Attracting healthcare professionals to remote and rural medicine: learning from doctors in training in the north of Scotland

BACKGROUND

Research exploring the experiences of trainee doctors in remote and rural locations is scarce. Our aim was to gain an understanding of the experiences and perceptions of Foundation Programme (FP) doctors training in placements in remote and rural areas of the north of Scotland.

METHODS

FP doctors training in remote and rural areas in Scotland took part in a qualitative study (focus groups and individual interviews) exploring their training experiences and career plans. To make sense of a potential multitude of factors, we selected social cognitive careers theory (SCCT) to underpin data collection and analysis.

RESULTS

A total of 20 trainees participated. Using data-driven analysis, three themes relevant to the SCCT emerged. These are the educational experience (e.g., opportunities to develop skills, greater responsibility), geographical isolation factors (e.g., the impact of staff shortages, poor accommodation, travel) and personal factors (e.g., social isolation, attitudes towards the experience).

CONCLUSION

Many factors impact on trainees' experience of learning and living in remote and rural medicine (R&R) environments. These experiences can be very positive for some individuals but factors external to the educational environment influence the perception of the overall experience. SCCT helps clarify the interaction between individual and contextual factors in career decision making.

Family-based behavioural management of childhood obesity: service evaluation of a group programme run in a community setting in the United Kingdom

A service evaluation of a pilot of a family-based behavioural management group programme for childhood obesity was conducted in a community setting in the United Kingdom. A total of 17 families with children aged 7.5-14 years completed the programme, which was delivered in 15 sessions over 6 months. Behavioural and psychological measures and age- and sex-adjusted z-body mass index (BMI) were assessed before and after programme. z-BMI was maintained. There was a significant increase in the amount of high-fibre foods and a decrease in the amount of low-fibre foods consumed and in sedentary behaviours. There were significant decreases in depression, abnormal dieting behaviour and bulimia and food preoccupation, and an increase in self-worth related to physical appearance. These positive behavioural and psychological changes suggest that this is a promising programme.

Evaluation of the XRCC1 gene as a phenotypic modifier in BRCA1/2 mutation carriers. Results from the consortium of investigators of modifiers of BRCA1/BRCA2

BACKGROUND

Single-nucleotide polymorphisms (SNPs) in genes involved in DNA repair are good candidates to be tested as phenotypic modifiers for carriers of mutations in the high-risk susceptibility genes BRCA1 and BRCA2. The base excision repair (BER) pathway could be particularly interesting given the relation of synthetic lethality that exists between one of the components of the pathway, PARP1, and both BRCA1 and BRCA2. In this study, we have evaluated the XRCC1 gene that participates in the BER pathway, as phenotypic modifier of BRCA1 and BRCA2.

METHODS

Three common SNPs in the gene, c.-77C>T (rs3213245) p.Arg280His (rs25489) and p.Gln399Arg (rs25487) were analysed in a series of 701 BRCA1 and 576 BRCA2 mutation carriers.

RESULTS

An association was observed between p.Arg280His-rs25489 and breast cancer risk for BRCA2 mutation carriers, with rare homozygotes at increased risk relative to common homozygotes (hazard ratio: 22.3, 95% confidence interval: 14.3-34, P<0.001). This association was further tested in a second series of 4480 BRCA1 and 3016 BRCA2 mutation carriers from the Consortium of Investigators of Modifiers of BRCA1 and BRCA2.

CONCLUSIONS AND INTERPRETATION

No evidence of association was found when the larger series was analysed which lead us to conclude that none of the three SNPs are significant modifiers of breast cancer risk for mutation carriers.

Targeted prostate cancer screening in men with mutations in BRCA1 and BRCA2 detects aggressive prostate cancer: preliminary analysis of the results of the IMPACT study

OBJECTIVE

To evaluate the role of targeted prostate cancer screening in men with BRCA1 or BRCA2 mutations, an international study, IMPACT (Identification of Men with a genetic predisposition to ProstAte Cancer: Targeted screening in BRCA1/2 mutation carriers and controls), was established. This is the first multicentre screening study targeted at men with a known genetic predisposition to prostate cancer. A preliminary analysis of the data is reported.

PATIENTS AND METHODS

Men aged 40-69 years from families with BRCA1 or BRCA2 mutations were offered annual prostate specific antigen (PSA) testing, and those with PSA > 3 ng/mL, were offered a prostate biopsy. Controls were men age-matched (± 5 years) who were negative for the familial mutation.

RESULTS

In total, 300 men were recruited (205 mutation carriers; 89 BRCA1, 116 BRCA2 and 95 controls) over 33 months. At the baseline screen (year 1), 7.0% (21/300) underwent a prostate biopsy. Prostate cancer was diagnosed in ten individuals, a prevalence of 3.3%. The positive predictive value of PSA screening in this cohort was 47·6% (10/21). One prostate cancer was diagnosed at year 2. Of the 11 prostate cancers diagnosed, nine were in mutation carriers, two in controls, and eight were clinically significant.

CONCLUSIONS

The present study shows that the positive predictive value of PSA screening in BRCA mutation carriers is high and that screening detects clinically significant prostate cancer. These results support the rationale for continued screening in such men.

The carrier clinic: an evaluation of a novel clinic dedicated to the follow-up of BRCA1 and BRCA2 carriers--implications for oncogenetics practice

BACKGROUND

A novel oncogenetic clinic was established in 2002 at the Royal Marsden NHS Foundation Trust offering advice and specialist follow-up for families with a germline mutation in BRCA1 or BRCA2. The remit of this multidisciplinary clinic, staffed by individuals in both oncology and genetics, is to provide individualised screening recommendations, support in decision making, risk reducing strategies, cascade testing, and an extensive research portfolio.

METHODS

A retrospective analysis was performed to evaluate uptake of genetic testing, risk reducing surgery and cancer prevalence in 346 BRCA1/BRCA2 families seen between January 1996 and December 2006.

RESULTS

661 individuals attended the clinic and 406 mutation carriers were identified; 85.8% mutation carriers have chosen to attend for annual follow-up. 70% of mutation carriers elected for risk reducing bilateral salpingo-oophorectomy (RRBSO). 32% of unaffected women chose risk reducing bilateral mastectomy. 32% of women with breast cancer chose contralateral risk reducing mastectomy at time of diagnosis. Some women took over 8 years to decide to have surgery. 91% of individuals approached agreed to participate in research programmes.

INTERPRETATION

A novel specialist clinic for BRCA1/2 mutation carriers has been successfully established. The number of mutation positive families is increasing. This, and the high demand for RRBSO in women over 40, is inevitably going to place an increasing demand on existing health resources. Our clinic model has subsequently been adopted in other centres and this will greatly facilitate translational studies and provide a healthcare structure for management and follow-up of such people who are at a high cancer risk.

The Brightness-Weight Illusion

Bigger objects look heavier than smaller but otherwise identical objects. When hefted as well as seen, however, bigger objects feel lighter (the size-weight illusion), confirming that the association between visual size and weight has a perceptual component. Darker objects also look heavier than brighter but otherwise identical objects. It is uncertain, however, if this association also has a perceptual element, or if it simply reflects the fact that, in English at least, the same verbal label (light) is applied to both surface brightness and weight. To address this, we looked for a brightness equivalent of the size-weight illusion. Paired-comparison judgments of weight were obtained for balls differing only in color. Based on vision alone, darker objects were judged to be heavier. When the balls were hefted as well as seen, this association was reversed (i.e., a brightness-weight illusion), consistent with it having a perceptual component. To gauge the strength of the illusion (in grams), a white and a black ball (both 129 g) were each compared against a set of mid-gray balls varying in weight. When the balls were hefted as well as seen, the white ball felt approximately 8 g heavier than the black ball, a difference corresponding to 6.2% of their actual weight. Possible environmental origins of the association between surface lightness and weight are considered.

Superior Mesenteric Artery (Wilkie) Syndrome complicated by Pneumomediastinum

Superior mesenteric artery syndrome is characterised by vascular compression of the third part of the duodenum, resulting in obstructive symptoms. This case has been selected for its unusual presentation with pneumomediastinum and for the strikingly abnormal cross-sectional findings. We present the case of a young male of asthenic build, who was admitted to hospital with a history mimicking Boerhaave's syndrome (spontaneous oesophageal perforation). Radiological features included pneumomediastinum, but also an astonishing degree of gastric and duodenal dilatation. Extraluminal retroperitoneal air was also noted, further complicating the patient's presentation. We explore the relevant imaging and surgical findings, and relate these to an initially puzzling diagnostic dilemma.

Randomized controlled trial of intubation with the McGrath Series 5 videolaryngoscope by inexperienced anaesthetists

BACKGROUND

The McGrath Series 5 videolaryngoscope might reduce the incidence of unexpected difficult tracheal intubation. If it also performs as well as a standard laryngoscope during uncomplicated intubations, there would be an argument for the McGrath to become the laryngoscope of choice in higher risk settings, such as rapid sequence induction by inexperienced anaesthetists. Therefore, we compared the McGrath and the Macintosh laryngoscopes during routine tracheal intubation performed by inexperienced anaesthetists.

METHODS

Single-blind randomized controlled trial with 120 adult patients allocated to intubation by first-year anaesthetic trainees, using a McGrath or Macintosh laryngoscope. The primary outcome was time to intubation. Secondary outcomes were quality of view at laryngoscopy and evidence of differential learning between using the two laryngoscopes. A Cox proportional hazards model was used to determine the effect of the laryngoscopes on time to intubation.

RESULTS

Duration of intubation was significantly longer (P<0.001) in the McGrath group [median (IQR); 47.0 (39.0-60.0) vs 29.5 (23.0-36.8) s]. There were no significant differences in other outcomes, including grade of laryngoscopy view, visual confirmation of tube placement, number of laryngoscopies, or complications (oesophageal intubation, hypoxaemia, and airway trauma). There was no differential learning effect.

CONCLUSIONS

There were no advantages to using the McGrath laryngoscope for uncomplicated tracheal intubation and duration of intubation was longer, so it should not be used as a first-line laryngoscope instrument by inexperienced anaesthetists.

Effect of pre-aeration and inoculum on the start-up of batch thermophilic anaerobic digestion of municipal solid waste

In this study, a short pre-aeration step was investigated as pre-treatment for thermophilic anaerobic digestion of the organic fraction of municipal solid waste (OFMSW). It was found that pre-aeration of 48 h generated enough biological heat to increase the temperature of bulk OFMSW to 60 degrees C. This was sufficient self-heating of the bulk OFMSW for the start-up of thermophilic anaerobic digestion without the need for an external heat source. Pre-aeration also reduced excess easily degradable organic compounds in OFMSW, which were the common cause of acidification during the start-up of the batch system. Careful consideration however must be taken to avoid over aeration as this consumes substrate, which would otherwise be available to methanogens to produce biogas. To accelerate methane production and volatile solids destruction, the anaerobic digestion in this study was operated as a wet process with the anaerobic liquid recycled through the OFMSW. Appropriate anaerobic liquid inoculum was found to be particularly beneficial. It provided high buffer capacity as well as suitable microbial inoculum. As a result, acidification during start-up was kept to a minimum. With volatile fatty acids (VFAs-acetate in particular) and H2 accumulation typical of hydrolysis and fermentation of the easily degradable substrates during start-up, inoculum with high numbers of hydrogenotrophic methanogens was critical to not only maximise CH4 production but also reduce H2 partial pressure in the system to allow VFAs degradation. In a lab-scale bioreactor, the combined pre-aeration and wet thermophilic anaerobic digestion was able to stabilise the OFMSW within a period of only 12 days. The stabilised inert residual material can be used as a soil amendment product.