The legal and medical consequences of child marriage.

The Marriage and Civil Partnership (Minimum Age) Act 2022 came into force in England on 27 February 2023 and made both registered and unregistered marriages involving people under 18 illegal in England and Wales. This means that such marriages which take place outside England and Wales will not be recognised and those who organised them, including parents, will have committed a criminal offence.This review considers issues related to families where such marriages have happened, including their impact on the health of the victim and any resulting children. It touches on religious and societal issues and the need for targeted and appropriate education.

The development of a novel, multilingual IBD knowledge questionnaire for Asian patients with inflammatory bowel disease.

BACKGROUND: Inflammatory bowel disease is an uncommon disease in developing nations whereby patient's knowledge on the disease may be limited. The CCKNOW questionnaire, a widely known questionnaire to assess patient's knowledge on the disease, may be too complex to comprehend for patients in developing countries. The aim of this study is to develop a new tool known as AIBDKQ questionnaire to evaluate the local inflammatory bowel disease patient's knowledge. METHODS: This was a prospective study carried out in four phases. In phase 1, three gastroenterologists with expertise in IBD generated a total of 21 questions related to the general knowledge of the disease in the English language. Phase 2 involved content and face validity whereby the questions were further validated by other gastroenterologists. In phase 3, the validated questions were translated into three languages namely Malay, Mandarin and Tamil which are commonly used in Malaysia. In phase 4 (statistical validity), administration of the questionnaires to patients and hospital staff were conducted to assess the construct validity, discriminative ability, predictive validity and reliability of the questionnaires. RESULTS: A total of 21 questions were generated initially. Further evaluation indicated that 20 items had adequate kappa and content validity index for relevance (CVI: 0.714 to 1, Kapp: 0.645 to 1) and clarity (CVI: 0.714 to 1, Kapp: 0.645 to 1). The questionnaires in four languages were administered to 213 patients to assess the construct validity. Six items were removed (three for low communality, one for small loading factors, two for cross loading), resulting in 16 final questions. Assessment with 34 hospital staff involving nurses, doctors and clerks showed significant differences in knowledge between the groups (F = 14.007, p < 0.001) and were able to discriminate doctors from nurses and clerks. Another group of 18 hospital staff administered with AIBDKQ and CCKNOW questionnaires showed a Pearson's correlation coefficient of 0.8 indicating strong correlation and concurrent predictive validity between the two questionnaires. Final assessment with 38 patients for reliability assessment revealed high intraclass correlation of the questionnaire among the four languages. CONCLUSIONS: The AIBDKQ has an excellent discriminant ability and internal consistency with a strong correlation when compared to the standard CCKNOW questionnaire.

Training pharmacy students to deliver bad news using the SPIKES model.

BACKGROUND AND PURPOSE: Delivery of bad news or negative health information is a complex skill critical to the provision of patient care. While counseling models with this focus exist within other health care professions, their use in pharmacy education is lacking. The purpose of this study is to assess pharmacy students' ability to deliver bad news with the implementation of a counseling model titled SPIKES (Setting, Perception, Invitation, Knowledge, Emotions with Empathy, and Strategy/Summary). EDUCATIONAL ACTIVITY AND SETTING: First-year pharmacy students attended a one-hour training on the SPIKES model and completed three simulations with its application. Pre- and post-training surveys were administered to assess confidence, attitudes, and perceptions. Student performance during the simulations was evaluated by teaching assistants (TAs) as well as a self-assessment using the same grading rubric. A paired t-test was used to test for significant mean improvement in competency scores, confidence, attitudes, and perceptions from Week 1 to Week 3. FINDINGS: One hundred and sixty-seven students were included in the analysis. There was a significant improvement in the student's self-assessment of their performance for each of the SPIKES components and summative scores. For the TA assessment, there was a significant mean improvement in the summative SPIKES score; however, within each component of SPIKES, only the knowledge component showed significant mean improvement. There was also a significant improvement in student confidence in the post-training surveys. SUMMARY: Implementation of the SPIKES protocol in the pharmacy curriculum showed an overall improvement in students' self-assessed performance in delivering bad news.

English Language Medical Schools in China: An Analysis of International Medical Graduates Practicing in the UK.

OBJECTIVES: From 2006, the Ministry of Education in China has approved universities to provide undergraduate medical training in English, targeting fee-paying international students. Students on these courses can face challenges in their clinical training, particularly in the domains of communication and professionalism. This study examines the proportion of doctors qualified from such medical schools who are currently listed on the UK medical register. METHODS: The UK General Medical Council register of medical practitioners was searched to identify doctors qualified from 33 Chinese medical schools who provide education in the English language. RESULTS: As of February 2022, 502 doctors whose primary medical qualification is from a university offering English language education in China were registered on the UK medical register. Four hundred twenty-five (84.7%) of these doctors were aged 39 and under, approximately double the proportion of doctors in this age bracket overall. Three hundred forty nine (69.5%) were staff grade and associate specialist doctors, 109 (21.7%) were doctors in training, 36 (7.2%) were on the General Practitioner (GP) register, and 20 (4.0%) were on the specialist register. Among doctors in training, the most common specialty areas were in general practice and psychiatry that are both facing recruitment shortages in the UK at present. CONCLUSION: A small but significant number of graduates whose medical training was in the English language in China are practicing medicine in the UK. These doctors are in younger age groups than the overall medical workforce, and are less likely to be in training, and specialist or GP posts. Among those in training, a high proportion are in GP and psychiatry training and could contribute to alleviating UK medical workforce shortages. Policymakers and educators should be mindful of the growing numbers of doctors qualified from these schools, and the additional support they may require considering the unique training environments they have encountered.

Thoracic trauma: Clinical and paleopathological perspectives.

OBJECTIVES: Although trauma is one of the most significant areas of study in paleopathology, most studies focus on fractures of single anatomical elements. Paleopathological research on regional trauma, such as of the thorax, is rare. This paper explores the causes, complications, and consequences of adult thoracic trauma using clinical data in order to inform paleopathological research. MATERIALS AND METHODS: Trends in paleopathological thoracic trauma literature were assessed by evaluating publications from Bioarchaeology International, International Journal of Osteoarchaeology, International Journal of Paleopathology, and American Journal of Biological Anthropology. Clinical publications on thoracic trauma throughout time were also assessed through a PubMed search, and modern prevalence data was found through trauma databases such as the National Trauma Databank. RESULTS: Consideration of thoracic trauma involving concomitant injuries is a recent trend in clinical literature and patient care, but paleopathological research on thoracic trauma has been limited. Since thoracic fractures tend to occur in conjunction with other injuries, assessing them together is critical to the interpretation of trauma in the past. CONCLUSIONS: Clinical research into thoracic fractures and concomitant injuries provides valuable data for paleopathological research. Evaluating the likelihood and consequences of concomitant injury in skeletal remains provides a more robust understanding of trauma in the past and its impact on past lifeways. SIGNIFICANCE: This paper provides a review of current clinical and paleopathological literature on thoracic trauma and demonstrates the importance of moving beyond the analysis of fractures or trauma of single anatomical elements. LIMITATIONS: Thoracic bones are often taphonomically altered and differentially preserved leading to difficulty in identifying and interpreting fractures. SUGGESTIONS FOR FURTHER RESEARCH: Practical application of the data presented here to archaeological samples will help to advance paleopathological understandings of thoracic trauma.

Surgery for Ulcerative Colitis in the White British and South Asian Populations in Selected Trusts in England 2001-2020: An Absence of Disparate Care and a Need for Specialist Centres.

Over the last decade, there has been extensive evidence that patients with inflammatory bowel disease from minority communities in the UK receive less than optimal care. In none of the studies has the role of surgery in the management of acute and severe ulcerative colitis been considered in any detail. A freedom of information (FOI) request was sent to 14 NHS Trusts in England, which serve significant South Asian populations. Details of the type of surgery patients from the South Asian and White British communities received between 2021 and 2020 were requested. Detailed responses were obtained from eight Trusts. Four hundred and ten White British patients underwent surgery for ulcerative colitis over this period at these eight Trusts, together with 67 South Asian patients. There was no statistically significant difference in the distribution across the types of surgery undergone by the two communities overall (χ2 = 1.3, ns) and the proportions who underwent an ileo-anal anastomosis with pouch (z = -1.2, ns). However, within individual trusts, at the University Hospital Southampton NHS Foundation Trust, a significantly greater proportion of South Asian patients had an ileo-anal anastomosis with pouch compared to White British patients. At Cambridge University Hospitals NHS Foundation Trust, all 72 patients who underwent surgery for ulcerative colitis were White British. This study has shown that, in general, for patients with a severe flare of ulcerative colitis where medical treatment has failed and surgery is warranted, the nature of the procedures offered is the same in the White British and South Asian communities. However, of concern is the number of units with low volume procedures. For most Trusts reported in this study, the overall number of Ileo-anal pouch anastomosis or anastomosis of ileum to anus procedures performed over a number of years was substantially below that required for a single surgeon to achieve competence. These findings reinforce the argument that inflammatory bowel disease surgery should be performed in a limited number of high-volume centres rather than across a wide range of hospitals so as to ensure procedures are carried out by surgeons with sufficient and on-going experience.

Ancient surgeons: A characterization of Mesopotamian surgical practices.

BACKGROUND: The Ancient Mesopotamian civilization, the earliest known, emerged in the fourth millennium BCE.1 While the advent of medicine is established, there is little understanding of surgery's origins. We sought to describe the characteristics and medical acumen of the surgeons of the first civilization. METHODS: Source documents and commentary on Mesopotamian medicine were systematically analyzed for evidence of surgery and physician descriptions. RESULTS: Early tablets reveal evidence of the incisional drainage of a scalp abscess and empyema, advanced wound care, fracture alignment, and possible caesarians without evidence of wound suturing, emergency procedures, trephination, or circumcision.2 While the asû and asipu understood disease processes, strong evidence of an inextricable connection between spiritual and diagnostic/curative roles exists. CONCLUSIONS: Mesopotamian physicians were diagnosticians and healers, approaching surgery as part of their holistic practice rather than a separate entity. Surgery was utilized as an endpoint to a careful process aided by objective evaluation and spiritual incantation.

"Islamic Medicine": A true discipline for the 21st century or quackery?

The purpose of this review is to consider the position of "Islamic Medicine" and whether it is a legitimate form of clinical care or quackery. The analysis is based on published work together with an identification of themes derived from testimonials on practitioners' websites, as well as a consideration of how such therapies are considered in medical search engines. "Islamic Medicine" covers Traditional or Yunani practice, Prophetic Medicine, Hijama and Ruqya. Their origins are discussed and, subsequently, current-day practice and its relationship to allopathic medicine. Reasons for antagonism to modern medicine are considered and the absence of a rational basis for many of the views expressed. In the case of Yunani medicine, its pre-Islamic origins are identified together with the impact of anti-colonialism and the potential role of clerics in wishing to distance medical care from Galenic concepts. In the case of Hijama, the absence of effective training and regulation and its promotion as a "lost sunna" are discussed alongside claims for miraculous cures. The movement of Ruqyah away from Qur'anic recitation in support of the sick towards a popularised approach to dealing with magic and possession is considered, together with consequential adverse publicity in the media. The consequences of a failure to adopt training practices for Yunani medicine, as recommended by the WHO, are identified. Accredited detailed courses monitored by external statutory regulatory agencies, based in institutions committed to providing the best healthcare, and supporting research would allow "Islamic Medicine" to become a significant role player in contemporary clinical practice and stop present-day quackery.

Telephone clinic improves gluten-free dietary adherence in adults with coeliac disease: sustained at 6 months.

BACKGROUND: A gluten-free (GF) diet is the only treatment for coeliac disease (CD), non-adherence to the diet is associated with greater morbidity. The study aimed to examine the effect of a telephone clinic, designed to increase GF dietary knowledge and adherence, in adults with CD. METHODS: A prospective study of 125 patients with histologically confirmed CD. Patients, not adhering to a GF diet (n=30), engaged in a personalised telephone clinic. Validated questionnaires were used to assess GF dietary adherence (Coeliac Disease Adherence Test; CDAT), knowledge of GF foods and CD-related quality of life (QoL). GF dietary adherence was assessed up to 12 months post telephone clinic. The control group completed the questionnaires only. RESULTS: GF dietary adherence (CDAT) median scores significantly improved at 3 and 6 months after the telephone clinic compared with baseline (16, 13 and 13, respectively, p<0.01). Reassuringly, the dietary burden QoL score remained similar to baseline values. No change in CDAT scores were observed in the control group. Change in GF dietary knowledge score was associated with improved GF dietary adherence CDAT score (r=-0.22; p=0.039). At 9 and 12 months, CDAT scores were similar to baseline values. CONCLUSIONS: Telephone clinics have a positive impact on dietary knowledge and GF dietary adherence in adults with CD, promoting health-benefitting behaviours in those previously not adhering to a GF diet. The study highlights the need for patients to have regular follow-up, with targeted reviews for those not adhering to a GF diet.

Traumatic thoracic rib cage and chest wall hernias: A review and discussion of management principles.

Traumatic thoracic or chest wall hernias are relatively uncommon but highly challenging injuries that can be seen after a variety of injury mechanisms. Despite their description throughout history there remains scant literature on this topic that is primarily limited to case reports or series. Until recently, there also has been no effort to create a reliable grading system that can assess severity, predict outcomes, and guide the choice of surgical repair. The purpose of this article is to review the reported literature on this topic and to analyze the history, common injury mechanisms, likely presentations, and optimal management strategies to guide clinicians who are faced with these challenging cases. We also report a modified and updated version of our previously developed grading system for traumatic chest wall hernias that can be utilized to guide surgical management techniques and approaches.

What Can a Jump Tell Us About Elbow Injuries in Professional Baseball Pitchers?

BACKGROUND: The incidence rate of elbow injuries has been rising in recent years among professional baseball pitchers. Determining valid screening procedures that allow practitioners to identify pitchers at an increased risk of such injuries is therefore of critical importance. PURPOSE: To validate the use of countermovement jump (CMJ) tests as a diagnostic tool for pitcher conditioning. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: More than 500 pitchers at a single professional baseball organization performed preseason CMJ assessments on a force plate before the 2013 to 2018 seasons. Three measurements were extracted from ground-reaction force data during the test: eccentric rate of force development (ERFD), average vertical concentric force (AVCF), and concentric vertical impulse (CVI). Athletic trainers at the organization collected detailed information on elbow and shoulder injury rates as well as workload (pitch count) throughout the rest of the season. Poisson regression models were fit to investigate the dependency of injury rates on CMJ test performance. RESULTS: ERFD, CVI, and AVCF were all significant predictors of elbow injury risk after accounting for pitcher age, weight, and workload. The analysis identified 3 specific indicators of heightened risk based on the results of a CMJ scan: low ERFD, a combination of low AVCF and high CVI, and a combination of high AVCF and low CVI. In contrast, shoulder injury risk was roughly independent of all 3 CMJ test measurements. CONCLUSION: This study supports the hypothesis of the entire kinetic chain's involvement in pitching by establishing a link between CMJ test performance and elbow injury risk in professional baseball pitchers. CMJ assessment may be a powerful addition to injury risk alert and prevention protocols. Pitchers in high-risk groups can be prescribed specific exercise plans to improve movement imbalances.

Inflammatory bowel disease and the South Asian diaspora.

Migration is associated with changes in the incidence of diseases, often linked to new environmental exposures or movement away from such exposures. Studies are complicated by the time and length of migration and also by differences in the experience of second- and third-generation migrants. South Asian people have migrated across the world. In this review, the incidence and prevalence of inflammatory bowel disease in these communities is considered, along with their potential role in future investigative studies of the diseases' etiology.

Surveillance for colorectal cancer and chemoprevention in ulcerative and Crohn's colitis: The need for clinical strategies to increase effectiveness.

This review considers why current strategies for surveillance and the prevention of colorectal cancer as a long-term complication are ineffective. The role of endoscopists, pathologists, and patients are investigated. Colorectal cancer is linked to poor compliance with therapy, and attention may be better directed at improving adherence to treatment than strengthening current surveillance programs. Clearly, 5-ASA compounds, particularly mesalazine, are the most appropriate agents to choose, but there may also be a place for the daily intake of folic acid. Currently, the evidence in support of ursodeoxycholic acid is mixed, and it cannot be recommended, in general, to patients for the prophylaxis of colorectal cancer risk. An alternative approach through better concordance with medications is considered. The situation in Crohn's colitis is less clear. Although the risk of colorectal cancer mirrors that in ulcerative colitis, there are no published community-based studies that exclusively assess the effects of surveillance on the early detection of cancer, and the benefits of 5-ASA compounds in treatment seem less certain than in ulcerative colitis. In addition, there have been no assessments of the effects of any medications on cancer risk in Crohn's disease.

Medical negligence and likely developments in Oman.

Medical mistakes can never be eliminated but they can be minimised. From the world of aviation, it is clear that simulation training can have dramatic beneficial effects. Such training, however, is compulsory. In contrast, in the world of medicine there are few countries which have adopted a comparable approach. Unless continued medical registration is directly linked to satisfactory performance in simulated exercises and real events, it is unlikely that significant reductions will be achieved. This review will concentrate on the situation where mistakes and their mismanagement have direct and adverse consequences for patients. It will not be concerned with the recognised complications of procedures and treatments, with the exceptions of poor communication where patients have entered into treatments unaware of the associated risks.

Risk of esophageal cancer in achalasia cardia: A meta-analysis.

INTRODUCTION: The association between cancer of the esophagus and achalasia has long been recognized. However, it has also been recognized that cancers themselves can give rise to achalasia-like syndromes. The risk of developing cancer is also a factor in assessing whether there is a potential role for surveillance in this disease. This paper uses published work to form the basis for a meta-analysis of the risk of developing esophageal cancer among patients with pre-existing achalasia. METHODS: This paper considered cancer risk reported in a range of studies of achalasia published over a 50-year period. Twenty-seven potential studies were identified. In 16 reports, it was possible to extract information on both length of follow-up and duration of achalasia so that person-years duration (PYD) could be calculated. The analysis was stratified between cancers identified in the first year after diagnosis of achalasia and cancers identified in subsequent years. RESULTS: From pooling the results of 16 studies, the incidence rate of esophageal cancer in achalasia patients was estimated to be 1.36 (95% CI: 0.56, 2.51) per 1000 person years. This is over 10 times higher than the general population incidence rates as reported by the lARC. CONCLUSIONS: Therefore, our meta-analysis shows that achalasia is a major risk factor for the development of esophageal cancer. This is supported by the results from the time-stratified analysis. Incidence of esophageal cancer per 1000 person years was lower in the first year after diagnosis of achalasia than in subsequent years. This is strong evidence against the idea that achalasia may be induced by esophageal cancer instead of vice versa.

The utility of CT scan for the diagnostic evaluation of acute abdominal pain.

AbdCT for the evaluation of AAP in the ED in the US may be excessive and is potentially (although rarely) misleading and harmful. A selective policy of 'AbdUS first' combined with an observation unit and/or surgeon evaluation prior to AbdCT is preferred to a 'routine AbdCT' policy. Repeated AbdCTs for abdominal pain are not recommended because of cumulative radiation exposure. Standardized and complete history and physical examination, such as that originally designed for computer-aided diagnosis of AAP, along with select laboratory testing and higher utilization of AbdUS lessens the necessity of AbdCT. 'Routine AbdCT' is particularly not necessary for the evaluation of suspected appendicitis. 'Routine AbdCT' lowers the negative appendectomy rate but at the expense of exposure to radiation. Right lower quadrant US and selective use of observation prior to AbdCT for suspected appendicitis, particularly in children, adolescents, and young adults, are warranted. MRI should substitute for AbdCT for the evaluation of suspected appendicitis during pregnancy.