Chapter 3 Defining Difference

Ovariotomy provides a useful way of unpacking not just the process of surgical innovation but also the usefulness of innovation as an analytical category in the history of medicine. How might we pin down the meaning of “innovation”—let alone “alternative innovation”—in surgery when these innovations themselves are unstable, changing entities that are difficult to define? Through the example of ovariotomy I show that alternative innovation need not necessarily imply competition between diverse innovations, but that such a framework might also be used to consider how different versions of the “same” operation arise

Belly-Rippers, Surgical Innovation and the Ovariotomy Controversy

This open access book looks at the dramatic history of ovariotomy, an operation to remove ovarian tumours first practiced in the early nineteenth century. Bold and daring, surgeons who performed it claimed to be initiating a new era of surgery by opening the abdomen. Ovariotomy soon occupied a complex position within medicine and society, as an operation which symbolised surgical progress, while also remaining at the boundaries of ethical acceptability. This book traces the operation’s innovation, from its roots in eighteenth-century pathology, through the denouncement of those who performed it as ‘belly-rippers’, to its rapid uptake in the 1880s, when ovariotomists were accused of over-operating. Throughout the century, the operation was never a hair’s breadth from controversy

Beyond ‘born not made’: challenging character, emotions and professionalism in undergraduate medical education

In this article we explore the historical antecedents and ongoing perpetuation of the idea that medical professionals must adhere to a specific ‘character’. In the late nineteenth century, an ideal of the medical student as ‘born not made’ was substantiated through medical school opening addresses and other medical literature. An understanding prevailed that students would have a natural inclination that would suit them to medical work, which was predicated on class structures. As we move into the twentieth-century context, we see that such underpinnings remained, even if the idea of ‘character’ becomes ‘characteristics’. This was articulated through emerging psychological and sociological perspectives on education, as well as medical school admission processes. The significance ascribed to character and characteristics-based suitability continues to exclude and limits who can access medical careers. In the final part of the article, we argue that a framework of uncertainty can and should be mobilised to re-evaluate the role of doctors’ education and critique long-standing notions of professional identity, via the integration of medical humanities and clearer professionalism teaching within medical curricula

Diphtheria and the risk of outbreaks of vaccine-preventable diseases in low-resource settings

This study aims to highlight the complex and multifaceted nature of vaccination drivers, uptake, and hesitancy in the face of the recent outbreak of diphtheria in Nigeria and its significant impact on the regional and global burden of disease. The outbreak has highlighted the continuing threat and vulnerability of vaccine-preventable disease (VPD) outbreaks or epidemics due to the low vaccine uptake in the country and across Sub-Saharan Africa (SSA). This study first identifies recent drivers and challenges to vaccine uptake. It then promotes the need for regionally based, interdisciplinary approaches with a focus on visual communication strategies, particularly in low-literacy settings. Ultimately, visual communication strategies would benefit from a broader evidence base to better understand the effectiveness and impact of design in promoting vaccine uptake. The study recommends that in the Nigerian context, addressing the threat of VPD outbreaks should be embedded in communication strategies, especially when they are designed considering the local population. This should occur alongside strategies to reduce psychological impact factors like stress associated with travel time for vaccination and waiting time at healthcare facilities. Vaccination programs should be linked to local sources of safety or individuals with high credibility to increase trust; healthcare workers should stop exaggerating the effectiveness of vaccines to stimulate demand; and fathers should be considered an important target group in intervention programs

The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial

Objective To evaluate whether a new computerised cognitive behavioural therapy intervention (SPARX, Smart, Positive, Active, Realistic, X-factor thoughts) could reduce depressive symptoms in help seeking adolescents as much or more than treatment as usual

The utility of presentation and 4-hour high sensitivity troponin I to rule-out acute myocardial infarction in the emergency department

Objectives: International guidance recommends that early serial sampling of high sensitivity troponin be used to accurately identify acute myocardial infarction (AMI) in chest pain patients. The background evidence for this approach is limited. We evaluated whether on presentation and 4-hour high-sensitivity troponin I (hs-cTnI) could be used to accurately rule-out AMI. Design and methods: hs-cTnI was measured on presentation and at 4-hours in adult patients attending an emergency department with possible acute coronary syndrome. We determined the sensitivity for AMI for at least one hs-cTnI above the 99th percentile for a healthy population or alone or in combination with new ischemic ECG changes. Both overall and sex-specific 99th percentiles were assessed. Patients with negative tests were designated low-risk. Results: 63 (17.1%) of 368 patients had AMI. The median (interquartile range) time from symptom onset to first blood sampling was 4.8. h (2.8-8.6). The sensitivity of the presentation and 4. h hs-cTnI using the overall 99th percentile was 92.1% (95% CI 82.4% to 97.4%) and negative predictive value 95.4% (92.3% to 97.4%) with 78.3% low-risk. Applying the sex-specific 99th percentile did not change the sensitivity. The addition of ECG did not change the sensitivity. Conclusion: Hs-cTnI >. 99th percentile thresholds measured on presentation and at 4-hours was not a safe strategy to rule-out AMI in this clinical setting irrespective of whether sex-specific 99th percentiles were used, or whether hs-cTnI was combined with ECG results

Heart Fatty Acid Binding Protein and cardiac troponin: development of an optimal rule-out strategy for acute myocardial infarction

Background: Improved ability to rapidly rule-out Acute Myocardial Infarction (AMI) in patients presenting with chest pain will promote decongestion of the Emergency Department (ED) and reduce unnecessary hospital admissions. We assessed a new commercial Heart Fatty Acid Binding Protein (H-FABP) assay for additional diagnostic value when combined with cardiac troponin (using a high sensitivity assay). Methods: H-FABP and high-sensitivity troponins I (hs-cTnI) and T (hs-cTnT) were measured in samples taken on-presentation from patients, attending the ED, with symptoms triggering investigation for possible acute coronary syndrome. The optimal combination of H-FABP with each hs-cTn was defined as that which maximized the proportion of patients with a negative test (low-risk) whilst maintaining at least 99 % sensitivity for AMI. A negative test comprised both H-FABP and hs-cTn below the chosen threshold in the absence of ischemic changes on the ECG. Results: One thousand seventy-nine patients were recruited including 248 with AMI. H-FABP 99 % sensitivity for AMI whilst classifying 40.9 % of patients as low-risk. The combination of H-FABP < 3.9 ng/mL and hs-cTnT < 7.6 ng/L with a negative ECG maintained the same sensitivity whilst classifying 32.1 % of patients as low risk. Conclusions: In patients requiring rule-out of AMI, the addition of H-FABP to hs-cTn at presentation (in the absence of new ischaemic ECG findings) may accelerate clinical diagnostic decision making by identifying up to 40 % of such patients as low-risk for AMI on the basis of blood tests performed on presentation. If implemented this has the potential to significantly accelerate triaging of patients for early discharge from the ED

Death and the doctor: the museum as a tool for understanding the needs of the dying

Over the past several years, the Ashmolean Museum at Oxford has been part of a multi- disciplinary team examining the question of how we train medical students to deal with those parts of their profession which are concerned primarily with the humanity of their patients. In collaboration with colleagues from Neuroscience, Psychiatry, History and Theology, the Museum has participated in an ongoing teaching experiment in which medical history, ethics and the visual arts are brought to bear on an understanding of medical professionalism - what it means to be a doctor and how to be a better one. Bringing together museum professionals, Expert Patient Tutors and doctors in curriculum planning and delivery, the work has been delivered online, using images from the museum’s collections, and live, using the Ashmolean galleries as spaces for the consideration of issues around death, dying and end-of-life care. This article and its preface reflect broadly on a decade of medical collaboration at the Ashmolean and specifically on the processes of both making and delivering teaching on dealing with death, in a cross-disciplinary, non-medical context, asking not only what the Museum can do for medical education but why medical education needs the museum

Computerised cognitive behavioural therapy for gender minority adolescents: Analysis of the real-world implementation of SPARX in New Zealand

Objective: SPARX is a form of computerised cognitive behavioural therapy (CBT) in serious game format funded via the Ministry of Health to be freely available in New Zealand. At registration users identify themselves as male, female, transgender or another option. We aimed to establish whether adolescent transgender users of SPARX, compared to adolescent male and female users, were more likely to have high mental health needs at baseline and were more likely to complete SPARX. We also sought to determine transgender adolescents’ reductions in depressive symptoms after using SPARX. Methods: Quantitative analysis of five years of usage data from the nation-wide delivery of SPARX in New Zealand. Results: There were 9079 adolescents who completed the registration process and used SPARX, 2.3% (n=207) identified as transgender. The majority of transgender registrants (69.0%) completing a baseline Patient Health Questionnaire - modified for Adolescents (PHQ-A) were categorised as having high mental health needs, significantly more so than male and female registrants (p<0.001). Over half of SPARX registrants completed the first module of the program, with subsequently lower proportions of transgender registrants completing Module 4 (p=0.005) and Module 7 (i.e. the last module, p=0.048). Of those registrants completing a baseline and subsequent PHQ-A, both male (n=247) and female (n=630) registrants, on average, had improvements in their scores (2.68 and 3.15 respectively) whereas transgender registrants (n=14) did not (-0.43) (p=0.048). Conclusion: This is the first study describing the impact of an e-therapy on transgender young people. The analysis of data from this free self-help intervention suggests that: transgender adolescents seeking treatment for depression have particularly high mental health needs; and, an existing well tested tool may be less effective for them than it is for others. Taken together the results appear to suggest targeted efforts may be required for transgender adolescents