Is it time for integration of surgical skills simulation into the United Kingdom undergraduate medical curriculum? A perspective from King’s College London School of Medicine

PURPOSE: Changes in undergraduate medical curricula, combined with reforms in postgraduate education, have training implications for surgical skills acquisition in a climate of reduced clinical exposure. Confidence and prior experience influences the educational impact of learning. Currently there is no basic surgical skills (BSS) programme integrated into undergraduate curricula in the United Kingdom. We explored the role of a dedicated BSS programme for undergraduates in improving confidence and influencing careers in King's College London School of Medicine, and the programme was evaluated. METHODS: A programme was designed in-line with the established Royal College of Surgeons course. Undergraduates were taught four key skills over four weeks: knot-tying, basic-suturing, tying-at-depth and chest-drain insertion, using low-fidelity bench-top models. A Likert-style questionnaire was designed to determine educational value and influence on career choice. Qualitative data was collected. RESULTS: Only 29% and 42% of students had undertaken previous practice in knot-tying and basic suturing, respectively. 96% agreed that skills exposure prior to starting surgical rotations was essential and felt a dedicated course would augment undergraduate training. There was a significant increase in confidence in the practice and knowledge of all skills taught (p<0.01), with a greater motivation to be actively involved in the surgical firm and theatres. CONCLUSION: A simple, structured BSS programme can increase the confidence and motivation of students. Early surgical skills targeting is valuable for students entering surgical, related allied, and even traditionally non-surgical specialties such as general practice. Such experience can increase the confidence of future junior doctors and trainees. We advocate the introduction of a BSS programme into United Kingdom undergraduate curricula

Binder-free all-carbon composite supercapacitors

Carbon-based electrode materials have widely been used in supercapacitors. Unfortunately, the fabrication of the supercapacitors includes a polymeric binding material that leads to an undesirable addition of weight along with an increased charge transfer resistance. Herein, binder-free and lightweight electrodes were fabricated using powder processing of carbon nanofibers (CNFs) and graphene nanoplatelets (GNPs) resulting in a hybrid all-carbon composite material. The structural, morphological, and electrochemical properties of the composite electrodes were studied at different concentrations of GNPs. The specific capacitance (Cs) of the CNFs/GNPs composite was improved by increasing the concentration of GNPs. A maximum Cs of around 120 F g−1 was achieved at 90 wt% GNPs which is around 5-fold higher in value than the pristine CNFs in 1 M potassium hydroxides (KOH), which then further increased to 189 F g−1 in 6 M KOH electrolyte. The energy density of around 20 Wh kg−1 with the corresponding power density of 340 W kg−1 was achieved in the supercapacitor containing 90 wt% GNPs. The enhanced electrochemical performance of the composite is related to the presence of a synergistic effect and the CNFs establishing conductive/percolating networks. Such binder-free all-carbon electrodes can be a potential candidate for next-generation energy applications

Living biointerfaces based on non-pathogenic bacteria to direct cell differentiation

Genetically modified Lactococcus lactis, non-pathogenic bacteria expressing the FNIII7-10 fibronectin fragment as a protein membrane have been used to create a living biointerface between synthetic materials and mammalian cells. This FNIII7-10 fragment comprises the RGD and PHSRN sequences of fibronectin to bind α5β1 integrins and triggers signalling for cell adhesion, spreading and differentiation. We used L. lactis strain to colonize material surfaces and produce stable biofilms presenting the FNIII7-10 fragment readily available to cells. Biofilm density is easily tunable and remains stable for several days. Murine C2C12 myoblasts seeded over mature biofilms undergo bipolar alignment and form differentiated myotubes, a process triggered by the FNIII7-10 fragment. This biointerface based on living bacteria can be further modified to express any desired biochemical signal, establishing a new paradigm in biomaterial surface functionalisation for biomedical applications

The interaction of Wnt-11 and signalling cascades in prostate cancer

Prostate cancer (PCa) is the second most common cancer among the male population. Conventional therapies target androgen signalling, which drives tumour growth; however, they provide limited survival benefits for patients. It is essential, therefore, to develop a more specific biomarker than the current gold standard, PSA testing. The Wnt signalling pathway induces expression of target genes through cell surface receptors. A non-canonical member of this family, Wnt-11, is evolutionarily highly conserved and is normally expressed by various cells in the developing embryo, as well as in the heart, liver and skeletal muscle of adult humans. We comprehensively review several cell signalling pathways to explain how they interact with Wnt-11, demonstrating its use as a potential biomarker for PCa. Several studies have shown that the expression of Wnt-11 is associated with gastric, renal and colorectal adenocarcinomas and PCa. Moreover, Wnt-11 affects extracellular matrix composition and cytoskeletal rearrangement, and it is required for proliferation and/or survival during cell differentiation. It was found that PCa cell lines express high levels of Wnt-11, which allows differentiation of the epithelial prostate tumour cells to neuron-like (NE) cells. The NE cells produce additional factors that can cause regression after treatment. Accumulating evidence shows that Wnt-11 could be a potential biomarker in diagnosing PCa. Many studies have shown both non-canonical and canonical Wnts interact with several signalling cascades such as PKC, JNK, NF-κB, Rho, PKA and PI3K. In particular, evidence demonstrates Wnt-11 is involved in the progression of PCa, thus it could have the potential to become both a specific disease marker and an important therapeutic target

Unlocking the Transcriptomes of Two Carcinogenic Parasites, Clonorchis sinensis and Opisthorchis viverrini

The two parasitic trematodes, Clonorchis sinensis and Opisthorchis viverrini, have a major impact on the health of tens of millions of humans throughout Asia. The greatest impact is through the malignant cancer ( = cholangiocarcinoma) that these parasites induce in chronically infected people. Therefore, both C. sinensis and O. viverrini have been classified by the World Health Organization (WHO) as Group 1 carcinogens. Despite their impact, little is known about these parasites and their interplay with the host at the molecular level. Recent advances in genomics and bioinformatics provide unique opportunities to gain improved insights into the biology of parasites as well as their relationships with their hosts at the molecular level. The present study elucidates the transcriptomes of C. sinensis and O. viverrini using a platform based on next-generation (high throughput) sequencing and advanced in silico analyses. From 500,000 sequences, >50,000 sequences were assembled for each species and categorized as biologically relevant based on homology searches, gene ontology and/or pathway mapping. The results of the present study could assist in defining molecules that are essential for the development, reproduction and survival of liver flukes and/or that are linked to the development of cholangiocarcinoma. This study also lays a foundation for future genomic and proteomic research of C. sinensis and O. viverrini and the cancers that they are known to induce, as well as novel intervention strategies

Minor Myocardial Injury After Percutaneous Coronary Intervention in Patients with Stable Angina: Pre-Existing Inflammation & Clinical Outcome.

Minor myocardial injury (MMI) is relatively common after complicated percutaneous coronary interventions (PCI) and is associated with increased risk of future cardiac events. It is possible that MMI may be detected by elevation of cardiac markers (e.g. enzymes and cardiac troponins). However, the occurrence, mechanism and long term outcome of minor myocardial injury after uncomplicated successful elective PCI in patients with stable angina has not been assessed previously. Cardiac troponins have been shown to be more sensitive and specific than CKMB for the detection of MMI. Therefore, the first purpose of our work was to study the occurrence of MMI after uncomplicated successful elective PCI in patients with stable angina by measuring cardiac troponin levels in serum after the procedure and to compare these results with serum CKMB. Much recent evidence supports the inflammatory nature of atherosclerotic coronary artery disease. Several inflammation markers have been implicated in this process with their serum concentrations increased in a variety of atherosclerotic disease. With this rapidly developing field in mind, the second purpose of our work was to examine the association of the systemic inflammatory state, reflected by different inflammation markers, with the occurrence of MMI. Such an association has never been studied before in this selected group of patients. Since relating the occurrence of MMI after PCI to outcome has important implications for clinical practice of interventional cardiology, the third purpose of the study was to prospectively evaluate the long-term prognostic significance of MMI after elective uncomplicated successful PCI which has never been reported before in patients with stable angina. Serum cardiac troponin I (cTnl), cardiac troponin T (cTnT) and creatine kinase MB (CKMB) levels were measured before and after uncomplicated, successful elective PCI in patients with stable angina. The frequencies of elevated cTnl and cTnT levels were significantly higher than that of CKMB after coronary intervention (p =0.00016 and 0.015, respectively). Inflammatory markers including serum levels of high-sensitivity C-reactive protein (CRP), interleukin-6, tumor necrosis factor-&alpha;, and intercellular adhesion molecule-1 were measured before PCI and were related to the occurrence of MMI after the procedure, and subjects were followed-up for adverse cardiac events for 24 months. Serum CRP was the only inflammatory marker that related to the occurrence of MMI after the procedure. CRP levels were above the reference range in 41% of patient group; of these, 46% developed MMI after PCI compared to 18% of patients that had a serum CRP within the reference range (p= 0.008). Patients with and without presumed MMI, identified by elevated cTnl levels, did not differ significantly with respect to age, body mass index, conventional coronary risk factors, medications, or severity of pre-existing coronary artery disease. Over a follow-up period of 24 months there was no significant difference in the medication used between the MMI positive and negative groups. The incidence of recurrent angina, repeat PCI, coronary bypass surgery and cardiac death was 54, 46,4 and 4% respectively in the cTnl positive patients versus 27, 16, 4 and 0% in the cTnl negative patients. Kaplan-Meier survival analysis showed that cTnl elevation was significantly related to cardiac events (p =0.0198, by log rank analysis). In conclusion, MMI identified by elevated serum levels of cardiac markers is not uncommon after elective uncomplicated successful PCI in patients with stable angina. Serum cardiac troponins, especially cTnl, were more sensitive than serum CKMB in detecting MMI. Cardiac troponin I elevation after elective uncomplicated successful PCI in patients with stable angina might be a marker of adverse long-term outcome. Increased serum CRP is common in patients with stable angina and is a significant and independent determinant of MMI after elective uncomplicated PCI indicating involvement of the systemic inflammatory state in the etiology of this periprocedural myocardial injury

Minor Myocardial Injury After Percutaneous Coronary Intervention in Patients with Stable Angina: Pre-Existing Inflammation & Clinical Outcome.

Minor myocardial injury (MMI) is relatively common after complicated percutaneous coronary interventions (PCI) and is associated with increased risk of future cardiac events. It is possible that MMI may be detected by elevation of cardiac markers (e.g. enzymes and cardiac troponins). However, the occurrence, mechanism and long term outcome of minor myocardial injury after uncomplicated successful elective PCI in patients with stable angina has not been assessed previously. Cardiac troponins have been shown to be more sensitive and specific than CKMB for the detection of MMI. Therefore, the first purpose of our work was to study the occurrence of MMI after uncomplicated successful elective PCI in patients with stable angina by measuring cardiac troponin levels in serum after the procedure and to compare these results with serum CKMB. Much recent evidence supports the inflammatory nature of atherosclerotic coronary artery disease. Several inflammation markers have been implicated in this process with their serum concentrations increased in a variety of atherosclerotic disease. With this rapidly developing field in mind, the second purpose of our work was to examine the association of the systemic inflammatory state, reflected by different inflammation markers, with the occurrence of MMI. Such an association has never been studied before in this selected group of patients. Since relating the occurrence of MMI after PCI to outcome has important implications for clinical practice of interventional cardiology, the third purpose of the study was to prospectively evaluate the long-term prognostic significance of MMI after elective uncomplicated successful PCI which has never been reported before in patients with stable angina. Serum cardiac troponin I (cTnl), cardiac troponin T (cTnT) and creatine kinase MB (CKMB) levels were measured before and after uncomplicated, successful elective PCI in patients with stable angina. The frequencies of elevated cTnl and cTnT levels were significantly higher than that of CKMB after coronary intervention (p =0.00016 and 0.015, respectively). Inflammatory markers including serum levels of high-sensitivity C-reactive protein (CRP), interleukin-6, tumor necrosis factor-&alpha;, and intercellular adhesion molecule-1 were measured before PCI and were related to the occurrence of MMI after the procedure, and subjects were followed-up for adverse cardiac events for 24 months. Serum CRP was the only inflammatory marker that related to the occurrence of MMI after the procedure. CRP levels were above the reference range in 41% of patient group; of these, 46% developed MMI after PCI compared to 18% of patients that had a serum CRP within the reference range (p= 0.008). Patients with and without presumed MMI, identified by elevated cTnl levels, did not differ significantly with respect to age, body mass index, conventional coronary risk factors, medications, or severity of pre-existing coronary artery disease. Over a follow-up period of 24 months there was no significant difference in the medication used between the MMI positive and negative groups. The incidence of recurrent angina, repeat PCI, coronary bypass surgery and cardiac death was 54, 46,4 and 4% respectively in the cTnl positive patients versus 27, 16, 4 and 0% in the cTnl negative patients. Kaplan-Meier survival analysis showed that cTnl elevation was significantly related to cardiac events (p =0.0198, by log rank analysis). In conclusion, MMI identified by elevated serum levels of cardiac markers is not uncommon after elective uncomplicated successful PCI in patients with stable angina. Serum cardiac troponins, especially cTnl, were more sensitive than serum CKMB in detecting MMI. Cardiac troponin I elevation after elective uncomplicated successful PCI in patients with stable angina might be a marker of adverse long-term outcome. Increased serum CRP is common in patients with stable angina and is a significant and independent determinant of MMI after elective uncomplicated PCI indicating involvement of the systemic inflammatory state in the etiology of this periprocedural myocardial injury

How educational theory can inform the training and practice of plastic surgeons

It is important to optimize our current learning and teaching models, particularly in a climate of decreased clinical exposure. With technical advancements and clinical care now more accountable, traditional methods of skill acquisition need to be revisited. The past decade has seen changes in plastic surgery curricula. There has also been a shift toward competency-based training programs reflecting the growing emphasis on outcomes-based surgical education. This review explores the role of educational theory in promoting effective learning in practical skills teaching. Key models of educational theory are presented and their application to plastic surgery training to an expert level are highlighted. These models include (1) learning within communities of practice (Lave and Wenger’s theory); (2) the role of the zone of proximal development and importance of the availability of expert assistance (Vygotsky’s theory); (3) skill acquisition and retention (Dreyfus’ and Dreyfus’, and Fitts’ and Posner’s theories); (4) development of expertise after repeated practice and regular reinforcement (Ericsson’s theory); and (5) the assessment of competence (Miller’s triangle). Future plastic surgeons need to possess a thorough understanding of the technical and nontechnical skills required to manage patients effectively. Surgical educators are therefore compelled to develop practical training programs that can teach each of these skills in a safe, learner-centric manner. It is hoped that new approaches to surgical skills training are designed in light of our understanding of educational theory to optimize the training of the next generation of plastic surgeons

Design and material analysis of regenerative dispersion magnetorheological (MR) damper

Magnetorheological (MR) dampers are widely applicable for vehicle suspension schemes, and MR fluid sedimentation is an indispensable problem of MR dampers. A Regenerative Dispersion MR Damper (RDMRD) under this research consists of a piston which contains piston and coil case cylinder, coil windings, piston rod, piston head cover, bobbin and one cylindrical tube to disperse MR fluids. In addition, external regeneration system has been added to generate electricity for the purpose of electricity supply in the piston. 2-D Axis symmetric model of RDMRD has been developed using Comsol Multiphysics in order to analyze power generation ability. Two magnetic field are generated inside the MR Damper, one internal piston coil and another external power producing coil. The induced magnetic field in the coil are evaluated for describing RDRMD power production capabilit