Types of intrapartum hypoxia on the cardiotocograph (CTG): do they have any relationship with the type of brain injury in the MRI scan in term babies?

Electronic foetal monitoring using cardiotocography is aimed at the timely recognition and management of foetal hypoxia. The primary objective of this study was to examine whether a relationship exists between the types of foetal hypoxia (acute, subacute, evolving, chronic), as identified on cardiotocography and the nature of hypoxic ischaemic encephalopathy, as observed on MRI scans after birth. We conducted a retrospective study of 16 babies born (out of 52,187 births) at St George's Hospital in London during 2006-2017 with a postnatal diagnosis of HIE. Of the 16 babies, only 11 had both MRI scans and CTG traces available. Of those, 9 showed evidence of intrapartum hypoxia on CTG, but only 6 demonstrated evidence of HIE on MRI. Those with acute hypoxia showed abnormalities in the basal ganglia and thalami. A gradually evolving hypoxia or subacute hypoxia was associated with lesions in myelination and cerebral cortex.Impact StatementWhat is already known on this subject? It has been reported that inter-observer agreement for CTG interpretation is low (30%) when pattern recognition based guidelines are used (Rhöse et al. 2014; Reif et al. 2016), even amongst 'experts' (Hruban et al. 2015). Furthermore, it has been shown that CTG traces do not reliably predict neonatal encephalopathy (Spencer et al. 1997).What do the results of this study add? Our study indicates that if 'types of intrapartum hypoxia' are used for interpretation, then inter-observer agreement increases to 81%, from the reported 30% when traces are classified into 'normal, suspicious and pathological' using guidelines based on 'pattern recognition'. Furthermore, our study shows a good correlation between the type of intrapartum hypoxia observed on CTG trace and the nature of injury observed on the MRI.What are the implications of these findings for clinical practise and/or further research? Improving inter-observer agreement of CTGs with the use of pattern recognition in combination with the good correlation to MRI scan findings ultimately leads to better management and post-natal outcomes. This is evidenced by the fact that after the introduction of physiology-based CTG interpretation and mandatory competency testing on CTG interpretation for all staff in 2010, St. George's Maternity Unit has half the nationally reported rate of cerebral palsy.

Simulation training for lobectomy: a review of current literature and future directions†.

With growing work-time restrictions and public expectations, the Halstedian educational model of 'see one, do one, teach one' is unfit for the modern training of thoracic residents. With the cardiothoracic surgical workforce set to decline by 50% over the next 10 years, new models are desperately needed to help trainees bypass the early error-prone phase of the lobectomy learning curve. In this review, we detail the development and validation of numerous simulators designed to teach trainees an array of skills ranging from basic technical skills to more complex non-technical skills. Given the recent increases in minimally invasive lobectomies, we critique both open and thoracoscopic simulators. We elucidate that whilst there are a growing number of thoracic simulators of varying fidelity available, fundamentally, there is currently a significant lack of well-designed trials validating various simulators for teaching lobectomy despite an awareness of their potential to improve surgical education. Furthermore, there is a void in the simulation training of non-technical skills within thoracic surgery. Encouragingly, there is a definite awareness of the ability of simulation to aid with the training of future thoracic surgical trainees.

Are we losing future talent? A national survey of UK medical student interest and perceptions of cardiothoracic surgery.

OBJECTIVES: Cardiothoracic surgery appears to have become a significantly less popular career option among UK medical graduates. This study aimed to elucidate the current levels of interest in pursuing a career in cardiothoracic surgery among surgically orientated UK medical students and to determine the factors underlying this decision. METHODS: An online cross-sectional survey generated using the LimeSurvey was distributed to the surgical societies of all 32 UK medical schools. This assessed current career intentions, previous experience and perceptions of cardiothoracic surgery and the factors that attract or deter them to the speciality. RESULTS: A total of 352 responses were obtained. Although 31% of the total cohort was considering a career in cardiothoracic surgery, only 14% of the final year students were. Seventy-five percent felt that they had received inadequate exposure to cardiothoracic surgery during their undergraduate curriculum, with 74% having spent no time on a dedicated cardiothoracic placement. Extracurricular exposure to the specialty was poor with 13% having attended a cardiothoracic conference/careers day. Approximately 50% of students were aware of the publication of surgeon-specific mortality data and previous scandals affecting the speciality; however, 80% claimed that this did not deter them. The main factor attracting students was the ability to significantly influence or save lives, whereas the main deterring factor was perceived competition levels. CONCLUSIONS: Although there remains healthy interest among UK students to pursue a career in cardiothoracic surgery, there is a worrying decline in desire over the course of medical school which appears to stem from a lack of engagement with the specialty both within undergraduate curricula and through extracurricular events.

Depression, anxiety, and post-traumatic stress disorder among youth in low and middle income countries: A review of prevalence and treatment interventions.

BACKGROUND: Low and middle income countries (LMICs) not only have the majority of the world's population but also the largest proportion of youth. Poverty, civil conflict and environmental stressors tend to be endemic in these countries and contribute to significant psychiatric morbidity, including depression, anxiety and post-traumatic stress disorder (PTSD). However, mental health data from LMICs is scarce, particularly data on youth. Evaluation of such information is crucial for planning services and reducing the burden of disability. This paper reviews the published data on the prevalence and randomized trials of interventions for depression, anxiety and PTSD in youth in LMICs. METHODS: PubMed and Google Scholar were searched for articles published in English up to January 2017, using the keywords: Low/middle income country, depression, anxiety, post-traumatic stress disorder, child, youth, adolescent, prevalence, treatment, intervention, and outcomes. RESULTS: The few prevalence studies in LMICs reported rates of up to 28% for significant symptoms of depression or anxiety among youth, and up to 87% for symptoms of PTSD among youth exposed to traumatic experienences, though these rates varied widely depending on several factors, including the assessments tools used. Most rigorous interventions employed some form or variation of CBT, with mixed results. Studies using other forms of psychosocial interventions appear to be heterogeneous and less rigorous. CONCLUSIONS: The mental health burden due to depression and anxiety disorders in youth is substantial in LMICs, with high needs but inadequate services. Youth specific services for early detection and cost-effective interventions are needed.