Delays in Multiple Sclerosis diagnosis (DIMES): protocol for a multicentre, observational study of multiple sclerosis diagnostic pathways in the United Kingdom and Republic of Ireland.

BACKGROUND: Multiple sclerosis (MS) is a leading cause of non-traumatic disability in young adults. Accumulating evidence indicates early diagnosis and early treatment improves long-term outcomes. However, the MS diagnostic pathway is increasingly complex, and delays may occur at several stages. Factors causing delays remain understudied. We aim to quantify the time taken for MS to be diagnosed, and characterise the diagnostic pathway and initial care provided, in the United Kingdom (UK) and Republic of Ireland (ROI). METHODS: Delays In MultiplE Sclerosis diagnosis (DIMES) in the UK and ROI is a multicentre, observational, retrospective study that will be conducted via the Neurology and Neurosurgery Interest Group (NANSIG) collaborative network. Any hospital in the UK and ROI providing an MS diagnostic service is eligible to participate. Data on consecutive individuals newly diagnosed with MS between 1st July 2022 and 31st December 2022 will be collected. The primary outcomes are 1) time from symptoms/signs prompting referral to neurology, to MS diagnosis; and 2) time from referral to neurology for suspected MS, to MS diagnosis. Secondary outcomes include: MS symptoms, referring specialties, investigations performed, neurology appointments, functional status, use of disease modifying treatments, and support at diagnosis including physical activity, and follow up. Demographic characteristics of people newly diagnosed with MS will be summarised, adherence to quality standards summarised as percentages, and time-to-event variables presented with survival curves. Multivariable models will be used to investigate the association of demographic and clinical factors with time to MS diagnosis, as defined in our primary outcomes. DISCUSSION: DIMES aims to be the largest multicentre study of the MS diagnostic pathway in the UK and ROI. The proposed data collection provides insights that cannot be provided from contemporary registries, and the findings will inform approaches to MS services nationally in the future.

Cross-sectional Survey of Medical student perceptions of And desires for Research and Training pathways (SMART): an analysis of prospective cohort study of UK medical students.

OBJECTIVE: Clinician-scientists are critical to medical innovation and research. However, the number of clinician scientists in the UK has been declining steadily over the last decade. One of the cited reasons is poor student recruitment to academic training pathways. The SMART study aims to assess current student perceptions on research and identify key factors influencing whether a student is interested in research. DESIGN: We conducted a cross-sectional survey study between January and May 2022. SETTING: This was a multi-centre national study with data collected across 40 universities offering medical courses in the UK. PARTICIPANTS: Participants were UK medical students enrolled in medicine for 21/22 academic year. MAIN OUTCOME AND MEASURE: The main outcomes were related to participant perceptions on research and whether they were interested in engaging with research in their future career. These measures were correlated with demographic and non-demographic details using regression analyses. RESULTS: One thousand seven hundred seventy-four individuals participated in the SMART survey from 40 medical schools. Nearly half the participants felt there were barriers preventing them from doing research (46.67%) and almost three-quarters felt it was at least somewhat difficult to combine research with medical school (73.49%). Of the options available, most commonly students did not want to pursue an academic career (43.11%) or training pathway (42.49%). However, most participants felt it was useful to do research at medical school (59.54%) and were also interested in doing more research in the future (69.16%). Regression analysis identified many factors influencing student's perceptions of research including year of study, gender, socioeconomic status, family background, research exposure at medical school, ethnicity, and country of pre-university education. CONCLUSIONS: The SMART study is the first of its kind in the UK, shedding light on medical student perceptions. While some express strong interest in academic careers, a larger proportion show a broader interest in research. Demographic factors like gender, parental occupation, and socioeconomic status play a role. Further exploration is needed for specific groups to address barriers, promote research, and boost academic pathway recruitment.

Interleukin-6 as a prognostic biomarker of clinical outcomes after traumatic brain injury: a systematic review.

Traumatic brain injury (TBI) is a major cause of mortality and morbidity worldwide. There are currently no early biomarkers for prognosis in routine clinical use. Interleukin-6 (IL-6) is a potential biomarker in the context of the established role of neuroinflammation in TBI recovery. Therefore, a systematic review of the literature was performed to assess and summarise the evidence for IL-6 secretion representing a useful biomarker for clinical outcomes. A multi-database literature search between January 1946 and July 2021 was performed. Studies were included if they reported adult TBI patients with IL-6 concentration in serum, cerebrospinal fluid (CSF) and/or brain parenchyma analysed with respect to functional outcome and/or mortality. A synthesis without meta-analysis is reported. Fifteen studies were included, reporting 699 patients. Most patients were male (71.7%), and the pooled mean age was 40.8 years; 78.1% sustained severe TBI. Eleven studies reported IL-6 levels in serum, six in CSF and one in the parenchyma. Five studies on serum demonstrated higher IL-6 concentrations were associated with poorer outcomes, and five showed no signification association. In CSF studies, one found higher IL-6 levels were associated with poorer outcomes, one found them to predict better outcomes and three found no association. Greater parenchymal IL-6 was associated with better outcomes. Despite some inconsistency in findings, it appears that exaggerated IL-6 secretion predicts poor outcomes after TBI. Future efforts require standardisation of IL-6 measurement practices as well as assessment of the importance of IL-6 concentration dynamics with respect to clinical outcomes, ideally within large prospective studies. Prospero registration number: CRD42021271200.

Motivations of medical students and doctors leaving the NHS explored in a residency training application webinar series.

BACKGROUND: Recent reports show that about 10% of UK-graduate doctors leave the country to pursue specialty training elsewhere. Our article aims to evaluate the motivating factors for UK graduates to leave the National Health Service (NHS), especially during the COVID-19 pandemic and Brexit. STUDY DESIGN: Cross-sectional study. METHOD: A novel 22-item questionnaire was disseminated at a webinar series regarding the application process to pursue residency training in six different countries/regions from 2 August 2020 to 13 September 2020. The data was analysed using Kruskal-Wallis rank-sum with post-hoc Wilcoxon test to compare the difference in significance among the motivating factors. RESULTS: 1118 responses from the UK medical students and doctors were collected; of which, 1001 (89.5%) were medical students, and 88 (7.9%) were junior doctors. There was a higher propensity for leaving after the Foundation Programme compared with other periods (p<0.0001 for all comparisons). There was no difference between desire for leaving after core surgical/medical training and specialty training (p=0.549). However, both were significantly higher than leaving the NHS after medical school (p<0.0001). Quality of life and financial prospects (both p<0.0001) were the most agreed reasons to leave the NHS, followed by clinical and academic opportunities and, subsequently, family reasons. CONCLUSION: Future work on the quality of life for doctors in the UK should be explored, especially among those considering leaving the NHS. Policymakers should focus on assessing the difference in working hours, on-call hours and wages that may differ among healthcare systems.

The Neurology and Neurosurgery Interest Group (NANSIG)-ten years of cultivating interest in clinical neurosciences.

Collaboration and successful teamworking are important components of clinical practise, and these skills should be cultivated early in medical school. The breadth of current medical school curricula means that students often have limited exposure to clinical neurosciences. Since its inception in 2009, the Neurology and Neurosurgery Interest Group (NANSIG) has become a national (UK and Republic of Ireland) example of student and junior doctor synergistic collaboration to deliver educational materials, research, conferences, seminars and workshops, as well as advocating for diversity in this field. Recently, it has expanded to incorporate an international audience and cater for a larger group of young medical professionals. The organisation has overcome numerous challenges and is constantly innovating new approaches to harness the necessary knowledge, skills and network to succeed in a career in neurosciences, neurology and neurosurgery. This article summarises the initiatives undertaken by the group over its first 10 years of existence and its organisational structure, as well as its future plans.

National audit of pathways in epileptic seizure referrals (NAPIER): A national, multicentre audit of first seizure clinics throughout the UK and Ireland.

BACKGROUND: Current guidelines set clinical standards for the management of suspected first seizures and epilepsy. We aimed to assess if these standards are being met across first seizure clinics nationally, to describe variations in care and identify opportunities for service delivery improvement. METHODS: Multicentre audit assessing the care of adults (≥16 years) referred to first seizure clinics from 31st December 2019 going backwards (30 consecutive patients per centre). Patients with pre-existing diagnosis of epilepsy were excluded. Anonymised referral, clinic, and follow-up data are reported with descriptive statistics. RESULTS: Data provided for 727 patients from 25 hospitals in the UK and Ireland (median age 41 years [IQR 26-59], 52% males). Median time to review was 48 days (IQR 26-86), with 13.8% (IQR 3.3%-24.0%) of patients assessed within 2 weeks. Seizure recurrence was seen in 12.7% (IQR 6.6%-17.4%) of patients awaiting first appointment. Documentation for witness accounts and driving advice was evident in 85.0% (IQR 74.0%-100%) and 79.7% (IQR 71.2%-96.4%) of first seizure/epilepsy patients, respectively. At first appointment, discussion of sudden unexpected death in epilepsy was documented in 30.1% (IQR 0%-42.5%) of patients diagnosed with epilepsy. In epilepsy patients, median time to MRI neuroimaging was 37 days [IQR 22-56] and EEG was 30 days [IQR 19-47]. 30.4% ([IQR 0%-59.5%]) of epilepsy patients were referred to epilepsy nurse specialists. CONCLUSIONS: There is variability nationally in the documented care of patients referred to first seizure clinics. Many patients are facing delays to assessment with epilepsy specialists with likely subsequent impact on further management.

Value of a UK medical degree for international students (VISION): a cross-sectional study.

OBJECTIVES: It is estimated that NHS staff consist of over 200 different nationalities, with a reported 30.7% of doctors holding a nationality other than British. Despite this, international medical students represent 7.5% of all medical students studying in the UK and pay on average, 4-6 times more in tuition fees when compared with the £9250 per annum (Great British Pounds (£) in 2021) paid by home students. This study's aim and objective are to evaluate the perception of the financial cost and value of the UK medical degree for international students and their motivations for pursuing such a degree. METHODS: This is a cross-sectional observational study enquiring about international premedical, medical and medical school graduates' perception of the value of the UK medical degree and factors influencing their decision to study in the UK.A questionnaire was developed and distributed to 24 medical schools and 64 secondary schools both internationally and across the UK. RESULTS: A total of 352 responses from 56 nationalities were recorded. 96% of international students identified clinical and academic opportunities as the most important factors to study medicine in the UK, closely followed by quality of life (88%). The least important factor was family reasons, with 39% of individuals identifying this factor. Only 4.82% of graduates in our study considered leaving the UK after training. Overall, 54% of students felt the UK degree was value for money. This belief was significantly higher in premedical students compared with existing students and graduates (71% vs 52% and 20%, p<0.001 for all comparisons). CONCLUSION: The quality of medical education and international prestige are attractive factors for international students to study medicine in the UK. However, further work is needed to ascertain reasons for the differing perceptions of the value by international students at different stages in their clinical training.

Current state of management and outcomes of facial nerve palsy in low-income and middle-income countries: a scoping review protocol.

INTRODUCTION: The aim of the protocol is to present the methodology of a scoping review that aims to synthesise up-to-date evidence on the management and outcomes of facial nerve palsy in low-income and middle-income countries (LMICs). METHODS AND ANALYSIS: The scoping review will be conducted per the Arksey and O'Malley's framework and the Joanna Briggs Institute Reviewers' Manual. The scoping review question, eligibility criteria and search strategy will be developed in accordance to the Population, Concept, and Context strategy. The search will be conducted in electronic bibliographic databases (Medline (OVID), Embase, WHO Global Index Medicus, Cochrane Library, Global Health, African Journals Online). The review will synthesise and report the findings with descriptive statistics and a narrative description of both quantitative and qualitative evidence. ETHICS AND DISSEMINATION: This scoping review does not require ethical approval. This protocol will describe the proposed scoping review that will map the evidence on the management and outcomes of facial nerve palsies in LMICs. The proposed review aims to collate and summarise published literature to inform policy-makers and healthcare organisations and governments and to identify knowledge gaps that will translate into future research priorities in LMICs.

Management and outcomes of intracranial fungal infections in children and adults in Africa: a scoping review protocol.

INTRODUCTION: The protocol presents the methodology of a scoping review that aims to synthesise contemporary evidence on the management and outcomes of intracranial fungal infections in Africa. METHODS AND ANALYSIS: The scoping review will be conducted in accordance with the Arksey and O'Malley's framework. The research question, inclusion and exclusion criteria and search strategy were developed based on the Population, Intervention, Comparator, Outcome framework. A search will be conducted in electronic bibliographic databases (Medline (OVID), Embase, African Journals Online, Cochrane Library and African Index Medicus). No restrictions on language or date of publication will be made. Quantitative and qualitative data extracted from included articles will be presented through descriptive statistics and a narrative description. ETHICS AND DISSEMINATION: This study protocol does not require ethical approval. Findings will be reported in a peer-reviewed medical journal and presented at local, regional, national and international conferences.

Towards Levelling the Playing Field for Prospective Overseas Applicants to Medical Schools in the United Kingdom.

Many factors are taken into consideration when students apply to pursue medicine in the United Kingdom. For overseas applicants, the tuition fees of the medical course are a significant factor, particularly for those from lower socioeconomic backgrounds. The reasons why the fees in some medical schools are significantly higher than in others are unclear. Transparency on the use of the tuition fees as well as providing overseas medical students, which now include European students post-Brexit, with more financial support in their studies would be imperative. This is to ensure students are able to choose their medical schools based on more important factors such as the student-curriculum fit.

Addressing the Quality of Hospital Care of Colorectal Cancer Patients Undergoing Surgery: What Can We Learn From the National Bowel Cancer Audit?

Introduction The National Bowel Cancer Audit (NBOCA) is the largest database in the United Kingdom that audits real-world data and allows comparison of the quality of care for colorectal cancer patients. This study aimed to highlight relevant clinical factors in the NBOCA that contribute to variation in the quality of care provided in different hospitals. Methods Data from 36,116 patients with colorectal cancer who had undergone surgery were obtained from the NBOCA. These were patients from 145 and 146 hospitals from the years 2016 and 2017, respectively. A validated multiple linear regression was performed to compare the identified clinical factors with various quality outcomes. The quality outcomes defined in this study were the length of hospital stay of more than five days, two-year mortality, 30-day unplanned readmission rate, 90-day mortality, and 18-month stoma rate. Results Four clinical factors (laparoscopy rate, abdominal-perineal-resection-of-rectum, pre-operative radiotherapy, and patients with distant metastases) were shown to have a significant (p < 0.05) impact on the length of hospital stay of more than five days and the 18-month stoma rate. The 18-month stoma rate was also a significant predictor (p < 0.001) with two-year mortality. Conclusion The NBOCA should consider adjusting for these factors when reporting the quality of care provided in hospitals. Hospitals should monitor the four clinical factors for colorectal cancer patients during perioperative care. When formulating a management plan for patients with colorectal cancer, clinicians should consider these factors along with the individual patient's history.

Are UK medical schools using recommended national curricula for the teaching of clinical neuroscience?

BACKGROUND: Medical schools are responsible for training medical students to recognise and commence management for a broad spectrum of diseases, including clinical neuroscience conditions. To guide medical schools on topics that should be taught, speciality bodies have produced speciality-based core curricula. It is unknown to what extent these guidelines are used in designing each medical school's curriculum. This survey aimed at assessing the use of these guidelines in designing clinical neuroscience curricula. METHODS: This is a national survey. A 21-item questionnaire was sent to faculty members involved in the development of the clinical neuroscience curriculum in each medical school in the UK. Data collection occurred from1st September 2020-31 st August 2021. The Association of British Neurologists (ABN) and the Royal College of Surgeons England (RCSEng) guidelines were used as a benchmark. Descriptive statistics are reported. RESULTS: Data was collected from 91.9% of eligible UK medical schools. 61.8% respondents were aware of ABN guidelines and 35.3% were aware of RCSEng guidelines. 17/28 (60.7%) topics recommended by the guidelines were taught in the neuroscience curricula of over 90% of the medical schools. Neurologists were involved in the design of the clinical neuroscience curriculum in 94.1% (n = 32/34) of medical schools, and neurosurgeons in 61.8%. Tutorials/seminars were used by all medical schools to teach clinical neuroscience content. Neurologists were involved in teaching at all schools and neurosurgeons in 70.6%. Objective Structured Clinical Examination (OSCE)/oral examinations and single best answer (SBA)/multiple-choice question (MCQ) tests were used in all medical schools as methods of assessment. CONCLUSIONS: There is variation between medical schools on what clinical neuroscience topics are taught and by whom. Multi-modality educational delivery was evident. Some medical schools did not currently use, advertise, or recommend external clinical neuroscience educational resources; but there was support for future use of external resources including guidelines.

Social and psychological impact of the COVID-19 pandemic on UK medical and nursing students: protocol for a national medical and nursing student survey.

INTRODUCTION: Healthcare students have played a significant role in the National Health Service during the COVID-19 pandemic. We captured data on the well-being of medical students during the acute phase of the pandemic with the Social and Psychological Impact of COVID-19 on medical students: a national survey Evaluation (SPICE-19) study. We will evaluate changes in mental health and well-being of medical and nursing students 1 year after SPICE-19, in a cross-sectional study, to understand the impact of the pandemic, and inform well-being policies. METHODS AND ANALYSIS: This study will be a national, multi-institution, cross-discipline study. An online 53-item survey of demographics, mental health and well-being will be used to record responses. Students studying for a medical or nursing degree at any UK universities will be eligible to participate. The survey will be advertised through the Neurology and Neurosurgery Interest Group national network. Participation is anonymous and voluntary, with relevant mental health resources made available to participants. ETHICS AND DISSEMINATION: Ethical approval was granted by the University of Oxford Central University Research Ethics Committee (R75719/RE001) on 21 May 2021. Study findings will be presented at national and international meetings, and submitted for publication in a peer-reviewed journal.

Management and Outcomes of Traumatic Pediatric Spinal Cord Injuries in Low- and Middle-Income Countries: A Scoping Review.

BACKGROUND: Traumatic spinal cord injury (TSCI) is a subset of neurotrauma, which is a significant contributor to global trauma mortality and morbidity in children. The management and outcomes of pediatric TSCI in low- and middle-income countries (LMICs) is unknown. We conducted a scoping review to characterize the methods of management and outcomes of TSCI in LMICs. METHODS: MEDLINE, Embase, and Global Index Medicus were searched from database inception to February 15, 2021. Studies reporting management or outcomes of pediatric TSCI in LMICs were included. Pooled statistics were calculated using measures of central tendency and spread. RESULTS: A total of 1171 studies were identified, of which 5 were included. A total of 212 patients were included in our review with age of participants ranging from 2.5 to 18 years (mean, 15.4 years). Most patients were male (n = 162; 76.4%). The commonest cited cause of injury were falls (n = 104/212; 49.1%). The most common level of injury was cervical (n = 83; 39.2%). Most patients underwent surgery (n = 134/212; 63.2%). The extent of injury was quantified and classified using the American Spinal Injury Association chart in only 1 study. Long-term management data were not present in any of the included studies. CONCLUSIONS: There is a scarcity of studies reporting the management and outcome of pediatric TSCI in LMICs. The paucity of studies in this domain provides insufficient data to be compared, reducing the ability to draw a strong conclusion. This situation hinders the development of guidelines to inform best practice.

Evaluating the impact of neurosurgical rotation experience in Africa on the interest and perception of medical students towards a career in neurosurgery: a protocol for a continental, cross-sectional study.

Introduction: Africa has the second highest neurosurgical workforce deficit globally. Despite the many recent advancements in increasing neurosurgical access in Africa, published reports have shown that the vast majority of undergraduate students have little or no exposure to neurosurgery. The lack of exposure may pose a challenge in reducing the neurosurgical workforce deficit, which is one of the long-term strategies of tackling the unmet burden of disease. Students may also miss the opportunity to appreciate the specialty and its demands as well as nurture their interest in the field. This study aims to assess the impact of a neurosurgical rotation during medical school in shaping the perception and interest of students towards a career in neurosurgery. Methods: The cross-sectional study will be conducted through the dissemination of a self-administered e-survey hosted on Google Forms from 21st February 2021 to 20th March 2021. The survey will contain five-point Likert scale, multiple-choice and free-text questions. The structured questionnaire will have four sections with 27 items: (i) socio-demographic background, (ii) neurosurgical experience, (iii) perception towards a neurosurgical career and (iv) interest in a neurosurgical career. All consenting medical students in African medical schools who are in their clinical years (defined as fourth to sixth years or higher years of study) will be eligible. Odds ratios and their 95% confidence intervals, Wilcoxon rank-sum test, Welch t-test and adjusted logistic regression models will be used to test for associations between independent and dependent variables. Statistical significance will be accepted at P < 0.05.

Evaluating the Impact of Neurosurgical Rotation Experience in Africa on the Interest and Perception of Medical Students Towards a Career in Neurosurgery: A Continental, Multi-Centre, Cross-Sectional Study.

OBJECTIVE: Africa has the second highest neurosurgical workforce deficit globally and many medical students in Africa lack exposure to the field. This study aims to assess the impact of a neurosurgical rotation during medical school in shaping the perception and interest of students toward a career in neurosurgery. STUDY DESIGN: Cross-sectional study. METHODS: A Google form e-survey was disseminated to African clinical medical students between February 21st and March 20th, 2021. Data on exposure and length of neurosurgical rotation and perception of, and interest in, neurosurgery were collected. Data was analyzed using descriptive statistics and adjusted logistic regression modeling. RESULTS: Data was received from 539 students in 30 African countries (30/54, 55.6%). The majority of participants were male and were from Kenya, Nigeria and South Africa. Most students had undertaken a formal neurosurgery rotation, of which the majority reported a rotation length of 4 weeks or less. Students who had more than 4 weeks of neurosurgical exposure were more likely to express a career interest in neurosurgery than those without [odds ratio (OR) = 1.75, p < 0.04] and men were more likely to express interest in a neurosurgical career compared to women (OR = 3.22, p < 0.001), after adjusting for other factors. CONCLUSION: Neurosurgical exposure is a key determinant in shaping the perception and interest of medical students toward a career in neurosurgery. Our findings support the need: i) for a continent-wide, standardized curriculum guide to neurosurgical rotations and ii) to advocate for gender inclusivity in education and policy-making efforts across the African continent.

Management and Outcomes of Low-Grade Gliomas in Africa: A Scoping Review Protocol.

BACKGROUND: Over the last decade, many advancements have been made in the management of low-grade gliomas (LGGs). Overall survival outcomes are correlated with factors such as postoperative residual volumes and specific tumor biomolecular profiles such as IDH mutation status. It is unclear whether these advancements have benefited LGG patients in Africa. This scoping review protocol outlines how the authors will evaluate the epidemiology, presentations, management and outcomes of LGGs in Africa. METHODS: MEDLINE, Embase and African Journals Online will be searched from database inception to date in order to identify the relevant studies. Patients of all ages with histologically and/or radiologically confirmed LGGs that were managed in an African country will be included. Surgical and chemoradiation management of LGG tumours will be considered. Original research, reviews, commentaries, editorials and case reports will be included. RESULTS: Primary outcomes of the review will include LGG management, morbidity and mortality. Secondary outcomes include epidemiology and recurrence of LGGs. DISCUSSION: This scoping review will be the first to evaluate the current landscape of LGG management and outcomes in Africa, highlighting pertinent themes that may be used to guide further research as well as health system strengthening efforts by policymakers and stakeholders. SCOPING REVIEW REGISTRATION: The protocol has been registered on the Open Science Framework (OSF; registration link: https://doi.org/10.17605/OSF.IO/E732G). HIGHLIGHTS: LGGs account for 17% to 22% of total brain tumours and have a median survival time between 5.6 and 13.3 years.Despite many recent advancements in the management of LGGs, there is a paucity in the data within the African landscape.This scoping review will be the first to evaluate the current landscape of LGG management and outcomes in Africa, highlighting pertinent themes that may be used to guide further research and policymaking efforts.