Sohaib R. Rufai

Inspiring Tomorrow’s Surgeons: The Benefits of Student Surgical Society Membership☆?>

OBJECTIVES To assess the perceived value of medical school student surgical society membership and its effect on determining future career aspirations. DESIGN Cross-sectional survey. SETTING Three UK medical school student surgical societies. PARTICIPANTS Undergraduate and postgraduate students. RESULTS Of 119 students, 60 (50.4%) completed the survey. Of the respondents, 62.3% indicated that the surgical society had increased their awareness and knowledge about the different surgical specialties. Of the respondents who had decided on a career in surgery before joining the society, 67.6% stated that participating in society events had better prepared them for the career. Plastic surgery (13.3%), general surgery (11.7%), and neurosurgery (11.7%) were the 3 most popular specialties for future careers. Surgical skills workshops (21.9%), conferences (21.1%), and careers talks (16.4%) were chosen by students as the most useful career-guiding events organized by surgical societies. CONCLUSION Participation in medical school surgical societies is perceived as a valuable part of undergraduate and postgraduate medical education in aiding students to decide on future careers.

A systematic review to assess the “Treat-and-Extend” dosing regimen for neovascular age-related macular degeneration using ranibizumab

Age-related macular degeneration (AMD) is the leading cause of irreversible blindness in the developed world. Monthly or as-needed (PRN) dosing strategies of intravitreal ranibizumab have been established as efficacious treatment options for neovascular AMD. More recently, the ‘treat-and-extend’ dosing regimen (TREX) is being adopted in clinical practice as it represents a patient-centric and economical option, reducing treatment burden by extending injection intervals when possible. However, the efficacy of TREX using ranibizumab monotherapy remains to be defined. Therefore, we performed a systematic review to assess the current evidence for TREX using ranibizumab by searching MEDLINE, Embase and PubMed. Of the 1733 articles identified, nine TREX studies were included in our analysis (n=748 eyes). Average patient age was 79.25 (range: 77.34–82.00; SD: 7.27). Baseline BCVA ranged from 48.5–68.9 ETDRS letters. BCVA improvement was 8.92 letters at 1 year (range: 6.5–11.5; SD: 7.54), as a weighted mean accounting for numbers of study eyes. The weighted mean number of injections at one year was 8.60 (range: 7.3–12.0; SD: 1.73). Previously, the landmark ANCHOR and MARINA trials reported gains of 11.3 and 7.2 letters, respectively, using monthly ranibizumab. Chin-Yee et al reported a gain of 3.5 ETDRS letters with 5.3 (S.D. 0.66) PRN ranibizumab injections as weighted means at 1 year in their recent systematic review. Our analysis suggests that TREX delivers visual outcomes superior to PRN and approaches similar efficacy to monthly injections. Further RCTs are needed to fully evaluate the efficacy and economy of TREX in the long-term.

Surgical follow-up in low-income and middle-income countries

The poorest third of the world’s population is estimated to receive only 3·5% of the 234 million surgical procedures undertaken annually. Despite being a small proportion of global surgical output, such procedures represent a substantial challenge for health-care providers in low-resource settings. This challenge is compounded by the burden of managing postoperative complications (particularly delayed complications), which patients might not present with, as evidenced by the low rates of follow-up in many lowincome and middle-income countries. In the context of cataract surgery, Nathan Congdon and colleagues (August, p e37) propose the possibility of using early postoperative assessment of all patients or late assessment only of those who return for follow-up without additional prompting as practicable methods to improve long-term patient outcomes in settings where barriers to adequate post-operative follow-up exist. Such approaches would be feasible in many resource-limited settings, and where appropriate should be extended to postoperative follow-up of other surgical procedures. However, a potential exists for many patients to slip through the net by not returning for followup assessment despite developing harmful postoperative complications. Paternalistic medicine persists in many developing countries. Yousuf and colleagues reported that most patients in Srinigar, India, avoid the responsibility of decision making and defer this responsibility to the doctor. Where self-reporting contradicts socially and culturally mediated beliefs, systems that rely on this mechanism might not be able to ensure continuity in patient care. We therefore recommend a protocol wherein the doctor explicitly advises the patient to return should they experience predefi ned complications. Furthermore, the health-care provider should attempt to facilitate travel and rebooking where possible.

Is an iris claw IOL a good option for correcting surgically induced aphakia in children? A review of the literature and illustrative case study

Refractive correction of aphakia in childhood can be a complex management issue following lensectomy for congenital cataract or ectopia lentis. Some children have inadequate capsular support to allow an ‘in the bag’ or sulcus fixated intra-ocular lens (IOL). In such cases, options for refractive correction include spectacles, contact lenses, or surgically fixed IOLs. Many methods of IOL fixation have been described, but none are widely adopted in children. In recent years, the iris-fixated Artisan Aphakic IOL has gained popularity, but there is still significant concern about the rate of corneal endothelial cell loss and IOL de-enclavation. Here, we review the current literature on the use of iris-fixated IOLs in children, the published data on endothelial cell loss and de-enclavation rates. We present a case illustrating the significant improvements in quality of life, which can be seen in selected children, and also the rate of endothelial cell loss, which can be encountered after initial surgery, and a re-enclavation event. We make the case that until more data are available on normal endothelial cell decline in early childhood, in addition to age-specific rates of endothelial cell loss and de-enclavation rates following surgery, the use of iris-fixated IOLs in children will continue to be a moot point and is unlikely to be widely adopted.

One-year real-world outcomes in patients receiving fixed-dosing aflibercept for neovascular age-related macular degeneration

PurposeTo investigate 1-year visual and anatomic outcomes of intravitreal aflibercept for neovascular age-related macular degeneration (nAMD) given at a fixed 8-weekly interval.MethodsRetrospective, single-practice data analysis from an electronic medical record system of 255 eyes (223 patients) with treatment-naïve nAMD receiving 8-weekly aflibercept.ResultsMean logarithm of the minimum angle of resolution best-corrected visual acuity (BCVA) improved from 0.66 at baseline to 0.50 at month 11 (P<0.0001). Mean central retinal thickness (CRT) decreased from 311 μm at baseline to 211 μm at month 11 (P<0.0001). Our mean VA gain of eight ETDRS letters was comparable to the VIEW 1 and VIEW 2 Trials’ results at the end of year 1. After loading at month 5, mean BCVA was 0.48 (P<0.0001), and mean CRT was 235 μm. At month 5, 143 eyes (56%) were inactive defined by the absence of macular haemorrhage and intraretinal fluid (IRF) and subretinal fluid (SRF) on optical coherence tomography, and 112 eyes (44%) remained active. At month 11, 136 eyes (53%) were inactive, and 119 eyes (47%) remained active. At month 11, 77% of inactive eyes after loading remained inactive, and 77% of the active eyes after loading remained active. At month 11, mean BCVA of the inactive group was 0.51, and mean BCVA of the active group was 0.48 (P=0.54).ConclusionsAflibercept administered by fixed dosing over 1 year improved VA and macular morphology in treatment-naïve eyes. Active lesions at month 11 do not have worse VA outcomes compared with inactive lesions. The macular status after loading is a reliable indicator of disease activity at the end of year 1.

Commentary to "Undergraduate Suture and Local Anaesthetic Training in the United Kingdom".

The correspondence by Jones et al. provides further proportion of UK undergraduates that would pass their support for improved suture and local anaesthetic training in the United Kingdom. The authors state that our national survey adds to a growing body of evidence highlighting potential insufficiencies in basic surgical skills (BSS) training in the UK. Jones et al. highlight that surgical societies are known to provide more BSS training than medical schools. The authors describe their suturing and wound management courses in which they provide students with “take-home” suturing packs following completion of the course, including disposable instruments, a wound care pack, 2 sutures and a small sharps bin. They state their goal was to promote reinforcement of their new skills at home through repeated practice, which results in long-term retention of BSS skills as demonstrated by Routt et al. This offers a practical solution to the problems highlighted in our national survey. It would therefore be valuable for the authors to perform a comparative study of the competence of students post-BSS course completion with take-home suture packs vs those without suture packs, after a significant time lag. If the differences in their skills are found to be significant, a recommendation could be made to the UK’s General Medical Council to advise the incorporation of take-home suture packs into the undergraduate curriculum to help maintain “Tomorrow’s Doctors” standards. Jones et al. suggest that because our questionnaire made specific reference to only performing skills “without supervision,” this may have underestimated students’ true confidence by excluding students who may be reluctant to close wounds without supervision. Though this may have been the case, we did so intentionally to evaluate the proportions of students competent in performing unsupervised skills prequalification in line with the General Medical Council “Tomorrow’s Doctors” standards. These competencies are then observed during foundation year 1, where newly qualified doctors nationally are assessed performing core competencies by a qualified supervisor as core procedures and directly observed procedures, after which they are expected to perform such procedures unsupervised. Therefore our national survey provides a snapshot of the