Progression through UK surgical training involves highly competitive national selection processes, particularly at entry into Core Surgical Training (CST) and subsequent entry into higher surgical training at ST3 level. Inequities in access to preparation resources and variability in mentorship remain recognized challenges. The Association of Surgeons in Training has developed national, trainee-led initiatives to support trainees at these key transition points. Preparing for a Career in Surgery (P4CS) and Preparing for Core Surgical Training (P4CST), established 10 years ago, supports foundation and early postgraduate doctors preparing for CST, while Preparing for ST3 (P4ST3), supports core trainees transitioning to higher surgical training. Both programmes are delivered nationally and incorporate thematic talks from successful candidates, portfolio clinics with personalized feedback, and mock interviews aligned with current CST and ST3 selection frameworks. Programme delivery has evolved from in-person to predominantly online formats to improve accessibility. Participation has increased steadily over time, with national reach across UK regions. Routine post-course evaluation demonstrated consistently high participant satisfaction across all programmes. Mean ratings for educational sessions ranged from 4.48 to 4.84 out of 5, while over 94% of participants reported adequate opportunities to ask questions and receive personalized feedback from faculty. Preparing for Core Surgical Training and Preparing for ST3 illustrate how trainee-led educational initiatives developed within professional associations can provide scalable, sustainable, and equitable support across the surgical training continuum. This model offers a transferable framework for supporting trainees navigating competitive postgraduate selection processes.
BACKGROUND:Chronic itch is common in primary care but is often under-examined, partly because clinicians lack a clear mechanistic framework for interpreting its diverse presentations. AIM:To provide generalists with a practical, mechanism-based model for assessing and managing chronic itch. METHODS:Evidence from neurobiology, dermatology, and internal medicine was synthesised into a four-driver framework describing skin-generated, systemic, peripheral nerve, and centrally mediated itch. Clinical patterns, mechanistic pathways, and aligned treatments were integrated into a unified model for primary care. RESULTS:Most chronic itch can be understood through a small number of mechanisms: keratinocyte stress and inflammatory cytokines in skin-generated itch; circulating mediators and neurohumoral imbalance in systemic itch; focal nerve injury in neuropathic itch; and sensitisation, amplification and conditioned scratching in centrally mediated itch. These mechanisms map to distinct clinical patterns and targeted therapeutic strategies. CONCLUSION:A structured assessment focusing on tempo, distribution, skin findings, systemic clues, and sensory change supports clearer diagnosis and more effective management of chronic itch in primary care.
BACKGROUND:The symbiotic relationship between industrial advancement and healthcare delivery has fundamentally shaped modern medicine. This comprehensive review article explores the historical and technological trajectory from the First Industrial Revolution (Industry 1.0) to the rapidly emerging Sixth Industrial Revolution (Industry 6.0), meticulously mapping distinct industrial milestones to their concurrent evolutions in clinical practice. METHODS:An exhaustive electronic search was conducted across multiple premier academic and clinical databases, including PubMed/MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library using specific technological enablers, clinical application domains and reported barriers to implementation. RESULTS:While Industry 1.0 through 3.0 focused on mechanization, mass production, and rudimentary automation, resulting in the institutionalization and digitization of medicine, the advent of Industry 4.0 introduced cyber-physical systems and the Medical Internet of Things/Internet of Medical Things. Subsequently, Industry 5.0 emerged to address the depersonalization of hyper-automation by reintegrating human-centricity, ethical governance, and mass personalization. CONCLUSION:This review posits that the global ecosystem is now transitioning into Industry 6.0, an era characterized by antifragile manufacturing, quantum computing, deep digital twins, and autonomous cognitive systems. By examining specific applications across diagnosis, treatment, screening, monitoring, prevention, and rehabilitation--with a particular focus on hightechnology fields such as orthopaedics--this paper illustrates a paradigm shift from reactive, standardized interventions to proactive, hyper-personalized, and autonomous healthcare delivery models.
Cardiovascular diseases remain the leading cause of mortality worldwide. Their increasing prevalence has focused attention on new promising biomarkers such as vascular calcification, although its assessment involves radiation exposure. Thus, this systematic review and meta-analysis aimed to examine the association between arterial stiffness, assessed through pulse wave velocity (PWV) and extracoronary arterial calcification (ECC), in addition to identifying possible factors influencing this relationship. A systematic search was conducted in PubMed, Scopus, and Web of Science according to PRISMA and MOOSE guidelines. Data extraction, quality assessment, and statistical analyses were performed according to predefined criteria. A total of 41 studies with 19 300 participants were included. Higher central PWV was associated with higher presence of ECC in both unadjusted and adjusted models (p-OR = 2.84; 95% CI: 2.25-3.59; and p-OR = 2.27; 95% CI: 1.66-3.11, respectively). Similarly, peripheral PWV was associated with ECC in both unadjusted and adjusted models (p-OR = 3.73; 95% CI: 2.76-5.05; and p-OR = 1.49, 95% CI: 1.26-1.75, respectively), though with considerable heterogeneity. Age, diabetes, low-density lipoprotein cholesterol, total cholesterol, pulse pressure, and body mass index were related to p-OR. Publication bias was identified in all models except the adjusted peripheral model. This meta-analysis highlights a significant association between central arterial stiffness and ECC, supporting PWV as a promising noninvasive biomarker. Given the cross-sectional nature of the available evidence and the observed heterogeneity, further prospective studies are needed to confirm these findings, clarify their clinical relevance, standardize measurement methods, and to strengthen the overall evidence base.
BACKGROUND:Artificial intelligence is increasingly used in health care and medical education. This study aimed to identify factors associated with medical students' attitudes towards artificial intelligence, with particular attention to digital literacy, emotional intelligence and artificial intelligence-related perceptions. METHODS:This cross-sectional study was conducted between November 2025 and January 2026 among 358 medical students. Data were collected using an online questionnaire including sociodemographic items, the Trait Emotional Intelligence Scale-Short Form, the Digital Literacy Scale and the General Attitude Towards Artificial Intelligence Scale. Group comparisons, correlation analyses, hierarchical linear regression and exploratory indirect-effect analysis were performed. RESULTS:Most students had previously used artificial intelligence (88.5%), while 59.5% reported ethical or legal concerns and 41.1% believed that artificial intelligence could reduce clinical reasoning. Digital literacy was positively correlated with attitudes towards artificial intelligence (r = 0.319, p < 0.001). In the final hierarchical regression model, digital literacy was the strongest independent factor associated with attitudes towards artificial intelligence (B = 0.242, β = 0.320, p< 0.001). Clinical educational stage, ethical or legal concerns, and perceptions regarding the impact of artificial intelligence on clinical reasoning were also independently associated with attitude scores. Previous artificial intelligence use and emotional intelligence were not independently associated with attitudes after adjustment. CONCLUSIONS:Medical students' attitudes towards artificial intelligence were associated more strongly with digital literacy and artificial intelligence-related perceptions than with previous use alone. Undergraduate medical education should integrate digital literacy, ethical awareness and reflective discussion on clinical reasoning into artificial intelligence-related teaching.
PURPOSE:Learner handover is the transfer of learner-related information between supervisors, rotations or educational phases. This narrative review examines learner handover in surgical and procedural training, including surgery, interventional cardiology, interventional radiology and gastrointestinal endoscopy, where information about prior performance may influence entrustment, supervision, case allocation and technical opportunity. RESULTS:Learner handover has been proposed as a way to mitigate the discontinuity inherent in rotational training and to enable earlier, more targeted coaching. However, empirical work on prior performance information shows that assessors can be influenced by what they are told before observing a learner, with both assimilation and contrast effects described. Learners report that handover can feel opaque, anxiety-provoking and reputationally risky when they do not know what is shared, by whom or for what purpose. In procedural specialties these concerns are amplified because reputational information may alter access to scarce cases, thresholds for hands-on participation and the level of supervision granted during invasive tasks. CONCLUSION:Learner handover should neither be adopted uncritically nor rejected outright. Surgical and procedural programmes should replace informal reputational exchange with structured developmental handover that is behaviourally specific, recent, proportionate, learner-centred, time-limited and linked to explicit coaching actions. The central task is to preserve continuity of coaching while preventing reputational contamination.
Abstract Background Cardiovascular disease is a leading cause of death globally, with type 2 diabetes mellitus increasing the risk. Lipid dysregulation, particularly increased LDL cholesterol and triglyceride concentrations, drives atherosclerosis, a primary driver of cardiovascular disease. Glucagon-like peptide-1 receptor agonists, initially designed for glucose control in type 2 diabetes mellitus, show potential in reducing cardiovascular risk factors, including lipid abnormalities. However, their impact on lipid metabolism remains unclear. Aim This systematic review and meta-analysis aims to evaluate the effects of GLP-1 receptor agonists on lipid metabolism and cardiovascular outcomes, and to determine the potential mechanisms by which GLP-1 receptor agonists affect cardiovascular risk factors, whether or not these are directly linked to lipid metabolism. Glucagon-like peptide-1 receptor agonists liraglutide, semaglutide and exanetide were investigated. Methods This systematic review and meta-analysis of randomized controlled trials was conducted in accordance with PRISMA guidelines. PubMed, Scopus and Cochrane Library were searched from 2000 to 2025 for randomized controlled trials evaluating liraglutide, semaglutide or exenatide in adults with type 2 diabetes and reporting lipid concentrations and/or major adverse cardiovascular events. The inclusion criteria were participants aged ≥18 years with or without type 2 diabetes, obesity and other comorbidities, reported in a randomized control trial (with placebo or antidiabetic or lipid-lowering drugs in the control arm), and the end points/outcomes of the trial, including cardiovascular events and lipid profiles, with a follow-up period of at least six weeks. English language articles only were considered, with full-text and open access. The exclusion criteria were case reports, case series, observational studies, proposed or ongoing clinical trials, letters to the editors, commentaries, diagnostic studies, narrative and systematic reviews and meta-analyses, studies performed on animals, cross-over trials, and post hoc analysis. Studies without a control arm, studies with GLP-1 receptor agonists in combination with other therapies as intervention, studies that included participants with gestational diabetes, studies that included participants already on other oral hypoglycaemic agents or insulin, or who had suffered cardiovascular events (acute myocardial infarction, angina, transient ischaemic attack, or stroke) within the last 30–60 days. Two reviewers (Akhere Mamudu and Praise O. Oloyede) independently extracted data. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Pooled mean differences for lipid outcomes and hazard ratios for cardiovascular outcomes were calculated using RevMan software. Heterogeneity was assessed using the I2 statistic. A fixed-effects model was applied where heterogeneity was low (I2 < 50%) and a random-effects model where heterogeneity was substantial. Results Systematic searches were performed according to PRISMA guidelines across three databases (PubMed/MEDLINE, Cochrane Library, and Scopus) using predefined search terms. Six hundred and seventy-two articles were identified. After applying exclusion and inclusion requirements, the number was reduced to 50 articles based on title selection. Twenty articles were chosen according to the relevance of their abstract. Lastly, five studies [1–5], whose full texts met the eligibility criteria, were included in the final review, comprising 18 227 participants. Meta-analysis demonstrated no statistically significant pooled reduction by liraglutide, semaglutide or exenatide in LDL cholesterol concentration (mean deviation = 0.03 mmol/L; P = 0.86) or triglyceride concentration (mean deviation = 0.11 mmol/L; P = 0.76). Glucagon-like peptide-1 receptor agonists were associated with cardiovascular safety across the five studies. Pooled analysis of major adverse cardiovascular events demonstrated a reduction favouring GLP-1 receptor agonists (hazard ratio = 0.89; 95% CI: 0.82–0.97; P = 0.009; I2 = 0%). Subgroup data from individual trials showed cardiovascular superiority for semaglutide and liraglutide, while exenatide demonstrated non-inferiority. Conclusions Glucagon-like peptide-1 receptor agonists confer cardiovascular protection in patients with type 2 diabetes mellitus; however, pooled analysis does not demonstrate a consistent lipid-mediated effect. Cardiovascular benefits appear multifactorial (via their effect on glycaemic control plus inflammation) rather than primarily driven by direct lipid modulation. Although the pooled analysis showed no statistically significant changes in triglyceride, LDL cholesterol, HDL cholesterol, or total cholesterol concentrations, a major decline in adverse cardiovascular events was found. These findings suggest that the cardiovascular benefits of GLP-1 receptor agonists are potentially mediated by mechanisms independent of direct lipid modification, underscoring the complexity of their role in preventing cardiovascular disease. References 1. Jensen JK, Zobel EH, von Scholten BJ, et al. Effect of 26 Weeks of Liraglutide Treatment on Coronary Artery Inflammation in Type 2 Diabetes Quantified by [64Cu]Cu-DOTATATE PET/CT: Results from the LIRAFLAME Trial. Front Endocrinol (Lausanne) 2021;12:790405. doi:10.3389/fendo.2021.790405. 2. Ripa RS, Zobel EH, von Scholten BJ, et al. Effect of Liraglutide on Arterial Inflammation Assessed as [18F]FDG Uptake in Patients With Type 2 Diabetes: A Randomized, Double-Blind, Placebo-Controlled Trial. Circ Cardiovasc Imaging 2021;14:e012174. doi:10.1161/CIRCIMAGING.120.012174. 3. Husain M, Birkenfeld AL, Donsmark M, et al. Oral Semaglutide and Cardiovascular Outcomes in Patients with Type 2 Diabetes. N Engl J Med 2019;381:841–851. doi:10.1056/NEJMoa1901118. 4. Koska J, Migrino RQ, Chan KC, Cooper-Cox K, Reaven PD. The Effect of Exenatide Once Weekly on Carotid Atherosclerosis in Individuals With Type 2 Diabetes: An 18-Month Randomized Placebo-Controlled Study. Diabetes Care 2021;44:1385–1392. doi:10.2337/dc20-2014. 5. Holman RR, Bethel MA, Mentz RJ, et al. Effects of Once-Weekly Exenatide on Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med 2017;377:1228–1239. doi:10.1056/NEJMoa1612917
BACKGROUND:Knee osteoarthritis (KOA) disproportionately affects populations practicing high-frequency ritual kneeling during religious/cultural activities, inadequately explained by conventional risk models. METHODS:Using Global Burden of Disease 2021 data from 34 countries, we analyzed KOA prevalence, incidence, and disability-adjusted life years (DALYs). Age-standardized rates were computed via Bayesian meta-regression (DisMod-MR 2.1). Temporal trends (1990-2021) were assessed using estimated annual percentage change and Bayesian age-period-cohort modeling, linking biomechanical and cultural factors to sex/region-specific burden. RESULTS:Countries with daily ritual kneeling exhibited KOA burdens exceeding global averages. Saudi Arabia (Islamic) showed a 500% female age-standardized prevalence rate (ASPR) increase since 1990 (4496.9 per 100 000 in 2021). Mexico (Catholic) and Thailand (Buddhist) reported female ASPRs of 4970.4 and 4386.1 per 100 000, respectively-48.7% higher than males in Thailand. Elevated female incidence (Thailand: 364.9; Mexico: 402.5 per 100 000) and DALYs (Thailand: 141.5 per 100 000) likely reflect the interplay of biological vulnerabilities, longevity, and cultural practices. Biomechanical factors correlated positively with KOA severity. CONCLUSION:Ritual kneeling is strongly associated with elevated KOA burden, likely mediated by biomechanical stress, cultural practices, and sex-specific vulnerabilities. Findings suggest the potential benefit of faith-sensitive interventions to mitigate disability while respecting traditions, aligning with WHO healthy aging goals. Key messages • What is already known on this topic Knee osteoarthritis (KOA) is a leading cause of global disability, but conventional risk models do not adequately explain the high prevalence observed in populations where frequent ritual kneeling is a common cultural or religious practice. While localized studies have suggested a link, the global burden attributable to this specific biomechanical stressor remained unquantified. • What this study adds • This study provides the first global epidemiological analysis using Global Burden of Disease 2021 data to suggest that high-frequency ritual kneeling is a significant potential risk factor for KOA. • It quantifies the burden across 34 countries, revealing that nations with daily kneeling practices experience KOA prevalence and disability rates significantly exceeding global averages. • How this study might affect research, practice or policy These findings underscore the need to integrate cultural and religious factors into public health strategies for chronic disease prevention. This evidence points to the potential utility of "faith-sensitive" interventions-such as promoting cushioned mats, chair-assisted worship, or collaboration with religious leaders-to mitigate preventable disability while respecting sacred traditions.
Productive struggle may be conceptualized as an educational construct which incorporates mental stress and 'struggle' within ongoing instruction to develop perseverance and deepen understanding rather than focus on the solution. Medicine, which involves diagnostic uncertainty and varied clinical presentations, necessitates the development of adaptive reasoning and critical thinking-skills that can be honed by the productive struggle process. In this article, we sought to discuss the concept of productive struggle in medical education, by exploring why it is important to facilitate clinical learning and highlight practical strategies and potential pitfalls such as patient and psychological safety with this pedagogical model. We proposed three strategies to incorporate productive struggle in medical education-namely core tutoring, case-based discussions, and clinical simulations.
Acute poisoning is a common reason for emergency department presentation and is often associated with diagnostic and therapeutic uncertainty. Although evidence-based guidelines and decision-support tools provide an important framework for management, their application in clinical practice requires contextual interpretation and clinical judgement. This educational reflective analysis was based on observations made during a four-week clinical toxicology observership at the National Poisons Information Service in Edinburgh, United Kingdom. A structured reflective framework derived from Gibbs' reflective cycle was applied to selected clinical encounters. The framework comprised six sequential stages: description, feelings, evaluation, analysis, conclusion, and action planning. Cases were purposively selected to illustrate key domains of acute toxicology decision-making, including ethical complexity and capacity assessment, physiologically guided treatment escalation, and avoidance of unnecessary intervention. Application of the framework facilitated examination of clinical reasoning processes underlying toxicology management. The cases demonstrated how guideline-based knowledge interacts with real-time physiological assessment, ethical considerations, and cognitive factors influencing diagnostic reasoning. Reflection identified potential cognitive biases and highlighted the importance of proportional decision-making in situations of diagnostic uncertainty. Structured clinical reflection provided a practical approach for making implicit clinical reasoning more explicit in acute toxicology practice. By encouraging re-evaluation of assumptions and careful interpretation of clinical findings, the reflective process supported balanced decision-making and appropriate use of guideline-based recommendations. Structured clinical reflection may help clarify clinical reasoning in acute toxicology and support more deliberate and proportionate decision-making under conditions of uncertainty.
Chronic kidney disease (CKD) is a significant global health issue, affecting ~10% of the world's population. In the USA, nearly 90% of adults with CKD are unaware of their condition, leading to delays in care and, in many cases, progression to end-stage kidney disease (ESKD) requiring renal replacement therapy (RRT). It is important to recognize that not all individuals with CKD will develop kidney failure. RRT options include hemodialysis (HD), peritoneal dialysis (PD), and kidney transplantation. Prior to initiating HD, a vascular access such as an arteriovenous (AV) fistula, AV graft, or central venous catheter, must be placed, typically by a vascular surgeon. In contrast, PD requires a surgically implanted catheter in the abdomen. This paper reviews the available RRT modalities and emphasizes the importance of offering conservative management as an alternative approach. Additionally, we explore emerging innovations such as wearable and portable HD devices, that have the potential to transform ESKD care and significantly improve patients' quality of life.
BACKGROUND:Alopecia areata (AA), an autoimmune disorder, represents a prevalent form of hair loss among individuals. Various therapeutic approaches exist for managing AA, with Janus kinase (JAK) inhibitors emerging as a promising treatment modality. Nonetheless, there is a paucity of rigorous studies directly comparing the efficacy of JAK inhibitors in cases of severe AA. OBJECTIVE:Evaluating the efficacy of different JAK inhibitors in the treatment of severe AA. METHOD:A comprehensive search was conducted across four databases-PubMed, Embase, Web of Science, and Cochrane Library-on February 10, 2025. Eligible studies were selected based on the PICOS framework. A Bayesian network meta-analysis was employed to extract and analyze data concerning the number of individuals achieving SALT20 and corresponding sample sizes. The relative efficacy of the interventions was evaluated using league tables and Surface Under the Cumulative Ranking values. RESULT:A total of 3866 patients with AA were included in the study, with a total of 10 interventions. Of these, the one that showed the best efficacy was deuruxolitinib_12 mg, but with wider 95% confidence intervals. Of all the JAK inhibitors, the one with significant efficacy and high precision of results was baricitinib_4 mg (OR: 2.59, 95% CI: 1.98-3.38). CONCLUSION:The efficacy of JAK inhibitors in the treatment of severe AA is definitive, and all possess a dose-dependent effect. This study provides valuable insights for clinicians in selecting appropriate pharmacological interventions for severe AA. Key messages What is already known on this topic: Alopecia areata is an autoimmune disorder characterized by patchy hair loss on the scalp. Previous studies have demonstrated that JAK inhibitors can effectively treat alopecia areata, but research comparing the efficacy of different JAK inhibitors is lacking. What this study adds: This study established a ranking of efficacy for different JAK inhibitors in treating severe alopecia areata, providing a reference for selecting clinical treatment regimens. How this study might affect research, practice, or policy: Future studies are needed to directly compare the efficacy of different JAK inhibitors in treating alopecia areata. This will provide more reliable evidence for formulating treatment regimens for alopecia areata.
