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Differences in Dignity: Reflections on a Surgical Placement in a Vietnamese Public Hospital.
Full text linkThis piece is a short reflection on the elective placement of a fourth-year medical student in Vietnam. It aims to evaluate the differences she perceived in healthcare systems between Vietnam and England. The article draws on her experiences over a four-week period and comments on how these have influenced her future practice. Overall, the text hopes to shed light on the important benefits which elective placements add to a medical student's journey towards becoming a proficient and empathetic clinicia
How have chest drainage practices evolved since the time of Hippocrates? A social historical review.
Full text linkBackground: Chest drainage is a life-saving procedure used to remove fluid or air from the pleural space. Hippocrates initially described this procedure, where he used a hollow tin drain to treat a patient with empyema. A literature review revealed that contemporary discussions around chest drainage focused more on its indications and complications, with less emphasis on its origin. This study sought to explore how history shaped modern practice of chest drainage, with focus on key developments and the individuals involved, over a period of four thousand years.
Methods: The nature of this study was qualitative social historical review. A diverse body of resources was accessed, including books, journal articles, website articles, guidelines and academic reports. These primary and secondary sources were thematically examined, and recurring ideas and patterns were identified. A chronological approach was taken, and the data was sorted into three overarching themes: pre-17th century, 18th-20th century, and modern-day. Within these major themes, developments in chest drainage practice, technique, or equipment were explored.
Results: Many developments were found. Key accomplishments include needle aspiration, closed underwater-seal systems, suction, and standardisation of chest tube sizes. Early debates about chest drainage centred on wound treatment and various types of chest tubes. As medicine advanced, fundamental principles such as negative intra-pleural pressure and siphon drainage were established, improving safety and efficiency. Yet, chest drainage was not generally adopted until the 20th century, when it gained popularity owing to its usage in World Wars and the influenza epidemic.
Conclusions: Chest drainage has undergone significant change since the time of Hippocrates. The necessity to drain undesirable fluid/air remains, but different modes of drainage now exist, and are practiced. Further research could concentrate on adapting chest drainage for disease-specific factors, or how guidelines for management of pleural disease have changed in recent years
Effects of exercise on autonomic function and quality of life in chronic liver disease (CLD) in Two Randomised Controlled Trials.
Full text linkBackground: The leading cause of death in patients with elevated liver fat is cardiovascular disease (CVD), particularly exacerbated by excessive alcohol consumption. Autonomic dysfunction correlates with increased CVD morbidity, mortality, and diminished health related quality of life (HRQL). It is hypothesised that exercise will improve cardiac autonomic function (CAF) and HRQL in metabolic dysfunction and excessive alcohol consumption (MetALD) and Metabolic Dysfunction- Associated Steatohepatitis (MASH) patients.
Methods: Data on CAF and HRQL were collected from two randomised controlled trials (RCTs): RCT 1: MetALD (n=27) and RCT 2: (Krag and Rinella, 2024) MASH patients (n=24). Hepatic and extra- hepatic variables, such as liver fat, body composition, and metabolic and liver function markers were evaluated. Patients in each RCT underwent screened and then randomised to 12-weeks of exercise or standard care. Baseline and post 12-weeks assessments of all measured were conducted.
Results: Exercise led to significant improvements in beat variables, systolic blood pressure, stroke volume and stroke volume index, in MetALD patients, with a time by treatment interaction. Conversely, no significant changes in MASH beat variables were noted. In the MetALD exercise group, significant within-group changes and a time by treatment interaction were noted, contrasting with the MASH patients. High frequency R to R interval (HFnu-RRI) % significantly decreased in exercising MetALD patients. While no significant changes were observed in MASH patients, all CAF variables improved. Exercise resulted in a 38% vs. 37% reduction in fatigue index scores (FIS), and a 13% vs 10% increase in chronic liver disease scores for MetALD and MASH patients, respectively. Associations were observed between fat mass and chronic liver disease scores and FIS, and between FIS and cardiac outcomes. MASH patients exhibited greater improvements in CAF compared to MetALD patients, whereas MetALD patients exhibited greater HRQL improvements. Liver fat decreased significantly in MASH patients but not in those MetALD. Body composition measures improved significantly in both RCTs, while metabolic and other outcomes did not differ
Conclusions: These findings demonstrate exercises potential to enhance CAF, improve HRQL and reduce fatigue in well-characterised MetALD and MASH patients, thus rejecting the null hypothesis. This comprehensive approach aligns with the biopsychosocial model, essential for effective clinical management. Recognising the importance of a patient-centred approach, considerations should include exercise intensity and type, with acknowledgement that exercise may not be suitable for all patients. Further research is warranted to understand the dual effects of metabolic dysfunction and alcohol on clinical outcomes in MetALD patients
Medicine Wheel for the Planet: A Journey Toward Personal and Ecological Healing (Jennifer Grenz)
No full textA molecular dynamic study of HIV-1 Tat protein as a potential therapeutic target.
Full text linkBackground: Research and development remain ongoing to continue improving the current landscape of HIV treatment. Important stages of the HIV life cycle such as transcription have still yet to be targeted by therapies, and one important transcriptional regulator is the ‘Trans-Activator of Transcription’, or ‘Tat’ protein. Despite widespread acknowledgement of Tat’s role in HIV replication, current information on Tat remains limited; at present the only molecular models of the protein available are of a portion of the binding site with TAR-RNA, and a model of Tat from HIV subtype B which is a less clinically relevant subtype. This project aims to produce a model or Tat subtype C both solo and docked with TAR-RNA, as well as characterising the properties, interactions, and behaviour of Tat and TAR RNA to inform future drug development.
Methods: Three molecular dynamic runs of Tat solo and two docked with RNA (one constrained, one unconstrained) were simulated using NAMD and run at Canterbury Christ Church University using accelerated GPU calculations and a 2-femtosecond integration timestep for a minimum of 500ns. VMD, PyMOL, and qtGrace software were used to run, visualise, and analyse the data produced using RMSD, hydrogen-bonding, RMSF, electrostatic mapping and PCA K-means clustering analysis.
Results: RMSD of solo Tat runs was found to be consistently higher than that of Tat when docked with RNA, both constrained and unconstrained. Hydrogen bond analysis supported this, with detailed analysis showing Arg55 – Asp67 H-bonding at 72.72% occupancy in Tat docked with constrained RNA compared to the highest occupancy of Tyr32 – Tyr26 at 24.90% for Tat solo. K-means clustering from PCA analysis again supported this, showing a large spread of data for solo Tat versus a more consistent and concentrated plot of data for Tat docked with RNA. Structural analysis allowed for visualisation, and combined with RMSF overlay showed the stretched and unstable conformation of solo Tat versus compact conformation when docked with RNA. Electrostatic mapping of these more compact structures revealed positively charged regions encompassing the core and binding functional domains, as well as a negatively charged tail which protrudes from the core structure and moves freely.
Conclusions: Solo Tat runs demonstrated the flexibility and relative unpredictability of the protein, suggesting that future drug development for Tat in unbound conformations may prove difficult. However, when docked with RNA, the more compact and stable structure may be better suited to drug design. The core and binding functional domains of Tat appear relatively strongly positively charged, and hydrogen bonding and RMSD data shows that these regions are far less subject to change. Novel models of full Tat subtype C, and Tat with TAR RNA have been produced from this project for distribution and further investigation into Tat. Repeat analysis with longer RNA strands to avoid constraining the RNA are recommended in future, as well as comparison between different HIV subtypes. Consideration of Tat interaction with other known transcription factors such as pTEFb may also prove useful, and deep docking to identify candidate drug molecules based on these findings is recommended
Comparison of subcutaneous GLP-1 receptor agonists, semaglutide and dulaglutide, on HbA1c and weight loss outcomes: A systematic review
Full text linkBackground: The aim of this systematic review was to ascertain whether semaglutide is more effective than dulaglutide on outcomes of glycosylated haemoglobin (HbA1c) and weight loss in adults. The objectives were to identify studies that compared the subcutaneously administered formulations of the two drugs, compare changes in outcomes stated, analyse the data and evaluate each drugs’ effectiveness and determine which drug is more effective at achieving the outcomes.
Methods: Studies were eligible for inclusion if they were published up to December 2023, written in the English language and involved adult participants only. Studies were excluded if they were of a qualitative methodology, contained paediatric samples, those that involved other subtypes of diabetes mellitus, including gestational diabetes and studies that investigated only semaglutide or dulaglutide. Two electronic databases, Medline and Embase, were searched up to 31 December 2023 for published studies with at least 3-month follow-up that compared semaglutide and dulaglutide on the outcomes of changes in HbA1c and weight. Included studies were assessed for risk of bias using the Cochrane Collaboration risk-of- bias tool v2.0 and the Risk of Bias in Non-randomised studies of Interventions tool, as appropriate. Data on the outcomes were then considered for appropriateness for statistical analyses. All included studies were deemed unsuitable for statistical analyses due to inconsistencies of implied data distributions and use of statistical methods and were therefore synthesised using descriptive statistics and a narrative analysis.
Results: A total of 3 studies (1343 participants) met the inclusion criteria, where study 1 was a non- randomised cohort study, and study 2 and 3 were randomised controlled open-label studies. Statistical analysis was unable to be conducted without reducing the validity of the analysis, due poor use of statistics overall within all the studies. As a result, a narrative analysis was conducted. Both semaglutide and dulaglutide were shown to reduce HbA1c and weight from baseline, with semaglutide showing overall greater reductions in both HbA1c and weight reduction. Overall, participants on semaglutide were more likely to experience adverse events and discontinue treatment due to this. However, dulaglutide was found to have higher rates of serious adverse events and death related to treatment than semaglutide.
Conclusions: Evaluation of the three studies showed that both GLP1-RAs are effective at reducing HbA1c and weight, with semaglutide achieving greater reductions in both outcomes overall. However, more robust and long-term studies needed on real-life populations to better determine the real-world, long-term efficacy and safety of these drugs.
In addition, it was concluded that more needs to be done to increase research proficiency in healthcare, especially in the field of statistics. Better training should be sought on the conduction of statistical analyses and reporting of research, such as the reporting of normalised data, so readers and future systematic reviews may make robust comparisons between studies
What are the barriers to accessing cancer care for LGBTQIA+ patients?
Full text linkBackground: LGBTQIA+ individuals are at increased risk of certain cancers yet there is evidence to suggest that they have worse cancer outcomes and reduced access to cancer care. This scoping review was conducted to evaluate what is currently known on this topic and to identify any knowledge gaps.
Methods: A scoping review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR). Four databases were searched to identify peer reviewed primary studies from January 2013 to October 2023. Out of 892 results, 37 papers were selected using inclusion/exclusion criteria and analysed using thematic analysis.
Results: Four major themes were identified – healthcare professional barriers, system barriers, personal barriers and intersectionality. Healthcare professional barriers include poor relationship between service user and HCP, discrimination from HCP, lack of knowledge from HCP, less frequent encounters with HCPs, limited research into LGBTQTIA+ specific needs, lack of cultural competency training and personal beliefs. System barriers found were financial barriers, administrative issues, external perceptions and lack of LGBTQIA+ resources. Personal barriers were lack of service user knowledge; family factors; acceptability of intervention; efficacy of intervention; internal barriers such as gender dysphoria, self-identity, personal experiences; perceived risk and sexual orientation disclosure. The fourth theme was intersectionality. Despite excluding papers which discussed SOGI and another minority in the selection process, intersectionality still came up in multiple papers, highlighting the complexity of studying human live experiences.
Conclusions: Overall, there are numerous barriers which are preventing LGBTQIA+ people from accessing cancer care. Despite this, more research is needed to understand these barriers, particularly for smaller minority groups within the LGBTQIA+ community and for cancer care post diagnosis
Systematic Review on Genetic Variation and Response to Opioid in Patients with Chronic Pain
Full text linkBackground: Opioids are prescribed in both primary and secondary care in patients with various forms of chronic pain. The efficacy of opioids has previously been seen to have some genetic influence. This systematic review aims to comprehensively review the literature on the impact of genetic variation on opioidefficacy in clinical practice in patients with chronic pain.
Methods: This systematic review followed the PRISMA method. Literature searches were conducted on Google Scholar, Ovid Embase, Cochrane Library (Wiley online version), and Pubmed, using keywords such as ‘Genetic variation’, ‘Response’, ‘Opioids, and ‘Chronic pin’ to identify studies published between 2013 and 2023.
Results: 13 studies are included in the systematic review, no papers were excluded via quality assessment. The analysis of these has shown that genetic variation affecting the μ-opioid receptor (OPRM1) can affect opioid response, with the A118G (OPRM1 rs1799971) haplotype having an impact on analgesia; somegenotypes (particularly those homozygous for OPRM1 mutations) require more analgesia, while others require less. Additionally, OPRM1 interacts with the ABCB1 opioid transporter genes, influencing beta-endorphin and opioid sensitivity. Genetic variations in the COMT enzyme can impact opioid efficacy, causing specific genotypes to require less opioids than others. The results were inconclusive due to their contradictory nature.
Conclusions: As there are differing results, within research, there is no significant correlation between geneticvariables and outcomes related to pain or opioid intake
“Physical touch” contact points used in procedural touch, from educational checklists, by undergraduate medical students.
Full text linkIntroduction: Despite being a fundamental form of human interaction, touch has received little focus in the literature, particularly as a tool in primary care consultations. The GMC outlines, in Outcomes for Graduates, that clinicians need to practice person-centred care, integrating safety and sensitivity into every consultation with a patient. As described by Cocksedge, George and Chew-graham, 2013, touch may be “procedural touch” (part of a clinical task) or “expressive touch” (physical contact unrelated to a procedure).
Methods: A qualitative study was conducted to identify which anatomical locations are most touched in clinical examinations and procedures by clinicians. Physical Examinations and Procedures were identified via the GMC Medical Licensing Assessment (MLA) content map. Data was collected from Objective Structure Clinical Examination (OSCE) checklists from reputable digital sources and analysed quantitatively.
Results: 37 checklists were analysed, with the Upper Limb, and Head and Neck, bodily regions being the most frequently touched across procedures and examinations. There were discrepancies between procedures and examinations, in terms of the proportion of required palpation such as otoscopy and examination of the ear. The blood transfusion procedural checklist lacked significant physical touch, which possibly contrasts the patient’s feelings around the daunting experience.
Conclusion: This research illustrates the frequent interaction with the upper limb for physical interaction between patients and clinicians during examinations or procedures, and the importance of educating students to demonstrate compassion and provide reassurance in a socially acceptable manner, while simultaneously assessing patients for signs of illness in the consultation. The hand emerged as a primary site of physician- patient interaction, so may warrant targeted research into how medical students are educated on the use of touch in their clinical practice. The project findings emphasize the necessity for further inquiry into the perspectives of medical students on the inclusion of expressive and procedural touch in their skills education
Communication, Consent, and Clinical Hierarchies: Reflections from a Medical Elective in the Philippines.
Full text linkThis article reflects on an elective placement in the Philippines, undertaken by a fourth-year medical student. It discusses disparities in healthcare systems, approaches to informed consent, communication practices, and the impact of clinical hierarchy on learning. The article aims to give insight into the ethical and cultural challenges in global practice and show the benefits of international electives for medical students, particularly the opportunities for improving clinical knowledge, ethical awareness, and adaptability
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