CMJ CATERHAM MEDICAL JOURNAL CATERHAM MEDICAL JOURNAL 2 02 0- 2 02 1 I SSU E
CMJ CATERHAM MEDICAL JOURNAL CATERHAM MEDICAL JOURNAL 2 02 0- 2 02 1 I SSU E
The Medical Society of Caterham School
In this section you will be able to see a few articles about the Society, what it is like to be a member and the sorts of things we have been doing. We have had a very busy year with interview prep and UCAT sessions, but we have also introduced associate members from other schools. Associate members of The Wright Society are members who do not come from Caterham School but are still part of The Wright Society; they can attend and present talks as well as coming to all of our sessions.
A piece from our Endorser for this year’s CMJ – Mr Shahnawaz Rasheed Our patron Dr Richard Wrights – Welcome to the Society Dan Quinton – What it has been like working on the Society this year President and Vice-President Reflections on their year Bethany Nancarrow and Sophie Cracknell What it is like to be an associate member PBL session A session to give the L6 students a taste of medical school learning UCAT session A session to prepare the L6 medics for taking this exam in the summer MMI evening An evening for U6 medics to improve their skills at an MMI interview Traditional interview evening An evening for U6 medics to improve their skills at a traditional interview
Mr Rasheed, our very kind endorser for this year’s edition of the CMJ It was a great pleasure to have been the guest speaker at the Moncrieff-Jones Society Annual Christmas Lecture in December to talk about my work in robotic surgery and disaster relief. I was so impressed with not only the huge audience but also the quality of questions afterwards from both parents and pupils of the School. This Society has been going for well over 50 years now and clearly maintains an incredibly high standard of talks each term by the pupils. The articles in Quantum Ultimatum each year are impressive and show how pupils research their chosen topic to a depth well above A Level and into undergraduate level. I was also delighted to hear not only from Alex Richings, President of the Moncrieff-Jones Society, but also Max Fogelman who has set up with Mr Quinton and another pupil, Louie Steel, The Wright Society, dedicated to helping aspiring medics, dentists and vets achieve their dream. The pandemic has highlighted like never before the importance of our amazing National Health Service and both these amazing school societies are playing an impressive role in developing not only science skills but also communication skills. While the world needs and has brilliant scientists we also need them to be good communicators and so I am very proud to be able to endorse both these societies this year, and wish them good luck in the future. Finally, I would like to thank Mr Quinton whose
idea it was to have these Christmas Lectures so many years ago and has been arranging them ever since. His deep passion for science is infectious and it is so wonderful so see how well he provides the pupils with the enthusiasm, knowledge and inspiration to succeed in all that they aspire to. Mr Shahnawaz Rasheed B Clin Sci, MBBS, DIC, PhD, FRCS Consultant Surgeon The Royal Marsden Hospital
Welcome from Dr Wright Welcome to The Wright Society, the home of aspiring medics, dentists and vets at Caterham School. I am honoured to be asked to be Patron of this new Society. For nearly two decades I have had a very close relationship with the School as all three of my daughters passed through this amazing institution, and now I have the pleasure of being the School’s Medical Officer. Over a decade ago, but still fresh in my mind, my eldest daughter Hannah moved into the Sixth Form at Caterham with the dream of becoming a doctor. I admired the way the Science Department nurtured and helped her - she could not have been in a better place to achieve her ambition. Caterham School has a long tradition of helping aspiring medics, no more so than during the last two decades under Mr Quinton’s guidance as Head of Science. I know first-hand his passion for helping medics secure places at University as both undergraduates and via postgraduate routes. The formation of this Society is therefore a very exciting step forward in his aim to make Caterham School the top school in the country for anyone wanting to study medicine. Having said that, both Mr Quinton and I share the same passion to help all aspiring medics and in particular those who do not have the opportunities and privileges provided by a school like Caterham. The links with schools like Oxted and the LAE is very exciting and the creation of associate memberships a brilliant idea to ensure correct advice and guidance is given to others wanting to pursue medicine. I have seen first-hand already how this Society has already helped steer
pupils from outside and better their chances of success in the next round of UCAS applications. I look forward to seeing how The Wright Society blossoms over the coming years and am proud to be part of helping our next generation of medics, dentists and vets achieve their dreams. Patron: Dr Richard EP Wright MB BS (Lond); MRCGP
On the left is Dr Wright our Patron and a major figure in medicine in Surrey. In the middle is his father Dr BJP Wright who worked in the NHS for 38 years and inspired Dr Richard Wright to enter medicine. On the right is his daughter Hannah Wright who is an Old Cat and a qualified doctor. To date the three Wrights have given a combined length of public service in the NHS of 73 years.
What it has been like working on the Society this year Dan Quinton
There are occasional times in life when the stars seem to align, and it is just ‘the right time’ to do something. That happened last summer when I saw in two incredible Caterham pupils the chance to create something special. I met with Max Fogelman and Louie Steel last summer term to flesh out ideas to create the best Medics Society of any school in the country. For me, no job is more important or rewarding than helping pupils who want to become medics, and I have never seen pupils more passionate about Medicine than Max and Louie. Dr Richard Wright is not only our school Doctor, but possibly the most important figure in medicine in Tandridge. His role in fighting Covid 19 in this area cannot be underestimated, though typically he has gone about it in his usual quiet and humble manner. He is a man of vast experience and parent of three girls who have been through the School. I taught two of them, with the eldest Hannah now a qualified Doctor in her own right. It made total sense to rename the Caterham Medics Society after Dr Wright and I was so proud that he also agreed to be Patron and play a big part in the day-to-day activities of the Society. The aim of the Society is to help pupils who are passionate about medicine achieve their dream of studying medicine at university, a goal that is ever more competitive and difficult to achieve. In the short existence of the Society so far, we have already surpassed my expectations with sessions on the UCAT exam, PBL tutoring and our weekly presentations on a wide variety of aspects of medicine. To be a member of the Society is not a walk in the park. We are highly critical of each and every member, preparing them
for the academic challenges and improving their interview skills and other personal qualities which they must have in abundance if they are to be offered a place to study medicine in the current climate. I am extremely proud of our associate membership scheme, where we have pupils from partner schools with little or no medics provision or help. Pupils from Oxted School and the LAE have joined our meetings adding qualities and contributions we could not have foreseen. In fact, as I write this, history was made in that we had our first presentation by a non-Caterham pupil last week: a stunning talk by an Oxted School Medic on the various vaccines being produced against Covid19. Dr Wright and I are very keen to develop this associate member scheme further to help medics less fortunate than our own pupils to achieve their dream. Finally, I cannot stress enough how impressive Max and Louie have been. I am extremely proud of them and how they have given up so much of their time and energy to create resources and advise and help their peers. They have nothing to gain from this. They talked for an hour recently with an Oxted pupil. Their interviews are over, so they cannot add this to their personal statement or talk about it in an interview. They are doing it simply to help others. If you had seen them it would have brought a tear to your eye, as it did mine. Max and Louie helped found The Wright Society and their names quite rightly are first in line on the honours board pride of place on the Biology corridor. I wonder whose names will follow over the next few years, but Max and Louie will always be the stars who aligned to launch this amazing and most worthy of societies.
Introduction from the President and the Vice-president This year it has been our pleasure to be the President (Max Fogelman) and Vice-President (Louie Steel) of the Wright Wociety. We have had a fantastic opportunity to help the medics get closer to achieving their dream of studying medicine. We have thoroughly enjoyed making the resources for the Lower Sixth members and delivering sessions for them. We have particularly enjoyed organising, making and running sessions for the Lower Sixth on the UCAT and what a PBL session is like. We have also been involved in making the CMJ, the first ever edition which we have both found a challenging but interesting experience. Max Fogelman, President
Louie Steel, Vice President
We are immensely fortunate to have our patron Dr Richard Wright be so involved with the Society. It is very rare to have such a generous and kind doctor who has given up lots of his time to help us, particularly with the current situation. We are also very lucky to have a fantastic team of teachers working with us to run the society such as Dan Quinton, Bethany Quinton and Aimee Seal. Without their kindness, insight and support we would have had a much harder time getting the Society to where it is today. They have not only helped us with the Society as a whole but helped us as individuals too, making the very daunting experience of applying to medical school seem more manageable.
Life as an Associate Member Sophie Cracknell and Bethany Nancarrow, Associate Members of The Wright Society
W
e are two of the first associate members of The Wright Society, who have had the opportunity to be a part of this amazing association, which as many of you know helps us aspiring medics to increase our future opportunities. We are going to talk about our experiences as part of this group from the perspective of an associate. Despite only starting as members in January, we have had the chance to find out so much, from informative talks from fellow members to having an opportunity to research and deliver a presentation of our own. It started out with a chat with Mr Quinton, who took the time to introduce us to the Society and how it all worked, as well as taking the time to get to know us individually and see where we could best improve. This was followed by our first session, which involved a presentation on radiology, which not only introduced us to a fascinating specialty
in the world of medicine, but also demonstrated the passion of members of the Society and the enthusiasm and curiosity of all the members, who were eager to find out more. While this seemed a bit intimidating a first, this has actually helped us develop our own critical thinking skills, which is obviously an essential skill as a doctor. It also has got us to think of things from different perspectives and helped us become more informed. These talks are an amazing opportunity, not just for each student to research a topic that interests them and develop their understanding, but also for us to investigate areas we might not have considered. As a result, it also broadens our understanding of key medical topics that are key to performing well at interview and furthering our knowledge of the profession. We were also lucky enough to be invited to a talk during our first week from Hannah Wright,
a recently qualified doctor, Dr Wright himself and a medical student currently studying at St. George’s. This was an incredible opportunity to hear about the profession from multiple perspectives and how your career can develop through the years. This talk also gave us the opportunity to ask any personal questions we might have that, due to the current situation, it is very difficult to get answered through volunteering or work experience. This evening also gave us a more in-depth understanding of the positives and negatives of a career in medicine. As if this wasn’t amazing enough already, we then had a series of in-depth presentations on the UCAT run by Louie and Max in Year 13. These was an incredibly interactive sessions (and we still have more to come!) and not only introduced us to this essential part of the application process, but also gave us tips and advice on how to maximise our chances of success. This was aided by an incredibly well puttogether booklet with sample questions to try to give us a better idea of what the UCAT entails, as well as advice on how and when is best to prepare. They carefully went over each section over several sessions and even have plans for more in the future. One of the other brilliant events that we were able to participate in was the PBL evening. This gave us an insight into one of the key teaching styles pioneered by Manchester that has now been implemented in many of the medical schools across the UK. Max and Louie created several medical (and veterinary for the aspiring vets) case studies for each group, which we then had to do some independent research on before the meeting, just like in medical school. We then split off into groups which allowed us to bounce ideas off each other and use our collective knowledge base to try and get to the bottom of each case. There was even a Year 13 in each group who was there to help with guidance and help us answer any questions that we had.
This was a very interesting and interactive evening that has allowed us to be able to find out more about the teaching styles at different universities and make more informed choices about our future. Following this, we were given the incredible opportunity to research and present a speech on a chose medical topic that interested us. Not only was this a highly engaging activity, through developing and broadening our knowledge of a particular aspect of medicine, but also incredibly useful in terms of allowing us to practice our presentation skills and build confidence, of which are essential to a successful interview. Deepening our understanding of particular topics also provides us with the opportunity to discuss them in detail in interview, thus demonstrating our passion and enthusiasm for the medical field. It also gave us the chance to be grilled by both staff and students, who are all very well-informed and inquisitive. Another amazing opportunity we received was the chance to discuss in depth with Mr Quinton, the medical schools we are thinking of applying to. This was invaluable in helping us to understand the need to apply tactically and to play to our strengths, maximising our chances of a successful application. Mr Quinton had previously got to know us on an individual basis so he was able to advise us on these decisions and where he thinks would suit us best. Overall, the chance to join TWS has been an incredible privilege, and even in the short time that we have been part of it have learnt so much. All members are highly dedicated and passionate, which creates an amazing environment to further our medical interests and hopefully improve our future prospects. This dedication of both students and staff to making this a worthwhile opportunity can clearly be seen, especially with the exceptional activities and talks that have been adapted so that they can still go ahead, even online!
PBL session A PBL course is a relatively new way of learning that many medical schools are adopting to train their medical students. It involves being split into groups of around 15 and discussing a medical case. Students will use the case to learn not only the clinical skills but also the scientific explanation of the case. This year we thought it would be useful for the Lower Sixth members to be able to experience what it is like to be studying at a PBL university. This led us to run a PBL session with the Lower Sixth being led by Upper Sixth members and a vet. We were very fortunate to have the vet Phil Fox-Manning running the veterinary session and the Upper 6th members Rob Bailey, Niamh Burke, Louie Steel and Max Fogelman running the medical sessions.
The Lower Sixth were given a number of case studies on a range of topics from geriatrics to trauma case. They then went through the cases, as a group and researched around the cases so that they could have a complete understanding of the case and what happened. This helped the Lower Sixth develop their communication and teamworking skills in a setting that was as close as possible to what it is like to be at medical school. These case studies encouraged them to look at not only the challenging scientific side but also the ethical implications of the treatment. The Lower Sixth said they found the session interesting and useful, they learned new skills such as looking at the patient holistically as well as finding out some new information such as the trauma triad of death. The session gave the Lower Sixth the opportunity to work in a group to find out more about the case study and get a feel for what it is like to be studying at a PBL medical school.
UCAT session The UCAT is an online assessment that is integral to the medical application process- so much so that many universities rank order applicants based on their respective scores and then decide a ‘cut-off’ for interview. The exam tests multiple skills, such as verbal reasoning, logic and decision making, quantitative reasoning and abstract reasoning. The average score is 2511/3600, so the exam is relatively low scoring, further demonstrating how challenging it is! Although the questions can be difficult, the biggest obstacle to success is the immense time pressure of the exam. Developing a wide range of skills and proficiencies is vital and will ensure the best possible chance at a good score. Some Upper Sixth Medics volunteered to run UCAT sessions for the Lower Sixth, in order to prepare them for the upcoming test. The idea was that the older students could share the information that they had acquired through studying
and learning about the exam. Over the Summer, the Upper Sixth students had studied for the UCAT, which is generally taken at the end of the Lower Sixth summer. Through this, they learnt about and used a variety of techniques and ‘shortcuts’ to reach success. The Upper Sixth students assimilated this information, as well as drew on their own personal experience, to run sessions virtually during lunchtimes. Firstly, they outlined the basics of the section, as well as detailing the key techniques relevant to the section. There was subsequently an opportunity to do ‘mini-mocks’ of the section, under timed conditions. This allowed the students to practice what they had learnt, as well as identify their weaknesses to then work on at a later date. The Lower Sixth students have got a great head-start on the UCAT, with the knowledge and information to get fully prepared to smash the exam!
Mock Mini Interviews evening On the 30th of November, the Upper Sixth Medics took part in a Mock MMI (Multiple Mini Interviews) evening on zoom. This was expertly organised by Mrs Brown and provided an incredible opportunity for development of interview skills in such a realistic environment. We are all so lucky to have such an incredible learning opportunity provided. We had many different stations, covering a variety of topics and themes that are likely to be tested upon in real interviews. Here are some highlights: STAT I ON 1 : ME DI C AL E T H I C S
This station focused on an elderly man who required an urgent leg amputation. His two sons disagree on the treatment. The elderly man refused the amputation, although this was the last possible treatment available. One agreed with his father by saying ‘No’, and another opting for the amputation. This tested our skills in being able to approach a medical situation holistically, considering all points of view in the management of a specific case. It covered a variety of important themes, including informed consent and next of kin laws, and was extremely useful practice for the inevitable medical ethics questions in our interviews. STAT I ON 2 : DATA I NT E R P R E TAT I O N
The second station focused on interpreting a graph: We were given the challenging task of explaining the trends seen in the graph. Many of the students found this station to be among the toughest, since it requires skills in a variety of different areas. We had to analyse the data, and subsequently explain the differences and similarities shown. Some examples of answers included different smoking trends, amount of cholesterol in blood (and
therefore quality of diet), inactivity and inheritance of alleles that may increase susceptibility in one particular gender. STAT IO N 3: VACCINAT IO N
We were given the challenging task of explaining the concept of vaccination to the interviewer. We were to assume that they had no prior knowledge of vaccines. Explaining a concept in detail from first principles is a skill that not many of the students had practiced and this proved extremely challenging. Furthermore, hitting the key points required by the interviewer was difficult. Many students gave a very detailed scientific explanation of the mechanism behind vaccination, whereas others gave a short overview and then subsequently detailed some of the positives and negatives to mass vaccination programmes- a topic that is especially relevant with the rollout of the COVID-19 vaccines. STAT IO N 4: DIAG RAM
It may seem unlikely, but this is the section in which the most students tripped up at. The task was simpleto describe this picture to the interviewer, and to try and get them to draw the most accurate replica as possible. Many students completely forgot about scaling, and many failed with being accurate enough in their description. Being asked such an obscure and creative question threw off the students, since no one could have known to prepare for anything remotely similar to this. It was an excellent test of clear communication and preciseness, which are incredibly important skills in medical practice.
Upper Sixth traditional interviews During virtual school, the upper sixth students had a virtual traditional interview mock. Mrs Brown organised for doctors who were affiliated to the school to act as interviewers on zoom, giving us questions and scenarios for us to respond to. There are 2 main types of interview: MMI (multiple mini-interviews) and traditional panel-based interviews. Different universities use different interview styles, and it essential for applicant to get well versed in the way both interviews work. Traditional interviews are where you have 2-3 interviewers asking you questions and discussing ethical scenarios. The skills required for traditional interviews are difficult to perfect without specific interview practice. For example, dealing with the pressure of being put on the spot with an unexpected or unknown question, or being able to formulate your answers in a clear and eloquent way. Furthermore, it can be extremely disconcerting when a group of doctors are
listening to you talk about medicine, since they are experts in the field and will instantly pick out any falsehoods or misconceptions in your answer. The interview session was followed by immediate feedback from the doctors, on the content of our answers, the way we held ourselves whilst talking and also the structure of our responses. Access to their skill, expertise and guidance is an indispensable asset for our medical applications, and it has no doubt helped the upper sixth acquire the offers that have eventually been achieved. The opportunity to have the traditional interview practice with a doctor has been incredibly useful. The upper sixth students are incredibly lucky and grateful that Mrs Brown put in the time and effort to organise the evening. We also are extremely grateful for the doctors who gave up their time to help us, especially during a pandemic when many of them are under such extreme stress and pressure.
M ED I C A L
Welcome to the medical section of the CMJ: This section focuses on medical issues that are currently challenging healthcare systems across the world. All of these articles were written by our current Lower Sixth members of The Wright Society.
Rosie Home Medicine during COVID-19 Rainis Cheng COVID-19 and mental health Michelle Wong How did COVID change the NHS Rosie Home Healthcare comparison | UK Vs USA Ivan Liu Healthcare comparison UK Vs Australia Fleur Masters Healthcare comparison UK Vs Singapore Rainis Cheng Healthcare comparison UK Vs Cuba Michelle Wong Healthcare comparison UK Vs South Korea
Medicine During the Pandemic: The Difficulties faced by NHS Doctors Rosie Home
The Covid-19 outbreak, as would be expected, has had a profound impact on medicine, and has also seen a considerable change for medical staff working in this environment. It has been an exceptionally difficult time for all, affecting the life of every single person on the planet, but very few have found the past year more trying than doctors, nurses, and all NHS health care personnel. They have been essential in their work during the pandemic, saving countless numbers of lives despite the high level of personal risk involved, but their mental well-being has been disregarded, with the amounts of stress they’re subjected to, which was already incredibly high, skyrocketing.
of stress the workers are subjected to is that of the risk of themselves or colleagues becoming infected and falling ill, and then the further added feelings of guilt if they were then to pass this on to family. All of these factors have lead to somewhat of a mental health crisis in hospital workers, with, in the same BMA survey, around half of the participants saying that they were planning on reducing their working hours after the pandemic is over, a fifth saying they plan on retiring early, and further fifth saying they plan on doing a different job entirely.
Mental health in hospital workers was already a growing problem before the start of pandemic, and it is now an topic that has become even more worryingly prevalent. Due to the very large rise in demand of care for Covid patients, many doctors have had to do a different job than that which they were used to and have had to work in critical care, fulfilling a notably more taxing role than before. A survey done by the British Medical Association involving almost 8000 doctors found that around 40 per cent have experienced higher levels of stress overall since the start of the pandemic, and almost 60 per cent identified as extremely fatigued. This goes to show just how much pressure doctors are under currently, which is subsequently leading to significant feelings of burnout across the NHS. On top of this, working as a doctor in this time has an unbelievable emotional toll. Many have seen more deaths in the past few months than they have in their entire career - often elderly individuals, lives ending with not a single loved one by their side. Witnessing this daily for months on end is something that most of us could only imagine having to face, but it is complete reality for these staff, many even suffering from symptoms of post-traumatic stress disorder due to their experiences. Yet another layer
One of the ways hospital medicine itself, and the whole care pathway, has changed a lot in the last year in the form of service shifts. Many changes have been made to the way in which care is provided in order to accommodate for the influx of Covid-19 patients, which has caused a large disruption to doctors and nurses day-to-day jobs. There was a very large increase in need for critical care facilities, and a reduction in demand for most other services; a 71.8% decrease in elective admissions was seen in May 2020 compared to the same time period in 2019, with referrals from GPs decreased by 71%. Thus, there have been many changes implemented across the NHS, but mainly in primary and community care, and specialist diagnosis and treatment.
through the lack of face-to-face contact and use of PPE, meaning the quality of their care has somewhat declined. This has also lead to burnout and other mental health issues amongst GPs – on a BMA survey conducted in August last year, consisting of nearly 1300 GPs, 50% reported work related mental health problems, with 40% saying these had worsened during the pandemic.
Large shifts have been seen in the way diagnosis and treatment by hospital specialists is done. In order to reduce risk of infection, most outpatient services became virtual, such as digital consultations, a ‘patient-initiated follow-up’ system was introduced, and new crisis services for mental illness were set up. Perhaps even more dramatic shifts have been seen in primary and community care; the role of general practice, as well as that of general practitioners themselves, has massively changed in the last year. Most patients are now seen in virtual consultations, with only 40% of appointments in October being face-to-face. Furthermore, during the early stages of the pandemic in March, NHS England advised all GP surgeries to move to a total triage system; patients are triaged before making an appointment, which is done either online or by phone. This means that GPs must now see many of their patients online and, even when seeing those they do get to meet face-to-face, full PPE must be worn – a stark contrast to the casual, non-clinical dress code that General Practitioners are used to. All rooms must also be cleaned and sanitized thoroughly between appointments, meaning there is a much slower rate of seeing patients. This all means that GPs cannot properly and sufficiently do their primary job of caring for patients; the Physician-Patient relationship is arguably significantly thwarted
The pandemic has brought much change to medicine and the way the NHS is functioning, as well as the day-to-day experience of health care workers. Certainly one of the biggest long term issues that Covid-19 has magnified in the NHS is mental health worries in healthcare workers, and is something that must be looked at carefully when the pandemic is over. More resources must be set up in order to support NHS workers mental health in the future or we risk losing significant numbers of our vital health care force. Some options that could be looked at in the future to help mitigate this problem include increasing pay and staffing levels, and providing access to psychological counselling services for health care workers specifically through the NHS. Hopefully, as the spotlight has been put on the NHS, many more people have realised the strain that health care workers job’s put on their mental health, and this becomes an issue that is looked at carefully in the future. As the highly anticipated
end to this traumatic time period seems to come into view, with continued roll out of the vaccine to the public, it is important that we do not forget the enormous sacrifices that healthcare workers have made over the past year for our safety, and that we continue to honour and show our support for them and the infinitely important work they have done.
References: British Medical Association. (2020). COVID-19: analysing the impact of coronavirus on doctors [Data Set]. Available at: www.bma.org. uk/advice-and-support/covid-19/ what-the-bma-is-doing/covid-19bma-actions-and-policy/covid-19analysing-the-impact-of-coronaviruson-doctors (Accessed: 7th January 2021) The health foundation. (2020). Surviving COVID: The impact of the pandemic on the mental health of NHS workers. Available at: www.health.org.uk/what-we-do/ responding-to-covid-19/survivingcovid/surviving-covid-impact-onthe-mental-health-of-NHS-workers (Accessed: 7th January 2021) Hallows, N. (2020) Doctors Reaching Breaking Point. Available at: www. bma.org.uk/news-and-opinion/ doctors-reach-breaking-point (Accessed: 6th January 2021) Johnson, T. (2019) The Importance of Physician-Patient Relationships Communication and Trust in Health Care. Available at: www. dukepersonalizedhealth.org/2019/03/ the-importance-of-physician-patientrelationships-communication-andtrust-in-health-care/#:~:text=The%20 physician%2Dpatient%20 relationship%20is,outcomes%20 and%20their%20medical%20care. (Accessed: 6th January 2021)
Gerada, C. (2020) We doctors usually thrive on stress, but the pandemic is leaving us on the verge of burnout. Available at: www.telegraph.co.uk/ health-fitness/body/strain-covid-19leaving-many-doctors-verge-burnoutmust-help/ (Accessed: 6th January 2021) Lewis, R. Pereira, P. Thorbly, R. Warburton, W. (2020) Understanding and sustaining the health care service shifts accelerated by COVID-19. Available at: www.health. org.uk/publications/long-reads/ understanding-and-sustainingthe-health-care-service-shiftsaccelerated-by-COVID-19 (Accessed: 7th January 2021) BMJ. (2020) Covid-19: how coronavirus will change the face of general practice forever. Available at: www.bmj.com/content/368/bmj. m1279 (Accessed: 5th January 2020) Hughes, D. (2020) Coronavirus: How GPs are changing the way they work. Available at: www.bbc.co.uk/news/ health-52910771 (Accessed: 5th January 2021) Clarke, G. Pariza, P. Wolters, A. (2020) How are total triage and remote consultation changing the use of emergency care? Available at: www. health.org.uk/news-and-comment/ charts-and-infographics/how-aretotal-triage-and-remote-consultationchanging-the-us (Accessed: 6th January 2021)
BMA (2020) Pressures in general practice. Available at: www.bma.org. uk/advice-and-support/nhs-deliveryand-workforce/pressures/pressuresin-general-practice (Accessed: 6th January 2021) Pulse. (2020) NHS advises ‘total triage’ as GP groups look to limit patient demand. Available at: www.pulsetoday.co.uk/news/ uncategorised/nhs-advises-totaltriage-as-gp-groups-look-to-limitpatient-demand/ (Accessed: 7th January 2021) BMA. (2020) COVID-19: general practice during the second wave. Available at: www.bma.org.uk/ advice-and-support/covid-19/whatthe-bma-is-doing/covid-19-bmaactions-and-policy/covid-19-generalpractice-during-the-second-wave (Accessed: 6th January 2021) Ogden, J. (2020) Online consultations: the future of NHS GP appointments? Available at: www.prescriber.co.uk/wp-content/ uploads/sites/23/2018/09/Onlineconsultations-lsw.pdf (Accessed: 6th January 2021) Bostock, N. (2020) Sharp rise in GPs reporting worsening mental health in COVID-19 pandemic. Available at: www.gponline.com/sharp-rise-gpsreporting-worsening-mental-healthcovid-19-pandemic/article/1692460 (Accessed: 6th January 2021)
Coronavirus and Mental Health in the NHS Rainis Cheng
At the start of lockdown and school closure in March 2020, people were confident that we would be able to fight off the coronavirus, and life would return to normal in a few weeks or at most, months. Now almost one year since the WHO declared this crisis a pandemic, nearing 93 million cases and 2 million deaths worldwide later, cases are still rising. How has the past year shifted our mental and social well-being, and how can we maintain health not only physically, but also in state-of-mind in these trying times?
G EN ERA L M E N TAL WE L L- B E I N G
ME NTAL H E ALT H INE Q UALIT Y
The pandemic has brought with it many socioeconomic challenges that add depth to the worries some may already have. Social isolation and loneliness, job and financial losses, housing insecurity are some of the materialistic worries that have become increasingly relevant. Alarmingly, people without mental health disorders prepandemic have begun to show symptoms, and those with conditions have seen increased severity.
As mentioned above, we are facing immense socio-economic challenges, and bearing the brunt of those are people who are already disadvantaged. Those with existing mental health challenges, victims of domestic abuse, patients with chronic diseases, labour and part time workers, people of colour, and many more. When crises hit, they are the first to be furloughed, the receiving end of racism, and the most vulnerable, but they are harder to reach and less likely to look for support, making it ever more important they are made aware of the assistance they need.
When we used to go for a walk or to the gym or to meet our friends when we felt sad, these coping mechanisms are lost as access to outdoor spaces have been limited and contact with loved ones have become riskier. Mental health services are crucial for people experiencing mental illnesses and have already been feeling the strain before the pandemic. In the face of an even larger demographic, mental health services have to work around the limitations of COVID-19.
PANDE MIC FAT IG U E
The WHO Regional Office for Europe defines pandemic fatigue as demotivation to follow recommended protective behaviours, emerging gradually over time and affected by a number of emotions, experiences and perceptions.
This is one of the more prominent and dangerous issues with mental wellbeing we have, more so because it potentially undermines preventative policies. In contrast, some see reports of pandemic fatigue as misrepresented. The media highlights large raves and claims widespread disobedience to policies, but in fact adherence to behavioural regulations are extremely high in the UK. Even so, the bombarding of overexaggerated news and particular choices of words may be triggering, especially as it feels like the sacrifice of our social lives and having to isolate does not seem to drive this pandemic to its finish. HEA LT HC A RE WO R K E R S
On the frontline of this pandemic, there is no doubt that their psychological wellbeing is being stretched to its fullest capacity. Pre-COVID, medical professionals have already been among the most stressful occupations prone to professional burnout, in addition, cognitive vulnerability is known to be hard to follow up with in health care workers, as they may have low self-efficacy and consider it insignificant. Past 2020 and into 2021, COVID-19 cases are still on the rise and hospitalisation has spiked in the few recent weeks, reaching saturation in many places. Healthcare workers are very likely to develop post-trauma stress disorder after a pandemic (referencing previous pandemics), and thee are already high levels of depression, anxiety and insomnia in frontline workers from China and Italy, where COVID-19 affect the most in its offset. Mental health care is desperately needed to support and help healthcare workers cope with their immense stress. COP I N G M E T H O DS
Setting a sleep-wake schedule and maintain it by limiting the amount of screen time. Exposure to light after dark, especially blue light from electronics with screens, challenges our natural sleep schedule, as it supresses melatonin (a hormone that regulates sleep-wake schedule) for longer time than other
visible wavelengths. It is inevitable we have to use electronics to take lessons, attend meetings, and work from home during the pandemic, but what we could do is stay away from them for the few hours before bedtime. It may just be the trick to prevent sleepless nights and maintaining circadian rhythm. Dealing with fatigue is another way to maintain mental wellbeing in isolation. While individually, our stressors and triggers may be different and we should identify and address them directly, an issue with fatigue commonly seen stems from video meetings. We are at school or at work the same amount of time we are sitting at our desks at home, but why is it harder to pay attention? In face to face reactions, we have all the social cues to signal timing and conversation, but online, all that is reduced to unsynchronised imagery, making it harder to grab the right timing. To top it off, your pet may be yearning for your attention and family members talking in the background may make it even harder to focus. There is not much to do to improve this experience, but what we can do is give ourselves time between lessons or meetings, talk to family members or walk around your home. Online stress reduction has been a way to connect with other people safely while still participating in activities. From meditation practices and mindfulness classes, yoga and stretching sessions and live physical activity workouts, many of us have taken to the world wide web to maintain and make connections, to discover new hobbies.
Having scheduled events to look forward to and diving deep into activities could help us take our mind off of stressors, even just for a short while, and let us still discover and fulfil our curiosity and sense of achievement from the safety of our homes.
information on support for NHS employees from the perspective of managers. www.nhsemployers.org/retention-and-staffexperience/health-and-wellbeing/taking-a-targetedapproach/taking-a-targeted-approach/mental-healthin-the-workplace
ORG A N I SAT IO NS P R OV I DI NG S U P P ORT
Grassroots Suicide Prevention has an app and website you can find help from. The Stay Alive app provides quick access to national crisis support helplines, a safety plan, wellness plan for recovery, and bereavement resources for people who lost loved ones. The app and resources aim to lessen one’s loneliness, and for people with suicidal intent and no one to turn to to “stay safe for now”. www.prevent-suicide.org.uk/ Mind mental health charity has a toolkit to look after your social needs, gives advice for what we can do to maintain physical and mental health under COVID-19, and where to look for help with practical needs (like food insecurity) when needed.
The NHS has a comprehensive list for mental health charities that can provide help for yourself or a loved one. Most charities and societies have office hour hotlines, with a few providing 24/7 free helpline. The list includes a wide variety of charities for specific uses or more general ones
The NHS Practitioner Health website compromised of a comprehensive list of support services and access therapy tailored to medical professionals. The NHS Leadership Academy Our NHS People website also offers similar online and real-time support. Some include 24/7 hotlines, or free online one-to—therapy services for NHS workers, each aimed to provide psychological support and follow up for medical practitioners, spanning text support, religious support, bereavement support, financial wellbeing support and virtual staff common rooms.
www.nhs.uk/conditions/stress-anxiety-depression/ mental-health-helplines/
www.practitionerhealth.nhs.uk/support-servicesaccess-to-therapypeople.nhs.uk/help/
SUP P O RT F O R N H S STA F F
One thing we could all take away from this time in isolation and distancing is that mental health can make or break our wellbeing. It is equally as important to maintain, and we have to be actively taking action to regulate our emotional being. Especially under the conditions we are under, it is normal to feel stressed and anxious, and it is okay to look for help and put yourself first.
www.mind.org.uk/information-support/coronavirus/ coronavirus-and-your-wellbeing/
The British Psychological Society has outlined three phases of support (a preparation phase, active phase and recovery phase) for NHS employers to back up employees as they respond to COVID-19, easing them into the process, helping them to stay strong during, and taking care of the aftermath of the pandemic. The following website from NHS employers also lists toolkits and talks for more
How did COVID-19 change the NHS? Michelle Wong
The current situation of the pandemic due to COVID-19 has been ongoing for a year and there is no doubt that the pandemic has had huge impacts on the NHS. Patients with the disease have put unprecedented demands on the acute care, especially on ICUs, which contributed to a dramatic increases of resources available to the hospitals to treat these patients. This includes reorganising hospital facilities, redeployment of existing staff and bring-in recently retired and newly graduated staff to work together.
1. DEALING WITH CORONAVIRUS PATIENTS
The direct impact of the virus has shown by the increasing demand of intensive care facilities. The existing evidence from UK and other countries strongly suggest that the virus affects some groups of the population more severely than others which are men, older individuals and Asian and black ethic groups having higher risk of death from COVID-19 (Collaborative). Historically, the UK’s number of ICU beds and level of staff has been low by international standards (Rhodes). While the total number of doctors and nurses has increased in the last decade, this has been outstripped by the increase in activity. In response, the NHS have tried to boost hospital capacity but is against a backdrop of relatively few spare ICU beds and existing staff shortage.
Figure 1 (Herbert) shows the number of admissions over the April-June 2017 per 1,000 people. It is shown that the rate of emergency admissions is highest among the population aged 90 and above: 164 emergency admissions for every 1,000 people, versus 27 for the population as a whole. The very oldest in the population are therefore the most likely to have emergency care disrupted over the course of the pandemic.
2. EFFECT ON CARE VOLUMES
To deal with increasing coronavirus cases everyday, the amount of resources for non-coronavirus patients has been reduced in order to maintain a balance in the NHS. NHS announced in March its intention to free up around 30,000 of its 100,000 general and acute hospital beds which was achieved through urgent dicharge of patients who are medically fit to leave and prosponement of all non urgent elective operations (Public Health England). The effect of the coronavirus outbreak to date differs across regions which results in different ways to deal with the cases and their capacity to redeploy existing resources towards treating those patients.
Figure 2 (Herbert) shows the number of elective and emergency NHS hospital admissions between the same period of time ranked by deprivation. As elective admission a evenly distributed across patients from differently deprived areas, the number of emergency admissions is higher among more deprived areas than in less deprived areas. This would suggest that disruptions to emergency care will have disproportionately affected older people and those who are the least affluent. 3. EFFECT ON CARE QUALITY
As the demand increase, the number of staff either coming out of retirement or joint in the workforce early has also increased. For example, the RCN estimated that 7,000 recently retired nurses returned in March (Thousands to return to nursing). However there is still fewer staff avaliable for treating other patients as more staff would need to focus on treating coronavirus patients. Also it is estimated by the RCP and the RCN that up to a quarter of NHS doctors and nurses had already had to take time off because of sickness or self isolation by March (Hope).
Chan (2020) shows that experience matters for doctor decision-making and resultant patient outcomes. So, even if numbers have been temporarily shored up, the composition and experience of the team, as well as its size, matter for the care that is provided to patients.
References
4. LONG TERM CONCERNS
Besley, T., Hall, J., & Preston, I. (1999, April 16). The demand for private health insurance: do waiting lists matter? www.sciencedirect.com/science/article/abs/pii/ S004727279800108X?via%3Dihub.
Firstly, the staffing issues would loom large. After this immediate crisis, a lot of staff would presumably return to retirement. With many areas already experiencing medical staff shortages, it is hard to see how this can be achieved without an increase in nurses’ and doctor’s wages in shortage areas thus affecting taxpayers. Secondly, waiting times for elective care would rise. Although waiting times are still below historic levels in early 1990s and before, they have been rising recently which cause public concerns. The response due to coronavirus would only increase the length of waits which relatively speaking longer waiting times in the NHS have led to an increased demand for private care (Baisley). 5. CONCLUSION
During this current pandemic, although there has been a large impact towards the NHS, there has been a groundswell in support for the NHS and satisfaction with the health services has a risen (Herbert). This support could transfer into greater support for tax rises to fund higher levels of health spending improving the facilities and quality of NHS.
A. Rhodes, J.-D. C., JH. Laake, K. D., NK. Adhikari, R. A. F., RD. Piers, E. A., H. Wunsch, D. C. A., N. Eastman, B. P., … JE. Zimmerman, W. A. K. (1970, January 1). The variability of critical care bed numbers in Europe. Intensive Care Medicine. link.springer.com/article/10.1007/s00134-0122627-8.
Chan, D. (2020). Influence and Information in Team Decisions: Evidence from Medical Residency. American Economic Journal: Economic Policy. Collaborative, T. O. S. A. F. E. L. Y., Williamson, E., Walker, A. J., Bhaskaran, K., Bacon, S., Bates, C., … Goldacre, B. (2020, January 1). OpenSAFELY: factors associated with COVID19-related hospital death in the linked electronic health records of 17 million adult NHS patients. medRxiv. www. medrxiv.org/content/10.1101/2020.05.06.20092999v1. COVID-19 and its impact on NHS workforce. RCP London. (2020, April 9). www.rcplondon.ac.uk/news/covid-19-andits-impact-nhs-workforce. Dan WellingsJohn ApplebyDavid Maguire Nina Hemmings Jessica Morris Laura Schlepper. (2020, April 3). Public satisfaction with the NHS and social care in 2019. www. kingsfund.org.uk/publications/public-satisfaction-nhssocial-care-2019. Herbert, A., Wijlaars, L., Zylbersztejn, A., Cromwell, D., & Hardelid, P. (2017, August 1). Data Resource Profile: Hospital Episode Statistics Admitted Patient Care (HES APC). International journal of epidemiology. www.ncbi.nlm. nih.gov/pmc/articles/PMC5837677/. Hope, R. (2020, March 30). Coronavirus: One in four NHS doctors ‘sick or in isolation’. news.sky.com/ story/coronavirus-one-in-four-nhs-doctors-sick-or-inisolation-11965886. Public Health England (2020), ‘Emergency Department – Syndromic Surveillance System: England (year 2020, week 21)’ (assets.publishing.service.gov.uk/government/ uploads/system/uploads/attachment_data/file/887777/ EDSSSBulletin2020wk21.pdf). Thousands return to nursing to help during COVID-19 pandemic: News: Royal College of Nursing. www.rcn. org.uk/news-and-events/news/uk-thousands-return-tonursing-to-help-during-covid-19-pandemic-230320.
The UK Healthcare System compared with other countries
1. US Vs UK Healthcare Systems Rosie Home The UK and US have drastically contrasting approaches to healthcare – the UK’s healthcare system offers universal coverage to all, regardless of social-class or income, built around the idea that healthcare is a basic right and not a privilege. In contrast, the US is the only one of the main 33 developed nations not to have a universal healthcare system, and each year many Americans end up in debt, or struggle financially, due to medical bills. The two countries are somewhat opposite ends of the spectrum when it comes to healthcare funding, but the outcome in terms of actual care is somewhat similar compared to other countries in the world.
S PE NDING STATS UK
USA
Amount spent Overall by government (2019)
£214.4 billion
£2.8 trillion
Amount spent Per resident (2019)
£3,000
£8,500
% of Overall GDP
10%
17.7%
H OW D O E S E AC H SYST E M WO R K ?
The primary difference between the US and UK healthcare systems is in the way that they are paid for - the UK has a publicly-funded, government run National Health Service, which is free at the point of access, but is paid for through taxation. It is a risk sharing system, which covers most health problems from preventative care to required medication. Furthermore, NHS employees are actually government workers – they negotiate contracts with the NHS for how much they can charge for their services, instead of charging patients directly for care. The funding of the US healthcare system is very different - it is a mixture of public and private sectors, but almost all care is provided for by the private sector, and most hospitals are run by private organisations. Therefore, doctors also work for these private organisations, and, unlike in the UK, are not employed by the public sector. This means most Americans have health insurance, in order for them to avoid paying massive sums of money if they get sick - as of 2018, only 8.5% of the population had absolutely no health insurance whatsoever. Many Americans receive insurance through their employer, accounting for about 50% of people, although this often doesn’t cover all health care, and 25% of Americans with insurance still struggle with their medical bills. Some Americans also receive their health care via government insurance - in 2018, around 35% of Americans. This is through public insurance programmes such as Medicare (for over 65s and those with disabilities), Medicaid (for people with limited resources and income), and Children’s Healthcare Insurance Policy (for families with income too high for Medicaid).
CARE STATS UK
USA
Doctors per 1000 people (2018)
2.9
2.6
Hospital Beds per 1000 people (2017)
2.54
2.77
Hospital Beds per 1000 people (2017)
81.16
78.54
Ventilators per 100,000 people (2017)
10.1
18.8
DIFFE RE NCE S IN STANDARD O F CARE
Despite the USA spending almost triple the amount of money on healthcare per capita, some indicators prove UK healthcare to be superior to that of the USA – for example the significant difference in life expectancy, and the UK’s higher number of doctors per 1,000 people. However, the US has both more hospital beds per 1,000 people, and ventilators per 100,000 than the NHS, which is somewhat unsurprising due to the NHS’ infamous chronic lack of beds. However, both healthcare systems fall short when it comes to all of these factors compared to other developed countries, proving that neither system is perfect.
2. Australia Vs UK Healthcare Systems Ivan Liu CO M PA RI SO N B E T WE E N ME DI C A R E & T HE N HS
The NHS is an organisation that provides mostly free healthcare services to all legal UK. The doctors and nurses in the NHS are renowned for their professional and compassionate attitude it is often admired and use as a standard for other health care systems. According the US-based Commonwealth Fund, a respected global health thinktank, the NHS is rated 11th best healthcare system in 2017. For some specific treatment there will be a small fee, but it is still far lower when compare private alternatives. The NHS is funded mainly by the government form general taxation. The NHS is also one of the largest single-payer health care healthcare system in the world. The NHS entitles UK residents with access to the full range of services offered, including primary care. However, in order to access NHS treatment that is not from a GP or Accident and Emergency, a patient must be referred to the relevant specialists at a specific NHS hospital. The NHS also does not pay towards prescription charges and each prescription filled costs £8.20. Some citizens are exempt from prescription charges and those using regular medication can purchase a pre-payment card for £104 per annum. However, the NHS has a lowincome scheme. In England the limit is £23,250 a year for people who live permanently in a care home
and £16,000 a year for everyone else. Any benefits that participants are entitled to are also available to their partner and any dependant young people. In Australia, Medicare is the NHS equivalent. They provide most of the health care to Australian residents. For Australian residents a Medicare card can be obtained at the age of 15 for free, with a Medicare card doctors can bulk bill which is a system where instead of billing the patient, will bill the government and eliminate prescription fees. Under the bulk billing system services providers are not allowed to charge the patient for the service and that all the required fees are charged towards the government. When comparing both the NHS and Medicare, the NHS directly provides health care workers and GP to clinics, while Medicare provides mainly financial support for doctors who bulk bill and hence provide free benefits to patient indirectly. Both UK and Australian citizens are both automatically entitled services from the NHS and Medicare respectively without any discriminations. The NHS provides schemes for low-income families and individuals while the Medicare provides a similar support scheme for everyone equally. In conclusion both the NHS and Medicare provide excellent health care for their citizens the difference is the way of operation.
3. Singapore Vs UK Healthcare Systems Fleur Masters In Singapore the health care system is monitored by the government and ministry of health; it has a large private sector. Public healthcare is run through a series of schemes: Medisave, MediShield Life and Medifund. These services are funded by employed individual, by law they are required to allocate a percentage of their salary into their Medisave account. When a citizen requires healthcare they can choose a tier of care (A, B1, B2+, B2 & C) In an A, one could expect a private room with an ensuite toilet and choice of doctor. In a C, you are in an open ward with 7 to 8 others and you have an assigned doctor.
Depending on income, the class of care and age they could have up to 80% of the bill subsidised, the rest of the money comes from the individual’s Medisave account. If the funds are insufficient, Medifund, a fund set up by the government, provides financial help to patients with remaining bills. Medishield life is an affordable insurance available for all Singaporeans; it supports individuals and their dependent towards paying high cost bills for prolonged illnesses. It is not essential, however; over 90% of the population have it. It costs $33 a year for a 29-year-old and $372 a year for a 69-year-old. The annual limit is $50,000 and a lifetime limit is $200,000. Medishield Life covers about 80-90% of a stay in a B / C ward. This map shows Bloomberg’s health efficiency index, it is based on: life expectancy, relative cost and absolute cost. Relative cost is measured as a percentage of GDP. Absolute cost is per capita in US$. Expenditure includes preventative and curative services, family planning, nutritional activities, and emergency aid. The index ranks countries with a lifespan greater than 70 years, a GDP above $5000 and a minimum population of 5 million.
In the UK the majority of people use the NHS. This is split into four organisations; one for each country.This is paid for by taxes and national insurance. After World War II the British welfare system started to look after the well-being of British people from “cradle to grave” and since 1948 it has insured basic healthcare services are free for all citizens. Only dental optical and prescription charges are not covered. Within the NHS, non-medical services are contracted e.g. laundry and catering. These profit-
Bibliography (all accessed 28th 1/2021) www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthcaresystem/bulletins/ ukhealthaccounts/2018
making businesses remain competitive and efficient to ensure they win the contract. Hospitals can gain additional funding by having a private ward, with private patient paying for the procedure. The profits can then be used to increase the funds available to the hospital. Private providers are not required to share information; this prevents comparisons being drawn between the services and the NHS. In 2018, 7,000 patients were transferred to the any NHS from private facilities due to lack of facilities.
www.lexology.com/library/detail. aspx?g=aec22ac7-cb7f-47e5-8af56a5f71c79498
www.moh.gov.sg/cost-financing/ healthcare-schemes-subsidies/medifund
www.kingsfund.org.uk/publications/articles/big-election-questions-nhs-privatised
www.singaporebudget.gov.sg/ budget_2020/about-budget/budget-features/govt-spending-on-education-and-healthcare
data.worldbank.org/indicator/SH.XPD. CHEX.GD.ZS?end=2018&locations=SG&start=2013
en.wikipedia.org/wiki/World_Health_ Organization_ranking_of_health_systems_in_2000
http://files.export.gov/x_5985.pdf
www.bloomberg.com/news/articles/2018-09-19/u-s-near-bottom-ofhealth-index-hong-kong-and-singapore-at-top
http://hdr.undp.org/sites/default/ files/hdr2019.pdf datacatalog.worldbank.org/dataset/ world-development-indicators www.indexmundi.com/facts/indicators/SH.MED.BEDS.ZS/compare?country=sg#country=sg:gb www.moh.gov.sg/cost-financing/ healthcare-schemes-subsidies/medifund
www.kingsfund.org.uk/publications/ nhs-hospital-bed-numbers data.worldbank.org/indicator/ SH.MED.PHYS.ZS?locations=GB www.moh.gov.sg/cost-financing/ healthcare-schemes-subsidies/medishield-life
www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=video&cd=&ved=2ahUKEwicvdfoj4DuAhUNXMAKHdSpBCkQtwIwAXoECAcQAg&url=https%3A%2F%2Fwww. youtube.com%2Fwatch%3Fv%3DWtuXrrEZsAg&usg=AOvVaw2gtjeyeVVU3FfLR5rjd6NS en.wikipedia.org/wiki/National_ Health_Service www.singaporeexpats.com/resources-in-singapore/articles/86/differences-between-european-and-singaporean-healthcare.htm
4. Cuba Vs UK Healthcare Comparison Rainis Cheng The Cuban healthcare system, borne out of a socialist ideology, is simultaneously considered as “a model for many countries”, and “hardly an example to follow”. How are the views on the same healthcare system so vastly different, and good or bad, what can we learn from it? ST RUC T URE O F T H E S N S
The National Health System (SNS for its acronym in Spanish), is the equivalent of the NHS in Cuba. Since the Cuban Revolution of the 1950s, all fiscal and administrative responsibility of healthcare provision are assumed by the government. The SNS has in place a three-tier system of care: primary (community-based), secondary (specialised attention), and tertiary (nationally administered treatment of particular diseases). A success of Cuban healthcare can be linked to the extensive network of primary care services, responsible for raising the basic health conditions of citizens by vaccination and screening programmes. Polyclinics have undergone extensive renovation in the past 20 years, and now provide a comprehensive set of services sufficient to handle 80% of cases. In the NHS, there is a shortage of GP services and most patients go to secondary care, putting it at risk of exceeding capacity.
RESOURCES, INVESTMENTS & INFRASTRUCTURE Category
Cuba
UK
Healthcare expenditure (% of GDP)
11.187%
9.997%
Healthcare expenditure (per capita, p.a.)
£240-£320
£2,989
Hospital Beds (per 1,000 people)
5.33 (2017)
2.46 (2019)
There is a dire need for more modern medical equipment, stable electricity and water, but the Cuban government could only resort to sourcing equipment from further countries because of the US trade embargo with Cuba. While the capacity of services may be more strained in the UK, there is no doubt that the NHS has invested in state-of-the-art equipment and new medical technology is always available. PE RFO RMANCE Category
Cuba
UK
Infant mortality (per 1000 live births)
3.9 (2019)
3.7 (2019)
Life expectancy at birth (years)
78.726 (2018)
81.256 (2018)
Cause of death by NCDs (% of total)
83.7% (2016)
88.8% (2016)
MED I C A L I N T E R NAT I O NAL I S M
Cuban healthcare has an eminent reputation particularly because of its outreach. There are 20,000 health tourists to Cuba each year, generating around £30million. High quality services and the top doctors are reserved for these patients. The low prices and satisfactory treatment bring sound feedback to Cuban healthcare. Cuba has made commitments with 68 countries, manned by 25,000 doctors. It provides more medical personnel to the developing world than all G8 countries (UK included) combined. They respond to natural disasters and are stationed in countries with under-developed medical systems. It is also one of the more controversial issues regarding Cuban healthcare policy. The Cuban government uses this work force to a political advantage, for example, so that they can import subsidised oil from Venezuela. MED I C A L P RO F E SS I O NAL S Category
Cuba
UK
Physicians (per 1000)
8.422
2.812
Salary (£, per annum)
Local: ~£100 Stationed overseas: ~£8,800
FY1: £28,243 Consultant: £82,096
Medical school yearly tuition (£)
£2,500-5,000*
£9,250 (UK/EU) £10,000+ (Intn’l)
*The Cuban government grants scholarships with full board to students from low income families, which are also open to international students, many from Latin America and USA
Something to take away from this would be the training of medical professionals. Medical school exists as part of the healthcare system, with mentoring and internships for practical learning. This not only equips students with practical and applied skills as they graduate, but also establishes professionalism, humility, and an appreciation to the
system. While some medical schools in the UK are also increasing medical student’s exposure during their time learning, we are still quite a way from the closely linked mentoring system in Cuba. The conditions for a Cuban doctor are not always ideal. It is reported that a taxi driver may earn more than a doctor in Cuba because of the insufficient support from the government. Many doctors opt for overseas missions mentioned above because they receive better pay from it, which leaves domestic system under pressure. The Cuban healthcare system is indeed well established, and the SNS has indeed figured out a most efficient and effective way of maintaining public health. Yet the issues with resources are not to be overlooked and have to be fixed in order to provide better healthcare.
3. South Korea Vs UK Healthcare Comparison Michelle Wong United Kingdom and South Korea have significantly improved quality of life over a short period of time. People are living longer than ever before but now we have a growing elderly population in need of more medical attention. South Korea spends about 8.1% of the GDP on healthcare while the UK spends 9.8% of the GDP on health care. South Korea’s Health Care system is formed by three main components: NHI – N AT I O NAL H E A LT H I N S U R A N C E
The NHI program covers most South Korean citizens as of 2000, but it is funded by three different sources: The insured contributes 5.08% which they take into account the age property gender and income, people who live in rural areas actually pay less than those who live in big cities. The government contributes 14% towards the funding; the tobacco surcharge occupies 6% which was an effort to reduce tobacco use in South Korean population. MA P – M E D I CA L AI D P R O GR AM
The Medical Aid Program covers 3.7% of the population and was established in 2004 in favour of low income citizens, children under 18 and people with rare and chronic diseases. This is funded by the central and local governments. Recently the NHI program provides partial funding as well.
LCIP – LO NG T E RM CARE INS U RANCE PRO G RAM
The Long Term Care Insurance covers 3.8% of elderly citizens over the age of 65 of those with age related conditions and is funded by the NHI, government subsidies and co-payments. The Government pays about 20% under a co-payment system With the result of high Life Expectancy and cutting edge technology, South Korea is one of the leading health care systems in the world. South Korea has many medical beds available as well as short waits for medical visits as hospitals are owned by the private sector. Patients are able to pay for insurance based on their income age and gender as well as other factors phave more freedom choosing their provide and where to get their care. However there are disadvantages of the South Korea healthcare system. Unlike the NHS, there is no medical referral system in South Korea as patients are able to choose where they receive their care. There is imbalanced premium between employed and self-employed individuals by the NHI as it is difficult to monitor their income. South Korea has a separation policy which there is a separation the process of prescribing and dispensing medications. Physicians and pharmacists can dispense medication without a prescription with very little regulation is the potential lead to overuse of drugs.
The NHS is the government funded medical and health care services that everyone living in the UK can use without being asked to pay the full cost of the service. Most healthcare services are ‘publicly funded’ as money has been allocated by government to pay for this visit to the doctor which is collected through UK residents by paying tax. The NHS was created with the moral that everybody shared the burden of paying for health services offered by doctors, nurses, midwives and dentists rather the costs coming directly from ill or injured people so “everyone-rich or poor, man, woman, or child – can use it or any part of it”. The NHS is provides good financial protection to the public from the consequences of ill health as it has the lowest proportion of people who skipped medicine due to cost across comparator countries. The NHS is also reactively efficient as the UK has the largest share of generic prescribing of all comparator countries at 86% in 2018 compared to an average of 50%. The NHS is also known for
performing well in managing patients with long term conditions for example diabetes which is proven that fewer than none in an thousand people are admitted to hospital for diabetes in a given year. However the NHS does not perform as well as South Korea’s Health care system on the average in the treatment of eight out of the 12 most common causes of death which includes deaths within 30 days of having a heart attack also within five years of being diagnosed with breast cancer, rectal cancer, colon cancer, pancreatic cancer and lung cancer. The NHS is ranked the third poorest performer compared to the 18 developed countries by amenable mortality whilst South Korea’s Health Care system was ranked fourth. The NHS also has consistently high perinantal mortality and neonatal mortality as 7 in 1,000 babies died at birth or in a week in 2016. Both systems have their strengths and weaknesses that they could improve on in order to make their system more beneficial to the country.
SC I ENI C T IAFLI C M ED
Welcome to the scientific section of the CMJ: In this section we have articles on medical topics that directly relate to the scientific side of medicine. Medicine is fundamentally evidence based and this section shows recent scientific advancements that are changing the way we do medicine.
Bobby Benford Long COVID-19 Thirisha Anpalakan Possible behavioural phenotypes in children with Down syndrome Keanu Khazanehdari How robotics has changed medicine Ruby Chan The relationship between sleep and Alzheimer’s Rainis Cheng Primary Ciliary dyskinesia and situs inversus Michael Wong The difference between vertigo and dizziness and the causes of vertigo Jeremy Chan Treating COVID
Long COVID Bobby Benford
Most people with COVID suffer the effects for around 2 weeks. Those who show signs and symptoms for up to 4 weeks are described as having acute COVID-19. Acute COVID-19 may lead to Long COVID. W HAT I S LON G COV I D?
The National Institute of Health and Care Excellence (NICE) defined post-COVID-19 syndrome as “signs and symptoms that develop during or after an infection consistent with COVID-19, continue for more than 12 weeks and are not explained by an alternative diagnosis”.
The term arises because the sufferer must have been diagnosed with COVID-19 (from a test or clinical symptoms). Symptoms usually develop after the acute phase. It is a syndrome as many people present multiple signs and symptoms and another may have multiple. Another major sign is clusters of symptoms. The guideline scope justified the use of these words as the symptoms can come from any system in the body, leading to symptoms ranging from fatigue and breathlessness to anxiety and diarrhoea. WH AT DO WE K NOW?
Long COVID symptoms Source: JAMA 2020; 324H6):603 -605
As of now, we do not have a clear idea why some people get Long COVID and others do not. Even the definition set by NICE shows this, as the only way to diagnose it is if the patient had had COVID-19 previously and their condition cannot
H OW DO WE T RE AT IT ?
Over 60 clinics for long COVID consultancy have been opened Source: national health executive
be explained by a different diagnosis. However, we are discovering what makes Long COVID more likely. A study conducted by King’s College London using data from 4,182 COVID Symptom Study app users who logged their health frequently and tested positive through swab PCR tests. The research provided more ideas about this poorly understood condition and identified “two main symptom groupings”. One group comprised respiratory symptoms such as cough, shortness of breath and headaches, and the second had multi-system symptoms affecting multiple organ systems including the brain, the heart and the gut. In the study, approximately 1 in 20 people would be ill for 8 weeks and 1 in 50 would suffer for 12 weeks or more. This data was extrapolated to fit the UK population and the ratio of people who would be ill for more than 12 weeks was found to be 1 in 45. An interesting discovery was the use of early disease features to predict the duration of the disease. They found correlations between Long COVID and multiple symptoms in the first week, older people and sex (women seemed to be more susceptible to Long COVID).
A large part of the treatment involves staying at home and pacing yourself to handle the symptoms. Exercises such as yoga help to stretch the muscles and relieve joint pain. The exercises can also help wellbeing and counteract depression or anxiety which can be symptoms. A focus on breathing techniques can help with the breathlessness and one should aim to make notes and plan the day in order to refresh the memory. The NHS is also offering specialist services including physical, cognitive and psychological assessments. After assessments, patients will be advised on their problems and/or referred to more advanced services such as sleep clinics, specialist lung disease services, cardiac services. By definition, Long COVID will be with us for many years to come. It will be a source of research which will lead to better treatment and outcomes.
Endnotes BHF, Long Covid: what it is and what you should do if you have it, www.bhf.org.uk/informationsupport/heart-mattersmagazine/news/coronavirus-and-your-health/long-covid#Heading5 NHS, NHS to offer ‘long covid sufferers help at specialist centres, www.england.nhs.uk/2020/10/nhs-to-offer-long-covid-help/
The Subsequent sub-diagnosis of people with Down Syndrome Thirisha Anpalakan D N A PAC KAG I N G WI T H I N O U R C E L L S , & T HE G EN ET I C S B E H I N D DOWN SY NDRO ME
Each cell in the human body usually consists of 46 chromosomes, 2 copies of each of the 23 chromosomes. Chromosomes are small “packages”1of DNA which are tightly coiled around proteins called histones. Every cell in the human body contains all of the genetic information (encoded in DNA) that is require for the organism to develop, survive and reproduce. Down syndrome is a genetic condition where a person has a total or partial duplication of chromosome 21 resulting in three copies of that
chromosome. The medical term for this is “Trisomy 21”1. It is a condition that is present at birth and can be diagnosed in-utero. Down syndrome is associated with physical and mental characteristics which will be combined with current research to develop a well-characterised behavioural phenotype for this syndrome. Among many, the typical physical features of Trisomy 21 are: flattened face, a short neck length below average and small ears. People with Down syndrome often exhibit an IQ in the mild-to-moderately low range, alongside delayed speech development.1
A D D RE SSI N G T H E B E H AV I O U R AL C HA RAC T E RI ST I C S ASS O C I AT E D WI TH D OW N SYN D R O ME
In this article I will be dividing the behavioural phenotypes into two subgroups among the many, which each contribute to the effects of Down Syndrome and therefore show two important factors which will prove useful for the further diagnosis led by healthcare professionals. These subgroups are adapted from a recent study2 and entail; motor coordination and speech, language and communication, where I have found that people with Down Syndrome seem to have more problems. Even though behavioural phenotypes are determined by both the environment and genetics there are certain behavioural phenotypes that exist as a spectrum within the Down syndrome community. The consolidation of this spectrum will give medical professionals another tool to further ensure the best treatment is given when consulting patients who also have Down syndrome. A study made by the University of Reading, shows that 92% of parents had noticed improvements in the children’s methods of communication, as a result of intervention.3
Although motor functioning could be associated with physical characteristics, here we are classing it as a behavioural phenotype because of the behavioural impacts it creates. Studies show that children who are diagnosed with autism (which is a spectrum disorder commonly found amongst people with Down syndrome) and ADHD (attention deficit hyperactivity disorder) exhibit evidence of impaired motor control abilities when compared to typically developing controls.4 Reports from Dmitriev(2001)5 describes 4 different types of infants on the topic of muscle tone and motor functioning: Type 1 (15%-25%) babies have good physical characteristics – such as muscle tone. Type 2 and 3 (50%-60%) babies show a difference between upper and lower body motor functioning. Type 4 babies (15%-25%) are weak all over and struggle to learn to sit up or to crawl. Jobling (1998) reported that 10-16 year-old children with Down Syndrome have specific motor impairments, including difficulty with movement of the limbs; for example: stepping over a stick while on a balance beam, and with fingers; pivoting thumb and index finger, as well as exercise such as
sit-ups and press-ups.6 Similar weakness are evident in motor planning (the ability to work out the plan of action before actually engaging in physical activity). The severity of motor impairments in people with Down syndrome exists as a spectrum, with even those mildly affected often benefitting from effective movement as this enhance confidence and contributes to self-worth.7 Language, speech and communication are also factors that are affected by the condition. Many children who have Down Syndrome have severe language delays8 in vocabulary size relative to mental age9. The difference between receptive and expressive language is that receptive is the ability to understand information, for example to be able to read and extract information and expressive is actually displaying information verbally, for example speaking and being able to form grammatically correct sentences. In receptive language, for children, due to the delay in speech, their understanding of word and phrase orders becomes easier as they grow up. One of the most important studies (Miller 199910) of early speech and language functioning in Down Syndrome had demonstrated that the majority (64%) of children with the syndrome aged 0-5 years fit a profile of receptive language that is relative to their mental age, while expressive language is a bit behind10. In addition, this study found that over time, the number of children who fit this profile increased to 72%, suggesting that some children may be “growing into” the receptive language profile as they grow older.10 Despite delays in speech and language, older individuals, such as young adults, show relative strengths in nonverbal communication, such as sign language and portraying certain gestures, like waving to indicate a greeting11. In terms of speech, articulation is a major struggle for many individuals; this is due to many reasons but one of them is related to motor-speech delay.11 However young adults with Down syndrome are very articulate also, this stresses the importance of the spectrum that these characteristics are spread across.
Furthermore, the difference in ear structure in patients who have Down syndrome can cause hearing problems; examples of these differences are narrow ear canals or when there is damage in the inner ear; when the hearing nerve is affected.12 These structural differences impede the transmission of sound to the inner ear and therefore overall sound detection. However, patients who have Down syndrome have decreased electrical activity detected due to the ear structural problems listed above and the lack of sound transmission. This can cause partial (conductive) to severe (sensorineural) hearing-loss13, as reported by Folsom, Widen and Wilson 198314. These are not being used in diagnosis currently; however, I believe these behavioural phenotypes could prove useful in the future to distinguish the different levels of severity in the syndrome.
This article has highlighted two subgroups that contribute to behaviour and therefore show two important targets of early intervention for improved quality of life will be briefly mentioned. Reports made by Cadoret & Beuter 199415 showed a focus of intervention on the upper body, where Types 3 and 4 babies may not respond as well as the other types.16 Therefore, future research might explore
additional upper body positioning supports along with increasing certain aspects of intervention, such as longer durations of sessions. Previous research on the speech, language and communication area had been mainly focused on the inabilities of adolescents and young adults in verbal working memory, how they relate to poor expressive language and learning outcomes.2 The inability to exhibit effective expressive language, may lead to frustration2 so early intervention in this area, such as speech therapy and clinics, for example: The Lejeune Clinic17, could lead to a better quality of, and more independent life. To conclude, often when we look at Down syndrome, we look at the medical aspects and the behavioural aspects of the condition may be forgotten about. This article describing behavioural phenotypes will enable doctors to understand the developmental pathways of Down syndrome and hence provide better care for their patients with Down syndrome. These sub-diagnoses could even be useful for people who have a diagnosis of Down syndrome in a family member.
Dmitriev, V. (2001). Early intervention for children with Down syndrome: Time to begin. Austin: Pro-Ed. 5
Fidler, D.J., Hepburn, S.L., Mankin, G. and Rogers, S.J., 2005. Praxis skills in young children with Down syndrome, other developmental disabilities, and typically developing children. American Journal of Occupational Therapy, 59(2), pp.129-138. 6
Jobling, A., 1998. Motor development in schoolaged children with Down syndrome: a longitudinal perspective. International Journal of Disability, Development and Education, 45(3), pp.283-293. 7
Sigman, M., & Ruskin, E. (1999). Continuity and change in the social competence of children with autism, Down syndrome, and developmental delays. Monographs of the Society for Research in Child Development, 64, v-114. 8
Chapman, R. S. (1999). Language development in children and adolescents with Down syndrome. In J. Miller, M. Leddy, & L. A. Leavitt (Eds.), Improving the communication of people with Down syndrome (pp. 81–92). Baltimore: Paul H. Brooks Press. [7] Fabretti, D., Pizzuto, E., Vicari, S., & Voterra, V.(1997). A story description task in children with Down’s syndrome: Lexical and morphosyntatic abilities. Journal of Intellectual Disability Research, 41, 165–179. 9
Miller, J. F. (1999). Profiles of language development in children with Down syndrome. In J. Miller, M. Leddy, & L. A. Leavitt (Eds.), Improving the communication of people with Down syndrome (pp. 11–40). Baltimore: Brookes Publishing. 10
Miller, J. F., & Leddy, M. (1999). Verbal fluency, speech intelligibility, and communicative effectiveness. In J. F. Miller, M. Leddy, & L. A. Leavitt (Eds.), Improving the communication of people with Down syndrome(pp. 81–91). 11
Bibliography : Centers for Disease Control and Prevention. 2020. Facts About Down Syndrome | CDC. [online] Available at: www.cdc.gov/ncbddd/birthdefects/downsyndrome.html [Accessed 24 December 2020]. 1
Fidler, D.J., 2005. The emerging Down syndrome behavioral phenotype in early childhood: Implications for practice. Infants & Young Children, 18(2), pp.86-103. 2
Jones-healey, I., 2016. Early Language Intervention For Infants With Down’S Syndrome. [online] Down’s Syndrome Association. Available at: www.downs-syndrome.org.uk/ about/research-campaigns/research-by-condition/earlylanguage-intervention-for-infants-with-downs-syndrome/ [Accessed 16 January 2021]. 3
Hill, L.J., Mushtaq, F., O’Neill, L., Flatters, I., Williams, J.H. and Mon-Williams, M., 2016. The relationship between manual coordination and mental health. European Child & Adolescent Psychiatry, 25(3), pp.283-295. 4
Hearing Loss in Children with Down Syndrome. 2019. [online] Available at: www.massgeneral.org/children/downsyndrome/hearing-loss-in-children-with-down-syndrome [Accessed 6 January 2021]. 12
Down’s Syndrome Association. 2015. Hearing Loss. [online] Available at: www.downs-syndrome.org.uk/news/ hearing-loss-2/ [Accessed 17 January 2021]. 13
Folsom, R. C., Widen, J. E., & Wilson, W. R. (1983). Auditory brain-stem responses in infants with Down’s syndrome. Archives of Otolaryngology, 109, 607–610. 14
Cadoret, G., & Beuter, A. (1994). Early development of reaching in Down syndrome infants. 15
Early human Development, 36, 157-173. Bauer, S.M., 2016. A Behavior Analytic Intervention to Teach Exploratory Motor Behavior to Infants with Down Syndrome. 16
The Lejeune Clinic. 1995. [online] Available at: www. lejeuneclinic.com/ [Accessed 15 January 2021]. 17
How has AI affected healthcare? Keanu Khazanehdari
AI and Robotics have made a big impact on healthcare: genetic testing, robotic surgery, cancer research, and data collection. Technology has developed to aid medics in different fields such as in surgery, robotics can be used to minimise damage by using tools that allow precise and accurate procedures. Professionals have used AI to aid them in diagnosing patients, such as in radiology with X-rays and MRI scans to locate where the problem is, or in dermatology where AI is used to detect skin cancer. The increase in AI has made healthcare systems more efficient by helping healthcare professionals to understand data better, allowing them to provide better feedback, guidance, and support for staying healthy. A DVA N TAG E S
AI and robotics help reduce human error. Humans have made mistakes from time to time such as forgetting crucial information which may have been caused by emotional factors or tiredness. AI helps us make decisions more efficiently by gathering all the data and quickly analysing many factors, suggesting the appropriate outcome. This reduces any errors and increases accuracy and precision reducing waiting times.
Medical staff can only work for a few hours, needing breaks because of the time-consuming work. Due to this, hospitals can’t treat as many patients as needed however using AI can help provide healthcare to patients 24/7 as AI does not have any personal needs to take care of. Machines can be used in repetitive jobs that are quite boring and tedious for humans. This helps free up time for the medical staff, allowing them to spend their time to focus on more pressing matters rather than paperwork.
D I SA DVA N TAGE S
Using AI to replace most repetitive tasks leads to unemployment because the machines work more efficiently. It makes us more dependent on technology. This could make medics lazier and perhaps less able to think as critically as they did before which could be a problem for future generations. Due to this dependency, if any problems were to occur towards the technology, medics may not be able to adapt and solve it. Robotics is much better when it comes to working but they can’t replace the human connection between medic teams and patients. These bonds are essential to team management allowing communication and collaboration. SUM M A RY
AI plays a crucial part in modern healthcare, allowing medics to accomplish things that were once impossible. Technology is ever-changing and improving, treating more patients than in the past. We don’t have to worry about robotics completely taking over healthcare because it lacks the human connection and emotion that there is between medical professionals and patients. In the future, the development of AI will heavily benefit healthcare by providing faster and easier access to patients such as making clinical diagnoses, making therapeutic drugs, and communicating with patients.
Bibliography: www.optimumhit.com/insights/blog/global/benefits-ofartificial-intelligence-and-machine-learning-in-healthcare/ Preizler, D., 2020. Benefits of Artificial Intelligence and Machine Learning in Healthcare | Optimum Healthcare IT. [online] Optimum Healthcare IT. Available at: <www. optimumhit.com/insights/blog/global/benefits-ofartificial-intelligence-and-machine-learning-in-healthcare/> [Accessed 9 January 2021]. www2.deloitte.com/us/en/pages/life-sciences-and-healthcare/articles/future-of-artificial-intelligence-in-health-care. html Deloitte United States. Future of Artificial Intelligence in Health Care. [online] Available at: <www2.deloitte.com/ us/en/pages/life-sciences-and-health-care/articles/futureof-artificial-intelligence-in-health-care.html> [Accessed 9 January 2021].
Relationship between sleep and Alzheimer’s disease Ruby Chan
Alzheimer’s disease (AD) is the most common cause of dementia. Sleep problems such as insomnia, fragmented and mistimed sleep are common in affected patients, increasing in severity with the progression of the disease. Recently, theories explaining the link between sleep and Alzheimer’s begin to arise - is poor sleep a risk factor for AD, or does AD lead to poor sleep, or both? W HY D O E S A L Z H E I ME R ’S DI S E AS E
DO E S S LE E P DE PRIVAT IO N CAU S E
C AUSE SL E E P P R O B L E MS?
ALZH E IME R’S DIS E AS E ?
The suprachiasmatic nucleus is a small region in the hypothalamus that controls the sleep-wake cycle by controlling the timing of production of melatonin, which induces sleep. AD causes loss or damage of neurons in the suprachiasmatic nucleus, causing it to malfunction. Melatonin secretion by the pineal gland reduces and becomes irregular, disrupting the sleep-wake cycle. Therefore a lot of AD patients report sleep issues such as excessive daytime sleepiness, insomnia and light and fragmented sleep.
The glymphatic system is a waste clearance system for the central nervous system. It facilitates exchange of cerebrospinal fluid with interstitial fluid to remove interstitial waste in the brain, including betaamyloid and tau. However, the system only seems to be in action when the brain is in a sleeping state, independent from the circadian rhythm. In 2013 [6], L. Xie and colleagues conducted several studies on mice. They found that in anaesthetised or sleeping mice, the volume of interstitial space (volume of space outside brain cells) in the
brain increases by 60%, allowing cerebrospinal fluid to remove metabolic wastes more efficiently. In another experiment done by the same group, by injecting radiolabelled beta-amyloid in the mice, they found that beta-amyloid is cleared two-fold faster in sleeping mice than in awake mice. In wakefulness, interstitial space contracts, which increases resistance to movement of cerebrospinal fluid. This causes accumulation of metabolic waste from neural activity. When a person is sleep deprived, the glymphatic system cannot clear the build up of beta-amyloid. A study conducted by E. Shokri-Kojori et al. (2018) [7] shows that after one night of sleep deprivation, beta-amyloid increased by about 5% in the participants’ brain. When betaamyloid accumulates, it increases the chance of formation of plaques, which damages neurons and increases the risk of AD. At the same time, tau is also accumulated under sleep deprivation. Tau is a protein found in neurons in the central nervous system and has a function of maintaining stability of part of the cytoskeleton of neurons. Abnormal hyperphosphorylation of tau causes them to stick together, forming neurofibrillary tangles, which are pathological hallmarks of AD, alongside amyloid plaques. A study done by J. Holth et al. (2019) [8] discovered that tau in cerebrospinal fluid increases by over 50% after sleep deprivation. When tau levels rise due to inefficient waste clearance, it is more likely for them to form tangles. To make things worse, the same study found that neurofibrillary tangles spread faster in mice with prolonged wakefulness compared to the control. Neurofibrillary tangles obstruct communication with other neurons and transport of substances within the neuron, which exacerbates neurodegeneration, leading to AD.
imply causation. There is correlation between sleep and AD, but the examples above do not tell the whole story. Our scientific knowledge on both AD and sleep are considerably limited, thus more evidence is needed to firmly prove their relationship.
Citation Welsh, David K, et al. “Suprachiasmatic Nucleus: Cell Autonomy and Network Properties.” Annual Review of Physiology, U.S. National Library of Medicine, 2010, www. ncbi.nlm.nih.gov/pmc/articles/PMC3758475/. Wang, Chanung, and Holtzman, David M. “Bidirectional Relationship between Sleep and Alzheimer’s Disease: Role of Amyloid, Tau, and Other Factors.” Neuropsychopharmacology : Official Publication of the American College of Neuropsychopharmacology, Springer International Publishing, Jan. 2020, www.ncbi.nlm.nih.gov/ pmc/articles/PMC6879647/. Jessen, Nadia Aalling, et al. “The Glymphatic System: A Beginner’s Guide.” Neurochemical Research, U.S. National Library of Medicine, Dec. 2015, www.ncbi.nlm.nih.gov/pmc/ articles/PMC4636982/. Benveniste, Helene, et al. “The Glymphatic System and Waste Clearance with Brain Aging: A Review.” Gerontology, Karger Publishers, 11 July 2018, www.karger.com/Article/ FullText/490349. National Institute on Aging. “What Happens to the Brain in Alzheimer’s Disease?” National Institute on Aging, U.S. Department of Health and Human Services, 16 May 2017, www.nia.nih.gov/health/what-happens-brain-alzheimersdisease. Xie, Lulu, et al. “Sleep Drives Metabolite Clearance from the Adult Brain.” Science (New York, N.Y.), U.S. National Library of Medicine, 18 Oct. 2013, www.ncbi.nlm.nih.gov/pmc/ articles/PMC3880190/. Shokri-Kojori, Ehsan, et al. “β-Amyloid Accumulation in the Human Brain after One Night of Sleep Deprivation.” Proceedings of the National Academy of Sciences of the United States of America, National Academy of Sciences, 24 Apr. 2018, www.ncbi.nlm.nih.gov/pmc/articles/ PMC5924922/.
CON C LUSI O N :
Holth, Jerrah K, et al. “The Sleep-Wake Cycle Regulates
Some researchers believe that the sleep-Alzheimer’s relationship takes the form of a vicious cycle. However, it is often said that correlation does not
Brain Interstitial Fluid Tau in Mice and CSF Tau in Humans.” Science (New York, N.Y.), U.S. National Library of Medicine, 22 Feb. 2019, www.ncbi.nlm.nih.gov/pmc/articles/ PMC6410369/.
Primary Ciliary Dyskinesia and Situs Inversus Rainis Cheng
CILIA
Cilia are hair-like projections on the surface of a eukaryotic cell, made up of microtubules coated by the plasma membrane. There are three different types of cilia: motile cilium, non-motile cilium, nodal cilium. Motile cilium is present in respiratory tract and reproductive system, non-motile cilium is present on various vertebrae cells, while nodal cilia is present in early embryonic development. Cilia has locomotive, cellular signalling and sensory functions. They are also involved in mechanoreception and chemoreception. ST RUC T URE O F C I L I A
Overall structure (axoneme) Nine microtubule doublets form an outer ring, linked together by nexin proteins. It is anchored to the cell by a basal body (fig.2), which is a ring of triple microtubules. Two central singlet microtubules are held together by a central bridge and surrounded by a central sheath. There may be additional motilityrelated structures attached. The presence and absence of these features cause a difference in the inner structure of the three types of cilia, as detailed in table 1.
MOT ILIT Y-RE LAT E D ST RU CT U RE S Figure 1 9+2 axoneme and adjacent structures of motor cilia
They are attached to the A ring of doublets in motile cilia and nodal cilia. The radial spoke assists in the attraction of the doublets to the central singlets. The inner dynein arm controls the rhythmic motion of the cilia as part of the nexin-dynein regulatory complex.
Type of cilia
Present in
Nine doublet microtubules
Two singlet microtubules
Motility-related structures
Motile cilia
e.g. respiratory tract
Present
Present
Present
Non-motile cilia
Nearly every type of vertebrae cell
Present
Absent
Absent
Nodal cilia
Early development of embryo
Present
Absent
Present
Table 1
C I L I A I N E M B RYO NI C L E F T- R I GH T AXIS D ET E RM I N AT I O N
From the development of a zygote to a foetus, the fertilized egg has to separate and specialize into the organs we need to function and survive. Cilia plays an immensely important part in the determination of left-right patterning and asymmetric positioning of internal organs for situs solitus, the normal configuration of thoracic and abdominal organs. In early embryogenesis, posterior tilt and clockwise motion of nodal cilia creates a leftward fluid flow in the extracellular space. This leftward movement is possible as these cilia lack a central pair. The nonmotile cilium senses the flow and sends signals to the lateral plate mesoderm in the congenital, which gives rise to visceral organs and cavities enveloping them.
This model in which one type of cilium generates flow and another senses it is referred to the “two-cilia hypothesis”. Chemical morphogens that are secreted into the cavity of the central node and are accumulated on the left periphery as a result of the flow. For example, a study shows that nodal vesicular parcels (NVP) containing electron-lucent particles emerges from all regions of the ventral node but flows towards the left periphery where it then bursts and is absorbed. Different concentration of morphogens affects the expression of genes in a particular cell, paving way for specialisation into tissue and organs. PRIMARY CILIARY DYS K INE S IA CILIA IN PRIMARY CILIARY DYS K INE S I A
The most prominent and noticeable defect in cilia of PCD is the abnormal functioning of dynein arms. Different kinds of defects in PCD are shown in fig.3. In relation to situs inversus, the types of defects that would cause abnormal positioning of visceral organs would be the defects in dynein arms and disorganisation defect. Absent dynein arms cause a weaker or random movement of the cilia. In contrary to the misbelief that cilia in PCD are immotile, the defects cause weaker randomised movement instead of strong directional beating. It is notable that primary ciliary dyskinesia usually affects the motilityrelated structures, thus defects relating non-motile cilia such as in the central complex and radical spokes do not have effect in causing laterality defects as situs inversus or situs ambiguous. Figure 2 Defects of PCD
Figure 3 A: situs soliltus; B: situs inversus totalis; C: situs ambiguous
responds to chemical stimulation. From there, the importance of cilia in embryogenesis and organ formation became evident, such that we could locate one of the explanations of situs inversus. However, not all cases of situs inversus are caused by PCD much about the condition still remains a mystery, the science for us to uncover in years to come. Science University of Copenhagen (7 May, 2015), YouTube,
P C D A N D SI T U S I NV E R S U S
Primary Cilia – the cells’ ultimate antennae. www.youtube.
Situs inversus is a congenital condition in which the major visceral organs are reversed or mirrored from their normal positions. Situs inversus does not require treatment and does not have major health consequences, but diagnosed patients have to carry around identification in the form of a bracelet or a card in order to inform medical professionals of special attention. For example, appendicitis is presented as pain in the lower right abdomen of individuals with situs solitus but on the left in individuals with situs inversus. However, situs ambiguous is commonly seen with other complications such as congenital heart disease, complications with systemic and pulmonary blood vessels, and cardiac development defects. As established previously, in embryogenesis, nodal cilium creates a leftward flow as to migrate morphogens to the lateral plate mesoderm for cell specialisation. Without the function of nodal cilia, the nodal flow is slow or absent, thus thoracoabdominal laterality becomes random. Genetically identical twins with PCD, are reported to have different one with situs inversus totalis and one with situs solitus. Random visceral organ positioning can be seen in fig.3. The cardial apex (C) points towards the left in situs solitus, with the liver (L) on the right and stomach bubble(S) on the left. In situs inversus, the visceral organs are completely mirrored, but in situs ambiguous, both the stomach bubble and the liver are on the same side, showing that placement of organs are not all or none. The cilium is one of the first organelles to be identified but only recently did we understand that they do not only generate movement but also
com/watch?v=NFAO65d7M3A&ab_channel=ScienceUniversityofCopenhagen R. A. Bloodgood (2010), Journal of Cell Science, Sensory reception is an attribution of both primary cilia and motile cilia. jcs.biologists.org/content/123/4/505 M. Adams (2010), Nature Education, The Primary Cilium: An Orphan Organelle Finds a Home. www.nature.com/ scitable/topicpage/the-primary-cilium-an-orphan-organelle-finds-14228249/ BYJU’S (2020), Cilia. byjus.com/biology/cilia/#:~:text=Cilia%20Structure,of%20motor%20proteins%20called%20 dynein Cilia. (2020). Ciliopathy Alliance. ciliopathyalliance.org/ cilia#:~:text=Structurally%2C%20each%20cilium%20comprises%20a,of%20microtubules%20(e.g%20bronchi). M.K. Wagner, H.J. Yost (2000), Left-right development: The roles of nodal cilia. www.sciencedirect.com/science/article/ pii/S0960982200003286 S.F. Gilbert (2000), Developmental Biology, Lateral Plate Mesoderm. www.ncbi.nlm.nih.gov/books/NBK9982/#:~:text=On%20either%20side%20of%20the,mesoderm%2C%20 which%20overlies%20the%20endoderm Cartwright, J. H. E., Piro, N., Piro, O., & Tuval, I. (2006). Embryonic nodal flow and the dynamics of nodal vesicular parcels. Journal of the Royal Society Interface, 4(12), 49–56. doi.org/10.1098/rsif.2006.0155 Noone PG;Bali D;Carson JL;Sannuti A;Gipson CL;Ostrowski LE;Bromberg PA;Boucher RC;Knowles MR. (2017). Discordant organ laterality in monozygotic twins with primary ciliary dyskinesia. American Journal of Medical Genetics, 82(2). doi.org/10.1002/(sici)10968628(19990115)82:2<155::aid-ajmg11>3.0.co;2-t Kennedy, M. P., Omran, H., Leigh, M. W., Dell, S., Morgan, L., Molina, P. L., Robinson, B. V., Minnix, S. L., Olbrich, H., Severin, T., Ahrens, P., Lange, L., Morillas, H. N., Noone, P. G., Zariwala, M. A., & Knowles, M. R. (2007). Congenital Heart Disease and Other Heterotaxic Defects in a Large Cohort of Patients With Primary Ciliary Dyskinesia. Circulation, 115(22), 2814–2821. doi.org/10.1161/circulationaha.106.649038
Vertigo Michael Wong
Vertigo is a sensation of feeling off balance. It is also typically defined as a sensation of spinning, an illusion of tilting or translating when you are actually still, or an impaired perception of otherwise normal motion. W HAT A RE T H E DI F F E R E NC E S BE T W EE N I T A N D DI ZZ I N E SS?
Most people would think vertigo and dizziness are the same thing, because both cause distortion to your vision, therefore it can be very hard to differentiate between the two. Dizziness is an altered sense of spatial
orientation, a distortion of where we are within a space and the balance feels off. Vertigo is when you feel a spinning motion but there is no motion at all. One key difference is that the spinning motion of vertigo can remain for a long period of time, or it comes on abruptly with a very strong response.
C AUSE S A N D T R E AT ME NTS F O R V E R T IG O
Vertigo is often caused by an inner ear problem. Some of the common causes are as follows: Benign Paroxysmal Vertigo (BPPV) This occurs when tiny calcium particles are dislodged from their normal location, which then form crystals and accumulate in the inner ear. Deep head hanging manoeuvre can be performed to get the loose crystals out of the canal. Meniere’s Disease It is caused by a build-up of fluids and changing pressure in the ear. Episodes of vertigo may occur with ringing in the ears, fluctuating hearing loss, or feeling like the ear is plugged, that may last up to several hours. Vestibular Neuritis It occurs when a viral infection, such as influenza and measles, infects the vestibular never in the inner ear. When the vestibular nerve is inflamed, it causes vertigo. As a spinning motion is resulted, it may also cause nausea, vomiting, balance issues and difficulty in concentrating. Labyrinthitis This is also a result of viral infection in the inner ear, but the difference between it and vestibular neuritis is that the cochlear nerve is also inflamed. As the cochlear nerve is responsible for sending information to the brain about spatial navigation and balance control, labyrinthitis causes difficulty in hearing and ringing in ears.
Most vertigo cases resolve itself without any treatment, but there are treatments to manage symptoms and underlying conditions, such as nausea and vomiting. The two medicines usually recommended by GPs are prochlorperazine (which helps relieve severe nausea and vomiting) and antihistamines (which helps relieve mild nausea, vomiting and vertigo). Therapies such as deep head hanging manoeuvre therapy and balance therapy may also be useful for patients to relieve their symptoms. For very severe vertigo cases, videonystagmography (VNG) balance test can be carried out. This tests the inner ear and motor function to find out the causes of dizziness or vertigo.
References: Nayana Ambardekar (2020) Vertigo: Symptoms, Causes and Treatment www.webmd.com/brain/vertigo-symptoms-causestreatment#1 Date of access: 28th December 2020 Regional Neurological Associates (2020) Dizziness vs Vertigo: What is the difference? www.regionalneurological.com/dizziness-vs-vertigo-what-isthe-difference/ Date of access: 29th December 2020 Cleveland Clinic (2019) Are dizziness and vertigo the same thing? health.clevelandclinic.org/are-vertigo-and-dizziness-thesame-thing/ Date of access: 28th December 2020
Medicine during COVID-19 Jeremy Chang
It has been more than a year since the first recorded case of SARS-CoV-2 or better known as COVID-19 was announced publicly. Since then, an exponential growth of the virus has led it to spread worldwide and not until recently have we developed vaccines to slow the spread of this lethal virus.
By acknowledging the root of how COVID-19 infects our body, researchers pinpointed emphasis on a specific receptor in our body that enables COVID-19 to infect human cells in hope for searching a potential cure for this pathogen. This receptor is the angiotensin- converting enzyme 2 or ACE2 receptor. It is the receptor that allows cellular entry of SARS-Cov-2 into human cells. The ACE2 receptor is a type 1 transmembrane metallocarboxypeptidase, which is an enzyme important in the Renin Angiotensin system- It is
crucial in regulating processes in our body involving blood pressure, inflammation and healing of the wound. More importantly, ACE2 regulates the action of a peptide hormone called angiotensin II (ANG II) which causes increase in blood pressure and inflammation, damage to blood vessels and other forms of tissue damage. (ANG II derives from ANG I converted by ACE enzymes, angiotensin is made in the liver.). ACE 2 modulates the hormone ANG II by breaking it down into other molecules to overcome the harmful effect of ANG II.
This receptor can be found throughout the body in lungs, kidneys, heart and even in leydig cells in testes. Therefore, it is true that COVID-19 can affect male fertility (for reference you can read the first article in bibliography section). Yet, our main focus should place on lung damage caused by inhibit of the ACE 2 receptor because the patient now becomes more susceptible to inflammation due to inability of breaking down ANG II.
At last, another method for treating COVID-19 can be using convalescent plasma from recovered patients. This is because after infection, the body produces antibodies to fight against the virus, as we know, this is the same principle as modern day vaccines.
Therefore logically, an anti-ACE2 antibody drug will be an ideal treatment for COVID-19 as it can prohibit SARS-CoV-2 from binding to the receptor and prevent entrance into human cells.
Bibliography;
Moreover, a protease called Transmembrane serine protease 2 (TMPRSS2) moderates the entry of viruses into human cells by a process called proteolytically cleaving (which is breaking down proteins into smaller polypeptides or amino acids by trimming them) and also stimulating the activation of viral glycoprotein ( or in this case, spike proteins on SARS-CoV-2). As a result, virus like SARSCoV-2 uses this protein to gain entrance into human cells. Therefore, by developing appropriate protease inhibitor for such proteins, it can become a medicine used for treating covid-19.
theconversation.com/what-is-the-ace2-receptor-how-is-
www.news-medical.net/news/20201122/COVID-19potentially-has-negative-impacts-on-male-fertility.aspx www.yourhormones.info/hormones/angiotensin/ it-connected-to-coronavirus-and-why-might-it-be-key-totreating-covid-19-the-experts-explain-136928 www.health.harvard.edu/diseases-and-conditions/ treatments-for-covid-19 www.rndsystems.com/resources/articles/ace-2-sarsreceptor-identified www.euprotein.com/feature_protein/ TMPRSS2?utm_source=google&utm_ term=transmembrane%20protease%20serine%20 2&adgroup=110949161915&gclid=Cj0KCQiAlZH_ BRCgARIsAAZHSBn3-e2ePWJx29aTWFX6R964moEsb5k_f1tJDWu2q59AROQB4NPsaAaAt1rEALw_wcB
VE T ERI N A RY
Welcome to the Veterinary section of the CMJ: In this section we have articles on veterinary science as well as how veterinary practice itself works. The Wright Society is not just for aspiring doctors but also aspiring vets and this section includes a variety of veterinary topics.
Murdo McIntosh Veterinary practice comparison UK Vs Australia Caitlyn Hocking Veterinary practice comparison UK Vs South Africa Caitlyn Hocking Canine Parvovirus Murdo McIntosh Lyme disease in dogs Interview with Charlotte Watson a current vet
Veterinary Practice Comparison UK Vs Australia Murdo McIntosh RSPCA acts in both Australia and the UK as the leading veterinary and animal support association. However, each country has their unique animals to deal with as well as different laws to comply to. The RSPCA is aimed at animal welfare whereas the British Veterinary Association and Australian Veterinary Association sorely look into veterinary practice and the ethical quires behind it. B RI T I SH V ET E R I NARY ASS O C I AT I O N
Animal welfare science is an evolving social concern. There is growing expectation that the veterinary profession will reflect modern scientific understanding of animals’ needs, preferences, pleasures, and pains across veterinary policies. The profession looks to BVA to lead public debate on the acceptability of current animal husbandry methods. The definition of ‘animal welfare’ incorporates all key determinants of an animal’s wellbeing, such as appropriate companionship and the ability to express
normal behaviours. Animal welfare strategy ‘Vets speaking up for animal welfare’, provides a framework to help vets advocate for good animal welfare outcomes for all animals. It identifies 6 priority areas as building blocks for further action: • animal welfare assessment • ethics • legislation • advocacy • education • international They have also developed a list of priority animal welfare problems, in close liaison with the specialist divisions, on which they are jointly developing positions and proactively campaigning. Under the animal welfare strategy, the BVA developed policy positions on the following welfare issues:
• Analgesia in calves
Live Export - Standards for the Export of Livestock
• Goat kid disbudding and analgesia
National leadership in animal welfare - the need for national leadership in animal welfare, and we continue to lobby the Commonwealth Government on this issue.
• Surplus male production animals • Welfare of livestock during transport • Non-stun slaughter
• Extreme conformation
Reactive animal welfare advocacy - continues to be active on a number of specific animal welfare topics which receive a high level of attention in the public debate. Ongoing priorities include:
• Use of aversive training devises in dogs and cats
• Puppy farms and breeding standards
AUST RA L I A N V E T E R I NARY ASS O C I AT IO N
• Breed-specific legislation and dangerous dog regulation
• Abnormal behaviour • Feather pecking in laying hens
Australia is split up between New South Wales, Queensland, Northern Territory, Western Australia, South Australia, Victoria, the Australian Capital Territory, and Tasmania. The Object of Veterinary Practice Acts should be to regulate the practice of veterinary science so as to ensure that acceptable standards are required to be met by veterinary practitioners so as to: • protect the health, safety, and welfare of animals • protect the public health, safety and welfare • ensure that consumers of veterinary services are well informed of the training, qualifications and competencies required by persons undertaking veterinary procedures • meet international trade requirements • provide for other related matters They have a similar animal welfare strategy to the BVA which includes: • Love is Blind campaign - Focusing on exaggerated breed features such as brachycephaly • Anaesthesia-free dentistry campaign • Pet Food Regulation Companion animal management - Part of sociallyresponsible pet ownership is ensuring pets are properly socialised, trained and cared for. Livestock welfare - standards and guidelines; these include development of standards for poultry welfare, welfare at abattoirs, and pig welfare.
• Urban animal management and unwanted companion animals • Online advertising of companion animals • Greyhound racing reforms • National Animal Welfare Standards and Guidelines • Restricted acts of veterinary science • Equine dentistry • Hendra virus • Humane control of invasive species With their key principles being (these are the principles to which both the board members and vets around the country have to put above all else): Animals are sentient beings that are conscious, feel pain, and experience emotions. Animals and people have established relationships for mutual benefit for thousands of years. Humans have a duty of care to protect animals. Where a person does not meet his or her obligations to animals in his or her care, animals may suffer. When this happens, the law must be able to adequately intervene to enforce compliance and prevent suffering. Animals have intrinsic value and should be treated humanely by the people who benefit from them. Owned animals should be safe from physical and psychological harm. They need access to water and species-appropriate food and shelter and should
be able to fulfil their important behavioural and social needs. They must receive prompt veterinary care when required and have as painless and stressfree a death as possible. Animals can be used to benefit humans if they are humanely treated, but the benefit to people should be balanced against the cost to the animal. They should not be used in direct combat or for purposes where suffering, injury or distress is likely to be caused.
Humans should strive to provide positive experiences to promote a life worth living for the animals in their care. We should strive for continuous and incremental improvement in the treatment and welfare of animals. Humans have a responsibility to care for the natural environment of free-living native animals. People should take steps to preserve endangered species and protect native animals from disease where possible.
UK Vs South Africa Caitlyn Hocking
• The SPCA (Society for Prevention of Cruelty to Animals) is an international organisation that covers animal cruelty cases across the world, as well as provide free veterinary clinics for those in poverty with pets. • There are some branches of this charity that are specialised to specific countries, for example the RSPCA (Royal Society for Prevention of Cruelty to Animals) which is primarily centred around the UK. • As much as the RSPCA is heavily relied upon for the care of animals here in the UK, their work is mainly around animal cruelty cases, with other charities, such as the PDSA, covering the majority of veterinary care for those with pets who do have the money to pay for their care.
• However, in South Africa, there are very few charities similar to the PDSA, and therefore it is the SPCA that covers not only cruelty cases, but also veterinary work for those in poverty which, in comparison, is a much larger percentage than here in the UK. Therefore, veterinary work in SA, while there are plenty of general practices, is largely centred around charities, unlike here in the UK where there is usually only one vet assigned to each RSPCA centre, with more available from other centres when necessary, and the majority of vets found in practices. • In the UK, pet insurance is very much encouraged; pet insurance is very much like any other insurance, whereby it is paid for with a payment plan, and then can be used to pay for treatment and surgeries much larger than usual (e.g. broken leg, pyometra, cancer treatment, etc.).
• In the long-run pet insurance can prove to save thousands of pounds and is highly recommended so that your pet is always covered for injuries and illnesses, and can therefore payment for treatment should not be an issue. • However, in SA, pet insurance is much less common; pets over there are very much pets and far from additional members to the family like in the UK (e.g. dogs mainly live outside and are guard dogs, cats are much less common, and anything smaller is very unlikely to be a pet), therefore owners are much less prepared to spend money on their pets and do not regard insurance as important, because if something requires a large amount of their money, they will most likely resort to euthanasia, and out there, this is very much accepted! • Leading on from this, referral practices in SA are much harder to find than in the UK; over here referral practices are heavily relied upon for treatment and surgeries that require specialised training, or for cases needing more time and attention than can be given in a general practice. • However, the less money owners are prepared to spend on their pets, the less referral practices
are needed and therefore there are much fewer referral practices in SA than in the UK. Therefore, specialised veterinary training in South Africa is much less vital than in the United Kingdom, because owners are less prepared to spend money on their pets, and so will rarely agree for them to receive treatment from a referral practice. • In the UK, there is a very wide variety of animals that are kept as pets, and no matter the animal, the majority of people are prepared to spend their money on treatment for this animal when and if it is needed • In SA, there is very small variation in the animals that are kept as pets; dogs are common but are usually used for security and are kept outside (therefore big dogs), cats are much less common than over here, and anything smaller than a cat is not likely to be kept as a pet Therefore, vets working in general practices in South Africa will see much less variation in their patients than over here in the United Kingdom, and so will be much less used to dealing with particularly small animals or a variation of certain types of animals (e.g. small dogs; not very effective guard dogs and so are less common pets in SA).
Canine Parvovirus Caitlyn Hocking
In puppies under 4 weeks of age, the myocardium is rapidly dividing and will therefore be targeted by Parvo, causing heart failure. G AST ROI N T E ST I NAL C E L L S
After the myocardium is further into development, the cells are dividing slower; gastrointestinal cells are rapidly dividing so are targeted by Parvo – it causes flattening of the villi, resulting in malabsorption. • Parvo can also target the cells of the bone marrow, causing immunosuppression, and therefore increasing susceptibility to secondary bacterial infections. • CPV is spread between dogs by direct or indirect contact with a dog infected by the disease, and particularly the faeces of such a dog.
• Typically, the virus enters the dog through the mouth, before spreading to the lymph and blood vessels, enabling the virus to travel throughout the body. • Vaccines can be used to prevent infection, but in untreated cases mortality rate can reach 91%. • The first vaccination typically occurs between the age of 6 and 8 weeks and the second one no younger than 10 weeks of age. • A booster is then needed at one year, and then every 3 years from then on to continue protection.
• Vaccines are not given to a pregnant dog as it can cause damage to the foetuses; instead the dog is usually vaccinated 2-3 weeks before breeding in order to optimise material antibodies which help to protect the puppies until they are old enough to be vaccinated.
T RE AT ME NT
AT RI SK
• Fluids – to replace fluid loss and repair any damage due to fluid loss
Puppies, particularly unvaccinated or under the age of 6 months -Unvaccinated dogs • Puppies are more susceptible to catching catching CPV as they are more likely to lick or sniff infected objects and they have no immunity before vaccination. • Unvaccinated dogs also do not have any immunity against the disease. SYM P TO M S
• Diarrhoea (strong smell, watery, and bloody) • Vomiting • Reduced appetite • Lethargy • Fever – this does not always occur; some may have an unusually low temperature and concurrent shock as a result of severe dehydration • A rapid and specific ELISA test carried out on the faeces of a dog confirms whether symptoms are of CPV F URT HER I N V E ST I GAT I O N
• Blood tests – these are used to determine the extent of immunosuppression (by white blood cell counts), and examine for anaemia and low protein levels • Faecal examination – these are used to identify and treat any parasites that may cause further complications • These help with both the prognosis and treatment plan
• Hospitalisation – because of the severity of the disease, hospitalisation is required to ensure correct treatment is followed and the dog can be isolated in the correct conditions • Isolation – to prevent the disease spreading and subsequent outbreaks
• Antibiotics – to treat and prevent infections that often occur due to immunosuppression • Medication – to reduce vomiting, nausea, and pain • Nutritional support – to replace loss of nutrients and speed recovery • While humans themselves cannot become sick with the virus, they can carry it on their hands and clothing, and can therefore pass it on to dogs that they come into contact with. • The virus can remain active in the environment for many months, for example on soil, cages, and toys, and continue to infect dogs. • Recovered dogs can shed CPV for up to 2 weeks after the illness. PRE VE NT ING T H E S PRE AD
• Washing hands thoroughly with soap and water. • Cleaning surfaces and objects, such as cages, bowls, clothing, toys, and floors, with Parvocidal disinfectant. • Isolating items/surfaces that cannot be disinfected for at least 7 months. • Isolating recovered dogs for at least 2 weeks after the have recovered. • VACCINATION – vaccination is absolutely key to stop the spread of canine parvovirus.
Lyme Disease in Dogs Murdo McIntosh
Lyme disease (also known as Borreliosis) is an illness spread by infected ticks. It can affect dogs, people, horses and very occasionally, cats. Lyme disease is caused by a bacterium (Borrelia) that attacks tissues around the body, most commonly the joints, but also organs such as the kidneys. Lyme disease spreads when an infected tick attaches and feeds, so keeping your pet up to date with a product that kills or repels ticks is the best way to prevent it. The tick is an efficient vector because uninfected tick larvae, nymphs, or adults feed on infected wildlife reservoir hosts, including birds and rodents, become infected, and then transmit the infection to larger mammals when taking their next blood meal. As ticks are indiscriminate in their choice of host, the pathogens can be transmitted from wild animals to companion animals and humans. A small percentage of dogs that get Lyme disease may get Lyme nephritis. This is a kidney disease thought to be caused by antibody/antigen immune complex formation that are deposited in the kidneys and lead to acute renal failure.
Nephritis is defined as inflammation of the kidneys. Lyme nephritis is an uncommon manifestation of the infection with the bacteria that causes Lyme disease, Borrelia burgdorferi. What makes Lyme nephritis so dangerous is that it is not only the infection that triggers this condition but also the immune system’s response to the infection. It is the development of an antigen-antibody complex that triggers inflammation in the kidneys and, ultimately, the destruction of the organ. Antigens are foreign proteins that trigger a response by the body’s immune system. Most antigens are viruses, bacteria, abnormal cells, etc. Antibodies are proteins produced by the immune system in response to antigens. Antibodies identify and tag antigens which signal white blood cells to destroy these foreign invaders. Usually, this process just
clears the infection or destroys abnormal cells before they can become tumours or cancers. Sometimes the antigen and antibody combine to form a single unit called an antigen-antibody complex. These complexes circulate throughout the bloodstream until they lodge in the body’s tissue. Once the antigen-antibody complex deposits in tissues it triggers an inflammatory response that damages the tissue itself.
T RE AT ME NT
The best defence to this condition is to vaccinate against Lyme disease before an infection occurs. It is usually a series of two vaccines and then once annually. Remember that this vaccine is only effective if given annually so don’t skip.
Dogs with Lyme nephropathy may require additional treatments, including:
SYM P TO M S
Common signs of Lyme disease include: • Limping, stiffness and swollen joints that shifts between legs • Fever/high temperature • Low energy (lethargy) • Swollen lymph nodes (glands) around the body • Vomiting • Diarrhoea • Drinking and weeing more Each dog with Lyme disease will have slightly different symptoms depending on which parts of the body it attacks. Most commonly, it affects the joints, but it can also affect other organs such as the kidneys. In some dogs, symptoms come and go.
Treatment for your dog will depend on the signs they are showing. Mild cases an often be successfully treated with antibiotics, but severe cases often require treatment such as pain relief and a drip (fluids given into the blood stream). Treating Lyme disease can take several weeks and sadly, for the worst affected dogs, treatment isn’t always successful.
• Pain relievers (such as low dose aspirin) • Omega – 3 fatty acids • Dietary therapy • Hypertension medications • Immunosuppressive drugs PRE VE NT ING LYME DIS E AS E
The best way to prevent Lyme disease is to prevent ticks. You can prevent ticks by: • Using tick collars, tablets or spot-on products. • Avoiding long grass, especially in the warmer months. • Avoiding places known for ticks (find out if ticks are common in your area). • Regularly checking your pet for ticks after walks, they are most common on the head, ears, armpits and belly.
Interview with
Charlotte Watson a current vet
What was the biggest surprise you found after becoming a vet, compared to what you expected it to be? For me it was having the responsibility. I think both before I applied and as a student shadowing other vets, you don’t really realise how you will feel when your decision is the one that counts. I think that is one thing which is really hard, dealing with the responsibility, as owners put a lot of trust in you to come up with a good plan which is suitable for them and their pet. Especially in modern times, we are a nation of animal lovers, so pets are family members for a lot of people.
The second thing was that not everyone will have the finances or be able to do the treatment option that you think is best. You have to adapt your plan and come up with what is best in the situation you must be very adaptable. No case is the same! You must be able to think on your feet. What advice would you give to applicants to get a realistic impression of the profession and the day-to-day working of being a vet? Although at the moment it is tricky, work experience is really important. Before I applied, I did many different weeks in lots of
different places. Broadly, it involves getting a range of experience in different practices, for example small animal practices or equine practices. It is also important to get out on farms and spend time lambing and calving on the job. At the end of the day, those people will be you clients if you go into that sector, so you must understand how the sector works and what sort of people you will be working for. It broadly divides into 2 categories: seeing the practice and how other vets work, but also spending time with the people that you will be working for.
Before applying to university, what sort of skills students could develop to succeed in studying to become a vet?
How did you find actually studying at university compared to your expectations?
From more of a vet perspective, getting some animal handling skills may be helpful (such as on work experience) may give you a head start on the course.
I went to Nottingham, which is a 5-year course. It is very good in the sense that it is very hands on and active. There are lectures, however there is lot of practical work complementing this, such as dissection and practical skills such as ultrasound and x-ray. I applied to Nottingham because I knew it was going to be a practical course and it thought that was important. Compared to a lot of people on other courses, you don’t realise how much time you must put in. For my contact hours it was like being at school, 9-5 every day, with extra work at the end of the day. I don’t think I was prepared for the volume of hours I had to put in, which is why I think it is really important to know that you really want to do it, since you will spend so many hours working.
Firstly, in your school career, becoming as efficient as you can with how studying works for you is key, because the volume of work you have to cover at university is vast compared to school and even A-levels. You already need to know what best study skills work for you. Also, time management is important because although you go to university to do your course, it is really important to do other activities that you enjoy.
What do you find most challenging about being a vet? I would say the emotional side of it. On a normal day, you might have a euthanasia scheduled in, you must be compassionate and professional to the owners and help them deal with that grief. Your next appointment may be with someone with a new puppy. You have got to be able to switch your emotions very quickly and not hold onto those emotions, because there might be a completely different tone that you need to strike with those different appointments. You are consistently seesawing from one thing to the other, and you have got to conduct yourself appropriately as a result of that.
I N T E RV I E WS
In this section you will see some of the interviews that were conducted with some of our Upper Sixth medics and old cat medics who are currently either studying or practicing doctors. We were immensely lucky to have the Old Cat medics do the interviews and they were very enjoyable for us to do from an Upper Sixth medics’ point of view.
Interview transcript with Louise Gardener, a medic who is currently a practicing doctor
Interview with Mai Wallace, a medic who is currently studying at Swansea
Interview with Ohis Ojo, a medic who is currently a practicing doctor
Interview with
Louise Gardener a practicing doctor
What surprised you most about starting to practice medicine?
What have the biggest challenges been both at med school and as a junior doctor generally?
I think maybe two things. Unfortunately you cannot save everybody in medicine. I definitely went in with this idea that you want to help every patient and do you best for them and try to make things better for them but unfortunately that’s something that I think pre going into it I had a lot of good thoughts about that but that’s something that surprised me that actually there’s a lot of patients that we can’t help, although we would love to if we could. And I think something else that maybe surprised me going in as a junior doctor is the amount of time that you spend doing admin related work in a loose sense and you spend a lot of time doing discharge summaries of patients, writing ward round notes. You go in thinking it is all patient centred care but actually the time you spend with the patient is less (as a junior, anyway).
One of them is definitely having enough time to see all the patients. You may have a ward of 30 people and you would love to spend time with every one of them but actually you don’t always get to spend that time. You have to prioritise doing the things that are going to help the patient. What’s it been like practicing medicine normally compared to practicing during COVID? As COVID hit, we were graduated early in my cohort and we were the cohort who worked as the interim F1’s and got brought up early. So, I haven’t actually practiced as a doctor pre COVID times. I obviously worked as a medical student but I’ve only known the hospital as COVID centred. There’s a very good team atmosphere. I think that pre
COVID times, everyone wanting to work together and a lot of people came from other specialties say from maybe specialties out in the communities; for example, I had colleagues who came from specialties such as dermatology or gum medicine and they came onto the COVID rota to try and help with those sort of things so I think that has definitely changed that mindset of working just within your specialty. This has become much more kind of cross working helping out colleagues trying to support each other which has been quite nice. I was on A&E up until the start of December and you had all the normal presentations in A&E as well as the COVID patients which brought its own challenges. So, you mentioned you were an interim F1 doctor. That was that like, how did that feel and what was going through your head as you were going onto the ward early? We all went into lockdown in March and we finished our exams the week before the whole country locked down, so we actually had done our exams we went away for Easter, we finished our exams, broke up for easter, thought we would be back sort of carry on our placements after exams. We never went back and we just kind of heard you have passed your exams and are graduating early and you have the option to start working as what they
called an interim foundation doctor. Normally you graduate around July time and you start as a doctor at the beginning of August but for us they graduated us online informally. I went into working in Kingston hospital which I really enjoyed and learnt a lot. It was probably better training for learning to be a doctor than I would have done if I was learning to be a doctor at medical school. And you got paid which was quite nice as well. I can imagine it would be quite stressful to be suddenly put on a ward. It was quite stressful, quite busy, it had where I was working a COVID mega rota and basically all the doctors who were in medicine got drafted into one massive rota. You worked in 4 teams and you basically worked around the clock with your teams. You did 3 shifts on and 3 shifts off. We did a combination of night shifts, we did weekends. It didn’t matter what day it was you just did your 13 hour day for 3 of them and then took 3 off. That was really nice as you got to know people from all specialties all grades we had us interims which were at the bottom of the experience ladder right the way up to consultants which brought its challenges but it was a really nice introduction to working as a doctor and working in the NHS.
L6 LOW E R SI XT H K E ANU K H AZANE H DARI
On this page you will see some of the Lower Sixth members of this year as well as why they would like to do medicine and what they got out of the society this year. The Lower Sixth this year have had a lot of events run for them focusing on their application to medical school as well as how they can develop the skills necessary to do well in their entrance exams and interviews. Many of these sessions have been made and led by the Upper Sixth who shared their insight and experience from the previous year when they applied. This has allowed for the Lower Sixth to gain as much insight as possible from people who are only a year ahead of them, this means the Lower Sixth have a clear idea of what is to come over the following year.
I believe as a medic, I will have a more positive impact in our society. I have always been curious in human biology and love solving problems that is why I believe by studying medicine I can significantly contribute and improve quality of lives. The Wright Society has inspired me further to follow my passion through guidance and being provided information about the medical world. The teachers and the members in the society are very supportive and knowledgeable and helped me to direct my career path and options.
RU BY CH AN
I want to study medicine because I think it would allow me to help people directly and it would be a very rewarding career. I am also inspired by my siblings, who are practising doctors and always tell me intriguing incidents from work. The Wright Society has been very helpful, and it has made me realise how much harder I have to work to be up to standard. I have also learnt a lot through other’s presentations and asking questions.
BOBBY BE N FO R D
RAINIS CH E NG
I want to study medicine in order to pursue a career as a GP. I have not yet decided on somewhere to study medicine but I am leaning towards the medical schools with integrated courses. TWS has been incredibly helpful in educating me about other fields of medicine, and about the application process. My favourite part was the PBL session organised by Max.
Medicine is always evolving and improving, which makes it a disciplinary that will always be fascinating to be a part of. The selflessness and good will required as a doctor, especially the need to be empathetic and patient-centred keeps us grounded and pushing through harder times. I wish to pursue a career in medicine for the continued discovery of knowledge, gratification of helping others, and to see in practice that I can make a change.
SHA RO N G E O R GE - KA LU
Being a doctor is the only thing that I have wanted to do with my life, when thinking about what sort of profession I would like to go into, nothing else has appealed to me like medicine has. What I find most interesting and look forward to the most about such a job, is really the interactions with patients; the nature of the job allows you to meet all kinds of people, from all walks of life.
MICH AE L WO NG
I want to study medicine because I’m really interested in helping people and having a career where I can actively see the difference that I can make in the world. Medicine stood out for me in the ability to diagnose and work out exactly what is wrong with the patient and decide how best to treat them. I think The Wright Society really helped members by offering weekly sessions that allow us to explore more within the field of medicine.
F L E UR M AST E R S
IVAN LIU
I want to become a doctor to positively impact the outcome of patients. After witnessing surgery for the first time I was amazed by the teamwork, communication between the surgeons and interactions between disciplines. I would like to study at Oxford due to the traditional course, the first three years are on biomedical science, the next three apply this to a clinical setting. Additionally the tutorials allow 4 hours weekly in which work is set and guided by experts.
The 19th century is the century of chemistry, 20th is about physics, and the 21st century is the year of biology and medicine. It is the best time to study biology and medicine. Studying medicine allows me to witness the progress of technology and also how it improves quality of lives of people.
MICH E LLE WO NG
ROSI E HO M E
I have always had a passion for science, particularly biology, and have also always known that I wanted to work in a job that made a genuine difference to society, so becoming a doctor was just the obvious and perfect option for me. The Wright Society has been incredibly valuable in its guidance with starting difficult medical school application process, and the weekly presentations are endlessly interesting, and have helped me learn about areas of medicine I had never really considered before.
I am an aspiring medic who wants to become a doctor, specialising in paediatrics. I hope to study medicine at the University of Cambridge. Having the opportunity to present in the Wright Society, I have not only done in-depth research on my field of interest but also other specialties which helped me broaden my horizons. The Wright Society provided me a lot of chances to talk to doctors, ask questions and become inspired.
C A I T LYN HOCK I N G
T H IRIS H A ANPALAKAN
After A levels, I hope to go to Edinburgh University to study veterinary nursing. I am looking at doing a 4 year course, which will give me the chance to do a dissertation. I have always wanted to go into the veterinary field of work, having been surrounded by it all my life, but looking into it more in recent years has consolidated it for me. So far The Wright Society has presented me with invaluable opportunities and resources, in particular the PBL event, which I found so interesting and incredibly useful.
I hope to read Medicine at Imperial College London. I would like to become a doctor because I want to try my very best to solve people’s medical problems so they can continue to live a content and joyful life without being restricted. I love working with children, so I aspire to become a paediatrician as I believe the voice of the youth can contribute greatly to the voice of the future. The Wright Society has taught me to become confident and has deepened my knowledge about many things in the journey to become a doctor, such as fantastic PBL and UCAT taster sessions, which made me less nervous as I had now been introduced to the skills that are tested.
U6 UP P ER SI XT H VE NU S H O
In this section you will be able to see a few of the Upper Sixth and hear about why they want to study medicine and what they have got out of the society. This year the sessions for the Upper Sixth have been focused on personal statements and preparing for interviews. We have been fortunate enough to have had doctors come in to help us with our interview prep, this has been invaluable as we have been able to greatly improve our answers to interview questions by being able to look at the question through the lens of a doctor.
Experiences of having received medical treatment since childhood have allowed me to understand the medical field more from a patient’s perspective. The ethos of medicine and the meaning of helping those when they are at their most vulnerable consequently serves as a driving motivation. The Wright Society has introduced me to the vast range of essential skills and life-long learning motivation. Stimulating ethical cases also led me to the realisation that medical knowledge cannot be solely relied on to treat a patient.
RO B B AILE Y
Growing up with my sister going through medical school and watching her progress impacted me when I was young, from this I think that medicine is something which I always had in my head and I built on this to get to applying this year! TWS has been great for me, it is somewhere that I was able to work on the necessary skills that I needed to develop and also be around others who like me had found the desire to apply for medicine. Overall, it has been a brilliant environment to learn and get valuable insight from peers and staff on a range of topics.
LO UI E ST EE L
I was motivated to study medicine because of the personal impact the work of healthcare professionals has had on my family. Growing up with a disabled family member, I was always acutely aware of the struggles people went through, and also the impact that the work of Doctors and Nurses could have on not only the physical health on a patient, but also the general well-being of them. The ability to truly help people when unwell and remedy disease is the main motivating factor in my decision to go into medicine. I have always enjoyed science at school, and I find the concepts that underpins Medicine in practice fascinating. To go into a field with so much human interaction, yet so much human biology and science that underpins the work is yet another factor in my motivation to study medicine.
MAX FO G E LMAN
I was drawn to medicine because of an encounter with a doctor when my mum was in hospital, at the time I was 9 and scared, I did not know wat was going on. But this doctor was amazing because they took the time to explain to me what was happening. That made all the difference to me because although I wasn’t the patient this doctor made a very challenging time easier. I was further drawn to medicine through my love and fascination of science in particular biology. I felt as though medicine was the best course to pursue as I could combine my desire to help people with my fascination of the human body.
LO U IS DAVIDS O N
JASM I N E KWO N G
I’m aiming to be a doctor that could change people’s lives! The interaction with my GP and the precious moments I had during volunteering and work experiences piqued my interest in choosing medicine. Specifically, I enjoyed the time spent communicating with and having fun with different children. Of course, The Wright Society has helped me a lot too. I have gained broader medical knowledge from various presentations, whilst at the same time expanding my ethical perspectives from the discussions with teachers and groupmates.
I wanted to be a medic ever since I was healed as a kid when I had a serious injury. They were able to turn a disaster into a success with ease. Since, I have done everything I can to be able to grant others that same experience I went through. I wanted to be a medic. The society has taught me how to prepare well for everything that comes my way, so it never is a surprise. Whether it be preparing for interviews, UCAT or even unfortunate events.
CMJ CATERHAM MEDICAL JOURNAL
caterhamschool.co.uk