions of the GBD study provide the international community with valuable data depicting trends in disease patterns from which health policy makers may base priority setting at both a national and an international level on public health issues, as well as informing future trends. Recently, considerable efforts have been made to define an internationally applicable standardised health metric to evaluate access to safe surgical care (incorporating disease burden and health system performance) in order to monitor trends and inform efforts in public health surveillance. Investment in improving disease monitoring and surveillance systems in lowand middle-income countries remains vital, as statistical undertakings in the developing world are inherently fraught. The limited inbuilt health infrastructure compromises capacity to collate adequate epidemiologic and vital statistics. Further regional descriptive epidemiology exploring the social determinants of health to improve the understanding of the heterogeneity in local perceptions of disease burden may also contribute to developing contextually appropriate measures to address local issues. Recent efforts to improve access to surgical care in lowand middle-income countries include the World Health Organization’s (WHO) Surgical Safety Checklist and the Global Initiative for Emergency and Essential Surgical Care Program. Despite compelling evidence of the benefit of surgical safety checklists in improving mortality and patient outcomes, a recent article by Urbach and colleagues suggested that implementation of the checklist in a Canadian hospital was not associated with a significant reduction in operative mortality or complications. Although it cannot be assumed that the institution of a checklist will inevitably facilitate an improvement in patient outcomes, hospitals in high-income countries are perhaps less likely to show improvements as they are likely to already have protocols in place to minimise adverse surgical events. In many resource constrained countries the effect of a checklist will likely bring about marked reductions in patient mortality and thus the findings to the contrary should be interpreted with due caution. With the growing evidence-base and increasing compliance with the checklist its use remains a vital component in the delivery of safe surgical care globally. At the 135th executive board meeting of the WHO, in May 2014, ‘Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage’ was discussed as an agenda item for the first time. This marks a significant milestone in the efforts of countless surgeons, healthcare professionals, non-governmental organisations, academics, students and civil society over the years in advocating for surgical care to be recognised as a global health priority. However, much remains to be done to ensure that a WHO resolution on this agenda item is passed. Furthermore, in order to ensure that current efforts to increase awareness of the need for improved surgical care in lowand middle-income countries bring about improvements in population health critical challenges such as gaps in surgical services, including strengthening the surgical workforce and health system infrastructure must be addressed. These challenges combined with garnering political commitment are crucial to sustained improvements in surgical care globally. There also exists a need to frame global surgery objectives within the wider landscape of global

Shortage of doctors, shortage of education.

We read Hoyler et al.’s [1] article on the shortage of doctors in the developing world with interest. In certain developing countries, despite there being 24 % of the world’s health burden, there remains only 3 % of the world’s health workforce [2]. This mismatch arises in part due to the discrepancy between the supply and demand of healthcare workers, with emigration being a significant contributor [1]. With an increasing life expectancy, the incidence of surgically treatable conditions is increasing in developing countries [2]. As Hoyler et al. [1] outlined, strategies to overcome this deficit include analysis of data on migration trends. A study conducted on health professionals who emigrated from developing countries found that the most important factor for leaving was professional reasons [3]. ‘‘Push factors’’ include undefined career structures and limited intellectual stimulation; in addition, ‘‘pull factors’’ included abundant opportunities for gaining additional qualifications and experience [4]. We believe that among other initiatives to improve healthcare in developing countries, improving the quality of the educational infrastructure is extremely important and possibly central to not only creating a better-quality workforce, but also offering a stronger incentive for trainees not to migrate. This may include, but is not limited to, using financial aid to increase the number of places in healthcare courses, improving training facilities within teaching and clinical settings, formalizing the training structures within the healthcare systems, and developing training programs in more rural areas. However, notably, training must be focused on the specific healthcare needs of different regions. Such strategies have already been utilized in certain parts of the world. One example includes the establishment of a medical degree focused on primary care in an attempt to increase the number of students that decide to join the primary care workforce (Universidae do Algarve, Portugal). The setup and outcome measures of these established courses could act as a template and validation for the development of translational courses in developing countries. Furthermore, access to educational resources from developed countries should be improved. The Health InterNetwork Access to Research Initiative has been successful in allowing developing countries to access the latest research articles. We believe that similar initiatives should focus on making educational resources from institutions open access also, especially for health courses, given the increasing availability of the internet in developing countries. This would help local health professionals within developing countries improve their own respective educational infrastructures. In recent years, financial aid initiatives have been focused on supplying material resources to developing countries, and the effectiveness of such strategies has been debated [5]. Greater sustainability might be achieved if some of these funds were directed to educational institutions in developed countries to provide openaccess resources to health professionals in developing countries. We hope that this will help developing countries overcome the ‘‘push’’ and ‘‘pull’’ factors causing the emigration of professionals while also improving the quality of the health workforce. S. Vivekanantham (&) D. Gnanappiragasam Imperial College School of Medicine, Imperial College London, London SW7 2AZ, UK e-mail: sayinthen.vivekanantham@gmail.com