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Book Reviews Articles

Perhaps the only ECG text you need….

Jayasinghe, S. Rohan. ECG Workbook, Australia: Elsevier; 2012.
RRP: $59.95

This is an Elsevier supported book review

Like tools are to a plumber, correct ECG interpretations are to a doctor. ECGs are the basis of diagnosis for many of the patients that walk through our hospital doors. Consider this: how many patients do you see that don’t have an ECG tucked into their notes?  And how often have you looked at an ECG and quietly thought to yourself, “what on earth is going on?” before sheepishly praying that the consultant doesn’t ask you to interpret it? Mastering an ECG is the foundation of being a doctor, an essential skill that you will not be able to shy away from. So in a quest to find a tool that would ease my ECG fears, I stumbled across this clever little book.

Jayasinghe takes both a logical and systematic approach in this text as he emphasizes the “importance of treating a patient and not an ECG”. Readers are provided with real life case studies and guided through a stepwise process to interpret an ECG. This provides an opportunity to not only practice this new skill set but also to formulate a clinical diagnosis and decide on appropriate and optimal management.

The workbook is divided into three convenient user-friendly sections.

Section 1 takes readers on a journey through the fundamentals of ECGs. Essential knowledge on cardiac conduction physiology is revisited, before explaining the derivation of the modern electrocardiogram by the Nobel prize-winning Dutch physician William Eithoven. Difficult concepts (for example, the accurate determination of the cardiac axis) are explained using both the two and three lead method. This is discussed before using a difficult yet more accurate methodical explanation of its relation to a hexa-axial reference system. The importance of correct limb placement is clarified before the author dives into providing the reader with six practical rules that should be applied when ‘eyeballing’ any ECG. This framework then provides an organized line of attack when attempting to read an ECG. Overall Section 1 studies the ‘normal’ ECG and highlights life-threatening ECG changes that require urgent therapeutic intervention.

Section 2 explores ECG based diagnosis through interpreting pathological ECGs, highlighting areas of study such as abnormalities in the P wave, PR segment, QRS complex, Q wave, R wave, S wave and ST segments. This section then focuses on STEMI associated ECG changes. The author should be commended for including pathologies with mixed ECG changes which are commonly seen in clinical settings such as pulmonary embolism, subarachnoid haemorrhage, takotsubo cardiomyopathy, hypokalaemia and hyperkalaemia before drawing the reader’s attention to drug induced ECG changes.

Everyone knows that practice makes perfect and that the key to mastering any new skill set is practice. The final section of this innovative book is clearly set out in workbook format containing a series of ECG tracings linked to a clinical scenario. A fill in worksheet guides the reader to interpret the ECG using the strategic framework taught in Section 1.

Many texts that attempt to help the reader master the art of ECG interpretation lack this crucial worksheet approach, which facilitates repetitive learning and ultimately allows the student to master the ability to interpret ECGs in the clinical context. Each case is followed by the answer, which has been carefully set out in the same systematic framework taught throughout the text. The author has clearly placed much effort into ensuring that the reader understands the importance of using a stepwise approach when faced with this somewhat daunting task. Additionally, the author endeavours to engage readers to teach them to stratify the significance of the ECG findings based on clinical relevance and urgency. This is a refreshing approach from a medical textbook.

Self assessment enables the reader to build confidence and precision, to gauge their competence and to hone weaknesses. Key concepts can be revisited and mastered as they work their way through this glorious all-in-one paperback.

This short but sweet text provides a comprehensive and systematic approach to learning ECG interpretation whilst ensuring relevancy to real life scenarios. The only criticism I have of this clever little lifesaver, which is small enough to effortlessly carry around hospital, is that it should be available in hard-back! All things considered, the author, an interventional cardiologist, should be applauded as he has succeeded in providing readers with the perfect balance of mastering the art of ECG interpretation whilst being able to apply it to diagnostic situations without getting lost in the detail.

Correspondence

A Lalji: liyah10@hotmail.com

 

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Feature Articles Articles

The role of Aboriginal Community Controlled Health Services in Indigenous health

“Our right to take back responsibility.” Noel Pearson, 2000 [1]

This emotive aphorism by Pearson embodies the struggle of Australia’s Indigenous people to gain control of their destiny, which for generations has been wrested from them into the power of governments. Although his statement was primarily directed toward welfare, the same right of responsibility can be applied to health, perhaps the gravest challenge facing the Aboriginal population. As Pearson alluded to, the only way to solve the health crisis is by enabling local communities to take charge of their own affairs. This principle of self-determination has led to the creation of Aboriginal Community Controlled Health Services (ACCHS), which has allowed over 150 Aboriginal communities throughout Australia control over their healthcare. [2] This article describes the founding principles behind community controlled health centres in Aboriginal communities through considering several different ACCHS and the unique challenges they face.

The fundamental concept behind each ACCHS – whether metropolitan, rural or remote – is the establishment of a primary healthcare facility that is both built and run by the local Aboriginal people “to deliver holistic, comprehensive, and culturally appropriate health care to the community which controls it.” [2] This is based upon the principle of self-determination and grants local people the power to achieve their own goals. From the beginning ACCHS were always intended to be more than exclusively a healthcare centre and each ACCHS has four key roles: the provision of primary clinical care, community support, special needs programmes, and advocacy.

ACCHS endeavour to provide primary healthcare as enshrined by the World Health Organization in the 1978 Declaration of Alma-Ata. This landmark international conference defined primary healthcare as:

“essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain… in the spirit of self-determination.” [3]

Although conceived subsequent to the advent of the community controlled healthcare movement in Australia, this definition echoes many of the underlying principles upon which ACCHS were founded, including the most important aspect – local control. Indeed, it is widely accepted throughout the literature that the community itself must identify its needs and problems so an effective and appropriate course of action can be undertaken. [4-7]

This principle is espoused in the National Aboriginal Health Strategy’s frequently quoted statement that “Aboriginal health is not just the physical well-being of an individual but the social, emotional and cultural well-being of the whole community in which each individual is able to achieve their full potential thereby bringing about the total well-being of their community.” [8] The notion of ‘community’ is an essential component of the Indigenous view of the self and therefore strongly related to health and well-being. Accordingly, ACCHS have a holistic view of healthcare, recognising that Indigenous healthcare needs to be multi-faceted and focus on cultural complexities that may not be appreciated by mainstream health services. As each Aboriginal community across the country has a distinct culture and language, [9] local control is paramount.

The concept of community control is not new. It can be traced back to early nineteenth-century America, where such services were used with success for improving the health of the poor and recent migrants. [4] The first ACCHS was established in the inner city Sydney suburb of Redfern in 1971. [10] Known as the Aboriginal Medical Service (AMS), it pioneered the concept of community controlled healthcare in Australia and, from modest beginnings, has now expanded into a major, versatile healthcare facility that provides free medical, dental, psychological, antenatal and drug and alcohol services to the large Aboriginal community in Sydney. Redfern’s AMS overcame struggles against an initially distrustful and paternalistic government through the dedication of visionary Indigenous leaders and support of benevolent non-Indigenous Australians. [10,11]

Specialised Indigenous policies are essential, as it is impossible to apply the same approach that is used in health services for non-Indigenous patients. Many Indigenous people are uncomfortable with seeking medical help at hospitals or general practices and therefore are reluctant to obtain essential care. [12] In addition, access to healthcare is often extremely difficult due to either geographical isolation or lack of transportation. Many Indigenous people live below the poverty line, so the services provided by practices that do not bulk bill are unattainable. Mainstream services struggle to provide appropriate healthcare to Aboriginal patients due to significant cultural and language disparities; [5,13] the establishment of ACCHS attempts to overcome such challenges.

For example, the Inala Indigenous Health Service in south-west Brisbane performed extensive market research to determine the factors keeping Aboriginal patients from utilising the mainstream health service. The results showed that several simple measures were highly effective in engaging the local community, such as employing an Indigenous receptionist and making the waiting room more culturally appropriate through local art or broadcasting an Aboriginal radio station. [12] In the five years following implementation of these strategies, the number of Indigenous patients at Inala ballooned from 12 to 899, and an average of four consultations per patient per year was attained, compared to the national Indigenous average of fewer than two. [14] A follow-up survey attributed patient satisfaction to the presence of Indigenous staff and a focus on Indigenous health. [12]

Nevertheless, the consequence of  longstanding obstacles to Indigenous access to mainstream healthcare is manifest in the stark inequity between the health outcomes of Indigenous and non-Indigenous Australians. The most recent data from the Australian Institute of Health and Welfare (AIHW) shows that the discrepancy in life expectancy between Aboriginal Australians and their non-Indigenous counterparts remains unacceptably high, at 11.5 years for males and 9.7 for females. [15] Moreover, studies demonstrate that Aboriginal people have significantly worse outcomes in key health indicators, including infant mortality, diabetes, heart disease, infectious disease and mental illness. [5,12,13,16] Such disparities indicate that a novel, tailored approach to Indigenous health is required.

Cultural understanding is essential, as demonstrated by the example of the Anyinginyi Health Aboriginal Corporation in the Northern Territory. Anyinginyi serves the twelve remote Aboriginal communities within a 100km radius of Tennant Creek and its name comes from the local Warumungu language, meaning ‘belonging to us’ [17] emphasising the community’s control of, and pride in, this service. Anyinginyi has always strived to be more than just a health service and has evolved to deliver many other community programmes. This is embodied by Anyinginyi’s insistence on ‘culturally appropriate’ healthcare for Aboriginal people. In addition to medical advice, the local Aboriginal community is offered support through various programmes that range from employment services to cultural and spiritual activities promoting Indigenous language and culture. One such social service is the ‘Piliyintinji-Ki Stronger Families’ initiative, which assists community members through access to support services relating to issues such as family violence and the Stolen Generations. [17] Indeed, ACCHS such as Anyinginyi have the additional benefit of providing employment opportunities for community members, as the vast majority of the employees are Indigenous. All new staff members participate in a Cross Cultural Workshop, as one of Anyinginyi’s goals is to ensure that the local Aboriginal cultures are respected and continue to thrive.

The other important arm of healthcare in ACCHS relates to population health, with initiatives ranging from education campaigns to immunisations and screening for diseases. [2] One of the first large-scale community health promotion campaigns run specifically for Aboriginal people was conducted by the Redfern AMS between 1983-1984 to encourage breast-feeding among the local Koori mothers. [11] It achieved such stunning success that it set a precedent for all future ACCHS to continue in the important area of preventative medicine, with similar campaigns for sexual health and safe alcohol consumption having been undertaken subsequently.

Moreover, each ACCHS runs special services that are dictated by local needs and priorities. In some instances, there is a specific health problem that needs to be addressed, such as poor nutrition or substance abuse. Other programmes are directed at specific groups, such as young mothers or the elderly. The flexibility of these special services allows each ACCHS to identify and address the most significant problems within its area – problems that can only be identified by the community itself. For example, the Danila Dilba Health Service in Darwin runs a programme called ‘Dare to Dream’ that provides support and counselling for young Indigenous people suffering from mental illness. [18] It is an early intervention programme that intends to identify and support adolescents exhibiting early signs of both behavioural and mental health problems. To this end, school visits are undertaken to promote awareness of mental health issues to students and staff, as well as the services that Danila Dilba has to offer. A ‘chillout’ centre has been set up in Darwin as a safe place for young people to come and allows the community workers to refer those who present to appropriate counselling services. As such, Danila Dilba is empowered to proactively address an important local issue in the most culturally-appropriate way.

ACCHS are also active in the area of advocacy. This involves providing a voice for the community so that their needs can be expressed. Although each ACCHS operates autonomously, they form a national network with their collective interests represented both on a state/territory level and also nationally. Each of the eight states and territories has a peak representative body that acts on behalf of all ACCHS within that jurisdiction. [2] Examples of these organisations include the Aboriginal Health & Medical Research Council of New South Wales and the Aboriginal Medical Services Alliance Northern Territory. At the national level the umbrella body overseeing all the different stakeholders across the country is the National Aboriginal Community Controlled Health Organisation (NACCHO). [2] Individual ACCHS, as well as NACCHO and the affiliated state or territory peak bodies, lobby all levels of government for increased funding and greater recognition of the issues facing Aboriginal communities. The collective weight of NACCHO as a national advocate allows each community’s needs to be heard.

Inevitably, the scope of the services each ACCHS can provide is restricted by funding, most of which comes from the Commonwealth or State and Territory Governments. [2] More money continues to be spent per capita on mainstream health services than on Aboriginal health, despite the great dichotomy in health outcomes. Indeed, the 2012 Indigenous Expenditure Report published figures showing that for every dollar spent on healthcare subsidies for non-Indigenous health, only $0.66 is spent on Aboriginal health. [19] This statistic covers all the key areas of healthcare expenditure, such as Medicare rebates, the pharmaceutical benefits scheme (PBS) and private health insurance rebates. Therefore, Indigenous patients are not receiving the same level of health service delivery, including clinical consultations and treatment, compared to their non-Indigenous counterparts. However, it is propitious to note that the funding bodies have recognised the value of the public health efforts of ACCHS, as the spending in this area is a $4.89 to $1.00 ratio in favour of Indigenous health. [19] Nevertheless, the priority needs to be placed on ensuring that sufficient funding exists to allow Indigenous patients to access health care subsidies as required.

In addition to inadequate funding, another major obstacle that ACCHS face is the difficulty in attracting and retaining doctors and allied health professionals. According to the AIHW’s most recent report, only 63% of Indigenous health services currently employ a doctor. [20] Consequently, a significant increase in the number of general practitioners working with Indigenous patients is required simply to provide adequate services. There is additionally a severe lack of Aboriginal medical students and general practitioners, which limits the opportunities for Indigenous professionals to provide culturally-appropriate care to their own communities. Census data from 2006 found that there were 106 Indigenous doctors nationally, accounting for only 0.19% of all medical practitioners. [21] These shortages are compounded further for ACCHS in rural and remote areas. By 2011, further data from Medical Deans demonstrated that the numbers had increased to 153 Indigenous medical practitioners nationally, along with 218 enrolled Indigenous medical students. Although promising, these numbers remain grossly inadequate to fulfil workforce demand. [22]

Services become stretched due to perpetual resource inadequacies. Understandably, the remoteness of some communities makes service delivery challenging, yet even major metropolitan areas with large Indigenous populations can struggle to adequately provide for those in their catchment area. Under-resourcing places major constraints on service delivery and different ACCHS throughout the country exhibit significant variation in the level of services offered. Some are large, employ several doctors and provide a wide range of services; others are much smaller and operate without doctors. [20] These rely on Aboriginal health workers and nurses to provide the bulk of primary healthcare.

As such, the success of the ACCHS concept would not have been possible without the contribution of Aboriginal health workers. The role of Aboriginal health workers, who are often sourced from the local community, is to provide the primary healthcare that ACCHS offer. [23] This involves assessing patients and then coordinating or providing the medical attention required. Health workers are able to treat certain conditions with the help of standard treatment guidelines and provide a selection of important medications to patients. Importantly, Aboriginal health workers have a liaison role between medical professionals and Aboriginal patients. They are often required to act as an interpreter between the patient and health professional, thus providing an intermediary for cross-cultural interactions, and therefore improving the quality of healthcare provided to the local community.

Due to the often quite remote locations of ACCHS and the scarcity of doctors and nurses, Aboriginal health workers perform many clinical tasks that would be provided by a medical professional in mainstream health services. Aboriginal health workers bear much greater responsibility than their colleagues in the public sector and often learn a wide range of procedural skills including how to perform standard health checks, vaccinations and venepuncture. [23] Indeed, some choose to specialise in a specific area (such as diabetes, pregnancy or infant care) thus gaining additional skills and responsibilities. Still others take on managerial responsibilities. This is in contrast to the public sector, where health workers are often fixed to one routine area or even to non-clinical work such as transportation or social assistance. [23] Without Aboriginal health workers performing these additional tasks, ACCHS would not be able to provide a sufficient level of service for the community. For this reason, Aboriginal health workers are rightly considered the backbone of community controlled health services.

As one example, the Pika Wiya Health Service in the South Australian town of Port Augusta runs two outreach clinics for communities in Copely and Nepabunna. Due to the shortage of doctors, these clinics are staffed entirely by Aboriginal health workers. Their invaluable contribution is evident, with 695 clinical encounters performed by health workers during 2008, [24] ensuring that the absence of doctors did not deny the local people the chance to receive healthcare. Whilst the major health issues faced by Indigenous people are broadly similar between urban and remote communities, these problems are often compounded by the remoteness of the location. Although these are challenges that Copely and Nepabunna will continue to have to face, the empowerment of Aboriginal health workers has helped redefine the direction of Pika Wiya’s outreach health services.

Aboriginal health workers face many difficulties. Perhaps the most significant is that, until recently, there had been no national qualifications or recognition of the skills they developed. [23] The introduction of national registration for Aboriginal health workers (from July 1 2012) and the new qualification of Certificate IV in Aboriginal and Torres Strait Islander Primary Health Care (Practice) have revolutionised the industry. [25] This has had the benefit of standardising the quality and safety of the Aboriginal health worker labour force. However, as the changes will increase the required length and standard of training, there is the potential for current or prospective health workers to be deterred by the prospect of undertaking study at a tertiary level, particularly if they have had limited previous education. Nevertheless, national registration is a positive step for recognising the important work done by Aboriginal health workers, and in providing them with the training to continue serving their communities.

In addition to doctors, nurses and health workers, medical students are also important stakeholders in Indigenous health. First, much has been done in recent years to increase the numbers of Indigenous medical students. For example, the University of Newcastle has been the first medical school to make a dedicated attempt at training Indigenous doctors and has produced approximately 60% of Australia’s Indigenous medical practitioners. [26] This achievement has been based on a “strong focus on community, equity and engagement by the medical profession.” [26] Encouraging community members to enter the profession can be an important way of addressing both the lack of doctors in Indigenous communities and paucity of doctors of Indigenous background. The benefits are broader than this, as Indigenous doctors provide strong role models for young Indigenous people and also have the opportunity to contribute with advocacy and leadership within Indigenous health.

Secondly, the medical student population as a whole is exposed to increasingly more Indigenous health as part of the core curriculum at university following adoption of the updated Australian Medical Council accreditation standards from 2007. [27] Additionally, some students even have the opportunity to spend time in an ACCHS and experience first-hand how the system works. There has been some criticism of these ‘fly in, fly out’ medical electives, where students are sent to ACCHS for short periods and then leave. [28] Whilst this model may be beneficial for the student, it fails to engage the local community as they are unable to build meaningful or lasting relationships with the student.

Better models allow for a longer-term placement and immersion in the community. These include the John Flynn Placement Programme where some students are able to spend a fortnight annually in an ACCHS in the Northern Territory over a period of four years. [29] Another example is the Northern Territory Clinical School, which allows third-year medical students from Flinders University to spend a whole year of study in Darwin, providing the opportunity for increased contact with local Indigenous communities. [30] Initiatives such as these help to build a relationship with the community, and allows for increased acceptance of the medical student. Additionally, the student is able to make a more meaningful contribution to various client’s healthcare. Prolonged or longitudinal attachments have also been shown to increase the likelihood of students returning as a doctor. [31] Certainly, there is much scope for the contribution of medical students to be harnessed more effectively.

It is abundantly apparent that any solution to address the health inequalities of Aboriginal people will only be effective if it recognises that the local Aboriginal communities must control the process of healthcare delivery. This is the principle upon which ACCHS were founded and can be attributed to their many successes, as demonstrated through the examples of Redfern’s AMS, Inala, Anyinginyi, Danila Dilba and Pika Wiya. In spite of the challenges posed by inadequate funding, under-staffing and often remote locations, these organisations strive to uphold the ideals of self-determination and community control. It is hoped that wider adoption of these principles by national governing bodies together with improved financial support will enable Indigenous Australians control over their lives and destinies, leading to better health outcomes.

Conflict of interest

None declared.

Acknowledgements

The author would like to thank the Australasian Faculty of Public Health Medicine for their generous support of this research through awarding the 2011 John Snow Scholarship for South Australia. Additionally, the author wishes to acknowledge the guidance of Dr Doug Shaw when preparing this work for presentation at the 2012 Population Health Congress.

Correspondence

M Weightman: michael.weightman@student.adelaide.edu.au

References

[1] Pearson N. Our right to take responsibility. Cairns, Queensland:  Noel Pearson and Associates; 2000.

[2] National Aboriginal Community Controlled Health Organisation. 2010-2011 Annual Report. Canberra, ACT: NACCHO; 2011.

[3] World Health Organisation. Declaration of Alma-Ata. Alma-Ata, USSR: WHO; 1978.

[4] Minkler M, Wallerstein N. Improving health through community organisation and community building: a health education perspective. In Minkler M, editor. Community organizing and community building for health. New Brunswick, USA: Rutgers University Press; 1998, 26-50.

[5] Stephens C, Nettleton C, Porter J, Willis R, Clark S. Indigenous peoples’ health – why are they behind everyone, everywhere? Lancet. 2005; 366(9479): 10-13.

[6] Horton R. Indigenous peoples: time to act now for equity and health. Lancet. 2006; 367(9524): 1705-1707.

[7] King M, Smith A, Gracey M. Indigenous health part 2: the underlying causes of the health gap. Lancet. 2009; 374(9683): 76-85.

[8] National Aboriginal Health Strategy Working Party. A national Aboriginal health strategy. Canberra, ACT: National Aboriginal Health Strategy Working Party; 1989.

[9] Burgess CP, Johnston FH, Berry HL, McDonnell J, Yibarbuk D, Gunabarra C, et al. Healthy country, healthy people: the relationship between Indigenous health status and ‘caring for country.’ Med J Aust. 2009; 190(10): 567-572.

[10] Marles E, Frame C, Royce M. The Aboriginal Medical Service Redfern: improving access to primary care for over 40 years. Aust Fam Physician. 2012; 41(6): 433-436.

[11] Foley G. Redfern Aboriginal Medical Service: 20 years on. Aborig Isl Health Work J. 1991; 15(4): 4-8.

[12] Hayman NE, White NE, Spurling GK. Improving Indigenous patients’ access to mainstream health services: the Inala experience. Med J Aust. 2009; 190 (10): 604-606.

[13] Zhao Y, Dempsey K. Causes of inequality in life expectancy between Indigenous and non-Indigenous people in the Northern Territory, 1981-2000: a decomposition analysis. Med J Aust. 2006; 184(10): 490-494.

[14] Deeble J. Expenditure on health services for Aboriginal and Torres Strait Islander People. Canberra, ACT: Department of Health and Family Services; 1998.

[15] Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander people: an overview 2011. Canberra, ACT: Australian Institute of Health and Welfare; 2011.

[16] Anderson I, Crengle S, Kamaka ML, Chen T-H, Palafox N, Jackson-Pulver L. Indigenous health in Australia, New Zealand, and the Pacific. Lancet. 2006; 367(9524): 1775-1785.

[17] Anyinginyi Health Aboriginal Corporation. 10/11 Annual Report. Tennant Creek, NT: Anyinginyi Health Aboriginal Corporation; 2011.

[18] Danila Dilba Biluru Butji Binnilutlum Health Service Aboriginal Corporation. Annual Report 2010. Darwim, NT: Danila Dilba Biluru Butji Binnilutlum Health Service Aboriginal Corporation; 2010.

[19] Steering Committee for the Review of Government Service Provision. 2012 Indigenous expenditure report: overview. Canberra, ACT: Productivity Commission; 2012.

[20] Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander health services report, 2010-11: OATSIH services reporting – key results. Canberra, ACT: Australian Institute of Health and Welfare; 2012.

[21] Australian Bureau of Statistics. Population distribution, Aboriginal and Torres Strait Islander Australians, cat. no. 4705.0. Canberra, ACT: Australian Bureau of Statistics; 2007.

[22] Cavanagh J. Medical Deans – AIDA: national medical education review. Canberra, ACT: Medical Deans Australia and New Zealand, Australian Indigenous Doctors’ Association; 2012.

[23] Mitchell M, Hussey LM. The Aboriginal health worker. Med J Aust. 2006; 184(10): 529-530.

[24] Pika Wiya Health Service Inc. Annual Report for Year 2007-2008. Port Augusta, SA: Pika Wiya Health Service Inc; 2008.

[25] Health Workforce Australia. Growing our future: the Aboriginal and Torres Strait Islander Health Worker project final report. Adelaide, South Australia: Health Workforce Australia; 2011.

[26] Lawson KA, Armstrong RM, Van Der Weyden MB. Training Indigenous doctors for Australia: shooting for goal. Med J Aust. 2007; 186(10): 547-550.

[27] Australian Medical Council. Assessment and accreditation of medical schools: standards and procedures. Part 2. Educational standards. Canberra, ACT: Australian Medical Council; 2006.

[28] Crump JA, Sugarman J. Ethical considerations for short-term experiences by trainees in global health. JAMA. 2008; 300(12): 1456-1458.

[29] Young L, Kent L, Walters L. The John Flynn Placement Program: evidence for repeated rural exposure for medical students. Aust J Rural Health. 2011; 19(3): 147–153.

[30] McDonnel Smedts A, Lowe MP. Efficiency of clinical training at the Northern Territory Clinical School: placement length and rate of return for internship. Med J Aust. 2008; 189(3): 166-168.

[31] Denz-Penhey H, Shannon S, Murdoch JC, Newbury J. Do benefits accrue from longer rotations for students in rural clinical schools? Rural Remote Health. 2005; 5(2): 414.

Categories
Articles Feature Articles

Physician Assistants in Australia: the solution to workforce woes?

This article reviews the potential for Physician Assistants (PAs) within Australia. An introduction to the PA role, training, and relevant history is included, as is motivation for considering implementation of the role within Australia. It specifically addresses the prospect of improving rural and Indigenous health services. The possible impact on other roles within Australia, including Nurse Practitioners and medical students, is also considered. Finally, it is concluded that larger trials are required to adequately assess the benefit of the profession to Australia.

Introduction to Physician Assistants

With the recent suspension of the Physician Assistant (PA) training programme at The University of Queensland, and reservations expressed by nursing and medical organisations, there is potential for ambiguity regarding the prospects of the profession in Australia. [1,2] Whilst the concept is relatively new to the country, it is well-established internationally, [3] and in the United States has mitigated certain deficits in health service provision. [4]

A PA is a licensed medical professional who operates within a set scope of practice under the authority of a supervising doctor. [5] Whilst they may complete tasks independently, the supervising doctor has final responsibility for the PA and the clinical care they provide. [4] The role is not designed to serve as an independent practitioner. [4] Thus, a PA’s scope of practice can vary significantly, depending on the health facility at which they are employed, the extent of further training undertaken, and the degree of clinical autonomy the supervising doctor is willing to allow. [4]

The concept of the PA was introduced in the 1960s in response to both a shortage and uneven geographic distribution of doctors within the United States. [4,6] The founder of the PA movement, Eugene Stead, initially intended an advanced nursing programme. However, the National League of Nursing rejected this proposal, prompting the utilisation of trained military medics as the pioneering class. [7] The first cohort of PAs graduated in 1967, [8] and since then a large number of tertiary institutions have commenced training programmes. [4]

Entry into training programmes is competitive, with at least two years of university study usually required as a pre-requisite. [4] Most candidates also have at least four years prior experience in a medically related field, having transitioned from allied health and nursing careers. [1,4]  PAs train for an average of twenty-five months in a course now typically designed as a Masters level programme, representing an abridged version of traditional tertiary medical education. [4] Similar to other medical professionals, PAs are required to undergo continuing professional education and meet recertification requirements. [8] In the United States, the recertification period is currently six years, although this will be transitioning to ten years from 2014. [9]

The role of PAs includes taking patient histories, performing clinical exams, diagnostics, patient education, basic procedural work such as suturing, and providing general assistance to doctors as required. [4] PAs may also complete more advanced tasks under the delegated authority of doctors, including endoscopy, critical care, and specialist outpatient clinics. [10-12] Importantly, evidence shows that in specific clinical situations PAs can provide a level of care comparable to doctors. [4]

The significance of the PA role to the United States health care system is clear, with over seventy thousand practising in 2010. The profession has expanded consistently since 1991, with graduates from over 150 accredited training facilities set to see in excess of ninety thousand PAs in the United States by 2014. Growth in the profession is predicted to continue, with numbers estimated to exceed 125 000 by 2025. [13]

Motivation for considering the role in Australia

The PA role has been discussed as a potential solution to problems facing the medical workforce in Australia and, although small in size, results of trials in Queensland and South Australia have been encouraging. [12,14] The 2008 Parliamentary Library report and 2011 Health Work Force Australia report have also recommended the profession be considered given the challenges facing medical care in Australia. [12,14] An ageing population, increased patient expectations and the burden of chronic disease all place considerable strain on a system already understaffed, whose employees are demanding more work-life balance than before. [15,16] The size of this problem is clear, with estimates that by 2025 over twenty percent of the total workforce in Australia would need to be employed in the health system to maintain services at their current level. [17] The response has been to increase medical graduate numbers and recruit doctors internationally, yet with demand set to exceed supply, PAs represent a possible solution to Australia’s expanding medical workforce requirements. [18] Arguments have also been made that PAs could decrease Australia’s reliance on International Medical Graduates (IMGs), which would be a move toward “self reliance” as recommend by the National Health Workforce Strategic Framework in 2004. [19,20]

Although the workforce shortage is a serious issue, perhaps a greater concern is the financial sustainability of the health care system. In 2009, approximately ten percent of Australia’s Gross Domestic Product (GDP) was spent on health care. [19] This is expected to growth at a rate of 0.5% per year, meaning health expenditure will account for twenty percent of Australia’s GDP by 2020. [19] Therefore, in an effort to achieve sustainability, avenues to mitigate this rising financial burden must be explored.  This provides motivation to consider the PA role within Australia, especially given evidence demonstrating their potential cost-effectiveness. [18,21-23]

The 2011 Health Work Force Australia report indicated a number of possible roles for PAs in Australia, including providing services that have traditionally been the sole domain of doctors. [1] Whilst this may seem like a new paradigm, the concept of dispersing such knowledge and expertise amongst various members of the health workforce is not new to Australia. Such change can already be seen in the medical profession with the development of General Practitioner (GP) proceduralists who, particularly in rural areas, perform tasks previously only completed by specialists. [24] This dynamic practice has been essential to ensuring service viability in rural areas, including maintaining obstetric services. [24] Paramedics have also been shifting towards a more professional role, utilising expanded skills bases, and in some instances having admission rights to hospitals. [25,26] The Nurse Practitioner (NP) role has also expanded within Australia, and NPs now complete extended patient assessments, prescribe certain items independently, and collaborate with doctors where required. [27] Whilst there are some reservations about the expanding scope of practice for non-doctor roles, the success of such redistribution of tasks in Australia provides motivation to review the way in which medical care is provided. [28] However, to ensure quality of care and patient safety, this should continue forward with consultation from appropriate medical governing bodies. [27,29]

The potential role of Physician Assistants in rural Australia

Rural communities in Australia currently experience significant disadvantage in accessing health care, with staffing shortages being exacerbated by an uneven distribution of practitioners that favours metropolitan areas. [2] This issue is set to be compounded by an ageing rural workforce and resultant practitioner retirement. [1] To a large extent IMGs have helped minimise this effect, with over half of doctors working in areas classified as small rural to remote being trained internationally. [2] However, evidence suggests that IMGs bonded to work in rural Australia tend to be dissatisfied both personally and professionally, [30] demonstrating a clear need to find a sustainable rural health workforce.   This provides a perfect niche to utilise PAs, with some research in the United States showing that as a profession PAs may be more willing than doctors to move to areas of need, including rural locations. [18] Such use of PAs to mitigate rural health workforce shortages is supported by both the Australian College of Rural and Remote Medicine and the National Rural Health Alliance. [18]

In an Australian rural pilot trial in Cooktown, PAs significantly reduced the requirement for doctor overtime despite increased caseload. This shows potential to reduce doctor fatigue and consequently the rural attrition rate, which is essential to ensure continued viability of rural health services. [14] The potential benefit of PAs was further seen in a Mt. Isa trial, which coincided with an H1N1 outbreak. During this time period, PAs conducted a fast-tracked clinic to decrease the burden on emergency physicians. [14] The benefit of their input continued over the following months, with Emergency Department presentations, particularly in the lower triage categories, decreasing following initiation of a PA-led primary care clinic. [14]

Furthermore, PAs have the potential to improve Indigenous health services. In the Queensland pilot, PAs at Wujal Wujal, Karumba and Normanton at times worked under remote delegation, improving access of the local Indigenous community to health professionals. [2] If expanded, this could yield an important step forward in health equity by ensuring that medical professionals are on-site to deliver the services these areas require. However, patient feedback regarding this service was difficult to obtain, with very few Aboriginal and Torres Strait Islander (ATSI) patients completing the feedback survey. [2] Scope of practice for PAs at one trial site was also restricted for ATSI children, requiring approval from a supervising physician before initiation of any therapy for patients below a pre-determined age. This was prophylactic rather than in response to any actual breach of care, on the basis that presentations of children in this group often do not reflect the true breadth of underlying illness. [2] It should, however, be remembered that PAs participating in the trial were trained internationally. If PAs were trained locally in programmes designed to meet the health needs of Australian populations, such measures are unlikely to be necessary.

The Queensland PA trials yielded no safety or treatment concerns over twelve months. However, due to their size, limited analysis, and issues regarding scope of practice, the benefit of the role to the local health system was unable to be completely established. Therefore, given the potential utility, further study should be completed to demonstrate if PAs can adequately address the rural and Indigenous workforce shortage. For these trials to adequately assess the role in rural Australia, implementation of a proper support network and a change in legislation, particularly surrounding prescribing rights, would be required. [14,31]

Further potential roles of Physician Assistants in Australia

PAs could also increase the capacity of procedural units by taking responsibility for low-risk routine tasks such as endoscopy, running specialised outpatient clinics, and providing early assessment of new cases in emergency departments, allowing doctors to focus on more complex tasks. [2,10,18] The same is true of general practice, where PAs have been shown capable of managing the majority of minor cases to a similar level of care as GPs. [32] In a recent United Kingdom-based study, PAs were shown to expand the capacity of trial sites to provide primary care to their local population. [32] Specific tasks performed by PAs in this trial included follow up of laboratory results, basic procedural work, completing PAP smears, and patient education. One major difficulty encountered was the inability to prescribe under current legislation, which has also been reflected in Australian trials. [32]

Concerns regarding impact on other roles in the Australian health care system

Concerns have been voiced that PAs may encroach on the role currently held by Nurse Practitioners (NPs) including the Rural and Isolated Practice Registered Nurse role, which was specifically designed to meet rural needs. [2,31] Counter-arguments have been made that the NP role is protocol-driven and based on a nursing model of care, whilst the PA role is based on the medical model with a greater emphasis on diagnostics; therefore, unique roles for both professions could be determined. [2] Despite this, the overlap between the two roles is significant. [5,14,38] As such, further trials of PAs must examine the impact on the NP profession, which is now well-developed within Australia. [2]

In terms of quality of care, numerous studies have shown that in certain areas of clinical practice, NPs, PAs and doctors achieve similar clinical outcomes and a similar degree of patient satisfaction. [4,
34-38] Therefore, given the proven NP role, unless evidence is produced demonstrating enhanced quality of care or ability to undertake tasks not performed by NPs, the cost of implementing this profession in Australia’s health care system cannot be justified. Even if such novel roles or quality addition could be proven, the cost of introducing and sustaining PAs including physician supervision demands careful cost-benefit analysis. [31] This is particularly important in the current era of unsustainable medical expenditure. Furthermore, as Australia continues to face a so-called “tsunami” of medical students, the requirement for further low- to mid-level clinical roles, particularly those not yet well-established, must be seriously reviewed.

The effect on physician and medical student training must also be determined, particularly given the increased numbers of medical graduates. The National Health Workforce Taskforce report illustrated the extent of this problem, estimating that in comparison to 2005, in 2013 over 600 000 more medical placement days per annum will be required to train undergraduates. [2] Therefore, as the role of PAs is examined, it is essential to ensure junior doctor and medical student training is not impaired. There are as-yet unsubstantiated claims that PAs may allow more time for senior clinicians to teach. [2,14] However, more research and consideration into this as it applies to the Australian context is warranted. [2] This is particularly important as, despite large increases in the numbers of medical graduates, a significant proportion of senior consultants are approaching retirement age. [39] This may lead to diminished clinical exposure for medical students, a situation which could be further exacerbated should consultants also be tasked with fulfilling PA teaching and ongoing supervision requirements. This is an issue already considered in the Queensland pilot trials, where PA scope of practice for certain procedural skills was limited to ensure junior doctors gained the necessary experience. [2]

Conclusion

Trials in Australia regarding PAs have been limited and utilised internationally-trained recruits with proven clinical acumen. [2,12,14] Therefore, despite encouraging results, larger trials are required to determine their potential to benefit the Australian health care system. Even if the conclusion was drawn that the implementation of PAs was the best way to meet the requirements of the Australian health care system, there are still multiple barriers that would need to be addressed. These include setting up appropriate prescribing rights under the Pharmaceutical Benefits Scheme, without which their effectiveness would be severely limited. [12] The potential for roles in rural and remote communities and procedural work seems encouraging. [2,17] However, concerns regarding the impact on the proven NP role and medical student training must be addressed in further trials before conclusions can be drawn on the wider impact of implementation in Australia. [2,31]

Conflict of interest

None declared.

Acknowledgements

Natasha Duncan: for proofreading and providing constructive feedback.

Correspondence

B Powell: benjamin.powell@uqconnect.edu.au

References

[1] Miller M, Siggins I, Thomson N, Fowler G, Bradshaw S. The potential role of Physician Assistants in the Australian context, Volume 1: Final Report. Adelaide: Health Workforce Australia; 2011 Nov. 39 p. Available from: http://www.hwa.gov.au/sites/uploads/hwa-physician-assistant-report-20120816.pdf.

[2] Urbis. Evaluation of the Queensland Physician’s Assistant Pilot – Final Report. Queensland: Urbis Pty Ltd; 2010 Aug. 61 p. Report No.: 17.

[3] Hooker RS, Hogan K, Leeker E. The globalization of the physician assistant profession. J Physician Assist Educ. 2007; 18(3): 76–85.

[4] Mittman DE, Cawley JF, Fenn WH. Physician assistants in the United States. Br Med J. 2002; 325: 485–7.

[5] Everett CM, Schumacher JR, Wright A, Smith MA. Physician assistants and nurse practitioners as a usual source of care. J Rural Health. 2009; 25(4): 407–14.

[6] Frossard LA, Liebich G, Hooker RS, Brooks PM, Robinson L. Introducing physician assistants into new roles: international experiences. Med J Aust. 2008; 188(4): 199–201.

[7] Jolly R. Health workforce: a case for physician assistants? Canberra: Parliamentary Library; 2008 Mar. 48 p.

[8] Hutchinson L, Marks T, Pittilo M. The physician assistant: would the US model meet the needs of the NHS? Br Med J. 2001; 323(7323): 1244–7.

[9] New certification process review [Internet]. National Commission on Certification of Physician Assistants; 2012 [cited 2013 Jan 19]. Available from: http://www.nccpa.net/CertMain.aspx.

[10] Newman HH, Smit DV, Keogh MJ, Stripp AM, Cameron PA. Emergency and acute medical admissions: insights from US and UK visits by a Melbourne tertiary health service. Med J Aust. 2012; 196(2): 101–3.

[11] Doan Q, Sabhaney V, Kissoon N, Sheps S, Singer J. A systematic review: The role and impact of the physician assistant in the emergency department. Emerg Med Australas. 2011; 23(1): 7-15.

[12] Ho B, Maddern G. Physician assistants: employing a new health provider in the South Australian health system. Med J Aust. 2011; 194 (5): 2568.

[13] Hooker RS, Cawley JF, Everett CM. Predictive modeling the physician assistant supply: 2010–2025. Public Health Rep. 2011; 126: 708-16.

[14] Kurti L, Rudland S, Wilkinson R, DeWittB D, Zhang C. Physician’s assistants: a workforce solution for Australia? Aust J Prim Health. 2011; 17: 23–8.

[15] Brooks P, Ellis N. Health workforce innovation conference. Med J Aust. 2006; 184(3): 105-6.

[16] Hooker R. The future of the physician assistant movement. Med J Aust. 2010; 192(3): 116.

[17] Brooks PM, Robinson L, Ellis N. Options for expanding the health workforce. Aust Health Rev. 2008; 31(1): 156-60.

[18] Hooker R, O’Connor T. Extending rural and remote medicine with a new type of health worker: Physician assistants. Aust. J. Rural Health. 2007; 15: 346–51.

[19] Gorman DF, Brooks PM. On solutions to the shortage of doctors in Australia and New Zealand. Med J Aust. 2009; 190(3): 152-6.

[20] Carver P. Self Sufficiency and International Medical Graduates – Australia. Victoria: National Health Workforce Taskforce; 2008 Sep. 23 p.

[21] Ho P, Pesicka D, Schafer A, Maddren G. Physician assistants: trialling a new surgical health professional in Australia. ANZ J Surg. 2010; 80(6): 430-7.

[22] Hooker RS. Physician assistants and nurse practitioners: the United States experience. Med J Aust. 2006; 185(1): 4-7.

[23] Laurant B, Harmsen M, Wollersheim H, Grol R, Faber M, Sibbald B. The impact of non physician clinicians : Do they improve the quality and cost-effectiveness of health care services? Med Care Res Rev. 2009; 66: 36S-88S.

[24] Robinson M, Slaney GM, Jones GI, Robinson JB. GP proceduralists: ‘the hidden heart’ of rural and regional health in Australia. Rural Remote Health. 2010; 10: 1402.

[25] Blacker N, Pearson L, Walker T. Redesigning paramedic models of care to meet rural and remote community needs. Paper presented at: The 10th National Rural Health Conference; 2009 May 17-20; Cairns, Australia.

[26] O’Meara PF, Tourle V, Stirling C, Walker J, Pedler D. Extending the paramedic role in rural Australia: a story of flexibility and innovation. Rural Remote Health. 2012; 12: 1978.

[27] Carryer J, Gardner G, Dunn S, Gardner A. The core role of the nurse practitioner: practice, professionalism and clinical leadership. J Clin Nurs. 2006; 16: 1818-25.

[28] Lawson K, Gregory A, Van Der Weyden M. The medical colleges in Australia: besieged but bearing up. Med J Aust. 2005; 183(11/12): 646-51.

[29] Kidd MR, Watts IT, Mitchell CD, Hudson LG, Wenck BC, Cole NJ. Principles for supporting task substitution in Australian general practice. Med J Aust. 2006; 185(1): 20-22.

[30] McGrail MR, Humphreys JS, Joyce CM, Scott A. International medical graduates mandated to practice in rural Australia are highly unsatisfied: results from a national survey of doctors. Health Policy. 201; 108(2-3): 133-9.

[31] Bosley S, Dale J. Healthcare assistants in general practice: practical and conceptual issues of skill-mix change. Br J Gen Pract. 2008; 58(547):120-4.

[32] Parle JV, Ross NM, Doe WF. The medical care practitioner: developing a physician assistant equivalent for the United Kingdom. Med J Aust. 2006; 185(1): 13-7.

[33] Tuaoi L, Cashin A, Hutchinson M, Graham I. Nurse Practitioner preparation: is it time to move beyond masters level entry in Australia? Nurse Educ Today. 2011; 31(8): 738-42.

[34] Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai W, Cleary PD, Friedwald WT, Siu AL, Shelanski ML. Primary outcomes in patients treated by nurse practitioners or physicians. J Am Med Assoc. 2000; 283(1): 59-68.

[35] Lenz ER, Mundinger MO, Kane RL, Hopkins SC, Lin SX. Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up. Med Care Res Rev. 2004; 61(3): 332-51.

[36] Roy CL, Liang CL, Lund M, Boyd C, Katz JT, McKean S, Schnipper JL. Implementation of a physician assistant/hospitalist service in an academic medical center: Impact on efficiency and patient outcomes. J Hosp Med. 2008; 3(5): 361-8.

[37] Lesko M, Young M, Higham R. Managing inflammatory arthritides: Role of the nurse practitioner and physician assistant. J Am Acad Nurse Pract. 2010; 22(7): 382-92.

[38] Hooker RS, Everett CM. The contributions of physician assistants in primary care systems. Health Soc Care Community. 2012; 20(1): 20-31.

[39] Schofield DJ, Fletcher SL, Callander EJ. Ageing medical workforce in Australia – where will the medical educators come from? Hum Resour Health. 2009; 7: 82.

 

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Letters Articles

A modern, effective and user-friendly approach to medical learning: an overview of spaced repetition programs

Effective and efficient methods of learning are important for medical students to tackle the plethora of information available. A technique that is gaining increasing popularity is Spaced Repetition Learning.

Spaced Repetition Learning (SRL) enhances retention by addressing our poor ability to process and retain information presented en mass at a single point in time. [1] Information is presented at varying time intervals depending on the student’s evaluation of their ability to recall facts. [2] The benefits of this technique have been shown in numerous studies. In mild Alzheimer’s disease, SRL proved useful for improving retention, visual memory and source recognition. [3,4] Another study compared massed versus spaced delivery of information to gastroenterology residents, who on assessment with multiple-choice quizzes showed enhanced long-term retention of facts with SRL. [5] Kerfoot et al also conducted several studies that demonstrated the applicability, efficacy and long-term durability of SRL teaching for urological trainees. [6-8]

Unfortunately, there is relative paucity of randomized trials involving medical students. A handful of studies conducted by Kerfoot et al have shown SRL significantly increases the effectiveness of learning. [9-11] One notable study in particular found that medical students using SRL were able to achieve the same results with significantly reduced study time, thus increasing the efficiency of study. [10] On the contrary, a well-constructed study has disputed the long-term effects of SRL, presenting evidence that the effects are primarily short-term. [12]

Several computer programs readily available use SRL methods, two of which are Anki and Mnemosyne. [13-15] Both programs are free to use (exception: Anki on iOS) and both allow an import and export of data in addition to supporting unicode, images, audio and LaTeX format. Anki also has the capacity to synchronise between devices, support video format and have multiple sides per card (Mnemosyne has a maximum of 3 sides per card). Both programs have cross-platform availability, and data from Mnemosyne is used to aid long-term memory research. [15]

To expand upon the use of Anki, with which the author has had more experience: it is a flashcard program that displays cards at varying intervals depending on how well one feels they have answered them in the past. Comprehensive and easy to understand instructions are available through the website, but in summary, the user writes a question and answer, and saves it to a ‘deck’ of cards. Each question can be labeled with one or more keywords (eg: ‘cardiology’). Cards with a certain label can be reviewed exclusively or excluded from reviews as desired. Decks of cards can also be shared to Anki’s online database or with other individuals. To begin learning without creating a new deck, downloading the “UK Finals Medicine” deck is a good starting point. There is also a varied range of other topics available including foreign languages, geography and musical instrument practice.

When reviewing a deck, the user is presented with a question (Figure 1), answers it (out loud, on paper, in their head) and clicks the mouse to view the answer. The user then grades their performance (Figure 2) and this is when spaced repetition theory is employed. By clicking “Again,” the card will automatically become due at the end of that review session. Clicking “Easy” the first time a particular card is answered will make it due in about a week. Each successive time a card is answered correctly, the card’s due date is pushed further into the future. Useful question examples for a complaint, such as chest pain, may include differential diagnoses, history questions, physical examination and investigations. For a disease, such as COPD, question prompts may include: definition, epidemiology, pathophysiology, aetiology, symptoms, signs, investigations, management, prognosis/staging and complications.

After using Anki for over a year, several benefits have become apparent. It ensures consistent new learning whilst refreshing the student of prior knowledge. Setting review deadlines and adhering to them means one can learn many facts effectively, which saves precious time. Answering questions out loud is perhaps the most effective way to clarify thoughts and consolidate your understanding of a topic. It is also particularly helpful for OSCE examination preparation. Another benefit is the accessibility of Anki, as it is available on most smart phones and can synchronise between devices and computers. The main shortfall of using SRL programs is that its efficacy depends on user commitment.

In summary, Spaced Repetition Learning has been shown to be an effective learning tool in research studies. There are a number of software programs currently available that are user friendly and free to use. From the author’s personal experience and literature review, the success of SRL should certainly be applicable to medical students and I look forward to seeing further objective research in the future to support its use.

Conflict of interest

None declared.

Correspondence

A Lambers: antonlambers@gmail.com

References

[1] Greene RL. Repetition and spacing effects. Learning and memory: A comprehensive reference. 2008;2:65–78.
[2] Baddeley A. Human Memory: Theory and Practice, Revised Edition. Allyn & Bacon; Rev Sub edition; 1997.
[3] Lee SB, Park CS, Jeong JW, Choe JY, Hwang YJ, Park CA, et al. Effects of spaced retrieval training (SRT) on cognitive function in Alzheimer’s disease (AD) patients. Archives of Gerontology and Geriatrics. 2009;49(2):289–93.
[4] Boller B, Jennings JM, Dieudonné B, Verny M, Ergis A-M. Recollection training and transfer effects in Alzheimer’s disease: Effectiveness of the repetition-lag procedure. Brain and Cognition. 2012;78(2):169–77.
[5] Raman M, Mclaughlin K, Violato C, Rostom A, Allard JP, Coderre S. Teaching in small portions dispersed over time enhances long-term knowledge retention. Medical …. Informa UK Ltd UK; 2010.
[6] Kerfoot BP, Baker H. An Online Spaced-Education Game to Teach and Assess Residents: A Multi-Institutional Prospective Trial. Journal of the American College of Surgeons. 2012;214(3):367–73.
[7] Kerfoot BP, Fu Y, Baker H, Connelly D, Ritchey ML, Genega EM. Online Spaced Education Generates Transfer and Improves Long-Term Retention of Diagnostic Skills: A Randomized Controlled Trial. Journal of the American College of Surgeons. 2010;211(3):331–1.
[8] Kerfoot BP. Learning benefits of on-line spaced education persist for 2 years. J. Urol. 2009 Jun;181(6):2671–3.
[9] Kerfoot BP, DeWolf WC, Masser BA, Church PA, Federman DD. Spaced education improves the retention of clinical knowledge by medical students: a randomised controlled trial. Medical Education. 2007 Jan;41(1):23–31.
[10] Kerfoot BP. Adaptive spaced education improves learning efficiency: a randomized controlled trial. J. Urol. 2010 Feb;183(2):678–81.
[11] Kerfoot BP, Brotschi E. Online spaced education to teach urology to medical students: a multi-institutional randomized trial. The American Journal of Surgery. 2009 Jan;197(1):89–95.
[12] Schmidmaier R, Ebersbach R, Schiller M. Using electronic flashcards to promote learning in medical students: retesting versus restudying. Medical Education. 2011.
[13]  Flashcard Software Comparison – Wikipedia [Internet]. [cited 2013 Feb 20]. Available from: http://en.wikipedia.org/wiki/List_of_flashcard_software
[14] Elmes D. Anki [Internet]. [cited 2013 Feb 20]. 2nd ed. GNUAGPLv3. Available from: http://ankisrs.net/
[15] Bienstman P. Mnemosyne [Internet]. [cited 2013 Feb 20]. 2nd ed. GPLv2. Available from: http://www.mnemosyne-proj.org/

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Letters Articles

Adult pertussis vaccinations as a preventative method for infant morbidity and mortality

Pertussis, or whooping cough, is a potentially fatal respiratory illness caused by the Bordetella pertussis bacteria. It commonly occurs in infants who have not completed their primary vaccination schedule. [1]

Since 2001, Australia’s coverage rate with the three primary doses of the diphtheria, tetanus and acellular pertussis-containing vaccine (DTPa) at twelve months has been greater than 90%. [2] Despite this high coverage rate, there has been a sharp increase in the incidence of pertussis. In 2008, the Victorian Government received notification of a 56% increase in reported cases (1,644 cases in 2008 compared to 1054 cases in 2007). That same year, New South Wales also reported over 7,500 cases, more than tripling their 2007 total. [3] Given these startling statistics, we must ask ourselves why we are seeing such a significant rise in the incidence of pertussis.

One well researched explanation for this increase is that the pertussis vaccine is not conferring lifelong immunity. A North American study investigating the effectiveness of the pertussis vaccine found that there was a significant increase in laboratory-confirmed cases of clinical pertussis in children aged eight to 13 years. This correlated to the interval after the end of the preschool vaccinations. [4] Other studies have suggested that immunity can wane anywhere between three to 12 years post vaccination, creating ambiguity as to when we become susceptible again. [5,6] This limitation is due to the current non-existence of a clear serologic marker correlating with protection from pertussis. Approximately two years after vaccination, pertussis toxin antibodies have reached minimal levels; however, protection from the disease remains. This suggests immunity is multifactorial. [5]

Despite this, there is widespread agreement that adults with waning immunity and who are in close contact with non-immune infants are a major source of transmission. [6,7] In 2001, a study was published which analysed the source of infection in 140 infants under the age of twelve months who had been hospitalised for pertussis. In the 72 cases where the source of infection could be identified, parents were the source in 53% of cases and siblings accounted for another 22%. [8] The Australian paediatric surveillance unit study of 110 hospitalised infants with pertussis demonstrated adults to be the source in 68% of cases, 60% of which were the parents of the infant in question. [9] Other potential sources that have been identified include grandparents and paediatric health workers. [6]

Since the establishment in 2001 of the international collaboration, the Global Pertussis Initiative (GPI), strategies to decrease the incidence of pertussis have been extensively discussed, with particular emphasis on reducing adult transmission to unprotected infants. [6] In general it has been noted that the control of pertussis requires an increase in immunity in all age groups, especially in adults. [10] Although the GPI agrees that universal adult vaccination would be an effective strategy to protect non-immune infants, this would be too difficult to implement. [2,8] Furthermore, we must be aware that the success of herd immunity is dependent upon the level of population coverage and also the degree of contact between the infected and the non-immune infants. [11]

Due to the difficulties with implementing universal adult vaccinations, more targeted vaccination strategies have been proposed. [10] The concept of a ‘cocoon’ strategy, in which adults in close contact with unprotected infants are given booster vaccinations, [11] has been trialed throughout Australia in various forms. [12] This strategy is simpler to implement, as new parents and family members are easier to access via their contact with health services and their motivation to protect their children. [6] Moreover, because of this motivation, it may be reasonable to assume new parents would be willing to pay for this vaccine out of their own pockets, reducing the economic burden of the increased use of vaccines on our health system.

One model has suggested routine adult vaccination every ten years from the age of 20 years, combined with the ‘cocoon’ strategy of vaccination, would best reduce the rate of infant pertussis infections. However, to date there are no clinical data confirming this strategy to be effective. [11] Furthermore, this particular model is unlikely to receive public funding due to the large expense required.

Another strategy, recently recommended by the Advisory Committee on Immunisation Practices (ACIP), is that of implementing maternal vaccinations. The ACIP reviewed data in 2011 that showed preliminary evidence that there were no adverse effects after the administration of the pertussis vaccine to pregnant women. This strategy would significantly reduce the risk of infection to infants before they were even born. [13]

As one can see, the question of how to increase immunity in our community is complex, given that current strategies are expensive and difficult to implement. As infant deaths from pertussis are easily avoidable, developing effective preventive strategies should be of high priority.

Conflict of interest

None declared.

Correspondence

T Trigger: talia.trigger@my.jcu.edu.au

References

[1] World Health Organisation. Pertussis vaccines: WHO position paper. WHO. 2010; 40: 385-400.
[2] Chuk LR, Lambert SB, May ML, Beard F, Sloots T, Selvey C et al. Pertussis in infants: how to protect the vulnerable. Commun Dis Intell. 2008; 32(4): 449-455.
[3] Fielding J, Simpson K, Heinrich-Morrison K, Lynch P, Hill M, Moloney M et al. Investigation of a sharp increase in notified cases of pertussis in Victoria during 2008. Victorian Infectious Diseases Bulletin. 2009; 12(2): 38-42.
[4] Witt MA, Katz PH, Witt DJ. Unexpectedly limited durability of immunity following acellular pertussis vaccination in pre-adolescents in a north American outbreak. Clinical Infectious Diseases. 2012; 54(12): 1730-1735.
[5] Wendelboe AM, Van Rie A, Salmaso S, Englund J. Duration of immunity against pertussis after natural infection or vaccination. The Paediatric Infectious Disease Journal. 2005; 24(5).
[6] Forsyth KD, Campins-Marti M, Caro J, Cherry J, Greenberg D, Guiso N et al. New pertussis vaccination strategies beyond infancy: recommendations by the global pertussis initiative. Clinical Infectious Diseases. 2004; 39: 1802-1809.
[7] Spratling R, Carmon M. Pertussis: An overview of the disease, immunization, and trends for nurses. Pediatric Nursing. 2010; 36(5): 239-243.
[8] Jardine A, Conaty SJ, Lowbridge C, Staff M, Vally H. Who gives pertussis to infants? Source of infection for laboratory confirmed cases less than 12 months of age during an epidemic, Sydney, 2009. Commun Diss Intell. 2010; 34(2): 116-121.
[9] Wood N, Quinn HE, McIntyre P, Elliott E. Pertussis in infants: preventing deaths and hospitalisations in the very young. Jounal of Paediatrics and Child Health. 2008; 44(4): 161-165.
[10] Hewlett EL, Edwards KM. Pertussis – not just for kids. The New England Journal Of Medicine. 2005; 352(12): 1215-1223.
[11] McIntyre P, Wood N. Pertussis in early infancy: disease burden and preventive strategies. Current Opinion In Infectious Diseases. 2009; 22: 215-223.
[12] Australian Government Department of Health and Ageing. Pertussis. Australian Immunisation Handbook 9th Edition [Internet]. 2008[cited 2013 Feb19]; 227-239. Available from: http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/23041983E698DFB7CA2574E2000F9A05/$File/3.14%20Pertussis.pdf
[13]. Advisory Committee on Immunization Practices (ACIP). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) in pregnant women and persons who have or anticipate having close contact with an infant aged <12 months. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report. 2011; 60(41): 1424-1426.

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Articles Letters

Management of high-grade vulvar intraepithelial neoplasia

Vulval intraepithelial neoplasia (VIN) is a condition which is increasingly prevalent, particularly in young women, [1] but is a topic rarely touched upon in medical school. The following article reviews current treatment methods for VIN, both surgical and pharmacological, as well as promising new treatment modalities still being researched.

VIN is a condition in which pre-cancerous changes occur in the vulval skin. The incidence of the diagnosis of VIN is approximately 3/100,000, increasing more than four fold since 1973. [2] Vulvar intraepithelial neoplasia is classified into two main groups based on morphologic and histologic features, consisting of VIN usual group and VIN differentiated type. VIN usual group can be subdivided into basaloid and warty subtypes, typically occurs in younger, premenopausal women and is related to HPV infection and cigarette smoking. VIN differentiated type typically occurs in postmenopausal women and is often associated with lichen sclerosus, which presents as white patches on vulval skin. The rate of progression to invasive vulvar cancer in women with untreated high-grade VIN is reported to range from 9.0 to 18.5%. [3] Half of women with VIN are symptomatic, with pruritis, perineal pain or burning, dysuria, a visible lesion or a palpable abnormality. The lesions themselves are often multifocal, raised and can vary in colour from white to red, gray or brown. Diagnosis involves a colposcopic examination, where VIN lesions produce dense acetowhite lesions with or without punctuation. The goals of treatment are prevention of progression to invasive vulvar cancer and symptom relief, as well as preservation of normal vulvar function and anatomy.

Current surgical therapies include excisional treatments or vulvectomy. The main advantage of excisional therapies over ablative or medical treatment is the ability to make a histopathological diagnosis based on the excised lesion, particularly as occult invasive squamous cell carcinoma is present in many of these women. [4]

Wide local excision is the preferred initial intervention for women in whom clinical or pathologic findings suggest invasive cancer, despite a biopsy diagnosis of VIN, to obtain a specimen for pathologic analysis. [4] Localised high-grade VIN lesions are best managed by superficial local excision of an individual lesion, with reported recurrence rates of 20 to 40%. [5]

Multifocal or extensive lesions that are not amenable to removal with local excision are best removed with a partial or simple vulvectomy. This involves removal of part of or the entire vulva, respectively, together with subcutaneous tissue and perineal tissues if indicated; [5] a last resort as neither normal function nor anatomy are preserved.

Laser ablation therapy is an alternative to excisional therapy, particularly for women with multifocal and extensive disease in whom cancer is not suspected. [6] CO2 laser vaporisation has been shown to be effective in eradicating VIN while achieving good cosmetic and functional results, with success rates of 40 to 75%. [6-7]

A systematic review showed that there were no significant differences in recurrence after vulvectomy, partial vulvectomy, local excision or laser evaporisation. [8]

Medical therapies aimed at preserving the vulvar anatomy are useful in younger patients, provided colposcopic examination and biopsies have excluded invasive disease. The primary medical treatment available is Imiquimod 5% cream, which has antiviral and antitumour effects via stimulation of local cytokine production and cell-mediated immunity. [9] A Cochrane review [1] concluded for women with high grade VIN, Imiquimod was better than placebo in terms of reduction in lesion size and histologic regression. This conclusion was based on the findings of three randomised placebo-controlled trials, with the largest trial reporting a complete response rate of 35% and partial response of 46%. [10] Common side effects reported were erythema, soreness, itching, burning, ulceration and flu-like symptoms; however, these side effects were be reduced by placing patients on an escalating dosing regimen. [1]

Agents such as cidofovir, 5-fluorouracil and photodynamic therapy are currently being investigated as treatment for vulval intraepithelial neoplasia. Cidofovir is an acyclic nucleoside analogue with antiviral activity, and a pilot study shows promising results. [11] 5-fluorouracil is a chemotherapeutic agent that inhibits DNA synthesis, with a review demonstrating a remission rate of 34%; [12] however, this agent is used less commonly in current practice. Photodynamic therapy, whereby a sensitizing agent is applied prior to irradiation of the vulva, has been demonstrated to cause complete response in 33 to 55% of patients with VIN 2-3. [7,13]

The major surgical interventions for VIN appear to be similarly effective and are appropriate when there is desire for a histopathological specimen to exclude invasive cancer. Medical interventions are useful when occult cancer is unlikely and preservation of normal vulvar anatomy is desired. Evidence appears to be strongest for Imiquimod as a conservative medical intervention for the treatment of high grade VIN. Other promising agents include cidofovir, but further investigation through large scale studies is required to characterise the efficacy of these therapies. Diligent follow-up is essential in detecting disease recurrence and monitoring the effectiveness of therapies. More research is needed to develop effective treatment strategies that preserve function and anatomy, particularly as the disease becomes more prevalent in young women.

Conflict of interest

None declared.

Correspondence

S Ai: sylvia.ai3@gmail.com

References

[1] Pepas L, Kaushik S, Bryant A, Nordin A, Dickinson HO. Medical interventions for high grade vulval intraepithelial neoplasia. Cochrane Database of Systematic Reviews 2011, Issue 4. Art. No.: CD007924. DOI: 10.1002/14651858.CD007924.pub2.
[2] Judson PL, Habermann EB, Baxter NN, Durham SB, Virnig BA. Trends in the incidence of invasive and in situ vulvar carcinoma. Obstet Gynecol 2006:107(5):1018-22
[3] Joura EA. Epidemiology, diagnosis and treatment of vulvar intraepithelial neoplasia. Gynaecol Oncol Path 2002:14(1):39-43
[4] NSW Department of Health. Best Clinical practice gynaecological cancer guidelines 2009. [online]. Accessed on 28/4/2012 from http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0010/154549/go_clinical_guidelines.pdf
[5] Holschneider CH. Vulval intraepithelial neoplasia. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2012.
[6] Hillemanns P, Wang X, Staehle S, Michels W, Dannecker C. Evaluation of different treatment modalities for vulvar intraepithelial neoplasia (VIN): CO2 laser vaporisation, photodynamic therapy, excision and vulvectomy. Gynecol Oncol 2006:100(2):271-5
[7] Sideri M, Spinaci L, Spolti N, Schettino F. Evaluation of CO2 laser excision or vaporisation for the treatment of vulvar intraepithelial neoplasia. Gynecol Oncol 1999:75:277-81.
[8] Van seters, M, van Beurden, M, de Craen, AJM. Is the assumed natural history of vulvar intraepithelial neoplasia III based on enough evidence? A systematic review of 3322 published patients. Gynecol Oncol 2004:97(2):645-51
[9] Mahto M, Nathan M, O’Mahony C. More than a decade on: review of the use of imiquimod in lower anogenital intraepithelial neoplasia. Int J STDs AIDs 2010:21(1):8-16
[10] Van Seters M, van Beurden M, ten Kate FJW, Beckmann I, Ewing PC, Eijkemans MJC et al. Treatment of vulvar intraepithelial neoplasia with topical imiquimod. NEJM 2008:358:1465-73
[11] Tristram A, Fiander A. Clinical responses to cidofovir applied topically to women with high grade vulval intraepithelial neoplasia. Gynecol Oncol 2005:99(3):652
[12] Sillman FH, Sedlis A, Boyce JG. A review of lower genital intraepithelial neoplasia and the use of topical 5-fluorouracil. Obstet Gynecol Survey 1985:40(4):190-220
[13] Fehr MK, Hornung R, Schwarz VA, Haller SU, Wyss P. Photodynamic therapy of vulvar intraepithelial neoplasia III using topically applied 5-aminolevulinic acid. Gynecol Oncol 2001:80(1):62-6

Categories
Letters Articles

Pentraxin 3 – A new player in twinning frequency

The conception of dizygotic twins is a complex trait.

It is thought to be influenced by a variety of environmental and genetic factors and displays significant regional variation in prevalence worldwide. [1] For example, in Sub-Saharan areas of Africa, twinning is very common (~23 per 1000 pregnancies), while in Asia twinning is much rarer (~5-6 per 1000 pregnancies). [2] Recent research has sought to determine the reasons behind the increased frequency of twinning in regions of Sub-Saharan Africa. Independent studies of women from Gambia and Upper East Ghana have given insight into gene mutations which may possibly increase the fertility of women and hence the frequency of twinning. Specifically, it was found that certain single-nucleotide polymorphisms (SNPs) in the gene of pentraxin 3 (PTX3), a key player in human fertility and innate immunity, occurred in higher frequency amongst the mothers of twins. [3] This report will review the known functions of PTX3 in immunity and fertility and their relation to twinning frequency.

Pentraxin 3 in innate immunity

PTX3 is a soluble pattern recognition receptor, which belongs to the acute phase reactants superfamily. [4] In the innate immune response, PTX3 is produced in response to primary pro-inflammatory signals such as interleukin 6 (IL-6) release or toll-like receptor activation. [5] It participates in immunity by recognising pathogens, facilitating complement activation and opsonisation. [6] Indeed, it is involved in immune defence against Aspergillus, Pseudomonas, Salmonella, Mycobacterium tuberculosis, cytomegalovirus and influenza. [7-9] Known mechanisms of anti-pathogenic action include the binding of sialylated ligands on PTX3 to membrane proteins such as haemagglutinins found in influenza viruses and cytomegaloviruses. As haemagglutinins are used by viruses for fusion and entry to host cells, the binding of PTX3 ligands to the haemagglutinins can block this function and hence lower the chance of viral infection.  [7,8] The anti-viral actions of PTX3 against cytomegalovirus can also activate downstream immune components such as interferon regulatory factor 3 (IRF3) and the interleukin-12/interferon gamma (IL-12/IFN)-γ-dependent effector pathway, which in turn heighten anti-fungal defences against species such as Aspergillus. [8] Previous experiments performed by Garlanda et al. also show that PTX3-null mouse models were more susceptible to fungal infections, suggesting that PTX3 plays a non-redundant antifungal role. [10]

Pentraxin 3 in fertility

PTX3 is not only a major player in immunity, it has also been demonstrated to be linked to fertility in various studies. Specifically, PTX3 interacts with proteins such as TNF-stimulated gene 6 (TSG6) and inter-alpha-trypsin inhibitor (IαI) to form multimolecular constructs which facilitate cross-linking in the hyaluronan matrix that surrounds the cells of the cumulus oophorus. [11] This is crucial to the stability and organisation of the cumulus matrix, as shown in animal studies where PTX3-null mice produced ova with abnormal cumulus oophorus, which led to lower litter counts. [12,13] The infertility resulting from PTX3 knockout is not surprising as a functional cumulus oophorus is required for oocyte maturation, movement to oviduct and penetration by sperm. [14-16] Notably, mouse and human PTX3 are highly conserved, suggesting that PTX3 may play a similar role in humans. [4] Further supporting the key, non-redundant roles of PTX3 in fertility is the finding that PTX3 is one of the most highly upregulated genes during the pro-inflammatory cascade at the foetal-maternal interface, which is crucial to decidualisation, blastocyst invasion, anchorage and implantation. [17-20]

Pentraxin 3 in twinning

It is clear that PTX3 plays a crucial role in immunity and fertility. Tying all these findings together is  research by Sirugo et al. and May et al. which demonstrate associations between twinning, female fertility and PTX3 SNPs in humans. [3,21] Sirugo et al. demonstrated that the frequency of certain PTX3 haplotypes differed in frequency between mothers of twins and mothers without twins in a sample of 130 Gambian sister pairs (p = 0.006– 3.03×10-6, depending on haplotype). [3] In concordance with this, data from May et al. based on a population study suggest that those findings may indeed be due to increased fertility conferred by the PTX3 mutations. [21] It was found that women with more than12 children had SNPs in PTX3 causing the highest production of PTX3 and that women with less than 2 children had SNPs which conferred the lowest production of PTX3. Specifically, rs6788044 SNP, which was associated with the highest PTX3 production (p = 0.003), was also associated with the highest fertility (p = 0.043). In addition, increased ex vivo LPS-induced PTX3 production, suggesting better immunity, was also associated with increased fertility (p = 0.040). [21]

Conclusion

Taken together, the data suggests that PTX3 may contribute to the high rates of twinning in Sub-Saharan Africa.  As increased PTX3 expression confers improved innate immune response, local selective pressures due to disease may skew epigenetic controls to favour these particular variants in particular populations where a strong immune response is crucial.  [3] Certain SNPs of PTX3 which are selected for also confer increased fertility, via mechanisms such as increased cumulus oophorus stability and regulation of the pro-inflammatory cascade of implantation.  While the role of PTX3 in multiple ovulations – a primary factor of dizygotic twinning – is still unclear, the contribution of PTX3 to successful implantation is also vital to twinning, by increasing the chance of survival of multiple blastocysts. In conclusion, the available evidence suggests that PTX3 may be an important contributor to twinning, at least in some African populations.

Conflict of interest

None declared.

Acknowledgements

I thank God, my family, the Brisbane research team I worked with and my Griffith University lecturers for their guidance and support of me in pursuing a career in medicine and research.

Correspondence

G Yeung: grassy_grace@hotmail.com

References

[1] Hoekstra C, Zhao ZZ, Lambalk CB, Willemsen G, Martin NG, Boomsma DI, et al. Dizygotic twinning. Human reproduction update. 2008;14[1]:37-47.

[2] Bulmer M. The biology of twinning in Man. Oxford, United Kingdom: Oxford Clarendon Press, 1970.

[3] Sirugo G, Edwards DRV, Ryckman KK, Bisseye C, White MJ, Kebbeh B, et al. PTX3 genetic variation and dizygotic twinning in The Gambia: could pleiotropy with innate immunity explain common dizygotic twinning in Africa? Annals of Human Genetics. 2012.

[4] Garlanda C, Bottazzi B, Bastone A, Mantovani A. Pentraxins at the crossroads between innate immunity, inflammation, matrix deposition, and female fertility. Annual review of immunology. 2005;23:337-66.

[5] Bottazzi B, Garlanda C, Salvatori G, Jeannin P, Manfredi A, Mantovani A. Pentraxins as a key component of innate immunity. Current opinion in immunology. 2006;18[1]:10-5.

[6] Bottazzi B, Garlanda C, Cotena A, Moalli F, Jaillon S, Deban L, et al. The long pentraxin PTX3 as a prototypic humoral pattern recognition receptor: interplay with cellular innate immunity. Immunological reviews. 2009;227[1]:9-18.

[7] Reading PC, Bozza S, Gilbertson B, Tate M, Moretti S, Job ER, et al. Antiviral activity of the long chain pentraxin PTX3 against influenza viruses. The Journal of Immunology. 2008;180[5]:3391-8.

[8] Bozza S, Bistoni F, Gaziano R, Pitzurra L, Zelante T, Bonifazi P, et al. pentraxin 3 protects from MCMV infection and reactivation through TLR sensing pathways leading to IRF3 activation. Blood. 2006;108[10]:3387-96.

[9] Olesen R, Wejse C, Velez DR, Bisseye C, Sodemann M, Aaby P, et al. DC-SIGN [CD209], pentraxin 3 and vitamin D receptor gene variants associate with pulmonary tuberculosis risk in West Africans. Genes Immun. 2007;8[6]:456-67.

[10] Garlanda C, Hirsch E, Bozza S, Salustri A, De Acetis M, Nota R, et al. Non-redundant role of the long pentraxin PTX3 in anti-fungal innate immune response. Nature. 2002;420[6912]:182-6.

[11] Scarchilli L, Camaioni A, Bottazzi B, Negri V, Doni A, Deban L, et al. PTX3 interacts with inter-alpha-trypsin inhibitor: implications for hyaluronan organization and cumulus oophorus expansion. The Journal of biological chemistry. 2007;282[41]:30161-70.

[12] Salustri A, Garlanda C, Hirsch E, De Acetis M, Maccagno A, Bottazzi B, et al. PTX3 plays a key role in the organization of the cumulus oophorus extracellular matrix and in in vivo fertilization. Development. 2004;131[7]:1577-86.

[13] Varani S, Elvin JA, Yan C, DeMayo J, DeMayo FJ, Horton HF, et al. Knockout of pentraxin 3, a downstream target of growth differentiation factor-9, causes female subfertility. Mol Endocrinol. 2002;16[6]:1154-67.

[14] Wassarman P. The mammalian ovum. Knobil E NJ, editor. New York: Raven Press; 1988.

[15] Yanagimachi R. Mammalian fertilization. Knobil E NJ, editor. New York: Raven Press; 1988.

[16] Tesarik J MOC, Testart J. Effect of the human cumulus oophorus on movement characteristics of human capacitated spermatozoa. J Reprod Fertil. 1990;88:665-75.

[17] Garlanda C, Maina V, Martinez de la Torre Y, Nebuloni M, Locati M. Inflammatory reaction and implantation: the new entries PTX3 and D6. Placenta. 2008;29 Suppl B:129-34.

[18] Hess AP, Hamilton AE, Talbi S, Dosiou C, Nyegaard M, Nayak N, et al. Decidual stromal cell response to paracrine signals from the trophoblast: amplification of immune and angiogenic modulators. Biology of reproduction. 2007;76[1]:102-17.

[19] Popovici RM, Betzler NK, Krause MS, Luo M, Jauckus J, Germeyer A, et al. Gene expression profiling of human endometrial-trophoblast interaction in a coculture model. Endocrinology. 2006;147[12]:5662-75.

[20] Tranguch S, Chakrabarty A, Guo Y, Wang H, Dey SK. Maternal pentraxin 3 deficiency compromises implantation in mice. Biology of reproduction. 2007;77[3]:425-32.

[21] May L, Kuningas M, Bodegom Dv, Meij HJ, Frolich M, Slagboom PE, et al. Genetic Variation in Pentraxin [PTX] 3 Gene Associates with PTX3 Production and Fertility in Women. Biology of reproduction. 2010;82[2]:299-304.

 

Categories
Articles Editorials

Thought the ‘bed shortage’ was bad, until the ‘surgeon shortage’ came along

“Make up your mind how many doctors a community needs to keep it well. Do not register more or less than this number.’’ George Bernard Shaw

If you have ever had the opportunity of finding yourself in a surgical theatre, the last thing you want to have on your mind are doubts about the person holding the scalpel. To ensure the highest professional standards are maintained, trainees of the Royal Australasian College of Surgeons (RACS) undergo a rigorous five to six year postgraduate training program prior to final qualification as a surgical consultant. [1] However, such a long and demanding training program has proven to be a double-edged sword for the surgical speciality. Studies have shown that one in four surgeons plan to retire in the next five years and that only sixteen percent of surgeons were under 40 years old. [2] The same study demonstrated that the average retirement age for surgeons has decreased by ten years. [2] These factors place an immense amount of pressure on surgical training programs, particularly in an era where the ageing population is creating more demand for surgical services. [2] While workforce shortage issues are by no means unique to the RACS, and indeed are felt by many medical colleges across Australia, this editorial will focus on the RACS to illustrate the issues affecting a broad range of medical specialities.

Along with many medical colleges around Australia, the RACS faces a looming workforce crisis with an ageing workforce approaching retirement and an ageing population with increasing healthcare needs, combining to create a critical demand for scarce services. The 2011 annual report published by the RACS highlighted that the number of first year surgical trainees across all specialties was 246 [3] compared to the 3000+ medical students graduating from around the country each year. While this represents a relatively small fraction of the available workforce pool, the RACS has taken the initiative to increase the number of surgical trainee positions by twelve percent compared to 2010. [3] Despite these gains, the RACS estimates that at least another 80 surgeons will have to graduate each year in addition to the 184 new surgeons currently graduating each year, in order to begin to redress surgeon workforce shortage. [4,5]

Low trainee numbers represent a composite of many factors, including financial limitations, need for skilled supervision and opportunity for practical experience. [6] The public sector has reached its full capacity for surgical training posts as such posts are funded by the State governments hence they are limited by budget provisions. [5] Consequently, underfunding, chronic shortage of nursing staff and lack of resources in public hospitals are seen as some of the main reasons for extended waiting times for surgery. [7] Due to the lack of such resources, it is a common trend now to see surgical lists being limited or procedures being cancelled because of time constraints. [7] Increasing the number of trainee posts will require significant fundamental changes, namely greater resourcing of the public health system. [6] To avoid the looming workforce crisis, governments will have to move quickly to ensure adequate training posts are in place across all medical specialties. [3,5] In Australia, more than 60% of elective surgery is in the private sector. [5] Novel training opportunities, such as those offered by the private sector, should also be considered as clinicians with the appropriate range and depth of experience required to train junior doctors are not limited to the public sector. [5] Lack of resources, funding, safe working hours and reduced clinical exposure are all elements that add to this crisis of looming workforce shortage. [6,8]

While there is a compelling argument to expand the number of trainee positions around Australia, the challenge is to maintain the highest standards for surgical trainees. [7] Emphasis on the number of training positions created is the priority of any college and is a crucial aspect in offering quality treatment in both the public and private hospitals. [7] However, increasing the number of trainees to accommodate and cope with surgeon shortage might result in reduced individual theatre time, which is not acceptable. [4,7] While this may relieve the workforce shortage, however, it would only create more specialists with limited exposure to a wide range of surgical presentations. [7] The aim of surgical training is to ensure that trainees progress through an integrated program that provides them with the highest professional responsibility under appropriate supervision. [9] This not only ensures exceptional quality but also enables trainees to acquire the competencies needed to perform independently as qualified surgeons. There are concerns nonetheless that if there is a large intake of surgeon trainees it may favour ‘quantity’ of trained surgeons over ‘quality’. [7] This is unacceptable, not only for the safety of our patients, but also in a world of increasing medico-legal implications and litigation. [7]

Another challenge affecting the surgical profession and surgical trainees is the issue of safe working hours. Currently, the reported working hours of the surgical workforce on average is 60 hours per week, excluding 25 hours per week on average spent on-call. [5] Although safe working hours are less of an issue in Australia than the rest of the world, it still affects surgical training. [10] Safety and wellbeing of surgical trainees is a top priority of the RACS. [7] Reduced trainee hours have been encouraged by research showing that doctor fatigue compromises patient care, as well as awareness that fatigue hampers learning. [10] Long hours traditionally worked by surgeons may result in concerns regarding safe working hours and the possibility that the next generation of surgeons will seek enhanced work-life balance. [4,7] Adding to the ominous shortage of surgeons, the challenge still remains whether surgical trainees can still assimilate the necessary clinical experience in this reduced timeframe. [7] More and more trainees place increased emphasis on work-life balance [5], making alternate specialisation pathways a real possibility that many consider.

Many, if not all, of the issues felt by the RACS across Australia are rarefied in rural Australia. Rural general surgery, much like its general practice counterpart, is facing an impending crisis of workforce numbers. [11] Despite increasing urbanisation, approximately 25% of Australians still live in rural Australia [12] and it is this portion of the population that is likely to be the first and worst affected by any further constriction in medical workforce numbers. Single or two-man surgical practices provide service to many rural and remote centres. [11] However in many areas where surgical services could be supported, no trainee surgeon is available. [11] Many current rural surgeons are also fast approaching retirement age. [11] In past years retention of surgeons in rural communities has been strong. [13] The lifestyle benefits, challenges and rewards all combined, have ensured that a large amount of rural surgeons are growing old in the country. [13] However, this perception may well be a thing of the past. [13] Younger surgeons are more likely to consider time off on call, annual leave and privacy as lifestyle considerations which compel them back towards the metropolitan area. [13] Such a shift in attitude towards limiting one’s workload combined with the continuing decline in Australian rural practices will apply various additional pressures on the rural surgeon workforce in the near future. [11]

Two main factors that determine if a trainee surgeon is more likely to pursue a rural career are the exposure to good quality rural terms as an undergraduate and having a rural background. [11,13] Selections for rural posts are more common in doctors from a country background who are more likely to return to, and remain in, a rural practice. [12,13] Acknowledging this factor, many Australian medical schools have now incorporated both mandatory and voluntary rural terms as a part of their curriculum. [11] In addition to these undergraduate initiatives, ongoing rural placements during postgraduate years may need to be established and given greater prominence. [11] A trainee being allocated to the same rural location over a period of years increases the possibility of the trainee settling in the same rural location following their training. [13] This may be due to familiarity with the social and cultural setting as well as the desire to provide continuous care for his/her patients. [13] As a result of these undergraduate and/or postgraduate initiatives, we can expect to witness the next generation of advanced surgical trainees with a foundation of rural experience, demonstrating a willingness to undertake rural terms as an accepted and expected component of their general surgery training. [11,13] These trainees may then choose to settle in the same rural location following training, thus decreasing the rural surgeon shortage.

The aim of surgical training is to ensure that trainees progress through an integrated program that provides them with increasing professional responsibility under appropriate supervision. [8] This enables them to acquire the competencies needed to perform independently as qualified surgeons. [9] The RACS has taken major steps to address its workforce shortage. Continuing efforts to provide for trainees and their needs are given place of prominence in the RACS 2011-2015 strategic plan. The RACS’ role in monitoring, coordinating, planning and provisioning of services, as well as obtaining adequate funding for surgical training programs, remains a major responsibility of the College. Emphasis on rural rotations at an undergraduate and early postgraduate level, consideration of the work-life balance of both trainees and surgeons and sufficient staffing of theatres, will help eradicate the surgeon shortage whilst ensuring that the finest surgical education and care is available to Australians into the future.

Conflict of interest

None declared.

Correspondence

J Goonawardena: j.goonawardena@amsj.org

References

[1] The College of Physicians and Surgeons of Ontario. Tackling the Doctor Shortage. Ontario: CPSO; 2004. p. 5

[2] Surgeon shortage looms. The Hobart Mercury 2006 March 22:26

[3] The College of Surgeons of Australia and New Zealand. The Royal Australasian College of Surgeons Annual Report 2010. Melbourne: RACS; 2011. p. 9

[4] Royal Australasian College of Surgeons. (2011, October 7). Surgeons warn of looming workforce crisis [Media release]. Retrieved from http://www.surgeons.org/media/293538/MED_2011-10-07_Surgeons_warn_of_looming_workforce_crisis.pdf

[5] Royal Australasian College of Surgeons. RACS 2011: Surgical Workforce Projection to 2025 (for Australia). Melbourne: RACS; 2011. P. 8-57

[6] Amott DH, Hanney RM. The training of the next generation of surgeons in Australia. Ann R Coll Surg Engl 2006; 88:320–322.

[7] Berney CR. Maintaining adequate surgical training in a time of doctor shortages and working time restriction. ANZ J Surg. 2011; 81:495–499.

[8] Australian Medical Association Limited. (2005 April 5). States and territories must stop passing the buck on surgical training [Media Release]. Retrieved from http://ama.com.au/node/1966

[9] Hillis DJ. Managing the complexity of change in postgraduate surgical education and training. ANZ J Surg. 2009; 79: 208–213.

[10] O’Grady G, Loveday B, Harper S, Adams B, Civil ID, Peters M. Working hours and roster structures of surgical trainees in Australia and New Zealand. ANZ J Surg. 2010; 80: 890–895.

[11] Bruening MH, Anthony AA, Madern GJ. Surgical rotations in provincial South Australia: The trainees’ perspective.  ANZ  J Surg. 2003; 73: 65-68.

[12] Green A. Maintaining surgical standards beyond the city in Australia. ANZ  J Surg. 2003; 73: 232-233.

[13] Kiroff G. Training, retraining and retaining rural general surgeons. Aust. N.Z.J. Surg. 1999; 69:413-414.

 

Categories
Articles Editorials

Freedom of information

Early last year, a David and Goliath battleraged between the most unlikely of foes. The gripes of a single blog post inspired a group of disaffected mathematicians and scientists to join forces and boycott the world’s largest publisher of scientific journals, Elsevier. Their movement, dubbed “Academic Spring”, was in response to the company’s political backing of the Research Works Act, a proposed bill in the United States (US) aimed at denying public access to scientific research funded by the US National Institute of Health (NIH). Drafted solely to benefit the interests of publishing companies, Elsevier reneged on its support for the bill following months of escalating protests and scathing publicity. Though the bill never saw the light of day, the struggle that unfolded was symptomatic of a more deep-seated and pervasive conflict between academics and publishers; a conflict that has been thrown into sharp relief by the rise of online publishing.

Since the publication of the first scholarly journal in 1665, journals have played an integral role in the scientific process. [1] As vanguards of modern day science, journals have been an enduring and authoritative source of the latest scientific research and developments. Academics form a key ingredient in the turnover and success of journals. Not only are they responsible for generating content, but they also volunteer as peer-reviewers for submissions relevant to their field of expertise and as mediators of the editorial process; a peculiar arrangement that plays into the hands of publishers. Before the arrival of the internet, journals facilitated the quick and widespread exchange of information throughout the scientific world. Publishers performed services including proofing, formatting, copyediting, printing, and worldwide distribution. [1] The digital age, however, rendered many of these tasks redundant and allowed publishers to dramatically reduce their costs. [1] Publishers also used the opportunity to offload further responsibilities onto the shoulders of academics, such as formatting and most copyediting, in order to significantly increase profits despite playing a limited role in the journal’s overall production.

The changing landscape of scientific publishing has seen commercial publishing firms acquire a lion’s share of the market from not-for-profit scientific societies in the last few decades. [2] The resulting monopolistic stranglehold has led to exorbitant subscription fees for access to their treasury of knowledge. Profit margins have hovered between 30-40 percent for over a decade, due in part to subscription prices outpacing inflation by seven percent per annum. [3] Moreover, publishers have exploited the practice of offering journals subscriptions in bundles, rather than on an individual needs basis, a crucial ploy underlying their profits. [4] Long-standing price increases, accompanied by dwindling library budgets, have gravely hampered the ability of libraries, universities, and investigators to acquire the most up-todate publications necessary for research and education. [4] The total expenditure on serials by Australian university libraries in 2010 was a staggering AU$180 million. [5] Even the most affluent libraries, such as Harvard, are declaring the situation as untenable and are resorting to subscriptions cuts. [3]

Along with cost, the principle of access for clinicians, scientists, and the general public alike underscores the ensuing debate. There is little argument that the accessibility of scientific findings is critical to the advancement of scientific progress. Consequently, the great paywalls of publishing houses have fostered an environment that stagnates the translation of science to the bedside and stifles medical innovation. Peer-reviewed literature is often funded by taxpayer-supported government grants. In Australia and New Zealand, over 80% of research and development is funded by the public purse. [6] In effect, governments have been held ransom by firms privatizing the profits accruing to publicly-financed knowledge. The barriers of access and cost also extend to developing nations. Without access to reliable medical literature, efforts to develop sustainable health care systems in these regions are severely undermined.

Researchers are equally culpable for their current plight. Typically, works of intellectual property warrant financial remuneration. However, writing for impact instead of payment has become both intrinsic and unique to academic journals, a paradigm from centuries before when journals were unable to pay authors for their work. [3] Impact, a proxy measure developed by commercial publishers, reflects an academic journal’s visibility for a given year. It is derived from the ratio between the average number of citations per article received during the two preceding years and the total number of articles it published during the same period. [7] The higher the impact factor of a journal, the greater its clout and influence. The importance placed on impact factor has become ingrained in the collective psyche of academia. Academics are competitively assessed on their publication record in scientific journals to secure grants and advance their careers. Inevitably, researchers have become servile to an archaic system, which serves only the interests of commercial publishers.

Open access (OA) represents a new business model in the academic journal industry, underpinned by the growth and reach of the internet. It provides unfettered online access to all research material, as well as the right to copy and redistribute it without restrictions. [1] Open access (OA) uses two channels of distribution: the “gold” or the “green” paths. [1] The “gold” path publishes articles in freely available OA journals that maintain peer review to preserve their academic reputations. The Public Library of Science (PLoS) and BioMed Central (BMC) are leading examples of OA publishers. The “green” path requires authors to self-archive their work on an online repository, available free of charge to the public. [1] Table 1 highlights some of the differences between traditional and OA journals.

Open access (OA) offers many advantages compared to traditional journal publishing. Evidence shows that OA has substantially increased the amount of scholarly work available to all, regardless of economic status or institutional affiliation, increasing the probability of research being read and, accordingly, of being cited. [8] Open access (OA) can integrate new technological approaches such as text mining, collaborative filtering, and semantic indexing, and has the potential to encourage new research methodologies. [8] A significant bone of contention with traditional journals has been the need for authors to relinquish copyright of their material. Open access (OA) allows authors to retain copyright, and provides readers and other authors with the rights to re-use, re-publish, and, in some cases, create derivatives of their work. [8] Furthermore, OA bridges both the digital and physical divide between the developing and developed worlds, mitigating some of the limitations faced by scientists in low-income countries to publish their work. Institutional repositories and OA publication fee waivers have been instrumental in promoting their research profile onto the international stage, by shedding the burden of cost. [9]

Despite offering free access to readers, OA has been plagued by its share of criticism. Traditional publishing firms, one of its fiercest opponents, contend that OA journals shift the cost of production from consumer to author, with fees ranging from $1,000-5,000 per article. [3] Whilst levelling this critique, commercial firms overlook the fact that they also foist publication fees onto authors which may even exceed the costs of OA journals. [1,3] Publication costs are now a common element in grant fund applications, and authors incur minimal to no charge. Inevitably, ethical concerns also arise from the OA model. The author-pay model may compromise the peerreview process as journals become financially dependent on researchers to publish articles. However, these concerns have been assuaged in recent years, due to the widespread number of high-quality OA journals that employ robust peer-review on par with their subscription counterparts. [1] The “green” route also poses problems for authors who may not possess the technical capabilities or resources to self-archive articles.
Open access (OA) represents the fastest growing business model for academic journals, and is likely to remain sustainable in the long-term. Many OA journals are now highly trusted, referenced, indexed, and well received. Its support has been bolstered by the evolving mandates of research funding agencies, including Australia’s National Health and Medical Research Council (NHMRC), the United Kingdom’s Wellcome Trust, and the NIH, placing research funded by their grants into the public domain within a year of initial publication. [7,10] Major data aggregators are also facilitating this trend, including PubMed and OVID, releasing OA databases and platforms dedicated to OA material. [11] Estimates project that 60 percent of all journal content will be published in OA journals by 2019. [11] Moreover, OA journals are rapidly approaching the same scientific impact and quality as subscription journals, particularly in the field of biomedicine, as suggested by one study. [7] Many have opined that OA could redefine measures of impact, using additional metrics such as number of downloads, bookmarks, tweets, and Facebook likes.Proponents of OA have turned their attention to how corporations like drug and chemical companies can support its efforts, which benefit from free access while contributing only a small subset of scientific articles and fees overall.

The advent of the internet has created a realm of possibilities for some and a minefield of challenges for others. Journals have navigated such obstacles for centuries, embracing new opportunities and adapting to change. Although the internet has effectively transformed publishers into “de facto” gatekeepers of their lucrative commodity, it has also been the impetus behind the OA revolution, proving to be a more cost-effective and equitable alternative to traditional publishing. But while OA continues to develop into the mainstay of journal publishing, perhaps its most immediate impact will be to diversify competition and precipitate a cultural change within the industry that sees science re-emerge at the forefront of its interests.

Conflict of interest
None declared.

Correspondence
S Chatterjee: s.chatterjee@amsj.org

References

[1] Albert KM. Open access: Implications for scholarly publishing and medical libraries. J Med Libr Assoc. 2006 Jul;94(3):253-62.

[2] Jha A. Academic spring: How an angry maths blog sparked a scientific revolution. The Guardian. 2012 Apr 9.

[3] Owens S. Is the academic publishing industry on the verge of disruption. U.S. News and World Report. 2012 Jul 23.

[4] Taylor MP. Opinion: Academic publishing is broken. The Scientist. 2012 Mar 19.

[5] Australian higher education statistics [Internet]. Council of Australian University Librarians; 2009 [updated 2012 Nov 29; cited 2013 Mar 5]. Available from: http://www.caul.edu.au/caul-programs/caul-statistics/auststats.

[6] Soos P. The great publishing swindle: The high price of academic knowledge. The Conversation. 2012 May 3.

[7] Björk BC, Solomon D. Open access versus subscription journals: A comparison of scientific impact. BMC Med. 2012;10(73).

[8] Wilbanks J. Another reason for opening access to research. BMJ. 2006;333(1306).

[9] Chan L, Aruachalam A, Kirsop B. Open access: A giant leap towards bridging health inequities. Bull. World Health Organ. 2009;87:631-635.

[10] Dissemination of research findings [Internet]. National Health and Medical Research Council; 2012 Feb 12 [updates 2013 Jan 25; cited 2013 Mar 4]. Available from: http://www.nhmrc.gov.au/grants/policy/disseminationresearch-findings

[11] Rohrich RJ, Sullivan D. Trends in medical publishing: Where the publishing industry is going. Plast Reconstr Surg. 2012;131(1):179-81.

Categories
Editorials Articles

The Australian Medical Student Journal: a nationwide endeavour

Welcome to Volume 4, Issue 1 of the Australian Medical Student Journal.

This issue of the AMSJ continues to develop our core aims of supporting medical student research by providing a dedicated journal for publication of outstanding medical student work and a focus on issues relevant to Australia in general and Australian medical students in particular. Key milestones for the Australian Medical Student Journal over the past months have included the online publication of the Australian Students’ Surgical Conference, the expansion of our editorial team to include seven new members, each talented upcoming physician-scientists, and a broader expansion of our medical student staff. Senior AMSJ staff are now located in every state across Australian and there are representatives at each medical school.

This issue the AMSJ received an unprecedented number of outstanding submissions from medical students across the country. Some key highlights for this issue include a timely review by Boulat and Hatwal of the case for male HPV vaccination. This review, published as the Australian government announces its world first initiative of immunising young men against HPV, was identified by our editorial team and reviewers as a excellent review of an important contemporary public health issue and has been awarded the best article prize for Volume 4, Issue 1. Other notable submissions include a rigorous comparative review of anaesthetic methods for paediatric elective inguinal herniotomy, a synopsis of treatment options for preventing cardiac sequelae in Kawasaki disease, a reflective essay on the humanising influence of fiction in psychiatry, and a case report of spontaneous intracranial hypotension. Editorials by Saion Chatterjee and Janindu Goonawardena discuss structural changes occurring in academic publishing and the current challenges faced by the medical workforce across Australia. We are also privileged to host articles from prominent Australians: Professor Larkins, Chair of European Molecular Biology Laboratory-Australia (EMBL-Australia) and the Victorian Comprehensive Cancer Centre (VCCC), Professor Bolitho, President of the Royal Australia College of Physicians (RACP) and Professor Hollands, President of the Royal Australia College of Surgeons (RACS), to provide a top-down perspective on issues important to medical students.

Health and medical research in Australia faces key challenges including sustainability and international competitiveness. The recent McKeon Review of Health and Medical Research in Australia provides a framework for how Australian researchers can help to maximise the health of all Australians and contribute on a global scale. A major facet of this review is the emphasis on collaboration. In a country with a population less than one fiftieth of our neighbours, China and India, and public research expenditure less than one thirtieth of the United States, collaboration is an integral component to achieving global impact. In his guest article, Professor Larkins, Chair of EMBL-Australia and the VCCC, offers his advice and experience as the Chair of two leading collaborative research initiatives in Australia. With the upcoming federal budget and election, we also spotlight the issue of sustainability in the healthcare system. Professor Bolitho of the RACP provides a considered perspective on the measures required to accommodate increasing numbers of medical graduates. Professor Hollands of the RACS and Associate Editor Janindu Goonawardena provide complementary perspectives on contemporary surgical training in Australia and discuss potential measures to address rural medical workforce shortages.

This issue of AMSJ represents the accumulation of many hours of voluntary work from AMSJ staff and reviewers. We have been privileged to lead a team of highly motivated, intelligent and hardworking medical students from across the country, without whom publication of this journal would not be possible. We would additionally like to thank our external peer reviewers, many who completed their first review this issue and many more who regularly contribute their time and expertise to the AMSJ. The initiative of publicly thanking reviewers will be continued this year, and their names published in the latter half of the year. Finally, we would like to thank all authors who contributed to the AMSJ and all our readers, who provide content and meaning to this publication. We hope you enjoy this issue and that it serves as motivation for medical students and nascent authors of future publications.