Plastic, Reconstructive and Cosmetic Surgery Lecture

Amidst by anecdotes of surgical complications and labels in society, plastic surgery has become a taboo subject. The media notably distorting plastic surgery as a cliché characteristic amongst celebrities, attaching a sullen image of disease of wealth and a cheating method of attaining beauty. With a high price tag and potentially a life-long alteration, Douglas McGeorge, a leading plastic surgeon, elucidates his understanding on the controvertible topic of Plastic, Reconstructive and Cosmetic Surgery.

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Having initially studied in general surgery, Douglas McGeorge practiced through all specialties before choosing to work solely in Plastic Surgery and finally as a consultant in his own private unit. He highlights that though the training was vigorous, he is at an advantage with an abundance of experience to work on a larger variety of body reconstruction. Whilst further stating, ‘I learn more and more about less and less until I know everything’, which I find as a perfect explanation for such doctor in a job which requires great attention to detail. Graduates of medicine now however, upon completing their 2 foundation years of training, can apply to any specialized department of their choice straight away. McGeorge’s clinic’s common procedures include facial rejuvenation, breast adjustment, Botox and fillers. To complete these procedures to the perfection and precision required, perceptual ability is key – the ability to work in space and implement a 2D idea into a 3D surgical procedure.

At the forefront of the talk, Mr. McGeorge approached the debate of ethics, articulating that the culture of today is set in a young-based world, where it is not uncommon to rejuvenate oneself. If the risks and complications are minimal, the liberty to be given what you are looking for should be offered openly. However the NHS only caters for more unpredictable cases such as cancer or first grade burns, hence he strongly felt that this personal choice should be considered to the same extent and be placed under the national insurance roof. Though unfortunately cosmetic surgeries are not miracle works, henceforth expectations can be higher than what it can provide, not to mention the increased phenomenon of revision to previous looks once dissatisfied. In addition to this, the process can be lengthy, due to maintenance surgeries every few months or years. As surprising as it may sound people can also develop addictions, admiring the satisfaction of altering every part of their body thus becoming more of an obsession than means of enhancing.  As very much known, expenses on plastic surgery are high, Mr. McGeorge remarked that £2,500 needs to be earned a week in order to keep his unit stable. Therefore he cannot afford to pay for all patients that refer to his unit with financial issues. The health service in his opinion is ineffective in using money, resulting in more cases being placed into the private sector with nothing to encourage the health service otherwise.

Personally speaking, the reinvigoration of confidence exceeds all downside, whilst not only improving quality of life and health, cosmetic surgery has become a method of emotional wellness and the effects are long-lasting. The skin graft a person may endure at the age of 30 will remain for the rest of their life, the breast-reduction a women may experience at the age of 21 will prevent her from risks of back problems at the age of 50 or rhinoplastic surgery for a 18 year old may remove nasal obstruction, helping them to breath and smell better. Often these factors are overlooked and we are quick to label, however with a broad and increasing number of people opting for plastic surgery, the future opens a prospectus for a renovated society both socially and physically.

Lecture: How Genomics Lights The Way

Last December, I attended the annual Christmas Lecture held at the Manchester Royal Infirmary as presented by the Manchester Centre for Genomic Medicine. The talk sought to provide an insight into their professional sector, whether that be from within their labs or interestingly besides a super computer, as well as introduce us into genetic variance and the lengthy process of genetic diagnosis and prognosis.

Broaching the anatomical side first, an introduction into Eukaryotic cells was explained (it was simply revision for me, however I’m sure some of the audience hadn’t studied Biology for a long time). They explained as humans we are made out of trillions of cells, constantly dying and duplicating via the process of mitosis (cell division). This takes place due to a command centre within our cells, called the nucleus, of which holds all our genetic information in the form of DNA. The speakers were all dressed colour coordinately and presented their roles within the Genome Department in pairs, as to reflect the DNA pairs constructed from 4 bases, hence Adenine pairing with Thymine and Guanine with Cytosine. Of course in order to exhibit ones genomics, DNA needs to be extracted first. A group of volunteers took to the floor for an experiment to extract their DNA by the homogenisation (bursting) of cheek epithelial cells resulting in a cloudy, string-like substance floating on the surface of the solution – this is DNA extracted to be visible to the naked eye. Though if not more fascinating, squeezed into each nucleus, DNA is 2 meters long when stretched end-to-end!

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Within every human, cells are divided by the many specific functions they hold in the body, such as beating cardiac cells or photo receptors in our eyes, as coded by our DNA, so what makes us uniquely different from each other? The answer is variations in our DNA sequence and DNA mutations. This sounds rather daunting when the biology behind it is not explained, thus to understand the significance of mutations another test was run by the genome team. This time I volunteered myself also, each volunteer was given a strip of paper coated with a specific chemical and told to hold it on the tongue for a few seconds. Some had no reaction, whereas myself and a few others cringed at the bitter taste, this is due to a specific mutation found in 50% of the population, that results in an immunity from experiencing this taste and occurs since birth. Funnily enough this chemical is very similar to that found in brussell sprouts, hence could explain the popular distaste for them. However, some mutations from birth and during your lifetime can be harmful.

In order to diagnose patients with these harmful mutations or rather genetic diseases, the Genomic researchers work hard to find variations in the DNA sequences of their patients to pin point which genetic disease they may be carrying and therefore how to treat them. To explain the process very simply, the DNA is extracted from the cell, it is cut into sections of DNA strands and in order to analyse these strands they need to be organised into the DNA sequence they are found as naturally. Hence the technicians, educated to use the super computers, analyse the DNA and in light of the Christmas spirit at the time, tinsel was used to display this. Our tickets for the talk which had been collected earlier, were now used to represent an unorganized sequence, they were then placed into a box representing a ‘super computer’, which began shaking to form a sequence. This would usually take a few days since the computer has to organise between 3 billion pairs of letters in the human genome and 20,000 genes, however we were swiftly given a result as a long chain of tinsel was pulled from the computer, in reality the computer draws a graph of each base in the sequence it has recorded and organised. Now with the full DNA sequence, the bases in the sequence can be compared to other sequences to determine the patients conditions. Hence if they have a rare genetic disorder, their sequence will be compared to their parents or healthy human DNA. If the patient has a cancer caused by DNA mutation, the tumor DNA will be compared to the patients normal DNA.

This extravagantly long process is known as Sanger’s Method and is second nature to the scientists in the lab as a video clip later played exhibited through the types of patients they help and their ongoing research. After the talk were were given a bag of sweets, including jelly beans and strawberry lace to make our own DNA molecule alongside instructions on how to extract our DNA at home! After being dumbfounded by the careful analysis and specific specialties required to test a single patient, never mind an entire family, the talk has left me to truly appreciate how essential these seemingly quiet ‘behind-the-scene’ roles are contributing to daily medical treatment and modern research.

Zika… Why is it so serious?

From different sources I have tried to compile a detailed but concise background on the research and developments of Zika thus far that are more significant or facts that highlight its seriousness.

Origin: 

  • —The Virus was first detected in Uganda in 1947 but previous outbreaks have never been of this scale
  • —The first cases in South America were reported by Brazil in May 2015
  • —It was first detected in the Zika Forest in Uganda in 1947 in a rhesus monkey, and again in 1948 in the mosquito Aedes africanus, which is the forest relative of Aedes aegypti.

Statistics:

 

  • —Brazil is most effected, with approximately 0.5-1.5 million people have been infected in Brazil —people possibly infected which is the largest outbreak ever recorded.
  • A WHO official said Zika could infect 3-4 million people a year in the Americas, which would include both people who develop symptoms and those who don’t.
  • —One hospital in Brazil, had gone from an average of 5 cases of microcephaly a year to 300 in the past 6 months

Transmission:

  • —The Zika virus is mainly transmitted through the bite of an infected Aedes mosquito
  • These mosquitos are aggressive, bite during the day, prefer to bite people and live near people
  • —A mother can pass in to her newborn around the time of birth
  • It is possible that it can be transmitted from a mother to her foetus during pregnancy
  • There has been one report of it being transmitted through a blood transfusion and another through sexual contact
  • —Spreads best near still water for mosquitoes to reproduce and in high density populations

Diagnosis:

  • —Many people don’t have any symptoms
  • —A blood test can confirm these symptoms to be caused by the Zika virus

Symptoms:

  • —fever
  • rash
  • joint pain
  • conjunctivitis.
  • muscle pain
  • headache.
  • The incubation period is not known, but is likely to be a few days to a week.
  • Microcephaly – possible link to babies born with underdeveloped skulls and brains The illness is usually mild with symptoms lasting for several days to a week

  • —Zika virus usually remains in the blood of an infected person for a few days but it can be found longer in some people
  • —Severe disease requiring hospitalization is uncommon
  • Deaths are rare

Current Action:

  • —No current treatment or vaccinations
  • —A vaccine will undergo trails in 2 years however may not be open to the public until another 10 years
  • WHO are taking steps like expanding mosquito spraying programs
  • —Advice in Brazil is to increase family planning and recommend couples to not get pregnant until more information is known. In El Salvador the government has asked to avoid pregnancy until 2018

Why is it so serious?

  • —Zika virus is a flavivirus thus it comes from the same family as the virus which causes yellow fever
  • Microcephaly can lead to neurological underdevelopment and brain damage in babies
  • Most people don’t know they have it as 80% don’t develop symptoms
  • The symptoms are similar to less serious illnesses such as flu

Research Paper – Stem Cells and Infertility

As part of the medlink research project, I have achieved a pass with merit on my topic of Does the Use of Stem Cells to Create Gametes Hold a Viable and Ethical Option for Infertility Treatment in the Future?

All successful papers are published on the medlink website. Here is a link for all the results. Here is the link to my paper.

ABSTRACT

Phenomenal advancements in stem cell research, has potentially discovered a new era for infertility treatment after successful trials in mice produced gametes from adult stem cells. 1 in 7 couples have difficulty conceiving, hence approximately 3.5 million people in the UK [1] attempt to time menstrual cycles, increase their sperm quality and undergo IVF treatment, yet in spite of this 15% of couples remain unsuccessful [2]. Alongside this, there are individuals who are infertile due to transgender surgery, chemotherapy and early menopause, which can cause much grief as IVF treatment isn’t always possible. The prospect of using stem cells to produce gametes has aroused much discussion as its ethics are highly questionable. Thus I propose the debate for the viability of such a ground-breaking medical discovery, morally and scientifically. On balance, the abundance of benefits this treatment could provide for many medical conditions, coupled with a renovated society from eradicating infertility in the future, outweighs all downsides, on the basis that current complications can be resolved.

 

INTRODUCTION

The known battle against infertility is captioned by the popularity of IVF treatment, of which celebrates 25 years of success since the first in vitro conception of Louise Brown, at a clinic based in Cambridge. Worldwide more than a million ‘test-tube’ babies have been born and Professor Alan Trounson, from the Monash Institute of Reproduction and Development in Victoria, Australia, further elucidates that IVF treatment has excelled so significantly that in fact ¾ of all infertile couples can be helped via this method [3]. This does not however hide the reality that some remain impossible to treat, especially those who are unable to produce egg and sperm cells. This has resulted in an increase in the number of people opting for donated gametes (figure 1) as data collected from the Human Ferilisation and Embryology Authority (2012-2013) affirms that in 2013, 10% of all IVF cycles used donated gametes and 4,611 DI cycles (broad term regarding fertility treatment using donor sperm) were also recorded [4]. Thus this displays a great popularity and it has been increasing over the last decade. Although this option is available, it is preferred by most couples to have their own biological children.

fig1
Figure 1: Number of patients receiving treatment with donated gametes,

In light of this, researchers have turned to the use of stem cells derived from the skin, to restore egg and sperm cells. Stem cells are defined as ‘an unspecialised cell characterized by the ability to self-renew by mitosis while in undifferentiated state and the capacity to give rise to various differentiated cell types by cell differentiation.’[5] There are two types of stem cells, adult stem cells, found in adults and have limited differentiation potential hence are termed multipotent, and embryonic stem cells, which are early stage stem cells that can form any tissue in the body and are pluripotent. In order to create germ cells genetically similar to the parent, adult stem cells are extracted from the parent and are reprogrammed to behave like embryonic stem cells. This is achieved by altering the adult stem cells to express high level of genes that control self-renewal and pluripotency, creating induced pluripotent stem cells (iPSC). In 2012, Mitinori Saitou, a stem-cell biologist stationed in Kyoto University in Japan, alongside his collaborators, used iPSCs derived from skin cells to create the first set of artificial gametes genetically similar to its parents, known as primordial germ cells (PGCs). He discovered that placing the PGCs into the testes of mice allowed them to mature to sperm and when placed into the ovaries, they matured into egg cells[6]. Instead of using adult stem cells, embryonic stem cells can be used, by extracting cells from a blastocyst conceived by a couple who are fertile, however the ethics of embryonic stem cells research hinder this option and couples wishing to have biological children cannot do so since the child’s genetics will carry part of the initial blastocyst [7].

fig2
Figure 2: Saitou’s approach to producing germ cells from stem cells

Based upon this awe-inspiring discovery, a research team led by Azim Surani of the University of Cambridge and Jacob Hanna of the Weizmann Institute of Science, are attempting to develop this method for use in humans instead of mice. Together they used male and female iPSCs to create gamete precursor cells (cells that have not yet specialised) with an efficiency of 25-40% [8]. Later they transpired that the PGCs found in humans are different to those in mice, due to a protein known as SOX17 which influences this mechanism in humans where as in mice a different protein known as SOX2 influences the mechanism [9]. Hence much research is still required before its application in humans is viable and it in turn opens the gates to ethical views also.

Undeniably, the possible implications for this new treatment are vast, for instance sex reassignment, chemotherapy induced infertility and postponing menopause. However since this phenomena is presently in its early stages, there are great doubts of whether this treatment, practiced in mice, will work in humans since sometimes the mice born are abnormal. Moreover, if it is possible complications should be kept to a minimum, for instance what are the potential complications of using this treatment on older women? Furthermore if human trials are to take place, considerations such as consent, confidentiality and human rights are greatly important.

 

DISCUSSION

Applications:

Infertility in Men:

Considering the variety people suffering from infertility, stem cell research holds great significance and a clear demand. Statistics and data of male infertility further supports this claim. It is evident that due to our modern lifestyle, problems and potential risk factors will accompany it, some of which may correlate to an overall decrease in fertility. As displayed by a study from Professor Niels Skakkebaek, at the University of Copenhagen, who recorded data of sperm count in semen for over 50 years and deduced that the count had fallen by 50% as well as recording that in the 1940s the normal sperm count per millilitre was above 100 million, however it has fallen to approximately 60 million. If infertility is to continue to drop at this rate, IVF treatment will become increasingly more difficult therefore the appeal for stem cell use will swell. It is said that infertility in males is caused by the mother’s condition whilst pregnant, for instance by obesity or smoking. Smoking whilst pregnant permanently reduces’ the child’s sperm count by up to 40%, whereas a male adult smoking, temporarily reduces the count by 15% only. Since it is very unlikely that our society will deviate greatly from these problems, to create any significant change in these statistics or that future generations will regain high fertility, as the reduced sperm count can be passed down genetically, this treatment has the potential to become very popular. Unfortunately, further studies infer that adult men exposed to low concentrations of chemicals with small oestrogenic properties such as pesticides, traffic fumes, plastics and supposedly soya beans, can experience reduced fertility [9]. Hence suggests that the demand for this treatment may be focused more towards men as they are more susceptible to infertility decline in their lifetime as well as from birth.

Since 1 in 100 men suffer from Azoospermia, the worst case of infertility in men [10] and around 15 to 20% of all young males have the abnormal sperm count of less than 20 million per millilitre of semen [9], the astounding developments by Renee Reijo Pera, a former director of Stanford’s Center for Human Embryonic Stem Cell Research and Education, provides a promising solution. They conducted some research with 3 healthy men, and though one man carried a mutation of his Y chromosome that prevented his body from producing sperm, the other two men were fertile. The iPSCs, converted from the skin cells given by these men, formed germ cells and were placed into the testis of mice but stopped differentiating before they could mature into sperm cells [10]. This is due to an evolutionary block which prevents the human germ cells to undergo spermatogenesis when placed into the testis of another species, unless the germ cells were place into a the testis of a very similar species [11]. Yet the mere idea that the infertile man’s cells could produce germ cells is fascinating and most importantly can be seen in use in the near future. Therefore Pera’s research gives hope for the many men currently infertile and those men in the future who will be part of the inevitable, as well as ever increasing, decline in fertility.

 

Infertility in women:

A prospectus to ‘cure’ infertility in women also seems encouraging due to successful trials in mice where 8 cubs were born via the use of stem cells. This method is rather unique, as the germ cells derived from iPSCs, were allowed to grow with a sliver of ovary cells from the mother and later transferred to the mother’s ovaries themselves to mature. The matured eggs were then removed via the normal IVF treatment method and fertilised in vitro [12].
fig3
Figure 3: mice born from stem cell and IVF treatment

This option has great potential, especially for incidences of early menopause – a topic not spoken about often, despite affecting more than 1 in 20 women in which 6% of all women do not know the cause of it. Early menopause increases the relative risk of heart attacks, strokes and bone disease but above all it is very distressing for a young person to accept due to its spontaneous nature, hence may give no chance to for them to freeze their eggs beforehand. Similar to the infertility in males, early menopause has become more prevalent over the years, as illustrated by data from 1980s where only 1% of women experienced it [13]. From this it can be inferred that the viability of this treatment is very high and since researchers plan to use the skin adult stem cells over the embryonic they used in mice, makes this option very socially acceptable and far less controversial. The main downside is that this treatment will not be available for another decade, since much safety testing and precaution is required with humans over mice during research of this method.

 

Transgender:

In its application for transgender individuals, who don’t have the appropriate gametes for their identified sex, there is tremendous benefit using this treatment as they will be able to connect with their gender completely. Research has already taken off to use this technique to support transgender individuals as displayed by a team led by Jonathan Tilly, a biologist, from the Massachussets General Hospital, who are trying to develop a method to create egg cells from human ovarian stem cells and were successful in mice trials. Now in human trials, the team used reproductive ovarian tissue donated by transgender women undergoing sex reassignment at the Saitama Medical Centre in Japan. They were then able to isolate the reproductive cells and produce immature egg cells, before injecting them into the mice to create follicles, hence producing mature eggs [14]. This is a necessary step for transsexuality, as there are 853 men between 2000 to 2010, who have undergone sex reassignment surgery [15] as well as approximately 1,300 to 2,000 people transitioning from male to female and between 250 to 400 transitioning from female to male in the UK alone, as stated in The Home Office’s ‘Report of the interdepartmental working group on transsexual people’ [16]. Thusly worldwide stem cells could provide so many the joys and fulfilment of having their own biological children and will hopefully create a world open to a flourishing Trans community.

 

Chemotherapy:

The battle against cancer is one that no one can truly relate to or understand how challenging and painful it is to endure, apart from those experiencing it. The diverse number of cancer patients who show perseverance and optimism, during the lowest point of their life, and survive, are people who I respect. Grievously, a side effect of chemotherapy is infertility. This has created a lot of problems, for example between 1999 and 2011, a French study recorded that 34% of chemotherapy treatment cases had been delayed before women were given gonadotoxic agents (drugs affecting the gamete producing gland used in chemotherapy) so that their embryos could be frozen [17]. Therefore though the option to remove gametes and freeze embryos for IVF treatment later is available, there may be detrimental effects if your chemotherapy is urgent and realistically shouldn’t be delayed – stem cells could be the answer to this dilemma.

Furthermore, a survey from the California Cancer Registry asked women about their infertility from chemotherapy and gives results from 1,021 women between the ages of 18 to 40, with 620 reporting that they were treated with only chemotherapy. The data presents a great correlation between age of diagnosis and likelihood of becoming infertile, for example at the age of 20, 18% were infertile with Hodgkin’s disease, whereas 57% were infertile aged only 35. Moreover, the proportions of women reporting acute ovarian failure were 8% for Hodgkin’s disease, 10% for non-Hodgkin’s disease, 9% for breast cancer and 5% for gastrointestinal cancers [18]. These percentages are relatively high and as only 5 main types of cancer were surveyed we can expect significantly more people using stem cells from other cancer therapies and diseases also.

 

IVF demand:

Due to great demands and successes in IVF treatment, stem cell reproductive treatment has the potential to follow on this trend, as demonstrated by its many applications listed above. In a survey conducted by myself, 117 senior school students between the ages of 14 to 18 answered questions on IVF treatment and infertility. 44% claimed that they knew 1 or more women who have either undergone or are currently undergoing IVF treatment (figure 4).

fig4
Figure 4: survey question – Do you know anyone who is undergoing / undergone IVF treatment?

Additionally, 55% reported to know at least 1 or more people born due to successful IVF treatment (figure 5).

fig5
Figure 5: survey question – Do you know of anyone born due to successful IVF treatment?

However there are some limitations, for example some students may know the same people who are IVF babies in the school and the survey was not on a great scale, therefore the results are not a completely reliable representation of the general public. Despite this, considering the small community of people asked, there are a substantial number of people part of IVF treatment and this will be sure to expand after the introduction of stem cells. 2.2% of all babies born in the UK in 2012 were due to successful IVF treatment and overall 221,555 babies from 1991 to 2012 in the UK were IVF babies [19]. Therefore stem cell reproductive treatment is worth investing in researching.

 

Ethics:

Applications for older women:

Adult skin stem cells, unlike embryonic, will always be available to remove in a person’s lifetime, therefore should older women, or women past menopause, be offered this treatment? It is not unknown that more pregnancy complications arise the older the mother however this doesn’t stop many from continuing to try for a child. This is likely to continue and in fact studies in the ages of women applying for IVF since the treatment first started in 1991, has slowly been increasing. Figure 6 shows that IVF treatment has increased by approximately 1 and ½ years of age and DI treatment has increased by 3 years, before the average becomes steady from 2006 onwards. We can deduce from this that the age may increase further after the introduction of stem cells for treatment, since many women post menopause can now have a new artificial supply of eggs.
fig6
Figure 6: Average age of women undergoing IVF and DI treatment using fresh eggs

Likewise, the greatest number of cycles performed per age has slowly increased over time and now peaks at the age of approximately 40 as well as the peak becoming more pronounced, as displayed by figure 7 [19].

fig7
Figure 7: Percentage of cycles started by patients’ age at start of treatment (1997–2013)

Henceforth, as older women are currently able to undergo IVF treatment, it may not be too difficult to provide stem cell treatment also, however if the age continues to steadily increase there will be less chance of a successful treatment. The gametes created from stem cells are very short lived and have a high fatality rate therefore if this is to accompany current data on IVF success at different ages, for example 32% of women under 35 years of age successfully have an IVF child whilst only 5% aged 43 to 44 do and 1.9% aged 45 above are successful, then it will be even less likely that an older women can realistically benefit from the stem cells [20].

 

Research on humans:

When researching and applying stem cell techniques in humans, caution is imperative. It is necessary that the human egg cells are made fully functional and that the follicles formed after maturing are also genuine, however there is still no evidence that the egg will fertilise normally or that there are absolutely no abnormalities after fertilisation. Many researchers claim that it is still a long way off before stem cells can be used in this manor, whether it be via a sliver of ovarian tissue or skin stem cells [21]. Embryonic stem cells continue to produce higher quality egg and sperm cells however the germ line cells created from adult stem cells, although they are less controversial, are not reaching the same degree of potency. In addition, part of the maturing process of a germ cell includes gene regulation, thus it is essential that the gametes are in full function so that this process can occur naturally on its own [22]. If not, there may be complications when the baby is born, as displayed by the genetic problems after Dolly the sheep was cloned and born, such as very short telomeres of her chromosomes resulting in rapid aging of her cells [23]. Only around 10% of the germ line cells created by embryonic stem cells actually survive, thus there is a high fatality rate. With this in mind, researchers and the public have a long time to wait before it is safe and medically viable in the future but with that said, its progression to this point in research has happened very rapidly in the past 5 years or so.

On the other hand, this research has hopes to use adult stem cells only, however recent research and future research will continue to use embryonic stem – a far more controvertible topic. Some argue that human life begins at conception therefore using embryonic stem cells is seen as taking an innocent life, others believe that mistakes are very easy when culturing stem cells in the lab which can cause damage or injury to a person. These are valid arguments, however it may also be argued that using stem cell materials that would otherwise be wasted after a miscarriage or IVF treatment failure, is the lesser of two evils. Furthermore the embryonic stem cells are completely undifferentiated hence cannot hold an identity or life on their own [24]. Overall, embryonic stem cells are not recommended for reproductive treatment as the couple will prefer to have their own biological children rather than divided between different people’s genetics and their own. Researchers are more focused on using adult stem cells and it is also what makes this treatment very distinctive.

 

Consent and confidentiality:

In there being such a diverse range of views on using stem cells for research, it is necessary that consent from the donors is attainted and that they understand how their cells will be used. Especially since people are more emotionally attached and give more moral value to their reproductive cells over other parts of their body. For example, some may be open to research in infertility but object to any research combining animal and human cells to mature germ cells. A method to allow scientists to use donated stem cells without need of consent is by using deidentified biological material which is not associated with a specific donor. For instance, IVF embryos or oocytes that fail to develop in the lab, hence cannot be transferred to the mother, can be deidentified and used. Similarly, frozen embryos that are left over after the couple have completed their treatment and no longer want more children, can either be donated to another couple or deidentified for the researchers. However there are some precautious measures are needed, such as there should be absolutely no leakage of confidentiality and an assumption needs to be held that the donors would not object to the manner in which their materials were used if they were told [25]. In order to see how open people are to stem cell research, I asked in my survey whether the students believed it is ethical to used stem cells for research, 73% believed that it was ethically correct, 1% believed it was not at all and 30% didn’t know (figure 8).

fig8
Figure 8: survey question – Do you believe that the use of stem cells for medical research is ethically correct?

With such a ground-breaking research, the donor’s confidentiality mustn’t be violated, thus any breaches by medical staff, computer hackers or theft of computers and records, should be controlled carefully to ensure identities remain hidden. This can be done by investigating the personnel who will have access to files, password protecting computers and isolating them in a closed room which requires a code or card for entry [25]. In all, if the donated stem cells are treated with respect and donors are made fully aware of the research before consenting alongside keeping their confidentiality, this research should be allowed to develop.

 

CONCLUSION

As elaborated in this paper, the viability of stem cell research to produce artificial gametes in the future holds a special aptitude, as envisioned by its many future uses in medicine. Notably, the millions infertile, whether it be from birth, via sex reassignment, chemotherapy or menopause, there is an unquestionable call for further research fuelled by its demand in patients. We have established that this range of applications is well supported by current research and through the variety of methods, statistics and success in trials, we can prove that this treatment has the potential to prosper. By looking at the exceptional success in IVF treatment we can use this as a concept to predict the popularity of stem cell treatment and hence the number of people who will fulfil their dreams of raising a family.

Drawbacks however are pinpointed towards ethical factors, thus consent and confidentiality of donors must be protected as stem cell experimenting is very controversial. The complications with human trials, from germ cells with a high fatality rate to unregulated genes, makes it unlikely that this treatment will be available soon. Additionally, as these studies are very new, it is difficult to foresee future dilemmas entirely, such as complication of older women using artificial gametes.

Despite all the complications scientists continue to research the future of artificial gametes. Modern science and research could find answers to the obstacles being faced by scientists today, to create a society free of infertility to anticipate for.

 

REFERENCES

1. https://tv.travelrepublic.co.uk/v2/hotels/eac581c4-1d9c-4a53-9ec9-bde1b6ae1bcb/232246?source=TV&dlid=69978598

2. http://www.medicaldaily.com/infertility-treatment-may-soon-include-artificial-sperm-egg-cells-derived-stem-cells-315622

3. http://www.dailymail.co.uk/health/article-189978/Is-end-infertility.html#ixzz3dpehqLDe

4. http://www.hfea.gov.uk/docs/Egg_and_sperm_donation_in_the_UK_2012-2013.pdf

5. http://www.biology-online.org/dictionary/Stem_cell

6. http://www.nature.com/news/rudimentary-egg-and-sperm-cells-made-from-stem-cells-1.16636

7. https://med.stanford.edu/news/all-news/2014/05/stem-cells-from-some-infertile-men-form-germ-cells-when-transplanted-into-mice-study-finds.html

8. http://www.nature.com/news/rudimentary-egg-and-sperm-cells-made-from-stem-cells-1.16636

9. http://www.independent.co.uk/news/science/out-for-the-count-why-levels-of-sperm-in-men-are-falling-1954149.html

10. http://www.independent.co.uk/news/science/new-infertility-treatment-could-grow-sperm-from-skin-cells-9312674.html

11. http://www.explorestemcells.co.uk/turning-stem-cells-into-sperm.html

12. http://www.dailymail.co.uk/health/article-2213103/Hope-infertile-women-scientists-create-eggs-using-stem-cells-use-IVF-produce-healthy-young.html

13. http://www.dailymail.co.uk/health/article-2012021/1-20-women-hit-early-menopause-Doctors-baffled-rising-numbers-40s-affected.html#ixzz3dyt0zzEI

14. http://uscfertility.org/making-human-eggs-stem-cells/

15. http://www.telegraph.co.uk/news/health/news/7613567/Number-of-NHS-sex-change-operations-triples.html

16. file:///C:/Users/sadia/Downloads/transdatapositionpaperfinal_tcm77-180898.pdf

17. https://en.wikipedia.org/wiki/Chemotherapy#Infertility

18. https://www.ucsf.edu/news/2011/08/10501/ucsf-study-shows-greater-impact-chemotherapy-fertility

19. http://www.hfea.gov.uk/docs/HFEA_Fertility_Trends_and_Figures_2013.pdf

20. http://www.hfea.gov.uk/ivf-figures-2006.html#1276

21. http://uscfertility.org/making-human-eggs-stem-cells/

22. http://www.explorestemcells.co.uk/turning-stem-cells-into-sperm.html

23. http://www.newscientist.com/article/dn3393-dolly-the-sheep-dies-young.html

24. http://occupytheory.org/embryonic-stem-cell-research-pros-and-cons-list/

25. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2726839/

 

FIGURES

1. http://www.hfea.gov.uk/docs/Egg_and_sperm_donation_in_the_UK_2012-2013.pdf

2. http://www.nature.com/news/stem-cells-egg-engineers-1.13582

3. http://www.dailymail.co.uk/health/article-2213103/Hope-infertile-women-scientists-create-eggs-using-stem-cells-use-IVF-produce-healthy-young.html

6. http://www.hfea.gov.uk/docs/HFEA_Fertility_Trends_and_Figures_2013.pdf

7. http://www.hfea.gov.uk/docs/HFEA_Fertility_Trends_and_Figures_2013.pdf

12

 

Mistakes and Medical Malpractice

What makes a good doctor? If your life was on the line who would you trust to treat you or a close family member or friend? At the end of the day doctors are human and can make mistakes but the consequences of these mistakes are astronomical in comparison to say a school teacher who can return the following lesson and correct their mistake.

Brian Goldman gave a fantastic ted talk on this and gave a great example of baseball stats. A fantastic base baller will have a batting score of 300 (meaning 3 out of 10 times he will successfully hit the ball), a legendary batter will have a score of 400. But in medicine we don’t expect less that a score of 1,000 (10 out of 10)

What are mistakes?

How is malpractice different to negligence?

  • Negligence is a sub category of malpractice but they key word is intent. Negligence is the lack of action by a medical professional normally without intent, especially not the intent to harm.
  • In order to prove this evidence is prime.

Examples of malpractice – how many can you work out from the pictures?

  • Misdiagnosis
  • Medication e.g. dosage
  • Lack of hygiene e.g. washing hands
  • Incorrect surgery site
  • Over-treating/testing
  • Poor coordinated care
  • Practical skills e.g. failure to do an emergency incubation

What can cause a mistake?

  • A consensus is around the movement to prevent medical errors is that often patients are receiving an unnecessary or excessive medical care
    • May argue that this is due to a lack of precise definitions for specific purposes – those that are responsible for making policy recommendations should say the exact features of what they want to study and say the ethical considerations, including what type of benefit or harm is recognised and who is the judge of this.
    • Excessive technology
      • Good: outweighs other price driving factors e.g. ageing population, increased public demand income growth & raising prices of medicine
      • Over diagnosis – e.g. breast cancer mammography’s over diagnosis was taught to healthcare professionals but the number of tests did not drop greatly – people rather have painful cancer treatment than the cancer itself thus questions reliability and trust of evidence of the treatments themselves
      • Good tests become poormore accurate test can give a poor outcome if the test is used on healthy people. (Sensitivity with disease, specificity without disease) sensitivity and specificity will increase (more people diagnosed) but its commonness will fall e.g. 1 in 2 to 1 in 100, so the likelihood of a positive test that is true decreases cannot guarantee clinical improvements

How to learn from a mistake?

  • Difficulties:
    • Guilt – 2nd victims after patient and family are doctors. Correlation to fear, anxiety, anger & social withdrawal, disturbing memories. (post traumatic stress disorder)
    • Confidence (bad doctor) – failure, worry about prestige, embarrassed to get support
    • Doctor-patients relationship
    • Suicide – difficulty forgiving
    • Healthcare laws – states to increase number of reporting’s & patient safety but nothing for docs.
    • Colleagues don’t address it – Medically Induces Trauma Support (MITSS) non-judgmental & confidential environment some institutions have 2nd hand trauma place but mainly in US.

When to say sorry?

  • 1st April 2015 – change guidance: still doesn’t mention mistake but rather notifiable safety incident occurred + GMC say apologise when ‘something goes wrong’ = apologising for everything including not a mistake e.g. inherent risk of treatment or procedure so apologising for medicine being an imperfect art – ‘I’m not going to apologies, I didn’t make a mistake
  • How soon to apologise? ASAP 10 working days – but questions whether both the patient & doctor are ready
  • Who to apologise to? To patient or ‘relevant person’ – no obligation to tell relatives unless patient has died. GMC say to have a supporter there.
  • What if it isn’t clear? No excuse to procrastinate. GMC says ‘all you know and believe to be true about what went wrong and why, and what the consequences are likely to be’ = patient doesn’t want to know details, take the burden off them and apologise. But royal college of psychiatrists says ‘giving incorrect info will potentially cause further harm and reduce rather than build trust’. GMC doesn’t address angry patients

What is doing the right thing?

  • Moral courage – act on the conviction that something is morally right even though you believe that something of personal value may be lost e.g. breaking bad news or paralysation
  • Duty of Candour: under England’s new duty of candour service NHS have to notify an incident of patient safety.

Reasons to be a doctor

I can’t pinpoint the exact time that I chose to be a doctor, or the moment/personal experience that sparked me, but rather it was something that I gradually focused a lot of my attention towards. I specifically remember in Year 6 wanting to be a ‘scientist’/’inventor’ – medicine is certainly a sub-sector of that considering that research studies and medical advancements. So to sort of clarify to myself how I got to where I am now, I have put my reasons into 2 general lists. I am open to other reasons, so feel free to write what inspired you to become a doctor in the comments!! It’s nice to get other points of views. I hope this helps some of you but above all your personal experiences whilst volunteering, work experience and growing-up will be the best answers you can give in an interview. If you are being genuine then you can’t be criticised!

Inspiration growing up:

  • Watching medical documentaries and articles
  • very large scope of specialities
  • wide career opportunities – researching, travelling, science institutes, lecturer, surgeon, GP, etc…
  • leadership and teamwork
  • Working alongside other great professions e.g. nurses, midwives, medical physicists, pharmacists, etc…
  • challenging and stimulating – requires problem solving and constantly ameliorating post-graduation
  • fascination in science and how the body functions, why it doesn’t, how its cured, how its made

Inspiration whilst on work experience/volunteering:

  • Working with and being part of families
  • Reward of treating a patient (even when they thought they wouldn’t be able to live) – improving quality of life
  • Explaining medicine to people/close gaps between medicine and the public
  • Part of community
  • Teaching students
  • 2 days are never the same
  • Applying your knowledge to benefit others
  • meeting people of different walks of life e.g. criminals

Being Mortal by Atul Gawande Book Review

Being Mortal by Atul Gawande

This book includes insights from a doctor on his experiences with death and his journey to understanding the emotional influences, ethical considerations and empathy in regards to families and patients experiencing terminal illnesses and ageing. This book truly hits the realities of death, however morbid it is. He states that despite being a general surgeon and frequently giving bad news to patients, he is in fact still learning the arts of palliative care.

I found this book enlightening. Whilst on work experience I feel that a mere week in a hospital department doesn’t fully represent the doctor-patient relationships that are formed over months and all the social factors that contribute to it. The majority of doctors I have shadowed have been overly keen to show me what they love about their jobs, what facilities they have, explaining illnesses and treatments in their field, etc… (probably because they don’t want to hurt my aspirations to become a doctor) However there were a few exceptions where I saw the difficulties of delivering bad news, social factors such as drugs and emergency hospice service to patients dying in the next 24 hours.

It was only upon reflection after reading ‘Being Mortal’ that I began to understand some of the difficult and heartbreaking cases I have seen. For instance, whilst on cardiology work experience, I listened to a family speak about the implications of a pacemaker on the life span of their mother (who was also suffering from Alzheimer’s alongside heart failure). They took a breath of relief when the consultant stated that it wouldn’t affect her life span. The doctor later told me that the family were concerned as they didn’t want their mother to live a life of long-term suffering. Atul Gawande broaches the topic of choosing between length of life and quality of life, as well as the difficulties of finding a suitable middle ground.

There are many ethics and realities Gawande addresses, but here are a few that I want to highlight:

  • Losing independence: as illness being stripping away the life that you have built and have grown close to so much, depression begins to take its toll. Starting small by not being able to make yourself a cup of tea, you brush it off thinking. This continues as other parts of your life begin to break down like your hand grip or your walking. To desperately keep hold of what you have always had and known, you keep ignoring it until something drastic happens… like a fall. The options social care can do for you such as care homes, despite their variety, they all have their down sides and nothing quite meets what you used to have. This is time when sacrifice of happiness couldn’t be more difficult.
  • Courage: Courage to both accept the inevitability of mortality and the courage to act on the truth that we find.
  • building a health system built upon what people want to achieve in their life rather than quality of treatments to build a more technological and modern health system: This is founded upon the difficulties people have working out when to allow nature to take control and to stop fighting. Instead thinking about how they want to spend the little time they have left. With new clinical trials of drugs and the huge variety of treatments, when a terminal illness looms over you it is difficult to not step away from another opportunity to live longer and push away that small hope – no matter the financial barrier, side effects or poor outcomes in statistics.

In all I would highly recommend this book (though it does require a certain emotional stamina – for me anyways). Those of you knowing that a career in medicine is for you this book adds to the crucial understanding that doctors are not always life-savers or there to be life-lengthening resources but rather they are there to support the fulfillments and aims people want from life.

General Radiology Day 2

After my very informative first day, I was stationed in the second radiology department at Wythenshawe Hospital responsible for patients referred from their GPs, inpatients or from other outpatient departments, rather than emergency patients. My timetable set me on a rotation to a different sub-specialty every hour, which left me exhausted by the end but kept me very busy and interested.

Chest X-ray:

Wythenshawe hospital is a chest specialist hospital therefore they have an entire room dedicated to chest x-rays which allows for quick digital imaging of patients. Due to its swift nature I saw patients of a variety of ages and fitness. The x-ray machine was on the wall and the patient is instructed to lean their chin on a rest which in turn places their chest on the centre of the x-ray board. This is done stood up and if the patient had limited mobility (e.g. over weight or old) they would hold the handles behind the board, which positions them in such a way that the shoulder blades move to the side exposing the lungs well. Younger and more flexible patients would place the back of their hands on the back of their hips which has the same effect.

The x-ray image is taken at full inspiration, which allows the contents of the lungs (e.g. scarred tissue, infections or lesions) to be better noticed against the black background of air. I asked the radiographer what difficulties arise when a disabled patient, in a wheelchair, cannot stand for the scan, she replied saying that though it is not greatly helpful, the scan is done whilst they are in their chair by moving the x-ray board down, however the chair does appear on the scan itself. The nurses were very good at small talk with the patients and relaxing the environment. With very few follow-up patients, some are nervous since it may be the foundation of their diagnosis. hence I saw the necessity of creating rapports with patients despite each appointment not lasting 5 minutes. The nurse did mention that seeing the follow-up patients improve was fascinating, for instance a 50 year old man we saw who had undergone a lung transplant, went from hardly being able to stand on the x-ray machine to his final scan to being very active and talkative. Unfortunately the nurse also mentioned that in her career she has seen a huge increase in the number of patients referred for chest scans due to risks associated with drug and alcohol abuse, especially in younger people.

General Radiology: 

Here referrals would include x-rays of various part of the body and unlike the chest x-ray machine, the images would not appear instantly on the screen, instead they have to be downloaded from a x-ray board which is placed under the appropriate body part requiring a scan. As I was speaking to the radiographer she mentioned that due to the dosage of x-rays given to the patient, the reasons for referral always have to be well justified (known as diagnostic consent) hence as part of her job it is not uncommon for her to deny requests despite complaints from doctors. There is no set dose of x-rays a person may have since it is always given on demand for instance onset from an RTC, however with younger patients a MR scan is always preferred despite it costing £500 per scan due to the exposure of x-rays.

The first patient we saw was an inpatient in bed who required a scan of his chest and foot. Two scans of the foot (one on its side and one from above) are needed to clearly see all bones, however since this patient was in extreme pain, with a cast on his foot and laid down, to position his food appropriately was difficult and consequently left the patient in pain (and later given paracetamol on his ward). Other general scans were of hands, abdomen and hips. Spine was particularly difficult since the board is placed under the bed hence it is moved often to be parallel to the mid-line of the abdomen. This also has to be done on the patients side.

It was interesting to see the range of machines, doses and boards which were chosen by the team for each scan type and patient. Moreover many of the patients were old, or with very fragile and tender body parts requiring to be scanned, hence the radiographers knew their anatomy well and were very careful in positioning the patients to not cause them too much pain alongside not damaging the patients fragile bones or tissue. Unsurprisingly during the summer the department is significantly less busy since many of the consultants are on holiday however normally the department is overflowing with so many patients that there are queues leading out of the radiology reception door – certainly the radiographers need to be able to work quickly as well as sufficiently.

Fluoroscopy: 

Here patients with pain in their hips due to many factors for instance wear and tear, are given a steroid injection guided by an x-ray machine. I saw no young patients, though apparently it is not unheard of either at the department. The procedure was lead by a consultant who was teaching a registrar practicing for the first time therefore I was able to learn the steps in the process. The patient is laid down on a flat table with a x-ray machine positioned above the hips on the appropriate side of the arthritis. A long needle is pierced steeply and quickly into the hip joint to cause as little pain to the patient and the consultant was well experienced without having to feel the hip too much with his hands beforehand ( good skill particularly if the patient is overweight) hence upon x-raying the needle it was always in the joint. A contrast is put through the needle first and x-rayed (appears black) to ensure that the fluid will enter exactly into the joint itself.

 

Nuclear Medicine:

Moving swiftly on, nuclear medicine is the use of isotopes injected into the body to create images from the radiation emitted and recorded by a machine. There are many uses of this for instance myocardial infusio, however since it is a very long scan (as the radiation is released slowly and pictures are taken in slides) I only saw 1 scan of the parathyroid glands which were supposedly overactive. Funnily enough, partway through this long scan where the patient had to remain still for up to half an hour, the fire alarm went off in our department, however the neighbouring departments did not have an intermittent alarm and no fire could be found thus suggests smoke. This didn’t last so the patient remained on the scan.


Additionally, scans of the bones are also conducted of which the radiographer found some examples to show me.

In the diagnosis for the bone scan was to check for the spread of bone cancer. She explained that the main isotope used is technetium since it has a good half life of 6 hours and this is enough time to allow all the scanning to be completed.

CT scan:

Since the hospital is the main lung hospital for the north west, they have many facilities dedicated to cystic fibrosis, lung cancer and other lung related diseases.

 cystic fibrosis

cancer

emphysema

Hence many of the CT scans taking place were of the lungs. One patient who was in particularly bad pain, could not lie down flat on her side, therefore despite it not being ideal, she was put to lie down on her side. They are told to lie down on their back with their arms above their head.

Emergency Radiology Day 1

On Monday of this week I arrived back home from my holiday to the middle east but due to time restraints I had to book my work experience on the same week in order to get all my plans for this summer completed. Though this meant I have been very jet lagged for the past couple of days, it does not take away from the amazing experience I have had at the Radiology Departments, both outpatients and emergency, at Wythenshawe Hospital!

DAY 1: Head and Neck Clinic at Wythenshawe Hospital is next to A&E for emergency referrals. In the morning I saw ultrasounds of the neck and mouth alongside small procedures of ultrasound guided biopsies. The first patient was a women with supposed stones in a duct in her neck, however as identified by the scan, the thyroid gland and the duct were both of the same size. Normally if there was a blockage one of the glands would swell. Hence despite of complaints of swelling around her neck, the radiologist concluded that it was probably referred pain from elsewhere. In order to better understand the common problems faced in the thyroid, the consultant explained to me the function of the parathyroid gland and some of its malfunctions – it controls the calcium levels in the body and has a negative feedback mechanism, resulting in no calcium being detectable in the blood. However if calcium Is detected this suggests that the parathyroid gland is hyper active. A patient came in after blood tests presented calcium in her blood despite having her parathyroid glands surgically removed earlier this year. However she had no evidence of the glands therefore she was referred for a nuclear medicine scan which can better pick up the parathyroid glands.

So short into my stay at radiology and I was already astounded by the great range of data the radiologists, radiographers and specialist nurses work with on a daily basis. They know their anatomy exceptionally well in order to be able to identify the different body parts on multiples scanners. As a simple example they need to know in a heartbeat the normal and diseased appearance of a parathyroid gland under an ultrasound, MR, CT and nuclear medicine scan, which will all appear differently. Whilst also understanding that the glands do not appear on a normal x-ray scan. This level of perception and analytical skill to diagnose illnesses is admirable.

Those with a parathyroid gland containing supposed stones (calcification) in their duct present a dilated duct and swollen, rough-surfaced gland when using an ultrasound. This was the case with the following patient, a middle-aged man with a swollen neck. The ultrasound presented no stones but his duct was full of sludge. The patient had had surgery to remove stones in the kidney however it is very unlikely that it was from the same cause. The patient claimed that when his neck would swell from eating he would massage the area but in doing so he once found grit in his mouth therefore the radiologist concluded that he has probably removed his stone on his own hence ended his consultation. This indicated to me the importance of communicating well with the patient to allow them to confide in you. A simple question of ‘how have you been doing recently?’ will instantly create a more friendly and comfortable relationship which in turn could lead to information that makes clearer the patient’s situation for example home life and symptoms.

Moreover nodules found on the thyroid gland cannot be identified as cancerous or benign until a biopsy has taken place. This is most commonly found in women and the chemical tested for is colloid which only presents itself in benign nodules. The procedure was guided by the ultrasound and is taken by a very fine needle. Generally speaking however cancer of the thyroid is very uncommon. In all I thoroughly enjoyed my first day at radiology and anticipated the remaining week. The following day (hence in my next post) I visited the general department of radiology and as wythenshawe is a chest specialist hospital, I will speak about my visit to the chest X-ray rooms alongside the other departments of CT, Nuclear Medicine, fluoroscopy and general scans.

Work Experience in Qatar – Accident & Emergency Day 2

For my final day in Hamad General Hospital I was in the female see and treat emergency department. During the Ramadan opening times for the hospital, I was in the evening shift and it wasn’t particularly busy until around 10 pm. Since it is a see and treat department the cases here are not severe at all and it does not take long at all before the patient is discharged. Whilst waiting for the first few patients I was speaking to some different consultants about the similarities and differences between Qatari hospitals and British hospitals:

Similarities:

  • Free public healthcare system
  • Very facilitated
  • Modern healthcare

Differences:

  • All departments are separated into female and male departments
  • Hamad General Hospital is very large thus there is no shortages of beds
  • Lots of security and CCTV in and around the hospital
  • The public hospitals are very much computerized. The emergency department however still do paperwork but in approximately 6 months time there will be more computers installed.
  • Biggest issue and largest difference is the huge shortage of staff (currently in UK there is an issue of shortages of GPs however). The majority of the staff have to have studied abroad since there is only 1 medical school in Qatar and it was established in 2004. Hence Qatar have not yet educated many specialists thus rely on professionals form abroad. This has resulted in shortages in staff.

The hospital is constantly reviewing its statistics and takes action appropriately, graphing its achievements against their initial targets per ward. Whilst in emergency I noticed this document on the notice board and read that they report on certain indicators:

  • international patient safety goal (IPSG)
  • length of stay
  • reporting cases of suspected abuse & neglect to social worker
  • discharged against medical advise
  • fall with or without injury

IMG_4992

The use of these indicators can be seen applied to blood sampling as presented in the graph above which illustrates new methods developed in the hospital, such as a new method to collect data per area for more accuracy, increased staff in the emergency department and introduced better labels for blood samples.

IMG_4993IMG_4994 IMG_4995 IMG_4996 IMG_4998

The emergency department has kept very well to hours of emergency patients in hospitals though a slight decrease but they have provided more solutions and targets, for instance daily bed manager, a new area of the department opened and increased staff.

IMG_4999

Alongside the many statistics presented above, studies of common injuries in the hospital were documented and below shows an example of Ankle Sprain Cases and development on how to diagnose it and treat it to be more cost effective and time effective, for example cutting down on the number of patient requiring an x-ray of their ankle by developing a new physical test for a specific injury.

IMG_5001 IMG_5002 IMG_5003

 

To conclude my experience in Qatar, it was the epitome  of awesome! I saw such a variety of departments and truly learnt the differences between the healthcare system in Doha to England as well as realizing that each system could benefit greatly by their unique methods.