Scottish Medical Research Articles

The UK Divide: Does Having a Pembrolizumab–Chemotherapy Option in Head and Neck Cancer Matter? Real-world Experience of First-line Palliative Pembrolizumab Monotherapy and Pembrolizumab–Chemotherapy Combination in Scotland

AimsThe Scottish Medical Consortium recently approved first-line pembrolizumab monotherapy or in combination with chemotherapy for head and neck squamous cell carcinoma in the palliative setting, contrasting with the decision made by the National Institute for Health and Care Excellence, who approved monotherapy alone in England and Wales. The aim of this study was to provide real-world performance data for first-line pembrolizumab-containing treatments for head and neck squamous cell carcinoma in the palliative setting in Scotland. Materials and methodsWe analysed the electronic records of patients who started pembrolizumab-containing treatment between 1 March 2020 and 30 September 2021. Outcomes included overall survival, progression-free survival (PFS), the duration of response and the disease control rate. Data were compared with the KEYNOTE-048 study and clinical factors were evaluated for association with survival. ResultsOur cohort included 91 patients (median follow-up 10.8 months). Patient characteristics were similar to those in the KEYNOTE-048 study, although our cohort had a higher proportion of patients with newly diagnosed, non-metastatic disease. For patients receiving monotherapy (n = 76), 12- and 24-month overall survival were 45% and 27%, respectively. For patients receiving pembrolizumab–chemotherapy (n = 15), 12-month overall survival was 60% (24-month overall survival had not yet been reached). Experiencing one or more immune-related adverse event (irAE; versus no irAEs), of any grade, was associated with favourable overall survival and PFS for patients receiving monotherapy in both univariable Log-rank analysis (median overall survival 17.4 months versus 8.6 months, respectively, P = 0.0033; median PFS 10.9 months versus 3.0 months, respectively, P < 0.0001) and multivariable analysis (Cox proportional hazards regression: overall survival hazard ratio 0.31, P = 0.0009; PFS hazard ratio 0.17, P < 0.0001). ConclusionOur real-world data support the KEYNOTE-048 study findings and the value of combination treatment options. Additionally, our data show that irAEs of any grade, as reported in routine clinical records, are associated with better outcomes in this patient group, adding to the growing body of evidence showing that irAEs are generally a positive marker of programmed death-ligand 1 (PD-L1) inhibitor response.

The Scottish Medical Imaging Archive: A Unique Resource for Imaging-related Research.

The Scottish Medical Imaging Archive: A Unique Resource for Imaging-related Research.

The Scottish Medical Imaging Archive: 57.3 Million Radiology Studies Linked to Their Medical Records.

Keywords: MRI, Imaging Sequences, Ultrasound, Mammography, CT, Angiography, Conventional Radiography Published under a CC BY 4.0 license. See also the commentary by Whitman and Vining in this issue.

The Women Making Their Mark in Modern Scottish Medical History.

Introduction: Women in medicine and surgery are a recent phenomenon. The aim of this study was to review the modern history of pioneering women in medicine and surgery in Scotland. Methods: A variety of sources were searched including Google, PubMed, and the Royal College of Surgeons of Edinburgh publications to source the material for this paper. Results: Despite over five centuries of Scottish universities offering medical degrees, women have only had the right to study medicine for 150years. However, the lives of women pioneers who either circumnavigated or surmounted this inequality, namely, "James Barry" and Sophia Jex-Blake, are briefly told. Conclusion: Doctors today owe a debt to those who pushed the boundaries, challenged the unfair rules and tackled institutional gender inequality in medicine. Reading about their lives and work is uplifting.

Scottish Medical Imaging Service - Technical and Governance controls.

ObjectivesThe Scottish Medical Imaging (SMI) service provides linkable, population based, “research-ready” real-world medical images for researchers to develop or validate AI algorithms within the Scottish National Safe Haven. The PICTURES research programme is developing novel methods to enhance the SMI service offering through research in cybersecurity and software/data/infrastructure engineering. ApproachAdditional technical and governance controls were required to enable safe access to medical images. The researcher is isolated from the rest of the trusted research environment (TRE) using a Project Private Zone (PPZ). This enables researchers to build and install their own software stack, and protects the TRE from malicious code. Guidelines are under development for researchers on the safe development of algorithms and the expected relationship between the size of the model and the training dataset. There is associated work on the statistical disclosure control of models to enable safe release of trained models from the TRE. ResultsA policy enabling the use of “Non-standard software” based on prior research, domain knowledge and experience gained from two contrasting research studies was developed. Additional clauses have been added to the legal control – the eDRIS User Agreement – signed by each researcher and their Head of Department. Penalties for attempting to import or use malware, remove data within models or any attempt to deceive or circumvent such controls are severe, and apply to both the individual and their institution. The process of building and deploying a PPZ has been developed allowing researchers to install their own software. No attempt has yet been made to add additional ethical controls; however, a future service development could be validating the performance of researchers’ algorithms on our training dataset. ConclusionThe availability to conduct research using images poses new challenges and risks for those commissioning and operating TREs. The Private Project Zone and our associated governance controls are a huge step towards supporting the needs of researchers in the 21st century.

An architecture for building cohorts of images from real-world clinical data from the whole Scottish population supporting research and AI development.

ObjectivesTo research and develop tools and methods for building cohorts of images linked to longitudinal healthcare records from real-world clinical images from the whole Scottish population. To provide this capability for the Scottish Medical Imaging service (provided by the Scottish National Safe Haven) to support research and AI projects. ApproachClinical images, especially when linked to routinely collected health data, are extremely useful for many types of research and AI development. However, finding and using clinical images for research data is challenging because: 1) Existing software used to search for images are designed for clinical care rather than research making it easy to find images for a particular patient. They are not designed to search for all images with particular characteristics e.g. slice thickness/scanning protocol/contrast agent/patient medication. 2) Reuse of clinical images for research requires de-identification, yet identifiable data can be present in many areas of the associated image file. ResultsThe PICTURES (InterdisciPlInary Collaboration for efficienT and effective Use of clinical images in big data health care RESearch) 5-year programme has developed an architecture for building cohorts of images based upon research criteria and providing these in a di-identifiable form within a Safe Haven environment. There are 3 zones: An identifiable zone which stores the raw image data and a MongoDB database which captures the metadata A de-identified zone which provides a database and tools for cohort building which do not require imaging data expertise Several Project Private Zones (PPZs) where researchers can install custom software and access the de-identified images for their project The architecture supports cohort building based upon features within pixel data, image metadata and linking to longitudinal health care records. ConclusionPICTURES is currently enhancing the cohort building user interface used by the National Safe Haven and supporting exemplar projects. The SMI service is live and accepting requests for more information. The software is open source and we welcome the use of the platform by other Safe Havens/research groups.

Concussion education in medical students studying in Scotland: an assessment of knowledge and future needs

ABSTRACT Background Physicians play a key role in ensuring athletes with concussion safely return to sport. Research has shown deficiencies in concussion education amongst physicians and medical students. However, studies have not previously been conducted in UK medical schools. Objectives To assess students’ concussion knowledge and learning in Scottish Medical Schools. Design A survey with 23 questions was distributed to Year 3–6 medical students studying in Scotland in October 2020. The survey included the following: (1) demographics, (2) concussion knowledge, e.g. ‘What is the role of headgear in preventing concussion?’ (3) concussion learning, ‘In which part of the curriculum should concussion be taught?.’ Frequencies of responses were calculated for each question. Results 200 students responded (response rate 8%). The average symptoms and management score were 87.3% and 31% respectively. 15% of participants knew that headgear has no role in preventing concussions and one participant identified the minimum “return to sport” timeframes for adults and children. 15% had learnt about concussion at medical school with 92.5% interested in receiving concussion teaching at medical school. Conclusion Knowledge gaps exist in managing and preventing sports-related concussion. There is a discrepancy between levels of concussion teaching and the desire and importance placed on concussion education.

Radiology for medical students: Do we teach enough? A national study.

ObjectiveA recent study has shown that the averaged time tabled teaching for a medical student across 5 years in the UK was 4629 hours. Radiology has been demonstrated to be an excellent teaching source, yet the number of hours allocated to this has never been calculated.The aims of this study were to evaluate and quantify the hours allocated to radiology teaching in Scottish Medical Schools and to evaluate if they can fulfil requirements expected from other Clinical disciplines and the upcoming General Medical Council Medical Licensing Assessment (GMC MLA).MethodsData pertaining to timetabled teaching for Radiology in Scottish Universities were obtained from the authors of the Analysis of Teaching of Medical Schools (AToMS) survey. In addition, University Lead Clinician Teachers were surveyed on the radiological investigations and skills medical students should have at graduation.ResultsMedical students in Scottish Universities were allocated 59 h in Radiology (0.3%) out of a total 19,325 h of timetabled teaching. Hospital-based teaching was variable and ranged from 0 to 31 h. Almost half (15 of 31) of Clinician Teachers felt that there was insufficient radiology teaching in their specialty. Thirteen of 30 conditions included in the GMC MLA were listed by Clinician Teachers, while 23 others not listed by the GMC were considered important and cited by them.ConclusionThis study demonstrates that medical students do not receive enough radiology teaching. This needs to be addressed by Universities in collaboration with the NHS in an effort to bring up this up to line with other developed countries and prepare students for the GMC MLA.Advances in knowledge(1) There is insufficient time allocated in Medical Students’ curriculum to Radiology.(2) Radiology teaching in medical schools fall short of University Lead Clinician Teachers’ and GMC expectations of medical students at graduation.

Radiology and the medical student: do increased hours of teaching translate to more radiologists?

Objectives:The UK has a shortage of Radiologists to meet the increasing demand for radiologic examinations. To encourage more medical students to consider Radiology as a career, increased exposure at undergraduate level has been advocated. The aim of this study was to evaluate if formal Radiology teaching hours at medical school had any association with the number of qualified Radiologists joining the General Medical Council Specialist Register.Methods:Total number of doctors joining the GMC Specialist Register as Clinical Radiologists, and those with a primary medical qualifications awarded in Scotland, was obtained from the GMC (2010–2020). Graduate numbers from all four Scottish Medical Schools (2000–2011) were also obtained. Hours of Radiology teaching for medical schools in Scotland were obtained from validated AToMS study.Results:Two hundred and twenty three (6.6%) of 3347 Radiologists added to the GMC Specialist Register between 2010 and 2020 received their primary medical qualification (PMQ) from Scottish Universities. The number of Radiologists from Scottish Universities joining the GMC specialist register was 2.6% of the total number of Scottish Medical Graduates. There was no association between the number of hours (Range 1–30) Radiology was taught to medical students and the number that joined the specialist register as Radiologists (p = 0.54 chi square trend).Conclusion:Increased exposure to Radiology teaching does not influence medical students’ decision to take up Radiology as a career. While continued Radiology exposure remains important, other strategies are required in both the short and long term to ensure radiology services are maintained without detriment to patients.Advances in knowledge:Increased hours of Radiology teaching in medical school was not associated with increased radiologists joining the profession.

Medical student assessments-frequency of radiological images used: a national study.

Objectives:Assessments are a key part of life for medical students at University. We know there is variation in these assessments across Universities. The aims of this study were to expatiate summative assessments in Scottish Medical Schools and to examine how frequently radiological images feature in them.Methods:All Scottish medical schools were invited to participate in the study. Data on objective structured clinical examinations (OSCEs; 5 years) and written assessments (3 years) were retrospectively collected for each university and results were collated. Each University was randomly assigned a letter from A to E and anonymised for data presentation.Results:10,534 multiple choice questions (MCQ) and 1083 OSCE stations were included in this study. There was wide variation in the number, type and timing of assessments across Scottish medical schools. There were highly significant differences in the number of OSCE stations and the number of MCQs set over the study period (p < 0.0001). Radiological images were used on average 0.6 times (range 0–1.1) in each OSCE examination and 2.4 times (range 0.1–3.7) for written assessments.Conclusion:In this detailed study, we demonstrated significant differences in medical student assessments across Scottish Universities. Given the importance of Radiology in modern medicine, the frequency and differences in which radiological images were used in assessments across Universities should be addressed.Advances in knowledge:This is the first national longitudinal study to quantify the role of radiological images in summative Medical Student Assessments. Great variability exists in the extent and how (clinical versus written assessments) radiological images are used to assess Scottish medical students. Radiological images are used infrequently in clinical assessments, but are present in every written assessment. These findings could help inform medical schools and academic radiologists as they prepare medical students for the imminent unified medical licensing examination, where Clinical Imaging is a subject with one of the highest number of associated conditions examinable.

Is there a need for formal undergraduate patient handover training and could an educational workshop effectively provide this? A proof-of-concept study in a Scottish Medical School

BackgroundPoor communication between healthcare professionals is recognised as accounting for a significant proportion of adverse patient outcomes. In the UK, the General Medical Council emphasises effective handover (handoff) as an...

Harmonising data from different sources to conduct research using linked survey and routine datasets

IntroductionHarmonization of different data sources from various electronic health records across systems enhances the potential scope and granularity of data available to health data research, providing more opportunities for research by improving the generalizability and effective sample size of a range of outcome metrics.&#x0D; Objectives and ApproachThis study describes data harmonisation for a UK longitudinal birth cohort, the Millennium Cohort Study (MCS) which was linked to routine inpatient and emergency department, and, where available, general practice and child health records for 1838 Welsh and 1431 Scottish consenting MCS participants. Datasets requiring harmonisation were: from Wales, Patient Episode Dataset for Wales (PEDW) and Emergency Department Data Set (EDDS) data and from Scotland, Scottish Medical Record 01 (SMR01) and Accident and Emergency dataset (A&amp;E2). Heterogeneous variables were created by transforming variable names, concepts, codes to improve scope for analysis.&#x0D; ResultsA harmonized dataset of 2166 participants and 5747 hospital admissions were derived of cohort members who had at least 1 hospital inpatient or A&amp;E event before their 14th birthday. Harmonisation included: dealing with date granularity by generating random dates of birth; standardising periods of data collection; identifying inconsistencies and then mapping and bridging differences in definitions of periods of care and levels of diagnostic and operational coding across countries and datasets.&#x0D; Conclusion/ImplicationsHeterogeneous variables from different data sources were pooled and converted into standardised data for research, extending existing harmonisation work, including curation of a population based anonymously linkable longitudinal cohort. [AA1] These methods are reproducible and can be utilised by other researchers and projects applying to use these routine data sources.

Integrating electronic health records from different sources across the UK: lessons from a record linkage study

BackgroundHarmonisation of different data sources from various electronic health records (EHRs) across systems enhances the potential scope and granularity of data available to health data research.&#x0D; ObjectiveTo describe data harmonisation of routine electronic healthcare records in Wales and Scotland linked to a UK longitudinal birth cohort, the Millennium Cohort Study (MCS).&#x0D; MethodsComparable secondary care data was linked, with parental consent, to MCS information for 1838 and 1431 children participating in MCS and residing in Wales and Scotland, by assigning, respectively, unique Anonymised Linkage Fields to personbased records in the privacy protecting Secure Anonymised Information Linkage (SAIL) databank at Swansea University, and by the National Health Service (NHS) Information Standards Division. Survey and non-response weights were created to account for the clustered sample, sample attrition and consent to linkage. Heterogeneous variables from the Patient Episode Dataset for Wales, Emergency Department Data Set for Wales, Scottish Medical Record 01 and Accident and Emergency dataset for Scotland were harmonised enabling data to be pooled and standardised for research.&#x0D; FindingsOverall linkage to harmonised health care data was achieved for 98.9% (99.9% for Wales and 97.6% for Scotland) of consented MCS participants. 66% of children experienced at least one hospital admission (total 5747 hospital admissions) up totheir 14th birthday, while 60% attended A&amp;E departments at least once (total 5221 attendances) between their 9th and 14th birthday. We managed date granularity by generating random dates of birth, standardising periods of data collection,identifying inconsistencies and then mapping and bridging differences in definitions of periods of care across countries and datasets.&#x0D; ConclusionsCombining and harmonising data from multiple sources and linking them to information from a longitudinal cohort create useful resources for population health research. These methods are reproducible and can be utilised by other researchersand projects.

Retraction notice.

At the request of the Journal Editor and the Publisher, the following article has been retracted. Sajid M.S. Bioethics and Medical Education. Scottish Medical Journal 2008; 53(2): 62-63. DOI: 10.1258/rsmsmj.53.2.62 The above paper has substantial unreferenced overlap to the following paper: Jafarey A.M. Bioethics and Medical Education. Journal of Pakistan Medical Association 2003; 53 (6): 210-214.

How are the principles of integration currently taught to Scottish medical students? Sharing ideas and building connections in undergraduate education

An introduction: (comprising background and problem statement) In April 2016, legislation came into force in Scotland implementing Health and Social Care integration. This project looks at teaching and promoting integrated care to medical students who will be involved in its future delivery. Description of policy context and objective: To explore how integration is currently taught to medical students with an aim to highlight and share innovation, and explore relevant incorporation into the undergraduate curriculum. Targeted population: This project looks at the medical undergraduate population in Scotland. Highlights: (innovation, Impact and outcomes) Staff involved in curriculum design from all five Scottish Medical Schools were interviewed, exploring healthcare system structure, health and social care integration, person-centred care and inter-professional teaching. Overall they demonstrated, to differing extents, these principles with specific teaching on professionalism, teamwork, communication, self-reflection etc. One university has introduced managing uncertainty at an early stage, another has introduced a module which focuses on the operation of a ward. Medical students work closely with nurses and allied health professionals (as well as families), giving insight into the healthcare system and holistic care. Some had strong inter-professional teaching with one university using clinical scenario/simulation teaching and group reflection with good feedback. Positive role-modelling of community facing specialities, joint teaching from doctors and other healthcare professionals, clinical skills taught by nurses etc. is displaying professional behaviour required for working within integrated services. These projects have received positive feedback from students, staff and patients involved. It has also encouraged use of new technology to encourage engagement of students. Comments on transferability: Each university’s curriculum is different and changes recommended need to be general to allow appropriate and relevant adaptation. A focus on the themes of integration – including empowering patients, families and communities; social determinants, managing risk, health inequalities, complexity, multi-morbidity – rather than detailed teaching on specifics of the Scottish healthcare system will make the teaching more relevant and transferrable to international students, those who move after graduation etc. Conclusions: (comprising key findings, discussion and lessons learned) There is already a lot of teaching on integration principles. There is understandable caution regarding adding material to an already full curriculum but the importance of integration is acknowledged with a willingness to explore this. One of the strongest themes was that the specifics of individual healthcare systems might not be relevant to all medical students. What is valued though, is creating doctors of the future who have a wide range of skills to adapt to an evolving healthcare landscape with a knowledge of the principles of integration. These findings are being fed back to the Deans of the Scottish universities to share ideas and to develop teaching further – creating links and continuity across medical schools. From this project there is now discussion developing with third sector organisations and the government to explore and develop ideas. Further learning/research: - Integration teaching in postgraduate medical education? - Integration teaching for nursing/allied health professional undergraduates? - Could these be connected?

PSY147 - Health Technology Assessment (HTA) for Orphan Drugs in Cost-Effectiveness (CE) Markets: Current Development and Future Trends

Current Health Technology Assessment (HTA) systems in cost-effectiveness (CE) markets have been criticised for preventing patients from gaining access to orphan drugs (ODs). This research aims to provide an update on HTAs for ODs in the UK, Australia and South Korea, and identify emerging criteria to improve market access for ODs in these markets. Guidelines and policies from HTA bodies were analysed to understand the latest HTA criteria in the UK, Australia and South Korea. Market-specific websites were assessed for updates and emerging trends for OD HTAs. Payers were interviewed where clarification was needed to validate and substantiate findings from secondary research. Given high price and limited data, ODs struggle to meet CE criteria for reimbursement in the UK, Australia and South Korea. Alternative mechanisms are being explored in these markets to support better access to ODs. In the UK, NICE has developed an “interim process” to evaluate highly specialised drugs for very rare diseases and the Scottish Medical Council (SMC) has introduced the “patients and clinicians engagement (PACE) program”. Both mechanisms aim to capture broader values of ODs, such as the nature of the disease or patient/physician voice. In Australia and South Korea, mechanisms exist to allow reimbursement of ODs that do not fulfil CE requirements but meet additional criteria, namely lack of alternative treatment, high disease severity and significant clinical improvement (e.g. “rule of rescue” in Australia). Further aspects of value for ODs are being considered, including societal benefits, such as caregiver quality of life. Multi-criteria decision analysis is being investigated, giving different weightings to various elements to better reflect the overall value of ODs. The CE markets are investigating different approaches for adapting OD HTAs with a common aim of improving market access. Cross-learning between these CE markets will be beneficial to identify an optimal mechanism.

Undergraduate medical education: looking back, looking forward.

This commentary briefly looks at some history of Medical Education in Scotland with a focus on the last two decades since the publication of 'Tomorrow's Doctors' by the General Medical Council in 1993. The current influences on Scottish Medical Education are discussed, and some of the advantages provided by technology are described. The piece concludes by emphasising the current strengths of Scottish Medical Education, which are learning from contact with patients and good clinical role models, to help students make sense of their clinical experience.

Head injury and mortality in the homeless.

Risk factors for head injury are also risk factors for becoming homeless but there is little research on this vulnerable group, who can be neglected by health services that specialize in acquired brain injury. This study investigates the prevalence of admissions to hospital with a head injury in the homeless and associations with later mortality. It compares homeless people with and without a record of hospitalized head injury (HHI) and the Glasgow population. Data were obtained from a U.K. National Health Service strategy to enhance care of the homeless. This included development and production of local registers of homeless people. In Glasgow, the initiative took place over a seven-year period (2004-2010) and comprised 40 general practitioner (family practice) services in the locality of 55 homeless hostels. The register was linked to hospital admissions with head injury recorded in Scottish Medical Records and to the General Register of Scotland, which records deaths. A total of 1590 homeless people was registered in general practitioner (family doctor) returns. The prevalence of admission to hospital with head injury in the homeless over a 30-year period (13.5%) was 5.4 times higher than in the Glasgow population. In the homeless with HHI, 33.6% died in the seven-year census period, compared with 13.9% in the homeless with no hospitalized HI (NHHI). The standardized mortality ratio for HHI (4.51) was more than twice that for NHHI (2.08). The standardized mortality ratio for HHI aged 15-34 (17.54) was particularly high. These findings suggest that HHI is common in the homeless relative to the general population and is a risk factor for late mortality in the homeless population.

Lessons from Yesterday: A Student's Reflection on Scottish Medical Education

The previous century has witnessed radical changes to the way in which medical students in Scotland are taught. Given the rapidly advancing medical landscape this is understandable, yet agreement on course content, how it should be taught and by whom, all remain contentious. However throughout the years the medical profession has endured, and skills have been passed down to successive generations; so are there any lessons to be learnt from our past? This paper suggests that there are, and seeks to illustrate the many parallels between 18th and 19th century teaching and today, including the quintessence of an inspirational teacher. A wide variety of 18th-21st century primary and secondary sources have been perused in the preparation of this paper.

Florence Nightingale and Mary Seacole: Which is the forgotten hero of health care and why?

This paper aims at correcting misinformation in circulation portraying Mary Seacole as a nurse, Crimean War heroine, and health care pioneer, even, for some, a replacement for Florence Nightingale, who really was a health care pioneer as well as being the major founder of the modern profession of nursing. The article focuses on the claims for Seacole made by C. Short in Scottish Medical Journal, 2011. It reports, using primary sources, on what Seacole actually did--running a business for officers, with kind acts on the side--short of constituting heroism, pioneering health care or nursing. The article concludes with remarks on how Nightingale came to be forgotten as a health care pioneer, with comments on the two major sources that attacked her reputation, F.B. Smith in 1982, and Hugh Small in 1998. Detailed refutations in peer-reviewed sources are referenced. Finally, it is suggested that recent scandals in English hospital care, documented in the Francis Report, may provoke a revival of interest in Nightingale's principles and methods.