Beneath our Skin

Beneath Our Skin Winter edition 1

Winter edition

Contents Prenatal Genetic Screening - Page 5……………………………………………………..Xinyu Gu Impact of Air Pollution on Respiratory Health in China - Page 8…………………………………………………Aryan Verma Personalized Medicine - Page 13…………………………………………Maria Michailidou Save Canine Lives from Heatstroke - Page 15…………………………………………….Alexandra Hide Hydronephrosis -Page 17…………………………………………………Tilly Black Peto’s Paradox:Why Blue Whales Can’t Get Cancer - Page 19………………………………………………Prithvi Gupta The Link Between Babies Born by Caesarean Sections and Allergies

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- Page 21………………………………………….Alexander Gunson How Cocaine Affects the Brain, and How Addiction To It Can Be Treated - Page 23………………………………….Alexander Manzavinatos The Complex Dynamics of Obesity in a Globalized World - Page 25……………………………………………….Mishel Kudel To What Extent is Sunak’s 15 Year ‘Transfer’ in the NHS Workforce Viable?

- Page 27……………………………………………...Charlotte Holt Should Euthanasia Be Illegal or Legal in the UK?…

- Page 30………………………………………………….Jimin Park Neurofeedback Therapy - Page 32………………………………………….Sunainia Nambiar What is CRISPR?

- Page 35…………………………………………….Elisa Westerhof NHS Medical Apprenticeships - Page 39………………………………………………..Anna Zaman Can Alzheimer’s Disease Be Inherited?

- Page 41………………………………………………..Mieke Visser

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Note from the Editors: This term’s publication of ‘Beneath Our Skin’ explores a breadth of topics ranging from why blue whales cannot get cancer, to the ethics behind euthanasia, to whether Sunak’s plan to transform the NHS is viable. With so much going on in the medical world, whether its new discoveries or governmental plans, we decided to cover a plethora of themes to reflect the current medical climate. It was an absolute joy reading all these articles and formatting them for the school and those interested in medicine to enjoy.

Thank you to all the amazing students who wrote for the issue this term!

Please enjoy, Mieke Visser and Anna Zaman.

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Prenatal Genetic Screening - Navigating the Ethics of Striving For Perfection In the ever-evolving field of medicine, prenatal genetic screening has become an invaluable tool for expectant parents. This technology gives insights into the genetic makeup of a developing foetus, allowing potential genetic disorders to be identified in the early stages of pregnancy. Prenatal genetic screening is now accessible to many pregnant individuals and is now a safer procedure involving less discomfort, ever since the introduction of blood-based, non-invasive prenatal genetic testing in 2012 (AAAS, 2015). While the benefits of this cutting-edge technology are clear, there are numerous ethical concerns about striving for perfection through prenatal genetic screening.

Reproductive Autonomy and Informed Decision-Making From chromosomal abnormalities to single-gene disorders, prenatal genetic screenings provide parents with information that guides them in making informed decisions about their pregnancy and prepares them for potential challenges should their child require additional care, promoting individual reproductive autonomy (Tsui et al., 2023).

While many diseases could be mitigated or prevented when treated in the early stages, others, such as Down’s syndrome, have no cure, and this begs the question: is it ethical to prevent such a condition by abortion? We cannot determine with certainty whether a genetic condition is actually present in the foetus or how the identified condition will impact a person’s life unless further invasive testing is done (AAAS,

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2015). Furthermore, the probability of false positives and negatives could also lead to wrong decisionmaking, creating stress in patients and demanding further testing. Therefore, it is highly important to provide patients with unbiased information, address the ethical implications when interpreting the test results, and ensure that the results are fully understood by the patients.

Genetic counsellors play a vital role in facilitating informed and autonomous decision-making, offering emotional support, and guiding parents through the complexities of genetic information. In order to empower parents to make informed decisions, healthcare professionals must make sure that the patients fully comprehend all the information presented to them, such as what the procedure tests for and how it works, its advantages and disadvantages, and the meaning of the test results. Moreover, there is a general consensus that prenatal screening should be offered within a non-directive framework, giving patients the autonomy to make decisions that align with their own beliefs without feeling pressured to conform to social norms. (Stapleton, 2016) Accessibility and Equity One notable feature of non-invasive prenatal genetic testing is that it has been introduced as a commercial product, which raises concerns for equity as this could mean that NIPT is not accessible to everyone. For example, the cost of Ariosa's Harmony test was 795 USD in 2014. The complexities surrounding costs make it more difficult to decide whether to pursue prenatal genetic testing and which test to choose.

(Minear et al., 2015) The findings from a study conducted in 2013 (Horsting et al., 2013) showed that “insurance coverage, billing policies, reimbursement, and price of NIPT” were major concerns of genetic counsellors when offering cffDNA testing to patients. Furthermore, many counsellors stated that patients often rejected testing because they were concerned about the cost or the absence of insurance coverage.

Overall, prenatal genetic screening should be made available to patients from all backgrounds, regardless of their socio-economic status. Ensuring that this technology benefits diverse populations is essential for preventing the division of society along genetic lines.

Genetic Discrimination Although prenatal genetic testing helps women to make better informed decisions and enhances their reproductive autonomy (Tsui et al., 2023), there is a growing concern over the increasing risk of societal discrimination and stigmatisation against people with genetic conditions. For example, in France, the organisation ‘Stop Discriminating Down’ aimed to condemn “the mass elimination of children with Down’s syndrome before birth” in 2017. In addition, as a way of protesting against the decision to reimburse NIPT, a ‘March for Life’ was organised in 2019 in Paris. However, these public responses had no real effect on policies (Perrot and Horn, 2022). There are also concerns that as the use of NIPT rises, individuals with genetic disabilities will receive less support and opportunities (Vanstone et al., 2018).

Additionally, the National Consultative Ethics Committee highlighted that NIPT would lead to ‘a new form of eugenics’ in its 2016 report. However, the study led by Perrot and Horn highlighted that women often utilise NIPT as a tool to gather information on the foetus’ health conditions in order to prepare for its arrival, rather than intending to terminate pregnancy if an aneuploidy is discovered. Nevertheless, our pursuit of perfectionism and anxiety about being deemed "undesirable" could contribute to the marginalisation of those with genetic disorders, perpetuating harmful societal prejudices and impeding collective efforts to create a more inclusive and diverse society. Therefore, it is vital that governments implement policies and utilise public funds to counteract bias, stigmatisation, and discrimination.

In conclusion, prenatal genetic screening has immense potential for preventing and managing genetic disorders, offering parents valuable insights into their child's health, and promoting reproductive autonomy and informed decision-making. On the other hand, although it can be challenging to balance our pursuit of health with respect for diversity and inclusivity, it is crucial to approach this medical

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advancement with ethical considerations. Therefore, the ethical issues of prenatal genetic screening should continue to remain a key focus as more progress is made in this realm of medicine.

References ● AAAS. (2015). The Pursuit of Perfection? Fetal Genetic Screening. [Online]. aaas.org. Last Updated: 16 September 2015. Available at: https://www.aaas.org/news/pursuit-perfection-fetalgenetic-screening [Accessed 5 January 2024]. ● Horsting JM, Dlouhy SR, Hanson K, Quaid K, Bai S and Hines KA. (2013). Genetic counselors' experience with cell-free fetal DNA testing as a prenatal screening option for aneuploidy.

[Online]. PubMed. Last Updated: 19 December 2013. Available at: https://pubmed.ncbi.nlm.nih.gov/24352524/ [Accessed 6 January 2024]. ● Greg Stapleton. (2016). Qualifying choice: ethical reflection on the scope of prenatal screening.

[Online]. NIH. Last Updated: 8 September 2016. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5487727/ [Accessed 6 January 2024]. ● Minear, M., Alessi, S., Allyse, M., Michie, M. and Chandrasekharan, S. (2015). Noninvasive Prenatal Genetic Testing: Current and Emerging Ethical, Legal, and Social Issues. [Online]. annualreviews.org. Last Updated: August 2015. Available at: https://www.annualreviews.org/doi/full/10.1146/annurev-genom-090314-050000#_i25 [Accessed 6 January 2024]. ● Perrot, A. and Horn, R. (2022). The ethical landscape(s) of non-invasive prenatal testing in England, France and Germany: findings from a comparative li. [Online]. nature.com. Last Updated: 04 October 2021. Available at: https://www.nature.com/articles/s41431-021-009702#article-info [Accessed 6 January 2024]. ● Tsui W-K, Yip Y-C and Yip K-H. (2023). Balancing Equity and Autonomy: The Utilitarian Case for the Public Funding of Non-Invasive Prenatal Testing in Hong Kong. [Online]. IntechOpen.

Last Updated: 23 October 2023. Available at: https://www.intechopen.com/online-first/1140432 [Accessed 6 January 2024]. ● Vanstone, M., Cernat, A., Nisker, J. and Schwartz, L. (2018). Women’s perspectives on the ethical implications of non-invasive prenatal testing: a qualitative analysis to inform health policy decisions. [Online]. BMC. Last Updated: 16 April 2018. Available at: https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-018-0267-4 [Accessed 6 January 2024].

-Xinyu Gu

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The Impact of Air Pollution on Respiratory Health in Children Air pollution is one of the world’s most serious environmental problems. Air pollutants continue to be major contributing factors to the incidence and exacerbation of acute and chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma), impaired lung development, cardiovascular diseases, and cancer [1]. In this article I will review the sources of air pollution and how they can impact children’s respiratory health.

Air Pollutants The WHO (World Health Organisation) defines air pollution as the contamination of the indoor or outdoor environment by any chemical, physical or biological agent that modifies the natural characteristics of the atmosphere. According to the WHO, 99% of the world population lives in areas where the air pollution exceeds the WHO air quality guidelines [2]. This annually contributes to 7 million premature deaths and 600,000 of those being from children under the age of 15 [3].

Air pollutants can be categorised into household air pollution (HAP) which is mainly cause by the combustion of fossil fuels for cooking or heating, and ambient air pollution (AAP) which is pollution in the air from natural and anthropogenic (man-made) activities. Natural activities include volcanic eruptions, forest fires, wind-blown dust and emission from decaying biomass. Common anthropogenic sources of AAP include combustion of fossil fuels for electricity and transport related air pollution (TRAP), decaying waste and agricultural purposes. [4] There are six main pollutants [1] [8]:

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Particulate Matter / PM2.5 Particles with an aerodynamic diameter of 2.5 micrometers or less. These pollutants are also known as fine PM and can penetrate deep into your lungs (entering bronchioles and alveoli) and potentially enter the body through the bloodstream, affecting major organs [2]. PM2.5 sources are the same as AAP and HAP, a tolerable level of exposure to PM2.5 is anywhere in between 0 – 35 micrograms per cubic meter (µg/m3) every 24 hours.

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Particulate Matter / PM10 Particles with an aerodynamic diameter of 10 micrometers or less. PM10 are coarse particles which deposit higher up in airways and cause more irritation and inflammation [4]. PM10 sources are the same as AAP and HAP, a tolerable level exposure to PM10 is anywhere in between 0 – 100 micrograms per cubic meter (µg/m3) every 24 hours.

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Ground Level Ozone (O3), Sulfur Dioxide (SO2), Carbon Monoxide (CO), Nitrogen Dioxide (NO2) These air pollutants are oxidants or pro-oxidants, high exposure to such particles encourages the formation of oxygen and nitrogen free radicals (short-lived ions which are very unstable and highly reactive) which induce stress in the airways and cause inflammation, potentially damaging the lungs [5].

O3 – causes irritation of the airways and airway hyperresponsiveness and bronchospasm.

Exposure to O3 can be tolerated under 0.125 ppm (parts per million) every hour.

CO – interferes with oxygenation of hemoglobin, in high concentration it can cause death by preventing O2 transport. Exposure to CO is unharmful between 0 – 9.4 ppm per 8 hours SO2 – easily dissolves in water and contributes to the formation of acid rain Such pollutants are emitted during the incomplete combustion of fossil fuels, e.g. in vehicle exhaust fumes, industrial activities and in power plants. Exposure to SO2 is tolerable between 0 – 75 ppb (parts per billion) every hour.

NO2 - can make individuals vulnerable to respiratory infections, lung disease, and possibly cancer. It contributes to the brownish haze seen over congested areas and to acid rain. Exposure to NO2 is tolerable between 0 – 10 ppb every hour.

Effects of Air Pollution on Children’s Health Air pollution can impact children in different ways before and after birth.

During Pregnancy Susceptibility During the prenatal period, the morphogenesis (a process whereby tissues and organs develop shape during embryonic development) of the lung takes place at 4 – 7 weeks of gestation and all the features of the lung develop late into the pregnancy, however the complete maturation of the lung continues into early adulthood. This means that prenatal babies are susceptible to the effects of air pollution, and it can impact their lung development as they grow [4]. Exposure during pregnancy occurs when the pollutants inhaled by the mother translocate to the fetus, causing them to be present in the developing fetus and placenta [6].

Impact on Respiratory Health of Children:

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Studies have shown that exposure to air pollution during early pregnancy can disrupt differentiation and morphogenesis. Later in pregnancy, air pollution affects the structural and functional growth of the lung.

This exposure can lead to impaired lung function and development even after birth [4]. There is increased possibility of post neonatal mortality when exposed to PM10 in excess of 10 µg/m3 or more [7].

Another study conducted in Taiwan has looked into the susceptible time windows in the development of pediatric asthma [10]. This birth cohort in Central Taiwan showed that prenatal and postnatal exposures to PM2.5 were associated with subsequent development of asthma in childhood. The vulnerable time windows to exposure being gestational week of 6 to 22 in utero and 9 to 46 weeks after birth. The authors declared that sensitive population, including pregnant women and young children, should avoid the exposure to AAP during these susceptible periods [10].

After Pregnancy Susceptibility Children, especially infants are one of the most susceptible to damage to their respiratory system because of over exposure to air pollutants. This is due to 3 main reasons: [5] Children have a much weaker immune system, which isn’t fully developed, increasing the chance of contracting respiratory damage.

Children have a higher minute ventilation than adults and when considering the ration of body weight to volume of air inhaled the volume of air passing through the airways of a child at rest are double that of an adult.

Children tend to spend more time outdoors resulting in a higher exposure to AAP (the main source of pollutants) On top of this, there are many other factors which may increase a child’s vulnerability to respiratory damage [5]: Individuals with (pre) existing chronic disease (Pre) existing chronic diseases affecting the respiratory system (asthma, Cystic Fibrosis, COPD) or the circulatory system (arrhythmias, hypertension, and ischemic heart diseases) are compromised leaving them more susceptible to respiratory damage.

Genetic Susceptibility If there is a history of disease in a family, the child may inherit a gene leaving them more vulnerable.

Impact on Respiratory Health of Children: Asthma and Wheezing Asthma is one of the most common chronic diseases among children. It is caused by the inflammation of the airways associated with excessive mucus production, reversible bronchoconstriction, and airway hyperreactivity. The asthma symptoms can include a combination of a wheeze, cough, shortness of breath and chest tightness. [4] Recently, a study was conducted, aiming to find the impact of AAP specifically TRAP on children with recurrent wheezing or asthma. They concluded that there is a significant association between the excess exposure of PM10 and NO2 (the 2 main pollutants released from TRAP) and the development of asthma exacerbations, and increased risk of respiratory morbidity in children. [9] On top of this, research was conducted in areas of high exposure to TRAP (areas near high traffic streets) and compared to areas of low TRAP levels such as in green areas of a city. This demonstrated that living in high exposure to TRAP leads to increased episodes of wheezing and asthma exacerbations. The results were concurrent with

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results of similar prospective studies in Sweden and China, further giving weight to the results. [9] Acute Respiratory Infections Respiratory infections are infectious diseases of the upper or lower respiratory tract cause by bacteria or viruses. Acute infections are short-term conditions which can typically be treated over a small period of time, whereas chronic diseases are those which develop over an extended period of time and require longterm treatment (like asthma).

Increased levels of PM10 and exposure to indoor biomass fuel (BMF) combustion (NO2 and SO2) can increase the risk of contracting acute respiratory infections. The association of increased risk of lower airway infection and indoor smoke exposure was first suggested in a Nepal study. By measuring the level of PM10, NO2 and SO2, the study showed a relationship between the risk of acute respiratory infection and exposure to indoor BMF combustion [11]. A meta-analysis further demonstrated that HAP exposure resulted in nearly 1.8-fold increase in the risk of pneumonia along with other acute infections in children under 5 years old. Similar results were found in a meta-analysis where 10 European birth cohorts, demonstrating over exposure to NO2 and SO2 in the first year of life have close association with the risk of pneumonia. [12][8] Effects of Air Pollution on Children’s Health To conclude, early exposure to high levels of air pollution can have a detrimental impact on the respiratory health of children, causing early damage to lungs resulting in impaired respiratory development and the contraction of acute and chronic respiratory diseases such as wheezing, asthma and lower respiratory tract infections like pneumonia.

References:

1) Vallero, D. A. (2019, January 1). Air pollution biogeochemistry. Elsevier eBooks. https://doi.org/10.1016/b978-0-12-814934-8.00008-9 2) World Health Organisation | Air pollution. (2019, July 30). https://www.who.int/health-topics/air-pollution#tab=tab_1 3) World Health Organisation | What are the WHO Air quality guidelines? (2021, September 22). https://www.who.int/news-room/feature-stories/detail/what-are-the-who-air-quality guidelines 4) Aithal, S. S., Sachdeva, I., & Kurmi, O. (2023, June 1). Air quality and respiratory health in children. Breathe. https://doi.org/10.1183/20734735.0040-2023 5) Arbex, M. A., De Paula Santos, U., Martins, L. C., Saldiva, P. H. N., Pereira, L. A. A., & Braga, A. L. F. (2012, October 1). A poluição do ar e o sistema respiratório. Jornal Brasileiro De Pneumologia. https://doi.org/10.1590/s1806-37132012000500015 6) Liu NM, Chen Y, Miyashita L, et al. The presence of air pollution particulate matter in cryopreserved placental tissue cells. ERJ Open Res 2021; 7: 00349-2021.

7) Lacasaña, M., Esplugues, A., & Ballester, F. (2005, February 1). Exposure to ambient air pollution and prenatal and early childhood health effects. European Journal of Epidemiology. https://doi.org/10.1007/s10654-004-3005-9 8) Wu, I. P., Liao, S., Lai, S., & Wong, K. S. (2022, February 1). The respiratory impacts of air pollution in children: Global and domestic (Taiwan) situation. Biomedical Journal. https://doi.org/10.1016/j.bj.2021.12.004

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Principi, N., Patria, M. F., Malerba, S., Montinaro, V., Prada, E., Senatore, L., ... & Esposito, S. (2014).

Impact of air pollution on respiratory diseases in children with recurrent wheezing or asthma.

Jung CR, Chen WT, Tang YH, Hwang BF. Fine particulate matter exposure during pregnancy and infancy and incident asthma. J Allergy Clin Immun 2019;143:2254e62.e5.

Ezzati M, Kammen DM. Indoor air pollution from biomass combustion and acute respiratory infections in Kenya: an exposure-response study. Lancet 2001;358:619e24.

MacIntyre EA, Gehring U, Molter A, Fuertes E, Klu € ̈ mper C, Kramer U, et al. Air pollution and respiratory infections € during early childhood: an analysis of 10 European birth cohorts within the ESCAPE project. Environ Health Perspect 2014;122:107e13.

-Aryan Verma

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Personalized Medicine: How genetics shape your treatment Precision Medicine is the approach of tailoring disease prevention and treatment to be specific to each individual. This is achieved by taking into account differences in people's environmental, biological, and lifestyle characteristics, factors that make us individual from one another.

Our biological components are often down to the sequences of our genes, which have a large influence on each person’s physical, behavioral, and psychological attributes. Therefore, it would be appropriate to assume their importance to make informed decisions regarding the patient’s treatment.

The study of a person’s genes is achieved through genomic profiling. This process begins by collecting a sample of cells which contain a full set of chromosomes and sequencing entire the DNA within them. The data can then be analyzed and put through an AI algorithm which will identify any genetic alterations in the DNA. Understanding genetic variations and their phenotypic differences helps create individualized treatment plans. It can lead to a diagnosis and even aid in the prediction of how different individuals may respond to specific medications, guiding the selection of the most effective treatment for each patient.

This mainly refers to the field of pharmacogenomics, the study of how an individual’s genetic makeup influences their response to drugs. This knowledge helps optimize drug selection and dosage to minimize adverse effects and therefore enhance treatment outcomes.

For an AI algorithm to recognize patterns displaying a link between a specific mutation to a particular phenotypic expression, a large amount of data must be inputted into the system to reduce the chances of false a diagnosis. Advances in technology, such as electronic medical records allow for data to be gathered from a large number of people from various research centers around the world. However, the benefits of sharing genetic data over digital platforms for health research and discovery must be weighed against potential privacy issues associated with it. The exposure or misuse of genomic data can result in abuse or stigmatization as well as possible discrimination in environments including employment, insurance, or education. Therefore, hospitals and companies must invest in cyber security to protect their patient’s confidentiality. Not only this but the data inputted must be accurate as well as reliable which can be very difficult to monitor. Mistakes in the data put into the algorithm may lead to inaccuracies when highlighting a mutation or diagnosing a patient.

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Another way medical treatments can be influenced by your genetics is the development of target-specific drugs. Target-specific drug delivery is a modern approach for administering pharmaceuticals to patients which involves raising the drug's concentration only in the component of the body of interest: such as the targeted organs, tissues, or cells. The majority of targets of these drugs are the signaling networks in cells linked to the development of disease. These medications alter cell communication pathways by inhibiting a key signaling protein by preventing a ligand from attaching to its receptor. This changes the interactions between cells and the development of a disease or the function of a drug. Another way target-specific drugs are implemented into precision medicine is through genetic testing; where certain mutations which promote tumor growth can be identified, allowing for the development of personalized medications that target cancer cells while protecting healthy organs.

Currently the process of precision medicine is not a widely accessible form of treatment across the world.

This is due to the costs involved with the use of advanced technologies or even the costs of genetic testing, interpretation of results, etc. Therefore, these components of the treatment, pose a financial barrier to many people. Despite this, I still believe that personalized medicine will be increasingly incorporated into the future of our healthcare systems. This is because it could improve certain treatment outcomes, whilst reducing adverse effects whilst also reducing healthcare costs as there will be less trial and error.

This does not necessarily require the in-depth study of your genes; it could be as simple as a well-written survey to collect data on your environmental and lifestyle characteristics. However, to conclude, personalized medicine has been driven by advancements in genetics. As our understanding of genomics continues to expand with the aid of new emerging technologies, personalized medicine has the potential to revolutionize medical practices, offering a more precise and personalized approach to patient care.

-Maria Michailidou

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Help Save Canine Lives From Heatstroke These past few years I have been doing a few internships at various clinics in the UAE, and one of the cases that I saw will stay with me forever. It was a condition so easily avoidable that I believe improved awareness about it could save dogs world-wide, particularly in areas with excessively hot climates.

I stood in the operating room shadowing a practicing vet, wearing ill-fitting scrubs and a nervous smile.

The day had so far been somewhat quiet due to the lull that the middle of the summer holidays always brought, though of course nobody said this aloud due to time-old superstition. The peace was abruptly broken when two nurses burst in with a stretcher, and a large golden retriever was rushed in and carefully laid out on a big metal table. I didn’t know what was wrong yet, just that something big was happening.

Everyone ran around retrieving various equipment, so I mostly tried to stay out of the way. The vet I was shadowing pushed into my arms a bag of cotton and a cold metal bowl full of pink disinfectant. She quickly instructed me to tear pieces of cotton, soak them in the solution, and hold them under the arms and paw pads of the panting dog. This was to help cool him down, since they are the main areas on a dog that heat can escape through.

Fans began blaring all around the table, which I felt turn the soaked cotton cold under my hands through evaporative cooling as I held them to the dog. The vet then presented the case with a brief yet firm explanation; the golden retriever belonged to an athletic young couple waiting anxiously downstairs. They had gone for a run outside in the early morning with their dog, and had not seen any signs that he was suffering before his case of heat stroke had become dangerously advanced.

The dog had painfully swollen, cracked paw pads from running on the brick pavement which had become blisteringly hot as the bricks effectively soaked up the sun’s rays from the early sunrise typical in the summer. He was heaving rapid, shallow breaths, and his golden pelt was soaked in water and perspiration. His pink tongue rolled out of his mouth to rest on the cool metal table, but most concerning was how he seemed to fight for each breath and was tired to the point of not being able to sit up or stand.

All these symptoms indicated a progressed case of heatstroke and can be summarized using the acronym HELP (Heavy panting, Excessive drooling, Lethargic drowsiness, Problems vomiting). 98% of dogs suffering from mild signs of this condition have a high chance of survival, however the more advanced cases are why 1 in 7 dogs that are taken to the vet with heatstroke don’t survive it. I left the clinic at the end of the day, with the team of vets and nurses constantly monitoring the dog who, despite appearing to have improved slightly, was still in a critical condition. When I came in the next morning, I was shocked with the news that he had passed away in a matter of hours from organ failure as his case of heatstroke had progressed beyond the point of being able to save him.

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We have to understand that dogs don’t respond to heat in the same way that humans do. Humans regulate body temperature through the many sweat glands all over our bodies. In contrast, dogs only have a few sweat glands located in their paw pads and around the noses, and their primary form of heat release is through panting. Another name for heatstroke is hyperthermia, and it is classified as when a dog’s internal temperature increases above 39 ˚ C. Other forms of hyperthermia include heat stress and heat exhaustion; however heat stroke is the most severe.

How can you treat and help your dog avoid heatstroke?

The most important factor is to avoid putting your dog in a situation where they are at risk of heat stroke.

The most common scenarios are when dogs are left in closed homes without air conditioning, are left in cars, or have insufficient access to water. Puppies and flat-faced breeds are at a higher risk of developing heat stroke, so additional care should be taken with them.

The second most important course of action if you start to recognize the symptoms of heat stroke in your dog is to begin cooling them down as soon as possible. This can be done most effectively by gently wetting them with a cool spray of water from a hose, and a fan blowing over their damp skin to help using evaporative cooling. Do not wrap a wet towel around them as it will trap the heat trying to escape, and don’t use ice baths or freezing water which can induce shock or cool them too rapidly. This can cause vasoconstriction (the constriction of blood vessels) which lowers their cooling capability. Visit a vet as soon as possible even if your dog appears to be recovering. They may require further medical attention such as intravenous fluids to treat dehydration, and blood tests to detect blood clots and assess organ function.

You can save your dog’s life by following this simple procedure, just as it could have saved this golden retriever’s life had his owners known the signs and what to do.

-Written by Alexandra Hide 12 EMO

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Hydronephrosis: What is it, how it can be treated and why it can be difficult to diagnose.

Simply, hydronephrosis is a kidney condition where one or both kidneys become swollen, due to unsuccessful drainage of urine through the ureters, causing a blockage. According to Cleveland clinic, 1 in 100 adults will experience hydronephrosis at some point throughout their life, so it is a very common condition to develop! Hydronephrosis has a range of causes, such as kidney stones becoming lodged in your urinary tract, tumours in/around organs in the urinary system, birth defects causing one to have a narrow urinary tract, or even pregnancy (expansion of the uterus can block the flow of urine). The severity of hydronephrosis depends on the individual cause and how long the obstruction has lasted. Due to these varying severities, symptoms are also varying, however some common ones include: sudden or intense pain in your lower abdomen/back/side, nausea, urinating more/less frequently than normal, painful urination (possibly with blood), being unable to entirely empty your bladder, or having UTI (Urinary tract infection). Typically, hydronephrosis is classified as mild, moderate or severe, while sometimes it is graded on a scale of 1-4 (1 being the mildest, 4 the most severe). These classifications are based on the extent of swelling of a kidney(s) and the loss of function it may experience. Severe cases of hydronephrosis can cause loss of kidney function, or in extreme cases, complete kidney failure, where a transplant would be needed. Symptoms usually correlate with the severity of the condition.

Hydronephrosis is mainly diagnosed through an ultrasound of the kidney, and blood tests and renal Mag3 scans (nuclear scans) can be carried out to aid diagnosis to analyse kidney function. Once again, treatments of Hydronephrosis also vary depending on the cause. For example, if the cause is due to a blockage of the urinary tract (e.g. kidney stones), then the blockage can be removed. Excess urine can also be drained from the kidney via a bladder catheter. However, if the cause is more complex, surgery may be needed. This includes narrow urinary tracts from birth needing to be widened, or arteries being moved to stop flow being cut off through the ureter. The kidney is surgically the most difficult organ to reach, so robotic surgery is often used; in Mediclinic City Hospital, the operating robot is called Da Vinci!. After treatment, patients need to be checked up on roughly every 6 months to ensure the affected kidney is functioning well and is not becoming blocked once again. Hydronephrosis is a condition which can be difficult or slow to be diagnosed. This is due to the kidneys positioning in the body, as well as the stage of hydronephrosis is reached; symptoms may not begin to show until classified more severely. The right kidney is especially difficult to diagnose for hydronephrosis, as it is located in a similar position to the appendix. This is why the severe pains of hydronephrosis can often be mistaken for appendicitis, as both conditions share common symptoms (lower abdominal pain being the most prominent).

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Hydronephrosis is a relatively common condition, so if caught in an early stage it can be quickly treated – however, if you experience a lower abdominal pain it is important to be seen by a doctor to ensure that any condition (whether it be appendicitis or hydronephrosis) is identified as soon as possible.

-Tilly Black

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Peto’s Paradox: Why Blue Whales Don’t Get Cancer We all know about cancer. It has plagued history for millennia, and now haunts the lives of millions, the emperor of all maladies. In the process of better understanding cancer to kill it, scientists discovered a biological paradox in 1977 that still remains a mystery: large animals appear to be resistant to cancer. This phenomenon is known as Peto’s Paradox, named after epidemiologist Richard Peto, who first noticed the apparent inconsistency in cancer rates across different animals.

Cells are essentially protein machines and perform various mediated complex chemical reactions which are coordinated, multistep, and fueled by energy from nutrients which form a metabolic pathway. This allows for activities to be carried out such as movement, reproduction, and growth. There are billions of trillions of reactions that happen over years and most of the time function perfectly allowing the organism to thrive; until something goes wrong. Considering that so many reactions are happening over such a long time, one of the reactions is bound to go wrong. Enough mistakes can accumulate and the whole cell will start to mutate. To stop this runaway effect, the cell can undergo apoptosis (programmed cell death), but cancer cells can evade programmed cell death and if the immune system misses them, they can consume resources and multiply.

Every animal can suffer from this, but we can see great abnormalities in the rates of cancer in different animals. Regardless of which animal you look at, cell size is almost the same, ranging from 10 to 100 micrometres – smaller animals just have fewer cells. In theory, since smaller animals such as mice have a smaller lifespan and fewer cells than humans, the likelihood of developing cancerous cells should be lower than a human. Yet the rate of cancer in mice and humans is almost the same; even more interestingly, elephants, who have roughly 100 times more cells than humans, and blue whales, who can have more than 1000 times as many cells as humans, do not suffer higher risks of cancer mortality than humans – they have lower cancer rates than us. This is what Richard Peto initially found during his studies of the relationship between lifespan and cancer onset.

The two most plausible explanations for this are evolution and hyper tumours. Multicellular beings emerged approximately 600 million years ago. As they continued to evolve, they got increasingly bigger, hence increasing the chance of mutations to produce cancer cells. Cancer has always been a challenge for organisms, with one study documenting “bone cancer in a 240-million-year-old reptilian amniote from the Triassic period.” (Haridy , et al., 2019). This means that early organisms had to evolve to develop their cancer defence systems so that they could survive from such a deadly disease through pressure selection, or have the species die out. Cancer is a result of many individual mistakes in specific genes of the same cell. These genes are called proto-oncogenes and are used for controlled cell growth and division

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normally, but once mutated they become oncogenes and activate when not needed – potentially leading to cancerous growth. They have an ‘opponent’ however, named tumour suppressor genes. There are two categories of these genes: Gatekeeper-genes and Caretaker-genes. Caretaker genes oversee the preservation of genetic information within cells, ensuring its integrity, while gatekeeper genes directly manage tumour growth by encoding proteins that either encourage or impede cell proliferation, differentiation, or apoptosis.

Studies have found that larger-bodied animals have an increased number of tumour-suppressor genes because of evolution: “Proto-oncogene activation decreased steadily will increasing body mass” (Gewin, 2013); “Large, long-lived organisms might have evolved to suppress cancer better than small animals by duplicating tumour suppressor genes” (Caulin & Maley, 2011). This can therefore explain why larger animals have lower cancer rates, animals evolving specific measures to supress cancer development more effectively.

In addition to this, we also have the theory of hyper tumours, which in short are the tumours of tumours.

When cancer cells divide, they can form tumours as we know, but this is very difficult to do since it requires lots of resources. The main limiting factor is the amount of nutrients they can plunder from the body. So, it tricks the body to create new blood vessels to the cancer for its growth. As the cancer cells continue to mutate rapidly, new cancer cells may arise which stop cooperating with the rest of tumour during metastasis. The metastatic subclones (Hyper tumours) can hinder the growth of the tumour through competition as they can be seen as ‘cheaters’ who take advantage of the vascular architecture built by the original tumour. They can cut off the original tumour cells from receiving their supply of nutrients therefore killing the tumour; cancer kills cancer. Larger animals could have more hyper tumours, and this process can repeat continuously which prevents cancer from becoming a problem for a large organism as it prevents the cancer from growing and becoming large enough to cause trouble. Think of a very small cancer that barely compares to the mass of large animals causing harm.

Of course, there are other proposed theories like cellular architecture and metabolism in larger organisms.

The multifaceted expanse of theories does show how we still do not have a definite answer, but the real questions is: why do we care?

Understanding the impressive cancer resistance seen in larger animals presents a promising avenue for revolutionizing our approach to combating this deadly disease. By studying the genetic and physiological traits that protect these animals from cancer, researchers envision not only developing more effective treatments but also potentially applying these insights to modify our own genetic makeup. This exploration of nature's mechanisms offers hope for finding innovative solutions to mitigate, or even eradicate, cancer—a disease that continues to pose significant challenges to human health. Perhaps nature holds the answer to transform our fight against cancer.

References Caulin, A. F., & Maley, C. C. (2011). Peto’s Paradox: Evolution’s Prescription for Cancer Prevention.

Retrieved from `National Library of Medicine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3060950/ Gewin, V. (2013, January 21). Massive animals may hold secrets of cancer suppression. Retrieved from Nature: https://www.nature.com/articles/nature.2013.12258 Haridy , Y., Witzmann, F., Asbach, P., Schoch, R., Fröbisch, N., & Rothschild, B. (2019, February).

Triassic Cancer—Osteosarcoma in a 240-Million-Year-Old Stem-Turtle. Retrieved from JAMA Oncology: https://jamanetwork.com/journals/jamaoncology/fullarticle/2723578?guestAccessKey=36a3caee1474-4c66-88e0-e38dc4e8304d -Prithvi Gupta

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The Link Between Babies Born by Caesarean Section and Allergies Food allergies can cause a person’s immune system to overreact to certain foods, triggering mild to life threatening symptoms. The condition affects an estimated 5% of children in the United States and is becoming more prevalent. Research in the past decade have shown that babies delivered by caesarean section (c-section), a surgical procedure for delivering a baby through incisions, have higher rates of food and environmental allergies, compared with those born by vaginal delivery.

From 2003 to 2007, a total of 1258 newborns were involved in research on this matter and were assessed at 4 different times: one month old, six months, one year, and two years. They indicated that c-section babies have a five times greater chance of developing allergies than those born naturally. In 2020, research conducted by Rutgers University and the Copenhagen Prospective Studies on Asthma in Childhood and the University of Copenhagen found that of the 700 children delivered by caesarean section was associated with more than a doubled risk of later asthma and allergies, as well as significant changes in the composition of the gut microbiota. An Australian study which drew data from nearly 500,000 healthy women, saw higher rates of metabolic disorders, such as diabetes or obesity in babies born from emergency c-section.

This has been found to be because caesarean section interferes with a baby’s ability to obtain beneficial germs from the mother’s microbiome. Every generation of mothers hands over its microbiome to the next, as the baby is coated with beneficial germs while being squeezed through the birth canal. This does not happen for babies born through c-section. It takes a while for those babies to develop a normal microbiome. In this time, while the immune system is also developing, they become more at risk to later developing diseases, like asthma, and allergies. Researchers found that delivery by caesarean section was associated with significant changes in the composition of the gut microbiota. Studies look to mitigate this by giving c-section babies probiotics but have not been as successful as hoped. Further research in understanding the role of a child’s microbiota and how this can influence health can lead to new prevention strategies and targeted efforts to fix disturbances in a child’s microbiome. Whilst, caesarean section is often necessary for medical reasons, such as complications during labour, it has also been performed electively in some cases. Therefore, with this research at hand, a parent may choose a different birth mode. It also means that the results indicate that caregivers should be aware of the risks of food allergies in caesarean-born children, reducing the risk of potentially fatal allergic events.

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However, it is important to note that not all children born by c-section develop food allergies, and many other factors contribute to the development of food allergies. Genetics, family history of allergies, and early-life environmental factors also play significant roles. In addition, Murdoch Children’s Research Institute reported that 30% of peanut allergies and 90% of egg allergies resolve naturally by the age of 6.

-Alexander Gunson

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How cocaine affects the brain, and how addiction to it can be treated: A highly addictive stimulant drug, cocaine has been a major public health concern for decades. It is the second most used illicit drug, with estimates suggesting that 18 million people worldwide use it. The use of cocaine can have severe consequences on an individual's well-being. Specifically, it has a significant impact on the brain, causing long-term changes that can lead to addiction and various neurological disorders.

Cocaine works by raising dopamine, a neurotransmitter associated with pleasure and reward, levels in the brain. It does this by blocking the reuptake of dopamine, causing it to accumulate in the synapses, resulting in a feeling of euphoria. This sudden and intense rush is highly addictive and is what leads addicts to repeatedly seek out the drug for a chance to experience the same effect.

With that said, the increased dopamine levels aren’t sustainable, causing the brain to attempt to restore balance by reducing the number of dopamine receptors. This leads to a decrease in the pleasurable effects of cocaine, causing individuals to take more significant doses to achieve the same high. This vicious cycle of increasing tolerance and dependence can quickly lead to addiction.

The continued use of cocaine also has damaging effects on the brain's structure and function. Regular cocaine use alters the activity and reward circuitry in the brain, which can lead to individuals being more likely to engage in impulsive and risky behaviors. The drug can also cause changes in the prefrontal cortex, the part of the brain responsible for decision-making and impulse control, leading to improper judgment, impulsivity, and a reduced ability to resist drug cravings as long term effects.

Cocaine affects the brain in other ways as well, as use has been linked to various neurological disorders, such as stroke, seizures, and movement disorders. The drug can cause constriction of blood vessels leading to and in the brain, which increase the risk of and can often result in a stroke. The drug also alters the electrical signals sent around the brain, which, in addition to its altering of the sympathetic nervous system, lowers the threshold of stimulation the brain can handle before a seizure occurs. Long-term use of cocaine has also been associated with movement disorders, such as Parkinson's disease, due to the damage it causes to the brain's dopamine-producing neurons. The effects of cocaine on the brain can also extend to an individual's mental health. Chronic cocaine use has been linked to an increased risk of

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developing mental health disorders such as depression, anxiety, and psychosis. These disorders have a massive negative impact on an individual's overall well-being and most importantly can further perpetuate drug use as individuals turn back to cocaine to self-medicate their symptoms.

As with the vast majority of addictions, the treatment of cocaine addiction is a complex and challenging process, requiring a combination of approaches and a variety of pathways to allow an individual to fully recover. The common procedure for treatment in 2024 involves a number of steps that aim to cleanse the body of the drug and work with the patient to reduce and eventually eliminate reliance on the substance.

The first step in treating cocaine addiction is detoxification, where the drug is flushed out of the body.

This process can be especially challenging as individuals may experience intense withdrawal symptoms.

These include mental difficulties such as depression, intense cravings, and insomnia as well as more physical challenges such and nausea and vomiting. These symptoms have potential to seriously harm an individual, and because of this detoxification should be done under medical supervision in a controlled environment to ensure the safety and of the patient.

After detoxification, behavioral therapies are essential in addressing the psychological aspects of cocaine addiction. These therapies aim to identify and modify the root causes of addiction, develop coping mechanisms, and prevent relapse. Cognitive-behavioral therapy (CBT) is a commonly used approach that focuses on changing an individual's thought patterns and behaviors related to drug use. It helps individuals develop skills to manage cravings and cope with triggers that may lead to drug use.

Another commonly used effective treatment for cocaine addiction is contingency management. This process involves providing incentives, such as rewards or vouchers, for maintaining abstinence from cocaine use across longer periods of time. This approach has been shown to be effective in reducing drug use and promoting long-term abstinence across many addictions to many different things.

Pharmacological treatments are constantly being researched for treatment of cocaine addiction, although as of yet no specific medication has been approved for this exact purpose by the FDA. However, controlled clinical trials have been conducted using medications marketed for other diseases and show promise in reducing cocaine use. For example, disulfiram, a drug often used to reduce alcoholism, has had some of the most positive results so far. Despite a lack of direct treatment, medicine is still often used to manage specific symptoms of addiction, such as antidepressants for depression and anti-anxiety medications. Furthermore, another promising treatment for cocaine addiction is the use of vaccines. These vaccines aim to producing antibodies abke to bind to cocaine molecules in the bloodstream, preventing them from reaching the brain's reward system and reducing the pleasurable effects of the drug. While still in the early stages of development, research has shown that these vaccines can reduce the amount of cocaine used and increase the chances of successful recovery once the patient is identified.

In conclusion, cocaine has a profound impact on the brain, leading to changes in structure and function, neurological disorders, and mental health issues. Its highly addictive nature makes it challenging to treat, and a combination of approaches is necessary to address the issue; yet, with continued research and advancements in treatment methods, hope continues to grow for individuals struggling with cocaine addiction. Addiction is a serious and pressing issue worldwide, making awareness about the dangers of drug use, with cocaine being a prominent example, and methods of treatment crucial in reducing its impact on individuals and society as a whole as it aims to move towards a healthier, illicit drug free future.

-Alexander Manzavinatos

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The complex dynamics of obesity in a globalized world Obesity is the accumulation of excessive fat that can lead to the presentation of health risks. BMI is the most common measure for obesity (using mass in kg/height meters 2); a calculation above 25 is considered overweight and above 30 is considered obese. The prevalence of obesity has rapidly increased.

Obesity is a multifaceted chronic disease which involves genetic and environmental factors of which the genetic factors are arguably more critical to the condition of an individual with this disease. This essay will explore the complex interplay between nature and nurture in influencing obesity.

A critical factor that contributed to the significance of nurture on the development of obesity is the global access to high-calorie and processed foods as they tend to come at a lower cost than more expensive foods. Due to a gradual increase in fast food outlets, this factor has become more prevalent between 1980 to 2000 (The number of fast food outlets has increased by 80% in the UK within this time frame).

Consequently, the exposure to food outlets that offer ‘take away’ meals has been associated with the increase in BMI and risk of obesity in the UK. The genetic component of obesity is also a prevalent factor. Twin studies involving both monozygotic and dizygotic twins (while monozygotic twins share 100% of their genes dizygotic twins only share around 50%) have shown that monozygotic twins tend to share more similarities in BMI than dizygotic twins.

Multiple large meta-analysis haves supported this. For example, a study involving 45 cases of twin studies suggested that the heritable nature of BMI ranges from 41% to 85%. Another study with 31 twin studies suggested a heritability of 47%-90% in adults. The similarities in BMI are more apparent in adult life than in adolescence or childhood. However, the range in both tests are over 30% which may suggest the need for a larger sample size to provide less deviation from the mean heritability of BMI. BMI, as a measure, can be good to compare the overall trend of increasing the risk in obesity but it lacks reliability for data as it does not account for muscle to fat ratio, metabolic health, or the distribution of fat in a body.

The exposure to food cues (involves promotion of food through advertisement, smelling food, seeing food or any situation an individual associated with food) has also led to increased energy intake. Specifically, exposure to food cues is more prominent due to the extensive number of food advertisements (that contribute to an estimate of ½ of the commercials on children programmed). An average hour can include up to 11 of which most advertise high calorie and low nutrient foods that are not suitable for a regular/everyday diet.

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One might argue that the contribution of leptin (hormone secreted from adipose tissue) and insulin acting as primary signals to regulate food intake and metabolism are crucial to understanding whether genetic or environmental components are more influential to the manifestation of obesity. Leptin is secreted based on the fat content in adipocytes (a storage site for energy in the body). As genetic factors can influence these hormones, an individual’s responsiveness and production of leptin may vary (some people will have leptin resistance) which can directly impact their risk of having obesity. Despite this, the concept of leptin resistance is also affected by environmental aspects. Increased diet and physical activity can change the bodies responsiveness to leptin and may decrease the resistance the individual had towards leptin. This can often override any genetic predisposition Lastly, the transition of technology in marketing and production of food have shifted from local markets to larger chains of supermarkets. Notably, these supermarkets are recognized for their cheap prices and the easily accessible processed food which is often considered easier to consume for ‘quick energy’ (foods used to rapidly increase the body’s energy levels). Most foods bought in supermarkets tend to be high in fat, salt, or sugar. The WTO’s deregulatory policies has also reduced barriers to trade food, which can lead to lower prices and possibly an increase in demand for these foods. Demographically, these changes have led to the westernization and increased consumption of refined carbohydrate in many middle-to-lowincome countries.

While genetic factors can impact the way that obesity may manifest as well as the risk of developing obesity, heritability is not an absolute concept. However poor lifestyle choices and environmental actors have an impact on obesity to a greater extent. Interventions should therefore be based on these factors including diet modification to accommodate for low-calorie and high nutrition foods, and increased exercise to the development -Mishel Kudel

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To what extent is Sunak's 15-year plan to 'transform' the NHS workforce viable?

Within the United Kingdom, the National Health Service is both a great source of pride and a system notorious for its many flaws. While free, standardised medicine encourages healthcare equity unseen by the some of the world’s most developed countries, it is true that its quality can be compromised. The NHS has long been a political weapon for many British parties, who pledge support for the system and gain votes.

Therefore, it is surprising that such little progress been made in this area if it has so clearly been identified by both the public and politicians as a severe point for improvement. The current prime minister, Rishi Sunak, aims to tackle this issue with a 15 year plan (published June 2023). But how do his ideas stand out from those who came before him? Through each of the three targeted areas of ‘train, retain, and reform,’ to what extent is Sunak’s plan to transform the NHS viable?

The ‘train’ area of the plan has the main aim of growing the workforce, through both recruitment and, of course, training more staff initially. Issues such as geographic and social economic disparity have been presented as reasons for why not all the people who want to work in the NHS are trained to. The plan sets out the introduction of apprenticeships from September 2024, enabling doctors to train while earning a salary, thus eliminating financial barriers for many aspiring medics. Additionally, the government hopes to open more medical schools, targeting diverse geographic locations around the country. Both initiatives hope to boost domestic recruitment and lower the costs of employing as many agency recruitment and international staff. Encouraging access into NHS careers in underprivileged areas also aims to maintain diversity within the workforce. Currently 25% of NHS staff are “Asian, black, or another minority ethnicity, compared to 13% of all working age adults in the UK.”1 The only question remains: what money are these medical schools and apprenticeships being funded with? Unfortunately, the plan does not clearly outline this, simply saying that “NHS England is committed to...develop[ing] a national policy framework that can be used locally to guide the use of funding” 2. Therefore, it is not actually said how this money will be obtained, neither does it acknowledge the fact that many students will pursue higher qualifications after their apprenticeship, as opposed to entering the workforce immediately. Within the case study of the Stokeon-Trent Health and Care course, it is encouraged that the apprenticeship is done alongside university study.3 While lessening the reliance on international staff promises lower expenditure, the means through which this will be done are unclear.

Secondly, the ‘retain’ strand centres around embedding the right culture and improving retention (creating a workplace that makes hospitalists want to stay). The system will build on interventions that have previously been successful, like having flexible opportunities for potential retirees and modernising the pension scheme. Such interventions include the NHS emeritus scheme, which connects partially or recently

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retired doctors with providers that seek the help only an experienced clinician can offer. 4 They will also commit to ongoing funding of health and childcare support, with the latter resulting in fewer staff members choosing to not return to work after the end of their paternity/maternity leave. While not confirmed, a “tie in” period has also been discussed for junior doctors to confirm that a certain number of their newly trained years will be spent giving back to the service that trained them. These ideas will help to ensure that a greater percentage of the employees that the NHS funds the training of will remain in the system, making their training a more worthwhile investment. This is a significant step, as the number of doctors that opt to leave the NHS is increasing, with 4,843 doctors leaving the UK to work abroad during the period of May 2021 and May 2022.5 Enhanced healthcare is also estimated to make a large difference in retaining staff. In particular, mental health support is highly sought from overworked and underpaid employees, with many leaving the workforce entirely due to burnout with a lack of services offered. 6 As such, this strand holds promise for retaining more staff members. Through low-cost initiatives that tackle the harsh culture of the NHS, the staffing gaps are set to reduce.

The third and final strand, ‘reform’ focuses on adjusting the way that NHS staff work and train. This will include creating innovative ways in which the multidisciplinary team can support each other so that qualified staff can spend more of their time with patients. Leading on from this, certain professionals will be able to expand their power (e.g. prescribing rights) within General Medical Council guidelines.

Furthermore, more staff will be channelled into mental health, primary and communicative care fields to focus on prevention, lessening the severe reliance on secondary care. In an effort to modernise the system, new technological advancements will be harnessed and developed with an experienced team to build upon the Topol Review. This report clearly highlights how artificial intelligence, robotics and genomics can improve efficiency.7 The final change will be implementing shorter medical school programmes and internships. However, there is reason to believe that this may be an unpopular choice for incoming medics, with many already opting for courses that are longer than necessary to complete an intercalated masters, year abroad or research project. Approximately one third of UK medical students complete an intercalated degree in addition to their MBChB degree.8 Aside from this, the incorporation of technology has immense potential to reduce waiting lists for both surgeries and laboratory tests. Moreover, the shift from secondary to primary care would indicate lower spending due to the cheaper requirements of clinics compared to hospitals. Research conducted by the Health Foundation found that “Over the four-year period studied (2004/05 to 2007/08), it is estimated improvements in primary care for stroke... may have reduced secondary care costs by some £165 million.”9 This reformation of the entire system is unique in that it does not require significantly more funding, but channels existing money into different areas where it will be most effective.

While not perfect, this new plan offers hope for the NHS that has not been so prominent in many years. In comparison to the 2019 Long Term Plan, it is far more detailed and realistic since not everything centres around receiving more funding, without any idea where this will come from. The ‘train’ strand is lacking in this slightly, as opening more medical schools requires more than just commitment to a framework for funding. However, targeting under-represented demographics has the potential to make the training pathway far more accessible. Secondly, the post-retirement plans laid out in the ‘retain’ strand may give support to the busiest fields of care offered by the NHS, at a cost lower than full-time employment. By reprogramming the way that seniority is regarded, junior doctors and consultants alike can support one another, which is also a great stride in tackling the stigma surrounding mental health support. Finally, the ‘reform’ strand seems the most pioneering of all. By changing the way that the NHS works and finding new jobs for each member of a multidisciplinary team, its effectiveness can be maximised. By allowing the nursing profession to cover some jobs of doctors, the workforce gap will again be lessened. With these collaborations alongside the use of technology from a heavily researched review, the NHS will be able to function to a fuller extent of its ability. There is no doubt that more funding is needed, but this plan highlights how slight changes further down in the system can have a vast impact higher up. As a result of

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this, Sunak’s 15-year plan appears much more viable than previous schemes, and has the potential to make a real difference to healthcare in the UK.

Bibliography: The NHS workforce in Numbers (no date) Nuffield Trust. Available at: https://www.nuffieldtrust.org.uk/resource/the-nhs-workforce-in-numbers (Accessed: 02 January 2024).

NHS Long Term Workforce Plan - NHS England. (2023) Available at: https://www.england.nhs.uk/wpcontent/uploads/2023/06/nhs-long-term-workforce-plan-v1.2.pdf (Accessed: 02 January 2024).

Childcare, Health & Social Care - Stoke-on-trent college (2023) Stoke. Available at: https://www.stokecoll.ac.uk/course-areas/childcare-health-social-care/ (Accessed: 02 January 2024).

Home (2023) NHS Emeritus. Available at: https://www.nhsemeritusconsultants.org/ (Accessed: 02 January 2024).

Johnson, H. (2023) Factcheck: How many UK doctors are going abroad and how does pay compare?, Channel 4 News. Available at: https://www.channel4.com/news/factcheck/factcheck-how-manyuk-doctors-are-going-abroad-and-how-does-pay-compare (Accessed: 02 January 2024).

Doctors plan to leave NHS in growing numbers due to burnout, Gmc warns (2023) The Guardian.

Available at: https://www.theguardian.com/society/2023/nov/12/doctors-plan-to-leave-nhs-ingrowing-numbers-due-to-burnout-gmc-warns (Accessed: 02 January 2024).

(No date) NHS choices. Available at: https://topol.hee.nhs.uk/the-topol-review/ (Accessed: 02 January 2024).

Nicholson, J.A. Cleland, J. Lemon, J. Galley, H.F. (2010) ‘Why medical students choose not to carry out an intercalated BSC: A questionnaire study’, BMC Medical Education, 10(1). doi:10.1186/14726920-10-25.

(No date a) Do quality improvements in primary care reduce ... - the health foundation. Available at: https://www.health.org.uk/sites/default/files/DoQualityImprovementsInPrimaryCareReduceSecond aryCareCosts_summary.pdf (Accessed: 02 January 2024).

-Charlotte Holt

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Should euthanasia be legal or illegal in the UK? Is there more to it than just the matter of being legal?

“To save a man’s life against his will is the same as killing him” Originated in Greece, the word euthanasia means ‘good death’; deliberate advancement of a person’s death for the benefit of that person and that of the family. Yes, some regard this matter as suicide (if performed by the patients themselves) or murder (if performed by another); no matter what, it is ending a person’s life. However, is it any better to keep a terminally ill person alive who is suffering from severe torment? Is it any better for their family to remain in agony of watching their beloved ones deteriorate beyond recognition? Is it fair for the government and its restrictions to interrupt family decisions?

Euthanasia will be moral under strict conditions and restrictions, and if allowed in the UK, it will improve the freedom of people’s choices and the right of life.

The Asian Age has reported that “Out of the 196 countries in the world, 9 countries had legalized euthanasia, including Netherlands, Belgium, Colombia, Luxembourg, Switzerland, Germany, Japan, Albania and the US.” (2018). The research indicates that there are a few requirements and conditions that must be met in order to carry out the practice in those listed countries. For instance, Canada has allowed euthanasia under the condition that consent needs to consistently be expressed, not implied. Netherlands allow euthanasia under the condition that the person should be experiencing unbearable suffering and there is no chance of it improving; by that being supported by a healthcare professional. As seen, these countries have allowed the act of euthanasia and created requirements so that most would be under control.

Moreover, euthanasia cannot be considered immoral just because it could be regarded as disrespecting the sanctity of life. Some people state, “Euthanasia is a discourtesy towards the dignity of human life.” Yes, it is true, but only when we consider solely the length or the amount of life lived. However, quality of life is just as important as the quantity of life. In other words, when it is hard to distinguish the difference between a person’s current quality of life from a torture (due to excessive pain caused by a condition), extending the length of life cannot be viewed as a way of valuing life: it is not living what people call a ‘sacred life’.

“Everyone has the right to live like a human being” – an affirmation from the Universal Declaration of Human Rights. Living a good-quality life means living with these rights and guaranteed human dignity.

Nevertheless, where it is impossible to find a cure or treatment with the modern medicine due to the disease being extremely rare, we should not be pressured to live a life in which human dignity is not

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preserved for legal reasons even in these situations. This is recognized as a violation of human rights.

Therefore, it can be said that euthanasia should be legally permitted to assure human rights, and euthanasia does not neglect life, but rather promises human dignity.

Moreover, if humans have the right and control over how they live their life, in the equal way, they should have the equal right and control over how they end their life, whether it would be through assisted death or not.

However, there are always negative sides to consider. There are people who criticize euthanasia, firmly stating that it is a murder or that it is a suicide, that it is not moral to end a patient’s life because they have the right to live longer, especially when some might unexpectedly recover! Victoria Arlen is a current television personality and former American Paralympian swimmer. She is famous for waking up from 4 years of vegetative state. She was able to recover to retrieve the motor skills and to walk in the time of a few years after waking up. This elucidates how someone can recover from an illness or disease that others could have given up on. Nonetheless, although there are cases such as Arlen, it is a rare incidence and it does not happen to every person in vegetative state. It is not right to put people in psychological pain just because they gained hope that their vegetative stated person could wake up. This would also require economical concerns as well as keeping a unconscious person alive needs many costly life supplies and additional hospital fees for guardians/families to pay for.

Even so, euthanasia cannot be considered a murder or suicide. It is different from the purpose. The euthanasia being mentioned here (to be moral and legal) is when it is used for patients who are both physically and mentally having trouble and pain. It is clear that these patients will have painful times in the future, and that is why euthanasia is used, if desired. Suicide can be avoided by mental consultation with doctors, but when a family member chooses to suicide, it can bring upon a huge depression and sorrow. Whereas, in the case of euthanasia, the family can prepare for the last moment and prevent colossal shocks. This is why euthanasia is essentially a different subject compared to suicide, and it is a significant error to consider euthanasia as a type of suicide/murder.

In conclusion, this is all about choices and decision-making. It is based on the decisions made by the family or the patients themselves. Some will decide to choose euthanasia, and some will not. This depends on their responsibility and deliberation about this act. The government should have restrictions and requirements to what extent they will allow the performance for safety concerns, but it is not a decision that the government interferes and chooses for the patient. Government is in charge of the state, but does not have the right to have control over every single individual’s life. Citizens of the state has the right to choose; the right to life should not be managed or controlled by the government. Restricting euthanasia within the country is limiting people on choices to end their life.

Therefore, euthanasia being legal would allow better provision of human rights in many countries.

However, although it is crucial to consider the legality of euthanasia, there are more aspects to consider when it comes to this act: the psychological health, the quality of life, and most importantly, the human rights. So, as well as one opting for euthanasia to be legal in countries around the world, we should always be looking at the more humane side of things rather than the restrictions, laws and yes-or-no matters, when it comes to discussing about euthanasia.

“Euthanasia is a prescription for all types of abuse of people at the most vulnerable times of their lives” – Nancy Elliot.

-Jimin Park

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Neurofeedback Therapy- A Overview

By Sunaina Nambiar, 13 JBA Neurofeedback therapy, also known as electroencephalographic (EEG) biofeedback, is quickly becoming popular as a new form of treatment for mental disorders, particularly anxiety, depression, and ADHD. But what exactly is neurofeedback therapy? How does it work? How does it help treat these mental illnesses?

To answer the first question, neurofeedback therapy is a non-invasive form of treatment that encourages the brain to develop new neuronal connections, facilitating healthier patterns of activity. The treatment is founded on the basis of neuroplasticity. Neuroplasticity is the ability of neural pathways in the brain to change and adapt with age and experience. Though this most commonly occurs as a result of learning new information (such as learning a new language), it can sometimes occur due to brain damage. However, neurofeedback therapy seeks to induce such changes in activity via measuring and controlling brain waves, helping the brain self-regulate.

The first stage of neurofeedback therapy is brain mapping. During this stage, EEG scanners are attached to certain points of the head in order to measure the electrical signals in different brain areas. These signals are then statistically analyzed to see brainwave patterns. The EEG data is then recorded and processed by a computer software program. A Quantitative EEG brain map helps detect the brain areas where there is too little or too much activity. It helps with identifying amplitude, location and dysregulation. This is done to formulate an exact treatment plan using neurofeedback therapy.

Neurons in the brain communicate with each other by electrical activity. This is presented in the form of brainwaves. There are several different types of brainwaves: Delta waves are the slowest brainwave. These are the most relaxing brainwaves and associated with deep sleep stages and relaxation. It measures from 0-4 Hz and has the highest amplitude. These waves are targeted in neurofeedback therapy to treat sleep disorders, such as insomnia and narcolepsy.

Theta waves are associated with creativity, intuition and daydreaming, and are a repository for memories, emotions, and sensations. The frequency range is between 5-7 Hz. Theta state is seen during light sleep or deep meditation. In this state you may experience vivid visualizations, profound creativity, flow of ideas and exceptional insight. Theta waves are targeted when the patient has ADHD, as those with the disorder tend to have excess theta levels, which results in disorganization, impulsivity, and excessive daydreaming.

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Alpha waves are produced naturally during states of calm, allowing the brain to be alert, yet relaxed.

Alpha brain waves are in the frequency range of 8 to 13 Hz. Alpha waves are associated with peacefulness and meditation. Alpha waves are typically targeted to combat conditions such as stress and anxiety, in order to induce relaxation.

Beta waves are high frequency, low amplitude waves that are commonly observed while awake. The frequency of these waves is between 14-40 Hz. These involve conscious tasks such as critical thinking, writing, reading, focus, sustained attention, alertness, excitement, and socialization. The brain waves are targeted during neurofeedback therapy to improve attention and focus.

Gamma waves are the fastest brain waves with the highest frequency, their range being between 30-100 Hz. These are observed when processing information from different brain areas simultaneously, passing information rapidly. They are associated with alertness, thought, and focus. Gamma waves are targeted during neurofeedback therapy to improve learning, memory, attention span and concentration, and are often targeted with cases of depression.

Brainwaves experiencing over-arousal results in fidgeting, impulsivity, hyperactivity and agitation, while brainwaves experiencing under-arousal is linked to poor concentration, insomnia and daydreaming.

In neurofeedback therapy, a computer monitors a person's brain for wave activity, then immediately provides feedback, through either visual or audio cues, such as light or sound. This feedback enables the brain to heal itself and adapt in response to extrinsic stimuli by reorganizing its functions and structure.

The therapist in charge of the neurofeedback therapy session will attach sensors to a person's scalp in order to record the brainwaves via EEG. Through neurofeedback, a desired state can be recreated, such as being relaxed and happy, and negative states can be avoided, such as being anxious and agitated.

The most common treatment via neurotherapy is allowing the patient to watch a video on a screen while the brain waves are measured. Manifesting the targeted brain waves enables the screen to brighten, enlarge, and allows the audio to become clearer and louder. If the targeted brain waves are inhibited, the screen dims, shrinks, and the audio decreases in volume. The aim of this is to train the brain via positive

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reinforcement and negative punishment, so that the brain repeats the desirable behavior (producing the targeted brain waves) in order to obtain a reward (a more pleasant viewing experience).

While neurofeedback therapy is a painless procedure, except perhaps extremely mild pain while inserting the sensors, there are often side effects experienced after the procedure. These include dizziness, fatigue, and headaches, though they are relatively minor, and go away a few hours after the session has ended.

These side effects decrease as the brain becomes used to neurofeedback therapy.

Neurofeedback therapy can be used to treat disorders both major and minor, from focus and attention, stress, memory, and learning, to depression, anxiety, ADHD, chronic pain, and sleep disorders. However, its effectiveness depends on age. Children would need regular, frequent sessions in order to maintain the new connections formed as a result of the therapy, while adults would need less frequent sessions, and may be able cease them completely once a treatment plan has been established, save from an occasional checkup. Neurofeedback therapy can be combined with other forms of treatment, such as medication or cognitive behavioral therapy, depending on the needs of the patient, though it may be possible to wean off medication in favour of the neurofeedback therapy, due to its effectiveness in managing symptoms, while CBT may still be needed due to its function as a treatment method to address the underlying causes of behaviour itself.

In conclusion, though neurofeedback therapy may not be a relatively new form of treatment for mental health issues, it certainly is gaining in popularity over the last few years for its effectiveness in assisting these conditions and being a relatively hands-off treatment plan, with the patient not having to actively find the motivation to manage their own disorders, such as having to take medication daily or keeping a journal as part of CBT. Of course, while it is important to exercise caution when choosing it as a treatment method, as with any type of medical help, it certainly presents itself as a new alternative in helping one manage the main different possible mental disorders they struggle with.

References: Chandra, S. What is Neurofeedback? A Psychiatrist’s Perspective: https://chandramd.com/what-is-neurofeedback/ Marzbani, H., Marateb, H., & Mansourian, M. Neurofeedback: A Comprehensive Review on System Design, Methodology and Clinical Applications: https://doi.org/10.15412/j.bcn.03070208/

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Clustered Regularly Interspaced Short Palindromic Repeats

By Elisa Westerhof Changing your genome? How is that possible? Where is it needed? Should it be done? Every living organism is determined by their genes. What if we could alter that code to fix a mistake, or change a characteristic? The idea of genetic engineering first arose in 1973, when biochemists Herbert Boyer and Stanley Cohen, invented a method of cloning genetically engineered molecules in foreign cells (1). This was aided by the work of Paul Berg, in 1971, where he conducted a gene-splicing experiment, allowing foreign DNA to replicate naturally in bacteria. These experiments were possible due to prior discoveries (2), such as the discovery of alleles by Gregor Mendel in 1866, and the development of the DNA model

by James Watson and Francis Crick with the help of Rosalind Franklins discoveries in the 1950s. CRISPR was first discovered in 1987 in Osaka University by Ishino (3), however, pioneers Jennifer Doudna (professor and biochemist at the University of California, Berkley) and Emmanuelle Charpentier (a microbiologist and director of Max Planck Unit for the Science of Pathogens) further discovered the CRISPR-Cas9 gene editing system, winning the Nobel Prize in Chemistry in 2020 (4). Charpentier discovered tracrRNA, while Doudna mapped the Cas proteins, where their collaboration enabled them to discover and develop the system of gene editing. The scientists became one of the few women to earn the Nobel prize, following 5 other since 1901. Angela Zhou, an information scientist, mentioned how CRISPR has been used to “modify immune cells to make them more effective at destroying cancer cells and to remove the HIV virus when it has integrated itself into the human genome. And CRISPR-based drugs are being developed to treat heart disease, blood disorders and blindness”.

HOW DOES IT WORK? CRISPR sequences are crucial for single-celled bacteria and archaea, since they function as their immune system. When a mobile genetic element, particularly a virus (small infectious agents), invades, action is taken to eliminate the threat immediately, protecting the prokaryote (5). Cas proteins cut out a segment of the viral DNA (acting like molecular scissors) to stitch into the bacterium CRISPR region, capturing a ‘chemical snapshot’ of the infection (6). The viral codes are transcribed into short pieces of RNA, which bind to the Cas9 protein (in the CRISPR region). This results in complexes which latch onto free floating genetic material, searching for a match to the virus, resulting in the destruction of the viral DNA. When the immune system has attacked the virus, short CRISPR sequences, called ‘spacers’ are derived

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(adaption), allowing there to be a ‘genetic memory’, comparable with lymphocytes in the human immune system. This allows CRISPR RNA to be produced within the bacteria (targeting), which will guide the bacterial molecular machinery to destroy the viral material.

USING CRISPR IN LABS This immune system can become a precise gene editing tool, targeting DNA in almost any organism, helping alter the DNA and change specific genes (6): 1. A guide RNA is designed in the lab to match the gene they want to edit 2. This RNA strand is attached to CAS9 3. Guide RNA directs the CAS9 to the target gene 4. The proteins molecular scissors snip the DNA 5. Once it is cut, the cell will try to repair it Typically, ‘nucleases’ trim and join the ends back together in the process of ‘nonhomologous end joining’.

However, this process is prone to mistakes, which can lead to extra or missing bases, often resulting in unusable or turned off genes. If scientists could add an extra template DNA to CRISPR, cellular proteins could perform a different repair process ‘homology directed repair’, where temporary DNA is used as a blueprint to guide the repairing process (this allows scientists to repair a defective gene or insert a new one). Overall, this produces rDNA (recombinant, meaning it contains a new, different genetic combination).

APPLICATIONS OF CRISPR This primitive, yet elegant defence system can be used in labs, farms, hospitals and more. CRISPR can lead to critical advances in patient care by drastically changing the trajectory of a disease as scientists learn the effects of turning on and off or changing genes within an organism. The first human clinical trial using CRISPR-Cas9 happened in China in 2016 using lung cancer patients (7) where the PD-1 gene (Programmed Cell Death Protein 1) was inactivated ex-vivo (outside the person), to keep lung cancer in check. This gene normally down-regulates the immune system allowing cancer to multiply, thus the inactivated gene enhances the body’s ability to fight the cancer. However, the success of this trial was kept confidential to the families. Later in July 2019, ex-vivo therapy using CRISPR-Cas9 was performed for a patient with sickle cell anaemia in the US (3), which significantly improved the patient’s condition for months, providing promising results, however the cost has limited further trials, which are estimated to be 0.5-1.5 million USD. Nevertheless, CRISPR can be used as a fast genetic editing system, providing advantageous outcomes.

Currently many clinical trials are taking place for the treatment of diseases such as: hearing loss (Hunter Syndrome), Huntington’s disease (stops part of the brain from working properly over time), Angelman’s syndrome (delayed development, problems with speech and balance), Parkinson’s disease, spinocerebellar ataxia (affects the cerebellum), cystic fibrosis (sticky mucus), turner syndrome (one of the X chromosome is missing or partially missing), muscular dystrophy, sickle cell anaemia, Gaucher disease (missing an enzyme to break down lipids). Promising future applications for CRISPR-Cas9 can be see in HIV and human papillomavirus.

In other settings, gene editing can result in plants that yield larger fruit, improve drought tolerance and drug resistance, and mosquitos that can’t transmit malaria as well as so much more!

ETHICS CRISPR is not a perfect process yet, meaning errors can occur and people may misuse it. One of the largest controversies is in the use of the human embryos, since it may lead to unfair enhancement

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purposes, but also is affecting the unborn baby who is given no autonomy as to what happens to them. It is believed these concerns should be managed through policy and regulation (8). Ethical discussions are centred around the human germline because these changes will be passed down to future generations, where it is difficult to predict the long-term changes. Gene editing may also lead to off-target effects (where more cells are affected) or mosaicism (when some cells carry the edit, but others do not). This can lead to an array of unknown consequences. Ethical questions are also raised about genetically edited microbes which may be released into the environment, causing unforeseen changes to the world.

A RECENT STUDY ON HEART DISEASE (9, 10) Hypertrophic cardiomyopathy (HCM) is the most prevalent genetic heart disease, where the left ventricle heart muscles thicken, leading to stiffness, causing arrhythmia, heart failure or sudden cardiac death.

Professor Eric Olsen is conducting a promising study to create in vivo therapy for the treatment of HCM. By editing the gene, he believes this will cause a lifetime fix, as heart cells turnover very slowly, stating it should be a “one-and-done therapy”. A test in mice revealed the editing efficiencies were over 30%, preventing the onset of HCM, showing similar cardiac function to healthy mice. Furthermore, researchers found injecting gene editing reagents to edit the CaMKIIδ gene may lead to protection from ischemia/reperfusion (IRI, cellular dysfunction and death as blood no longer flows to the muscles).

Further research is being conducted to repair permanently damaged tissues following a heart attack, which may lead to many exciting opportunities in the advancements of CRISPR-Cas9 gene editing!

References: 1. Science History Institute, Herbert W. Boyer and Stanley N. Cohen, no date https://www.sciencehistory.org/education/scientific-biographies/herbert-w-boyer-and-stanley-ncohen/ 2. FDA, Science and History of GMOs and Other Food Modification Processes, April 19, 2023, https://www.fda.gov/food/agricultural-biotechnology/science-and-history-gmos-and-other-foodmodificationprocesses#:~:text=1973%3A%20Biochemists%20Herbert%20Boyer%20and,human%20insulin% 20to%20treat%20diabetes.

3. Irina Gostimskaya, CRISPR-Cas9: A History of Its Discovery and Ethical Considerations of Its Use in Genome Editing, August 15, 2022, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9377665/ 4. Josh Fischman, Nobel Prize in Chemistry Goes to Discovery of ‘Genetic Scissors’ Called CRISPR/Cas9, October 7, 2020 https://www.scientificamerican.com/article/nobel-prize-inchemistry-goes-to-discovery-of-genetic-scissors-called-crispr-cas911/

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5. Ekaterina Pak, CRISPR: A game-changing genetic engineering technique, July 31, 2014, https://sitn.hms.harvard.edu/flash/2014/crispr-a-game-changing-genetic-engineering-technique/ 6. Andrea M Henle, How CRISPR lets you edit DNA, January 24, 2019, https://www.youtube.com/watch?v=6tw_JVz_IEc 7. D Cyranoski, CRISPR gene editing tested in a person, 24 November, 2016 https://internationalstudents.unipa.it/dipartimenti/di.chir.on.s./.content/documenti/IntervistaCRISPR-Nature.2016.20988.pdf 8. National Human Genome Research Institute, What are the Ethical Concerns of Genome Editing?, August 3, 2017 https://www.genome.gov/about-genomics/policy-issues/Genome-Editing/ethicalconcerns 9. Rebecca Roberts, Base Editing Tackles the Most Common Genetic Heart Disease, May 22, 2023, https://www.science.org/doi/10.1126/science.ade1105 10. Corrie Pelc, Heart disease: CRISPR gene editing may repair damaged tissue after a heart attack, January 13, 2023 https://www.medicalnewstoday.com/articles/heart-disease-crispr-gene-editingmay-repair-damaged-tissue-after-heart-attack

First use of CRISPR https://go.gale.com/ps/i.do?id=GALE%7CA471282615&sid=googleScholar&v=2.1&it=r&linkaccess=ab s&issn=00280836&p=HRCA&sw=w&userGroupName=anon%7Eb1a913aa&aty=open-web-entry

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NHS Medical Apprenticeships: What are They, and What Do They Mean for the Future of Healthcare?

In January 2023, funding for the Medical Doctor Degree Apprenticeship was confirmed by Health Education England (HEE), enabling 200 medical doctor degree apprentices to begin their course in September 2024. However, what does this actually mean? And how does this affect doctors and healthcare professionals who will undertake the traditional pathway into medicine?

As stated by the NHS, these medical apprenticeships aim to ‘offer routes into many of the more than 350 NHS careers through a mix of on-the-job training and classroom learning.’ It was introduced by the government as a way to combat the NHS workforce crisis, a highly alarming issue. This can be evidenced through the fact that more than 85% of junior doctors say they know other junior doctors who have left to work in a different profession, or to work as a doctor in a different country. These apprenticeships incentivize people to apply because they mean you can become a doctor without actually going to university, and although the course is still 5 years long, you get paid from day one (the National Minimum Wage for apprentices is £5.28 an hour). This is highly attractive as you don’t end up with years of medical school debt as you don’t pay any tuition fees, and you still get the same qualifications as a doctor who undertook the traditional pathway into medicine.

However, these apprenticeships have caused great discontent within the healthcare community, with many believing it will lead to a two-tiered training system. With medical apprentices being entitled to annual leave and a pension as well as pay, many aspiring medics taking the traditional route into medicine feel that their hard work is being undermined. Additionally, the issue of how these apprentices will be able to obtain the same level of expertise knowledge as traditional medical students has been called into question.

One critic says, ‘The reason we do a five-, six-year degree is to understand things like why we’re stopping certain medications. If the work side if the apprenticeship is a role where you’re taking instructions, you’ll never understand why you’re doing something, which is what you learn on a placement.’. Another doctor says ‘I’ve done HCA (Healthcare Assistant) work while at medical school. I enjoyed it, but it wasn’t applicable to my medical degree. I learnt more in lectures.’. This shows the possible challenges that

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apprentices may face, without the proper knowledge and understanding of why specific treatment are given or why one drug is chosen over another, how effective will these apprentice doctors be?

To conclude, although the government has attempted to take action against the NHS workforce crisis, it is difficult to tell whether these medical apprenticeships will have a positive impact on healthcare in the UK. The fact that junior doctors are already unhappy with the scheme and feel that the apprenticeships undermine their hard work and effort, it doesn’t seem likely that they will help solve the depleting numbers of NHS workers. Arguably, the government should be focusing on retention of current NHS workers rather than recruitment. Furthermore, If the training of doctors is not matched to those who have undertaken the traditional medicine pathway, or if a two-tiered system is created then the government seemingly has no back-up plan to address this. Therefore, although advocates for the apprenticeship claim they can ‘widen participation in medicine and help plug hospital workforce gaps in areas struggling to recruit,’ the future is uncertain, and only time will tell how beneficial these medical apprenticeships will be for the NHS. Bibliography: - British Medical Association- https://www.bma.org.uk/news-and-opinion/two-tribes - Gov UK- https://educationhub.blog.gov.uk/2023/06/30/nhs-doctor-apprenticeships-everything-youneed-to-know/ NHS- https://www.healthcareers.nhs.uk/career-planning/study-and-training/nhs-apprenticeships -Anna Zaman

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Can Alzheimer’s disease be inherited?

Most of us has heard the term Alzheimer’s disease but do we understand it? Alzheimer’s disease is a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks. What makes an Alzheimer’s patients’ brain different from those not suffering from the disease is abnormal clumps, now called amyliod plaques. This was found by Dr Alios Alzheimer in 1906.

As well as these clumps, there are tangled fibres also present within an Alzheimer’s patients’ brain now called neurofibrillary as well as loss in connections between nerve cells. And as we all know from GCSE or A level biology, the connections and ability for electrical impulses to be sent across nerve cells is key for brain function. Resulting in Doctors thinking this is the main cause of Alzheimer’s disease.

In 2010 we knew of 10 genetic areas associated with Alzheimer’s, today we know of about 80 genes associated with Alzheimer’s. Understanding which genes play a role – and what role they play – may help identify new methods to prevent, delay or treat dementia. Apoliprotein E (APOE) is a well known gene that influences the risk of having Alzheimer’s disease. APOE gene is involved in making a protein that helps carry cholesterol and other types of fat in the bloodstream. Problems with this process is thought to contribute to the development of Alzheimer’s. APOE is found in many different alleles, (versions of the same gene).

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APOE e2 may provide some protection towards the disease. Roughly 5-10% of people have this allele and if someone with this allele develops Alzheimer’s it would be later in life than someone with the APOE e4 allele.

APOE e3, the most common allele, and is believed to have neutral effect on the disease.

APOE e4 increases the risk for Alzheimer’s disease and is associated with earlier disease onset.

About 15-25% of people have this allele and 2-5% of people carry two copies.

Each person inherits two APOE alleles. One from each biological parent, and therefore there are six possible combinations. Someone who inherits two APOE e4 alleles is more at risk than someone who inherits two APOE e3 alleles.

However, genetic variance also plays a role in whether you develop Alzheimer’s. Research suggest that the degree of risk may be affected by genetic ancestry- the global geographic region from which a person

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is biological descend. For example, Africa, Asia, American Indian or European descent. Some rare genetic variants are listed below that are known to cause the disease. A child whose one of these parents carry this genetic variation has a 50/50 chance of also inheriting the gene and therefore will also develop Alzheimer’s. A child with these genetic variants has a strong probability of developing Alzheimer’s before the age of 65. This is classified as early-onset Alzheimer’s.

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Amlyiod precursor protein (APP) on chromosome 21 Presenilin 1 (PSEN1) on chromosome 14 Presenilin 2 (PSEN2) on chromosome 1

Changes in these three genes causes the production of abnormal proteins that are associated with the disease. Each of these mutations causes the breakdown of the protein called APP, which is a protein that is not yet completely understood. However, the breakdown of this protein causes the formation of sticky amyloid fragments which cluster and form plaques on the brain. Which is one of the physical differences of Alzheimer’s.

Due to one of these three genetic variants being found on chromosome 21, a person with Down syndrome has a high chance of developing Alzheimer’s disease. With 50% of people with Down syndrome developing symptoms in their 50-60’s. This is since they have two chromosome 21’s, and therefore one greater set of genes that break down APP than someone without.

Genetic testing can now be done to test whether a person has dementia, however, it is not routinely done in the clinical setting. This is because sometimes the symptoms are prevalent enough as well as family history of dementia allows doctors to diagnose Alzheimer’s without any tests. Nevertheless, tests can be done to test for APP and PSEN1 and PSEN2. Genetic testing for Alzheimer’s is rather used to further understand the disease rather than diagnosing individuals. To conclude, any person can develop Alzheimer’s disease, and is caused by many external and lifestyle factors. Yet, as seen from the three genetic variants that can be inherited, some genes can cause people to develop Alzheimer’s quicker than others and therefore can be inherited and passed on to other generations. However, there is no definite reason or cure for Alzheimer’s disease and therefore is still an area within science and medicine that is still being researched to try and understand the uncertainties more.

-Mieke Visser

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