Shaping Perceptions and Inspiring Future Neurosurgeons: The Value of a Hands-On Simulated Aneurysm Clipping Workshops at a Student-Organized Neurosurgical Conference.

Objective Early exposure to niche specialities, like neurosurgery, is essential to inform decisions about future training in these specialities. This study assesses the impact of a hands-on simulated aneurysm clipping workshop on medical students' and junior doctors' perceptions of neurosurgery at a student-organized neurosurgical conference. Methods Ninety-six delegates were sampled from a hands-on workshop involving hydrogel three-dimensional printed aneurysms clipping using surgical microscopes. Consultant neurosurgeons facilitated the workshop. Changes in delegates' perceptions of neurosurgery were collected using Likert scale and free-text responses postconference. Results Postworkshop, 82% of participants reported a positive impact on their perception of neurosurgery. Thematic analysis revealed that delegates valued the hands-on experience, exposure to microsurgery, and interactions with consultant neurosurgeons. Thirty-six of the 96 delegates (37.5%) expressed that the workshop dispelled preconceived fears surrounding neurosurgery and improved understanding of a neurosurgeon's day-to-day tasks. Several delegates initially apprehensive about neurosurgery were now considering it as a career. Conclusion Hands-on simulated workshops can effectively influence medical students' and junior doctors' perceptions of neurosurgery, providing valuable exposure to the specialty. By providing a valuable and immersive introduction to the specialty, these workshops can help to dispel misconceptions, fears, and apprehensions associated with neurosurgery, allowing them to consider the specialty to a greater degree than before. This study of a one-time workshop cannot effectively establish its long-term impact on said perceptions, however.

The influence of birthweight and breastfeeding status on BMI outcome at first year of primary school: a retrospective study of an Irish child cohort.

Recent data shows one in four children in Ireland are classified as having overweight or obesity, putting them at increased risk of health complications in both childhood and adulthood. The primary aim of this study was to retrospectively investigate the association between body mass index (BMI) outcome at first year of primary school and sex, birthweight and breastfeeding status in a cohort of Irish children. A secondary aim was to assess whether parents were concerned about their child's growth. This study examined data from the National Child Health Screening Programme on 3739 children in their first year of primary school education in the Irish counties of Sligo, Leitrim and Donegal. This data was collected between March 2013 and December 2016. 10.8% and 7.1% of the children included in this study were classified as having overweight and obese BMI outcomes, respectively. A greater proportion of males had underweight, overweight or obese BMI outcomes compared to females, and this was statistically significant (p ≤ 0.001). Overweight and obese BMI outcomes were significantly more common among those born with a high birthweight, compared to those with a low or healthy birthweight (p ≤ 0.001). There was a greater proportion of obese BMI outcome in those who were never breastfed compared to those who were ever breastfed, and this difference was statistically significant (p = 0.041). Among those who were ever breastfed, there was a statically significant (p = 0.009) difference between BMI outcome at first year of primary schooling and the duration of time they were breastfed for. When asked whether they were concerned about their child's growth, the majority of parents who responded expressed no concern (96.1%). CONCLUSION: This study found an association between BMI outcome at first year of primary school education and sex, birthweight and breastfeeding status in a cohort of children in the North-West of Ireland. The majority of parents did not express concern related to their child's growth at first year of primary education. WHAT IS KNOWN: • One in every four children in Ireland are classified as having overweight or obesity. • Birthweight and breastfeeding status are factors known to be associated with weight status in childhood. WHAT IS NEW: • This study investigated whether there was an association between sex, birthweight and breastfeeding status and the BMI outcome of a cohort of Irish children in their first year of primary school education (median age: 5.2 years). • This study also included an exploration of parents concern related to their child's growth at first year of primary school education.

An exploration into the influence of birthweight and breastfeeding status on the weight status of 3-year-olds in an Irish cohort.

BACKGROUND: Childhood obesity is a growing concern in Ireland. Childhood obesity can increase the risk of developing many non-communicable diseases and have lasting psychological and social consequences. AIM: The aim of this study is to explore if weight at birth and breastfeeding status influence the weight status of 3-year-olds in an Irish cohort. METHOD: This retrospective cohort study utilised data (National Child Health Screening Programme) on 3-year-olds born between 1 January 2011 and 3 March 2014 in the North West of Ireland. RESULTS: Overall, 4144 children were included in the study. The main findings of this study were that 5.4% (n = 222) and 7.1% (n = 296) of the cohort were overweight or obese respectively with a higher percent of males than females in each category. Just under 55% (n = 2266) of the cohort were never breastfed, with only 7.4% breastfed for greater than 6 months. Those born with a high birthweight were more likely to be overweight or obese at 3 years (p ≤ 0.001). CONCLUSION: These findings provide regionally specific data and highlight the need for focussed public health efforts to reduce the prevalence of overweight and obesity in children aged 3 years in this area. Interventions from pregnancy through childhood are warranted, with an initial emphasis on breast feeding initiation and maintenance.

Conservative versus Interventional Treatment for Spontaneous Pneumothorax.

BACKGROUND: Whether conservative management is an acceptable alternative to interventional management for uncomplicated, moderate-to-large primary spontaneous pneumothorax is unknown. METHODS: In this open-label, multicenter, noninferiority trial, we recruited patients 14 to 50 years of age with a first-known, unilateral, moderate-to-large primary spontaneous pneumothorax. Patients were randomly assigned to immediate interventional management of the pneumothorax (intervention group) or a conservative observational approach (conservative-management group) and were followed for 12 months. The primary outcome was lung reexpansion within 8 weeks. RESULTS: A total of 316 patients underwent randomization (154 patients to the intervention group and 162 to the conservative-management group). In the conservative-management group, 25 patients (15.4%) underwent interventions to manage the pneumothorax, for reasons prespecified in the protocol, and 137 (84.6%) did not undergo interventions. In a complete-case analysis in which data were not available for 23 patients in the intervention group and 37 in the conservative-management group, reexpansion within 8 weeks occurred in 129 of 131 patients (98.5%) with interventional management and in 118 of 125 (94.4%) with conservative management (risk difference, -4.1 percentage points; 95% confidence interval [CI], -8.6 to 0.5; P = 0.02 for noninferiority); the lower boundary of the 95% confidence interval was within the prespecified noninferiority margin of -9 percentage points. In a sensitivity analysis in which all missing data after 56 days were imputed as treatment failure (with reexpansion in 129 of 138 patients [93.5%] in the intervention group and in 118 of 143 [82.5%] in the conservative-management group), the risk difference of -11.0 percentage points (95% CI, -18.4 to -3.5) was outside the prespecified noninferiority margin. Conservative management resulted in a lower risk of serious adverse events or pneumothorax recurrence than interventional management. CONCLUSIONS: Although the primary outcome was not statistically robust to conservative assumptions about missing data, the trial provides modest evidence that conservative management of primary spontaneous pneumothorax was noninferior to interventional management, with a lower risk of serious adverse events. (Funded by the Emergency Medicine Foundation and others; PSP Australian New Zealand Clinical Trials Registry number, ACTRN12611000184976.).

Climate Change Impact: The Experience of the Coastal Areas of Bangladesh Affected by Cyclones Sidr and Aila.

Bangladesh is considered one of the countries most at risk to the effects of climate change and its coastal area is most vulnerable. This study tries to explore the experiences of cyclones Sidr and Aila affected people living in the coastal areas of Bangladesh. This study was conducted in the cyclone Sidr affected Amtali Upazila of Barguna District and in the cyclone Aila affected Koyra Upazila of Khulna District. Primary data collection was done using Focus Group Interview and then a thematic analysis approach was used for analysis. Three core themes emerged from the analysis and they are, firstly, impacts of climate change on the socioeconomic condition of the people, secondly, the impact on the health status of the population, and finally the impact on vulnerable people. Findings show that the effects of climate change have serious consequences on the livelihood patterns of the affected population and on their overall health status. As a result, the unfavorable health condition of these affected people makes them more vulnerable to various emerging diseases.

Study protocol for a randomised controlled trial of invasive versus conservative management of primary spontaneous pneumothorax.

INTRODUCTION: Current management of primary spontaneous pneumothorax (PSP) is variable, with little evidence from randomised controlled trials to guide treatment. Guidelines emphasise intervention in many patients, which involves chest drain insertion, hospital admission and occasionally surgery. However, there is evidence that conservative management may be effective and safe, and it may also reduce the risk of recurrence. Significant questions remain regarding the optimal initial approach to the management of PSP. METHODS AND ANALYSIS: This multicentre, prospective, randomised, open label, parallel group, non-inferiority study will randomise 342 participants with a first large PSP to conservative or interventional management. To maintain allocation concealment, randomisation will be performed in real time by computer and stratified by study site. Conservative management will involve a period of observation prior to discharge, with intervention for worsening symptoms or physiological instability. Interventional treatment will involve insertion of a small bore drain. If drainage continues after 1 hour, the patient will be admitted. If drainage stops, the drain will be clamped for 4 hours. The patient will be discharged if the lung remains inflated. Otherwise, the patient will be admitted. The primary end point is the proportion of participants with complete lung re-expansion by 8 weeks. Secondary end points are as follows: days in hospital, persistent air leak, predefined complications and adverse events, time to resolution of symptoms, and pneumothorax recurrence during a follow-up period of at least 1 year. The study has 95% power to detect an absolute non-inferiority margin of 9%, assuming 99% successful expansion at 8 weeks in the invasive treatment arm. The primary analysis will be by intention to treat. ETHICS AND DISSEMINATION: Local ethics approval has been obtained for all sites. Study findings will be disseminated by publication in a high-impact international journal and presentation at major international Emergency Medicine and Respiratory meetings. TRIAL REGISTRATION NUMBER: ACTRN12611000184976; Pre-results.

New Wisdom to Defy an Old Enemy: Summary from a scientific symposium at the 4th Influenza Vaccines for the World (IVW) 2012 Congress, 11 October, Valencia, Spain.

Both seasonal and pandemic influenza cause considerable morbidity and mortality globally. In addition, the ongoing threat of new, unpredictable influenza pandemics from emerging variant strains cannot be underestimated. Recently bioCSL (previously known as CSL Biotherapies) sponsored a symposium 'New Wisdom to Defy an Old Enemy' at the 4th Influenza Vaccines for the World Congress in Valencia, Spain. This symposium brought together a renowned faculty of experts to discuss lessons from past experience, novel influenza vaccine developments, and new methods to increase vaccine acceptance and coverage. Specific topics reviewed and discussed included new vaccine development efforts focused on improving efficacy via alternative administration routes, dose modifications, improved adjuvants, and the use of master donor viruses. Improved safety was also discussed, particularly the new finding of an excess of febrile reactions isolated to children who received the 2010 Southern Hemisphere (SH) trivalent inactivated influenza vaccine (TIV). Significant work has been done to both identify the cause and minimize the risk of febrile reactions in children. Other novel prophylactic and therapeutic advances were discussed including immunotherapy. Standard IVIg and hIVIg have been used in ferret studies and human case reports with promising results. New adjuvants, such as ISCOMATRIX™ adjuvant, were noted to provide single-dose, prolonged protection with seasonal vaccine after lethal H5N1 virus challenge in a ferret model of human influenza disease. The data suggest that adjuvanted seasonal influenza vaccines may provide broader protection than unadjuvanted vaccines. The use of an antigen-formulated vaccine to induce broad protection between pandemics that could bridge the gap between pandemic declaration and the production of a homologous vaccine was also discussed. Finally, despite the availability of effective vaccines, most current efforts to increase influenza vaccine coverage rates to higher levels (i.e., above 70-80%) have been ineffective in highly developed countries where the vaccine is used, hindered by the public's skepticism towards vaccines in general. New educational and social media methods to increase vaccine acceptance and coverage were discussed. While the first priority should be the development of improved influenza vaccines, a particular focus on the aging global population is critical. It is also important to draw lessons from other academic disciplines that can help to inform vaccine education programs, policy, and communication. By tailoring communications and patient education using an understanding of cognitive bias and the model of preferred cognitive styles, the likelihood of effecting desirable health decisions can be maximized, leading to improved vaccine coverage and control of influenza and other vaccine-preventable diseases.

Resolution of sleep-disordered breathing in a dialysis-dependent child post-renal transplantation.

This case alerts paediatricians and renal physicians to the potential for significant sleep-disordered breathing in children with renal disease, particularly those with end stage kidney disease requiring dialysis. In some cases, management of the underlying renal disease may result in amelioration of the sleep-disordered breathing. Proactive sleep history taking and formal sleep monitoring in experienced centres may be indicated for these children to limit morbidity, especially if respiratory support is indicated.

Epidemiology and outcome of acute kidney injury in New Zealand children.

OBJECTIVES: To determine the aetiology, incidence and short-term outcomes of New Zealand children with acute kidney injury (AKI) requiring renal replacement therapy (RRT) over a 6-year period. METHODS: A retrospective chart review of all children requiring RRT for AKI from January 2001 to December 2006 at Starship Children's Hospital, Auckland, New Zealand was conducted. The primary outcome was survival to discharge. RESULTS: A total of 226 children required RRT for AKI over the 6-year study period. The annual incidence was 4.0 per 100,000 total population under 15 years of age. The commonest causes of AKI were post cardiac surgery (58%), haemolytic uraemic syndrome (17%), sepsis (13%) and glomerulonephritis (4%). The survival rate to hospital discharge was 89%. A total of 40% of all surviving children had one or more abnormalities at the time of discharge suggestive of ongoing renal dysfunction (hypertension, continuing need for antihypertensive medication, reduced estimated glomerular filtration rate or abnormal urinalysis). More Maori and Pacific Island children were treated for AKI than would be expected from population data (P < 0.0001). Sepsis and glomerulonephritis were seen more commonly as causes of AKI in Maori and Pacific Island children compared with New Zealand European children. CONCLUSION: In our study, 40% of surviving children had evidence of short-term renal dysfunction at discharge following AKI. This suggests that all children should undergo a period of follow-up after any episode of AKI to look for resolution or further development of signs of renal injury.

Cancer progression: is inhibin alpha from Venus or Mars?

The inhibin field has been perplexed by the information that inhibin alpha is a tumour suppressor in mice yet is elevated in women with ovarian cancer. Furthermore, we have consistently observed a down-regulation or loss of inhibin alpha in prostate cancer patient samples and cell lines. However, our latest data have prompted us to re-evaluate the role of inhibin alpha in prostate and other cancers. Using the analogy of TGF-beta as a springboard for our hypothesis, we offer a unifying model whereby the previously conflicting observations in mice, men and women can be explained. We propose that initially inhibin alpha is tumour-suppressive and is expressed in benign and early-stage primary cancers. Tumour-suppressive inhibin alpha is then silenced as the tumour progresses but is reactivated as a pro-metastatic factor in advanced, aggressive cancers.

Novel androgen receptor gene mutations in Australian patients with complete androgen insensitivity syndrome.

We have identified androgen receptor (AR) gene mutations in eight Australian subjects with complete androgen insensitivity syndrome (AIS). Four individuals, from three families, have novel mutations that introduce premature termination codons. Two siblings have the nonsense mutation Glu681X, and another subject has the nonsense mutation p.Ser884X. The other subject has a CA insertion at codon 829 (c.2847_2848insCA), causing a frameshift mutation that introduces four nonsense amino acids prior to a Stop codon. All the termination codons occur in the ligand binding domain, and cause reduced androgen binding in patient genital skin fibroblasts. Four further patients have missense mutations. One subject has two different mutations, p.Ala645Asp in the hinge region of the receptor, and p.Arg752Gln in the ligand binding domain. Both these mutations have previously been reported in patients with AIS, but the combination of these two mutations in one subject is unique. Another subject has a novel c.2533G>C transversion at the first nucleotide in exon 5, introducing the amino acid change p.Gly724Ala at a highly conserved residue in the ligand binding domain. Androgen binding is normal in fibroblasts from this subject, although other point mutations at this amino acid totally abolish binding. Two other subjects have mutations previously described as causing AIS, namely p.Arg779Trp and p.Val889Met substitutions in the ligand binding domain of the receptor. The p.Arg779Trp mutation is associated with the detection of a truncated AR protein in this patient's fibroblasts, suggesting the mutation renders the receptor susceptible to proteolysis.

Activin betaC-subunit heterodimers provide a new mechanism of regulating activin levels in the prostate.

Activins are formed by dimerization of beta-subunits and, as members of the TGF-beta superfamily, have diverse roles as potent growth and differentiation factors. As the biological function of the activin C homodimer (betaC-betaC) is unknown, we sought to compare activin A (betaA-betaA), B (betaB-betaB), and C homodimer bioactivities and to investigate the consequences of activin betaC-subunit overexpression in prostate tumor cells. Exogenous activin A and B homodimers inhibited cell growth and activated activin-responsive promoters. In contrast, the activin C homodimer was unable to elicit these responses. We previously showed that the activin betaC-subunit heterodimerized with activin betaA in vitro to form activin AC. Therefore, we hypothesize that the activin betaC-subunit regulates the levels of bioactive activin A by the formation of activin AC heterodimers. To test this hypothesis, we measured activin AC heterodimer production using a novel specific two-site ELISA that we developed for this purpose. In the PC3 human prostate tumor cell line, activin betaC-subunit overexpression increased activin AC heterodimer levels, concomitantly reduced activin A levels, and decreased activin signaling. Overall, these data are consistent with a role for the activin betaC-subunit as a regulatory mechanism to reduce activin A secretion via intracellular heterodimerization.

New perspectives on growth factor-sex steroid interaction in the prostate.

Many organs respond to both sex steroids and growth factors. Regulation of these pathways is integral to cell-cell communications during development and aberrant changes cause disease pathogenesis. Traditionally, paracrine and endocrine actions of growth factors and steroid hormones are considered independently. Recently, new data indicated that activin/TGFbeta and sex steroid signalling are linked; explicitly, that the pathways cross-talk intracellularly. Here we present new perspectives on these interactions, using examples predominantly from the prostate, as it is a well-characterised organ in this context. While this information provides insight to the potential mechanisms behind these interactions, it also presents a new challenge; the action of any of these factors cannot be considered exclusively without considering the impact on the other biological pathways.