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Postgraduate Medical Journal current issue

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Alcohol and other substance use among medical and law students at a UK university: a cross-sectional questionnaire survey


Purpose of the study

To examine the use of alcohol and other substances among medical and law students at a UK university.

Study design

Anonymous cross-sectional questionnaire survey of first, second and final year medical and law students at a single UK university.


1242 of 1577 (78.8%) eligible students completed the questionnaire. Over half of first and second year medical students (first year 53.1%, second year 59.7%, final year 35.9%) had an Alcohol Use Disorders Identification Test (AUDIT) score suggestive of an alcohol use disorder (AUDIT≥8), compared with over two-thirds of first and second year law students (first year 67.2%, second year 69.5%, final year 47.3%). Approximately one-quarter of medical students (first year 26.4%, second year 28.4%, final year 23.7%) and over one-third of first and second year law students (first year 39.1%, second year 42.4%, final year 18.9%) reported other substance use within the past year. Over one-third of medical students (first year 34.4%, second year 35.6%, final year 46.3%) and approximately half or more of law students (first year 47.2%, second year 52.7%, final year 59.5%) had a Hospital Anxiety and Depression Scale anxiety score suggestive of a possible anxiety disorder.


Study participants had high levels of substance misuse and anxiety. Some students’ fitness to practice may be impaired as a result of their substance misuse or symptoms of psychological distress. Further efforts are needed to reduce substance misuse and to improve the mental well-being of students.

Stopping antithrombotic therapy after acute upper gastrointestinal bleeding is associated with reduced survival



Antithrombotic drugs are often stopped following acute upper gastrointestinal bleeding (AUGIB) and frequently not restarted. The practice of antithrombotic discontinuation on discharge and its impact on outcomes are unclear.


To assess whether restarting antithrombotic therapy, prior to hospital discharge for AUGIB, affected clinical outcomes.


Retrospective cohort study.


University hospital between May 2013 and November 2014, with median follow-up of 259 days.


Patients who underwent gastroscopy for AUGIB while on antithrombotic therapy.


Continuation or cessation of antithrombotic(s) at discharge.

Main outcomes measures

Cause-specific mortality, thrombotic events, rebleeding and serious adverse events (any of the above).


Of 118 patients analysed, antithrombotic treatment was stopped in 58 (49.2%). Older age, aspirin monotherapy and peptic ulcer disease were significant predictors of antithrombotic discontinuation, whereas dual antiplatelet use predicted antithrombotic maintenance. The 1-year postdischarge mortality rate was 11.3%, with deaths mainly due to thrombotic causes. Stopping antithrombotic therapy at the time of discharge was associated with increased mortality (HR 3.32; 95% CI 1.07 to 10.31, P=0.027), thrombotic events (HR 5.77; 95% CI 1.26 to 26.35, P=0.010) and overall adverse events (HR 2.98; 95% CI 1.32 to 6.74, P=0.006), with effects persisting after multivariable adjustment for age and peptic ulcer disease. On subgroup analysis, the thromboprotective benefit remained significant with continuation of non-aspirin regimens (P=0.016). There were no significant differences in postdischarge bleeding rates between groups (HR 3.43, 0.36 to 33.04, P=0.255).


In this hospital-based study, discontinuation of antithrombotic therapy is associated with increased thrombotic events and reduced survival.

Surgical safety checklist training: a national study of undergraduate medical and nursing student teaching, understanding and influencing factors



Use of the WHO surgical safety checklist is consistently recognised to reduce harm caused by human error during the perioperative period. Inconsistent engagement is considered to contribute to persistence of surgical Never Events in the National Health Service. Most medical and nursing graduates will join teams responsible for the perioperative care of patients, therefore appropriate undergraduate surgical safety training is needed.


To investigate UK medical and nursing undergraduate experience of the surgical safety checklist training.


An eight-item electronic questionnaire was distributed electronically to 32 medical schools and 72 nursing schools. Analysis was conducted for the two cohorts, and responses from final year students were included.


87/224 (38.8%) of medical students received teaching on the surgical safety checklist, compared with 380/711 (52.0%) of nursing students. 172/224 (76.8%) of medical students and 489/711 (66.9%) of nursing students understood its purpose and 8/224 (3.6%) medical students and 54/711 (7.4%) nursing students reported never being included in the Time Out. After adjusting for confounding factors, provision of formal teaching in checklist use increased understanding significantly (OR 50.39 (14.07 to 325.79, P<0.001)), as did routine student involvement in time outs (OR 5.72 (2.36 to 14.58, P<0.001)).


Knowledge of perioperative patient safety systems and the ability to participate in safety protocols are important skills that should be formally taught at the undergraduate level. Results of this study show that UK undergraduate surgical safety checklist training does not meet the minimum standards set by the WHO.

Surgical academic reach: the higher degree effect quantified



Proof of professional specific academic attainment is embedded within the Joint Committee on Surgical Training 2013 general surgery curriculum, mandating that all higher general surgical trainees (HST) obtain three peer-reviewed publications to qualify for Certification of Completion of Training. Yet, Modernising Medical Careers (MMC) has been associated with a trend away from the gold standard postgraduate credentials of higher degrees by research. This study aimed to evaluate the academic achievements of a post-MMC UK Deanery HST cohort to determine what additional benefits higher degree study might confer.


The Scopus bibliographic database (Elsevier, RELX Group) was used to characterise the academic profiles of 101 consecutive HSTs and supplemented with Intercollegiate Surgical Programme Curriculum data. Primary outcome measures were numbers of publications, citations and Hirsch indices (HI).


Thirty-seven HSTs (36.6%) had been awarded higher degrees (29 Doctor of Medicine, 8 Doctor of Philosophy). Academic profiles of HSTs with higher degrees were stronger than those of HSTs without, specifically: median (range) publication numbers 16 (2–57) vs 2 (0–11, P<0.001), citations 93 (0–1600) vs 6 (0–132, P<0.001), first author publications 6 (0–33) vs 3 (0–106, P<0.001), communications to learnt societies 30 (5–79) vs 8 (2–35, P<0.001) and HI 6 (1–26) vs 1 (0–6, P<0.001).


Proof of academic reach by higher degree was associated with important enhanced professional credentials, strengthening HIs sixfold. Trainers and trainees alike should be aware of the relative magnitude of such benefits when planning educational programmes.

Securing a cardiology speciality training programme in the UK: how did other people do it?



Application to cardiology specialty training is competitive with uncertainty among candidates as to what the secret recipe for a successful appointment is. We aimed to investigate objective variables, which were demonstrated by successful appointees to cardiology training schemes in the UK.


Data from successful cardiology applicants for the years 2014 to 2016 were obtained from the Joint Royal Colleges of Physicians Training Board under the Freedom of Information Act. These data included basic demographics as well as objective scores awarded for selection categories such as qualifications, academic, teaching and other achievements.


There were a total of 976 applicants during the study period, of whom 423 were successfully appointed, generating a competition ratio of 2.3 applicants for each position. There was an increasing proportion of successful female applicants (22% in 2014, 28% in 2015 and 32% in 2016). Median scores for postgraduate exams (14/14), presentations (6/6) and quality improvement (10/10) scores corresponded to maximum possible scores, whereas median scores for additional undergraduate and postgraduate degrees were 0. Median scores for prizes, publications and teaching experience were 6/10, 4/8 and 9/10, respectively.


The secret to a successful cardiology training appointment is associated with completion of all postgraduate clinical exams, completion and presentation of quality improvement projects, national presentations and substantial teaching achievements. At least half of the successful candidates had no additional undergraduate or postgraduate degrees but had evidence of some prizes and publications. The ratio of successful female candidates is rising, but remains less than males in cardiology training.

Tricks of the trade: time management tips for newly qualified doctors



The transition from medical student to doctor is an important milestone. The discovery that their time is no longer their own and that the demands of their job are greater than the time they have available is extremely challenging.


At a recent surgical boot camp training programme, 60 first-year surgical trainees who had just completed their internship were invited to reflect on the lessons learnt regarding effective time management and to recommend tips for their newly qualified colleagues. They were asked to identify clinical duties that were considered urgent and important using the time management matrix and the common time traps encountered by newly qualified doctors.


The surgical trainees identified several practical tips that ranged from writing a priority list to working on relationships within the team. These tips are generic and so applicable to all newly qualified medial doctors.

Potential implication

We hope that awareness of these tips from the outset as against learning them through experience will greatly assist newly qualified doctors.

A systematic review of interventions to foster physician resilience


This review aimed to synthesise the literature describing interventions to improve resilience among physicians, to evaluate the quality of this research and to outline the type and efficacy of interventions implemented. Searches were conducted in April 2017 using five electronic databases. Reference lists of included studies and existing review papers were screened. English language, peer-reviewed studies evaluating interventions to improve physician resilience were included. Data were extracted on setting, design, participant and intervention characteristics and outcomes. Methodological quality was assessed using the Downs and Black checklist. Twenty-two studies were included. Methodological quality was low to moderate. The most frequently employed interventional strategies were psychosocial skills training and mindfulness training. Effect sizes were heterogeneous. Methodologically rigorous research is required to establish best practice in improving resilience among physicians and to better consider how healthcare settings should be considered within interventions.

Effect of prescription medications on erectile dysfunction


Erectile dysfunction (ED) affects about 50% of men in the USA and is primarily attributed to physiological (organic) and psychological causes. However, a substantial portion of men suffer from ED due to iatrogenic causes. Common medications such as antihypertensives, non-steroidal anti-inflammatory drugs and antacids may cause ED. Physicians should be aware of the various prescription medications that may cause ED to properly screen and counsel patients on an issue that many may feel too uncomfortable to discuss. In this review, we discuss the physiology, data and alternative therapies for the ED caused by medications.

Split hand/foot malformation: a potential clue to underlying FGFR1 mutation in patients with isolated congenital hypogonadotropic hypogonadism



Congenital hypogonadotropic hypogonadism (CHH) is characterised by absent or arrested pubertal development due to abnormal hypothalamic gonadotropin-releasing hormone (GnRH) secretion or its action. A number of candidate genes (more than 20) have been identified to underlie CHH either acting alone or in combination. The prototype example of isolated CHH is Kallmann syndrome (KS) which has four subtypes: type 1 (mutation in anosmin gene), type 2 (mutation in fibroblast growth factor receptor 1 (FGFR1)), type 3 ((mutation in prokinecitin receptor 2 (PROKR2)) and type 4 (mutation in prokinecitin). Loss-of-function mutations of FGFR1 or KS2 are responsible for about 10%–12% of patients with CHH. FGFR1 is expressed in a number of tissues, including the brain and skeletal system. Spontaneous reversal of CHH with restoration of normal gonadal functions is seen in about 20% of patients and many of them have FGFR1 mutation.

Case history

Two teenaged sisters (19 years and 16 years) were referred for evaluation of delayed development...

Doctor wont see you now: changing paradigms in mountain medicine


The evolution in communication and digital technologies is revolutionising the practice of medicine. A physician is now able to oversee provision of healthcare at a distance. In this paper, we argue that practice of telemedicine is an essential and evolving aspect of high altitude and expedition medicine. We acknowledge the lack of international consensus, limited legislation as well as possible reservations towards telemedical practice. Given some unique social and medical aspects of participation in remote, high altitude expeditions we propose a number of guiding principles for those involved in provision of telemedical services for such endeavours.

Hydroxychloroquine-induced restrictive cardiomyopathy: a case report


Case presentation

A man in his 60s presented to our clinic for worsening exercise capacity, dyspnoea on exertion for 18 months and chest pain not associated with exercise. He had medical history of rheumatoid arthritis (RA), Sjogren’s syndrome, Raynaud’s phenomenon, gastro-oesophageal reflux, dyslipidaemia and Parkinson’s disease. He was on hydroxychloroquine (HCQ) for RA at the time of presentation. A nuclear stress test was normal. Cardiac angiogram showed left ventricular ejection fraction of 55%, normal coronary arteries, normal systolic pulmonary pressure but elevated left ventricular end-diastolic pressure, right atrial pressure, pulmonary capillary wedge pressure and right ventricular end-diastolic pressure, which were compliant with diastolic dysfunction and possibly infiltrative cardiomyopathy.

Two-dimensional (2D) echocardiogram showed left ventricular relaxation abnormality and pulmonary hypertension. Cardiac MRI (CMR) showed thin myocardial wall with basement segment thickness of 0.7 cm, well below average myocardial mass and dilated right ventricle. There was no evidence of myocardial scar, infarction...

A proposal based on a review of reforms for improving medical education in India


Medical education is a continuum that extends from undergraduate (MBBS) to postgraduate and continuing medical education.1 The MBBS course has been one of the sought-after courses in India. However, the preference of Indian students to become doctors is probably declining in recent years. Some of the reasons for this could be the long duration of medical education and paucity of programme with career-specific orientation. MBBS graduates are trained with the aim of channelling them to cater to primary healthcare. However, evidence shows that medical students prefer to practice after obtaining higher degrees; also, patients demand care from such doctors. The number of postgraduate seats and training sites are limited. This possibly creates imbalance in the healthcare delivery system. There is also paucity of curricular reforms which reflect the increase in specialisations.2 Owing to the advances in medical science, there is a felt need for today’s...

Whatever happened to silence?


Silence used to be integral to medicine. It now seems to be disappearing. A generation or two ago, hospital wards were often as quiet as places of worship. Doctors proceeded along the beds in ceremonial calm, and a sister or charge nurse would reprimand any nurse whose voice was raised above a murmur. Today, the sound environment has deteriorated badly in many places. All day and night, electronic machines bleep and whirr, alarms go off constantly, trolleys clatter and squeak, and staff banter with each other. As studies show, noise in some hospitals has now reached truly problematical levels, impairing patients’ rest and sleep, and presumably their health as well.1 2

Silence is disappearing from medicine in other ways too. In the past, it was common for doctors to make careful use of silence in their conversations with patients, sometimes for five or ten seconds at...