Res Medica

Editorial

James F Waddell — 2017-12-31

Editorial by Dr. James F. Waddell

SafeTALK suicide training: An evaluation of attitudes and actions among medical students

Brooke Wilson — 2017-12-31

Background: SafeTALK is a half-day gatekeeper training program on recognizing persons at risk for suicide and intervening appropriately. Primary care clinicians have been increasingly targeted for suicide intervention training; however, evidence surrounding the effectiveness of safeTALK is lacking, particularly among medical learners. The aim of this study was to assess whether suicide literacy and intervention skills were enhanced by safeTALK training among medical learners.

Methods: Undergraduate medical students from an Ontario university were invited to complete an online survey regardless if they had taken safeTALK training as part of their curriculum. Suicide literacy was measured with the Literacy of Suicide Scale (LOSS) and intervention skills were measured with the Suicide Intervention Response Inventory (SIRI).

Results: The majority believed that suicide risk assessment training was very important to undergraduate medical education. Although limitations were noted, this study did not demonstrate that safeTALK training significantly improved medical students’ suicide literacy levels or suicide intervention skills.

Conclusions: A more comprehensive program including the epidemiology of suicide and mental health disorders in addition to intervention skills is recommended to ensure medical learners are equipped to dispel the stigmas surrounding suicide and offer the appropriate care and follow up to their patients in future practice.

Assessment of existing layperson knowledge on the role and use of an AEDs in amateur sports clubs: A systematic review of the literature

Paul Ryan — 2017-12-31

Introduction: Sudden cardiac arrest (SCA) causes up to 5000 deaths each year in Ireland. 70% of cardiac arrests in Ireland occur out of hospital. Global incidence of out-of-hospital SCA ranges from 20-140/100000 people, and survival ranges from 2%-11%. The large increase in Automated External Defibrillator (AED) distribution and availability has led to an increasing interest into layperson recognition of and response to SCA.

Objectives: The purpose of this paper is to systematically review previously conducted studies relating to knowledge, understanding and attitudes among laypersons in relation to the use of an AED in the event of a SCA. This review aims to assess and critically appraise the existing literature relating to this topic on a global level in order to identify future research directions with an aim to improving layperson recognition of and response to SCA.

Methods: Studies were identified through an electronic database search in combination with expert recommendation. A three-step selection process was applied to determine applicability to this review.

Results: Ten studies were reviewed and critiqued. Three themes emerged:

Knowledge and understanding of the concept of an AED.
Willingness to use an AED in the event of a SCA.
Reasons for unwillingness to use an AED in the event of a SCA.

Results were compiled and discussed.

Conclusion: There is a paucity of literature relating to layperson understanding of AED function and use. The evidence suggests only a minority of laypersons would be confident or willing to use an AED in the event of a nearby SCA. The extent to which an educational intervention could impact upon layperson understanding and confidence in use of an AED is poorly understood at present.

Keywords: AED; layperson; public; understanding; attitudes; knowledge; awareness.

The efficacy of statin administration prior to elective PCI in reducing the incidence of post-procedural myocardial infarction or all-cause mortality: a systematic review

Aniruddh Shenoy — 2017-12-31

Abstract

Background: Observational studies show that statin-naïve patients presenting with acute coronary syndrome (ACS) undergoing elective percutaneous coronary intervention (PCI) have significantly higher rates of myocardial infarction (MI) and mortality. We plan to review the evidence for giving statin naïve patients statins 24 hours pre-PCI, with the aim of reducing post-procedural MI and mortality.

Objective: To critically evaluate and appraise primary and secondary literatures that investigate the efficacy of pre-treatment loading of a statin in improving outcome for patients with ACS undergoing percutaneous coronary intervention (PCI).

Review Question: What is the efficacy of statin administration prior to elective PCI in reducing the incidence of post-MI or all-cause mortality?

Methods: We searched the Cochrane Database of Systemic Reviews for systemic reviews and NICE CKS database for relevant NICE clinical guidelines. We then searched the MEDLINE database and Cochrane Central Register of Controlled Trial (CENTRAL) for relevant randomised control trials (RCTs). Our search was limited to peer reviewed papers published in the last 10 years, between 1st February 2006 to 1st February 2016. Our exclusion criteria were as follows: patients previously on statin therapy; statin administration outside 24 hours of PCI; unsuitable outcomes measured; papers not available in full and non-randomised trials. We conducted a systematic review on eligible papers acquired from this search.

Results: Our literature search yielded 86 papers. After reviewing these papers, 80 papers were excluded. Six papers were included in the final review in which 2207 patients received either high-dose statin treatment (n=1111) or placebo/usual care (n=1096). The ARMYDA-ACS trial showed that short-term pre-treatment with atorvastatin reduces the incidence of major cardiac events in patients with acute coronary syndromes undergoing elective PCI (OR=0.12, CI: 0.05-0.50; p=0.004). These findings were consistent with NAPLES II Trial in which preloading with atorvastatin reduced the risk of MI (OR=0.56 CI: 0.35-0.89). On the other hand, the ALPACS trial showed atorvastatin preloading had no significant benefits over usual care. They found that preloading with atorvastatin was not statistically significant reducing for post-procedural MI (OR=0.92, CI: 0.50-1.69) or mortality (OR=1.06, CI: 0.07-17.01). Three papers reported that the use of rosuvastatin given prior to elective PCI was associated with a significant reduction in post-procedural MI in patients. These were Yun KH. et al. (OR=0.50, CI: 0.25-0.98), Wang Z. et al. (OR=0.31, CI: 0.10-0.91) and Cay S. et al. (OR=0.05, CI: 0.01-0.41).

Conclusion: 5 out of the 6 studies reviewed showed supported the effectiveness of pre-procedural statins use in reducing the risk of post-procedural major cardiac events in patients undergoing elective PCI. These findings support routine use of statins in patients with ACS undergoing elective PCI.

A Comparison of the Early Responses to AIDS in the UK and the US

Samuel Hallsor Booth — 2017-12-31

Upon its emergence in the western world in the early 1980s, AIDS marked the beginning of a new chapter in the history of communicable disease. In the early stages of the epidemic there was a distinct lack of knowledge about the causation or transmission of the disease, rendering control of the situation a practical impossibility. It was clear that AIDS necessitated a definitive response from several sectors of society. With its apparent associations with then largely marginalised groups of society, namely homosexuals and injecting drug users, virtually no aspects of the response to AIDS were free from the influence of social and political perceptions of the disease and its victims. The US and the UK have strong political and cultural links and in this essay I will compare the responses of these two nations to the AIDS epidemic at a scientific, political and community level and explore the interactions which occurred therein.

The sword and the knife: a comparison of ancient Egyptian treatment of sword injuries and present day knife trauma.

Katherine Jane Wade — 2017-12-31

The Edwin Smith papyrus is the oldest known surgical treatise, thought to have been written in 1700 B.C. It was first discovered in Luxor in 1862 and was first translated from hieroglyph script by Egyptologist, James Henry Breasted in 1930. The papyrus details forty eight traumatic injuries which are topographically organised and considered formulaically through examination, diagnosis, prognosis and treatment.

The Khopesh was an ancient Egyptian sickle shaped sword which was thought to have been used to inflict a slash-type sharp force injury during battle. Treatment of these slash-type wounds as described in the Edwin Smith papyrus are compared with the current treatment of equivalent slash-type injuries, commonly knife wounds in the twenty first century.

Comparison of a variety of components involved in the treatment of historical and modern slash-type sharp force wounds has illustrated that despite advances in medical practice, some of the basic principles of our current treatment regimes are derived from practices established thousands of years ago by the ancient Egyptians.

Overview and audit against Motor Neurone Disease (MND) Association guidelines of a MND consultant’s practice over the last 3 years at the [Hospital]

Dominic Adam Worku — 2017-12-31

Background: Motor neurone disease (MND) is an incurable neurodegenerative condition. Recent guidelines from the MND Association UK (MNDA) emphasise prompt diagnosis and monitoring of quality of life (QOL). However, primary literature indicates that diagnosis is often delayed through several factors, including unawareness of how MND presents and delays through multiple secondary referrals. The [hospital] operates an internationally-recognised MND clinic whose service has not been audited against the MNDA UK guidelines for the last 3 years.

Aim: To assess how well the MND consultant’s service ensures prompt diagnosis and the provision of end-of-life care or appropriate respiratory or nutritional support.

Methods: Using the [hospital’s] database, records from 77 patients consulted consecutively in the MND clinic were obtained. Service parameters were compared against reference standards for diagnostic delay and treatment provision.

Results: 84.4% of referrals came from neurologists outside of the MND service, with only 13% from general practitioners. On average, it took 14.7 months for patients to be seen in the MND clinic following symptom onset. Riluzole and percutaneous endoscopic gastrostomy (PEG) were prescribed faster in bulbar-onset versus limb-onset patients, by 4 times and 9 times respectively. End-of-life care discussion was recorded for 26% of patients.

Conclusion: Diagnosing MND remains challenging for primary care physicians, which may be alleviated by disseminating recent Red Flag Committee guidelines. Investigation and treatment provision differed between MND subtypes, given the poorer prognosis associated with bulbar-onset. End-of-life care documentation remains low, which is an issue for the multi-disciplinary team (MDT) to resolve through incorporating palliative services.

Recurrent Aspergillus endocarditis in an immunocompetent patient: challenges in diagnosis and management

Yuan Ye Beh — 2017-12-31

We describe an unusual case of recurrent Aspergillus endocarditis in an immunocompetent 64-year-old lady. Four weeks after aortic valve replacement surgery, she presented with an inferior ST elevation myocardial infarction. Coronary angiography demonstrated compromise of the ostium of the right coronary artery, which was successfully treated by primary angioplasty and stenting. Six weeks later, she suffered from a subarachnoid haemorrhage secondary to a mycotic aneurysm. A transoesphageal echocardiogram suggested a large aortic root vegetation. She underwent urgent aortic root replacement with removal of the vegetation, which was subsequently confirmed to be caused by Aspergillus. She was discharged on long term anti-fungal medication (Voriconazole), which she discontinued after seventeen weeks. Several years later, she presented with non-specific symptoms and was ultimately diagnosed with a recurrence of Aspergillus endocarditis. This case illustrates one of the many non-specific ways Aspergillus endocarditis can present. A high index of suspicion can prevent significant life-threatening complications.

Paediatric illness and care: more than just feeling poorly

Rebecca Black — 2017-12-31

The medical education curriculum in the UK includes a component on understanding and appreciating the psychosocial aspects of illness and care. Yet, children’s own experiences of illness and care are often overlooked. This article explores these neglected experiences and insights through an examination of paediatric epilepsy. The psychosocial implications of being diagnosed and living with epilepsy for children and their families are wide-ranging, affecting physical and emotional wellbeing and involvement in everyday activities, as well as being burdensome to manage and treat. As such, children and their families have to utilize various coping strategies in order to incorporate epilepsy into their lives. Obtaining and appreciating children’s own experiences and perspectives can highlight key challenges for healthcare professionals working with these patients and their families, including recognizing children’s autonomy, effective communication with them, and acknowledging the wider context of children’s lives.

Concussion in Rugby Union and the Role of Biomechanics

Gregory J Tierney — 2017-12-31

Due to the physical and high-impact nature of rugby, head impacts can occur within the game which can result in concussion injuries as well as other moderate-to-severe head injuries ¹. Concussion has been defined as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces”¹ and was found to be one of the more common brain injuries throughout the world.² This is particularly true in sport; it has been estimated that over half of all concussions are sports related.³ A systematic review of the incidence of concussion in contact sports found that rugby union has a higher incidence rate compared with other sports such as American football and soccer.⁴

Unlike other sports injuries, detecting a concussion is difficult as the neuropathological changes cannot be recognized on standard neuroimaging technology.^5,6 \Therefore, if a player is suspected of having a concussion, they are removed from play for a Head Injury Assessment (HIA). The HIA is a standardized tool for the medical assessment of concussion injuries in rugby and aims to improve detection and patient education.⁷ The HIA assesses a range of degenerative concussive symptoms including memory, cognitive ability, balance and player discomfort. This concussion diagnosis protocol therefore relies heavily on side-line medical staff to identify if a player is exhibiting concussive symptoms. A major disadvantage to this is that concussion has a variable natural history, with transient, fluctuating, delayed and evolving signs or symptoms.⁸) This means that symptoms can take up to 48 hours to become apparent.⁸ It has therefore been acknowledged that the content of the HIA will be modified as the research around concussion diagnosis evolves.⁸

The reliance on side-line medical staff to accurately identify concussive symptoms means that there is a possibility a concussed player may remain on the field; this is one problem that biomechanical research into concussion is trying to overcome. This study will give an overview of concussion in rugby union with a focus on incidence, severity and protection strategies. It will discuss current biomechanical research and further biomechanical research required in the area of concussion injuries in rugby union.

Henry Gray and John Fraser: Scottish surgeons of the Great War

Tom Scotland — 2017-12-31

Between 1914 and 1918, the British Expeditionary Force fighting in France and Flanders sustained 2.7 million battle casualties. Just over one quarter (26.1%) were never seen by the medical services. These were men who had been killed (14.2%), were missing (5.4%), or were prisoners of war (6.5%). Most of those who were missing had been killed and their bodies never recovered. Just under three-quarters of the wounded (73.9% or 1 988 969) were seen and treated by the medical services and 151 356 died.[i] The worst single day in British military history was Saturday 1 July 1916, the first day of the Battle of the Somme, when there were 57 470 casualties, of whom 20 000 were killed or died from their wounds. In nearly a quarter of a million admissions dealt with by the medical services, 58.5% of wounds were caused by high-explosive shellfire, 39% by bullets (mostly from machine guns), 2% were caused by grenades, and 0.5% from bayonets.

'How will the 'internet of things' impact delivery and training of surgery? Are we heading for a global surgical reticulum?’

Halimat Afolabi — 2017-12-31

From self-driving cars to smart cities, the internet of things (IOT) promises to revolutionise every aspect of our lives. IOT refers to any device that is able to collect and transmit data via the internet. The excitement surrounding the field is spurred by the marriage of IOT and artificial intelligence (AI), which will lead to ‘smarter’ and more personalised devices. IOT technology has already begun to infiltrate several industries and healthcare is no exception. In this essay I will outline existing and potential impacts of IOT technology in the delivery and training of surgery.

Preliminary assessment of the value of computer-assisted learning (CAL) in undergraduate endocrine medical education

Christopher J Graham — 2017-12-31

2017 RMS Conference Abstracts

James F Waddell — 2017-12-31