London Postgraduate Medical and Dental Education

Background Placenta Accreta Spectrum (PAS) disorders has been reported to be associated with a maternal mortality rate of 7–10%, worldwide, and many women who survive, experience life changing morbidity. Triple P procedure (p- perioperative placental localization and incision on the myometrium above the upper border of the placenta; p- pelvic devascularisation; and p-placental non-separation and myometrial excision) was developed in 2010 as a novel conservative alternative to peripartum hysterectomy to avoid severe maternal morbidity and mortality). There have been several modifications to the original Triple P Procedure to achieve “pelvic devascularisation” based on locally available resources. Objective To determine the effectiveness of the Triple P Procedure and its modifications on reducing the blood loss and the rate of peripartum hysterectomy in women who were diagnosed to have placental accreta spectrum (PAS) by reviewing the published literature. Materials and methods PubMed, Embase and Google Scholar Search searches were made using “Triple P” and “Modified Triple P.” Papers selected were assessed independently for content, data extraction and analysis. The following parameters were included for the analysis: total number of cases, total EBL, need for blood transfusion, injury to adjacent pelvic organs (urinary bladder, ureter, bowel), need for embolization, admission to intensive care unit (ICU), post-operative in-patient hospital stay, peripartum Hysterectomy, for “Modified” Triple P Procedure, the nature of the modification.Study characteristics were extracted using a predesigned data extraction table. Results The literature search identified 6 articles on the Triple P Procedure and 8 articles on the modified Triple P Procedure which were deemed eligible for analysis and comparison, based on the inclusion criteria. 75 patients had the Triple P procedure with an estimated mean blood loss of 2.31 L and a blood transfusion rate of 52%. The bladder injury rate was only 1.3%. None of the patients had a peripartum hysterectomy. Overall, 654 patients had the Modified Triple P procedure with an estimated mean blood loss of 1.4 L and a blood transfusion rate of 64.5%. The mean hospital stay was 3.86 days and 6.1% had a peripartum hysterectomy. Conclusion The Triple P Procedure and the Modified Triple P procedure are associated with lower estimated blood loss as compared to the reported rates with a peripartum hysterectomy. The Triple P Procedure was associated with lower rates of inadvertent injuries to the bladder and ureters as compared to the Modified Triple P Procedure and reported rates with peripartum hysterectomy. Both the Triple P and the Modified Triple P Procedure are associated with very low rates of peripartum hysterectomy (0% and 6.1%, respectively).

Postpartum hemorrhage (PPH) is an obstetric emergency and refers to excessive blood loss after birth. Loss of blood volume and oxygen-carrying capacity may lead to maternal hypovolemia and hypotension resulting in tissue hypoxia, the onset of anaerobic metabolism, and multiorgan failure. If timely and appropriate action is not taken, cardiac arrest and maternal death may occur. If the amount of blood loss exceeds 500 mL following a vaginal birth or 1000 mL during or following a cesarean section, it is termed PPH. Similar to any other surgical hemorrhage, PPH is classified into primary PPH (occurs within 24 hours of birth) or secondary PPH (between 24 hours and 12 weeks postpartum). PPH is a major contributor to maternal deaths worldwide, and it is estimated that a person dies because of PPH approximately every 5 minutes. Therefore, measures should be directed at prevention and early detection of PPH with prompt management. The prevalence of PPH varies globally and is influenced by location, socioeconomic factors, and the availability and quality of health care. The World Health Organization reported that PPH accounts for a quarter of global maternal deaths. The Mothers and Babies Reducing Risks through Audits and Confidential Enquiries report from the United Kingdom (2023) highlighted that despite rare mortality due to hemorrhage, the number of people dying of obstetric hemorrhage is not decreasing, particularly among people with abnormally invasive placentation. Additionally, substandard care was found to be responsible for more than 50% of deaths due to PPH in the United Kingdom. Therefore, it is vital that adequate healthcare infrastructure, trained and competent healthcare professionals, and immediate access to resources, interventions, and multidisciplinary teams are essential both in well-resourced and resource-restrained healthcare systems. Healthcare professionals must identify the potential risk factors for PPH and initiate preventive measures whenever possible. Additionally, they must respond swiftly if PPH occurs and ensure a multidisciplinary, multilayered approach for a synchronized response to optimize outcomes. This review article emphasizes the etiopathogenesis, diagnosis, and management of PPH based on current scientific evidence as well as international best practice recommendations.

Current treatment strategy for managing Weber B ankle fractures is mainly governed by mortise congruency, malleolar alignment, deltoid ligament competence and fracture stability. While nonoperative treatment has yielded good functional outcomes in satisfactorily aligned stable injuries, a biomechanical rationale is not firmly established. Furthermore, current radiographic analysis is obscured by observer inaccuracy and beam rotation. This study aimed to utilize weightbearing CT and computational biomechanics to analyse 3D mortise displacement and contact mechanics in Weber-B ankle fractures and compare them with the uninjured contralateral side. 32 patients were included who sustained a Weber-B ankle fracture and underwent bilateral weightbearing CT imaging at injury. Segmentation into 3D models of bone was performed semi-automatically, and individualized cartilage layers were modeled based on a previously validated methodology. The 3D mortise congruency was evaluated by use of following parameters: alpha angle, fibular length, talocrural angle, medial gutter- and tibiofibular clear space- distance mapping. Contact mechanics were evaluated by the mean and maximum contact stress of the tibiotalar articulation. Statistical analysis revealed that there were no significant differences for all anatomical parameters. There was also no significant difference between the mean contact stress of the injured (2.10 ± 0.42 MPa) and uninjured side (2.10 ± 0.41 MPa), nor the maximum contact stress of the injured (7.67 ± 1.55 MPa) and uninjured (7.47 ± 1.67), respectively. Contact mechanics were unaffected in congruent Weber-B fractures. These findings support consideration of nonoperative management in such cases, given their presumably low risk for posttraumatic arthritic development in the long term. Level of Evidence: Level III; retrospective case-control study.

Background Exposure to surgery during medical school is limited. We ran a mentorship scheme pairing students at a medical school with local surgeons to improve undergraduate insight. We evaluated the effectiveness of mentorship in increasing surgical exposure and drivers for students seeking surgical mentorship. Methods 35 surgeons across 7 specialties were recruited and matched with 37 students in years 2–4 for 7 months. Quantitative and qualitative evaluation was done with pre-, mid- and post-scheme questionnaires. Students rated confidence across pursuing a career in surgery, surgical exposure, career insight, understanding the application process, contacts, portfolio development, research knowledge and pursuing extra-curricular activities related to surgery using a 5-point Likert scale. Paired t-tests were performed to measure students’ confidence before and after the scheme. Results Of students that completed all 3 questionnaires (n = 21), conducting research/audit was most frequently selected as a main goal (81.0%), followed by theatre experience (66.7%) and career progression support (28.6%). The number of students that had assisted in theatre increased by 50.0%. Confidence ratings across all domains increased with 7/8 (87.5%) exhibiting a statistically significant improvement (p < 0.05). The greatest improvement was seen in having adequate contacts in surgery from 2.05 to 3.33 (p = 0.00). 95.2% would recommend the scheme. Conclusions Students gained significantly more surgical experience and were better equipped with the knowledge required to pursue a surgical career. Mentorship schemes are invaluable in supplementing the undergraduate curriculum and empowering students. Trial registration Ethical clearance granted by King’s College London Research Ethics Committee, Reference Number MRSU-22/23-34530. .

Institutional Research associations across the world are re-imagining and redesigning their professional development and capacity building activities. This paper outlines the professional development activities of the Association for Institutional Research (AIR) in the United States (est. 1966), the European Association for Institutional Research (EAIR) (est. 1978), the Southern African Association for Institutional Research (SAAIR) (est. 1994) and the United Kingdom and Ireland Higher Education Institutional Research Network (HEIR) (est. 2008) and argues that a more sophisticated approach to IR is needed, informed by systems thinking, aimed at proactive engagement with policy-makers and managers, organisational learning, direct links to institutional strategy (‘a seat at the table’), and the analysis and use of larger volumes of data.

The anterior cruciate ligament (ACL) is a vital but frequently injured structure. An ACL injury can result in dysfunction, meniscal injuries, and the early onset of osteoarthritis. This article aims to discuss favourable reconstruction techniques through a literature review with consideration for novel methods in order to identify superior methods that provide a patient’s return to function. Current surgical options include reconstruction using different types of autografts and allografts.

Sleep and mood/emotion influence learning and academic achievement. However, inconclusive/contradictory findings have been reported. Unlike previous studies that examined either sleep or mood and grade-point-average (combined result of several assessments over long period), this study examined UK university students for the relationship of test scores with both, previous night’s sleep-duration, and mood/emotion approximately an hour before the test. Mood/feelings data were collected by presenting a selection of emojis and text. Here, test scores did not associate with night sleep-duration. There were no differences in distribution of scores across sleepers of 5, 6, 7 and 8 h and sleeping for less than these hours did not increase the odds of scoring low (scoring ≤ 25%). There was no significant difference in distribution of night-sleep-hours between high scorers (score ≥ 75%) and low scorers (score ≤ 25%). Furthermore, test scores did not associate with feelings/emotions. There were no significant differences in the distribution of scores across different feelings. Unhappy/negative feelings did not increase the odds of scoring low. However, feelings (specifically expressed through selection of words/phrases) predicted scores (p = 0.01) and both negative and positive feelings associated with increased odds of high score (p ≤ 0.04). Night-sleep-duration positively associated with feelings (p < 0.001). Distribution of night-sleep-duration differed between feelings (p ≤ 0.003). Night sleep of less than 5, 6, 7 or 8 h increased the odds of feeling unhappy/negative (p ≤ 0.01). This data (i) defies the generic notion of a night of sub-optimal sleep-duration negatively affecting scores, (ii) provides empirical evidence of association between night-sleep-duration and emotions/mood/feelings, and (iii) proposes that sleep may affect learning via mood.

Relative uteroplacental insufficiency of labor (RUPI‐L) is a clinical condition that refers to alterations in the fetal oxygen “demand–supply” equation caused by the onset of regular uterine activity. The term RUPI‐L indicates a condition of “relative” uteroplacental insufficiency which is relative to a specific stressful circumstance, such as the onset of regular uterine activity. RUPI‐L may be more prevalent in fetuses in which the ratio between the fetal oxygen supply and demand is already slightly reduced, such as in cases of subclinical placental insufficiency, post‐term pregnancies, gestational diabetes, and other similar conditions. Prior to the onset of regular uterine activity, fetuses with a RUPI‐L may present with normal features on the cardiotocography. However, with the onset of uterine contractions, these fetuses start to manifest abnormal fetal heart rate patterns which reflect the attempt to maintain adequate perfusion to essential central organs during episodes of transient reduction in oxygenation. If labor is allowed to continue without an appropriate intervention, progressively more frequent, and stronger uterine contractions may result in a rapid deterioration of the fetal oxygenation leading to hypoxia and acidosis. In this Commentary, we introduce the term relative uteroplacental insufficiency of labor and highlight the pathophysiology, as well as the common features observed in the fetal heart rate tracing and clinical implications.

Objectives To alert the paediatric community of this unusual presentation of electrolyte abnormalities, the most differentials, and management steps. Methods Prospective and retrospective data collection during the admission of this patient to the neonatal unit. Results Secondary pseudohypoaldosteronism is a condition characterized by aldosterone resistance in renal tubules. It is highly associated in the literature with urinary tract infections and malformations, especially in male infants. A three day old term male infant was admitted in the neonatal unit with jaundice. Apart from hyper- bilirubinaemia, his laboratory test results revealed hyponatremia and hyperkalaemia, and pyuria. He was treated with intravenous fluids, calcium gluconate, enteral feeding, and antimicrobial therapy. Electrolyte disorders were addressed and he was discharged on the 7th day of hospitalization without any sequelae. His urine culture showed mixed growth and his renal ultrasonography showed no abnormalities. Conclusion Transient pseudohypoaldosteronism is an important consideration in the differential diagnosis in infants with hyponatremia and hyperkalaemia, even when investigations show no abnormality. It should be considered in cases presenting for a different primary reason and where such electrolyte imbalances are an incidental finding. References • Fountain JH, Kaur J, Lappin SL. Physiology, Renin Angiotensin System. [Updated 2023 Mar 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470410/. • Watanabe T. Reversible secondary pseudohypoaldosteronism. Pediatr Nephrol 2003; 18 :486. https://doi.org/10.1007/s00467-003-1104-6. • Llana I, Sanchez-Redondo M, Benedit M, et al. 960 Secondary Pseudohypoaldosteronism Due to Pyelonephritis: Two Cases Report. Archives of Disease in Childhood 2012; 97 :A274. • Rodríguez-Soriano J, Vallo A, Oliveros R, Castillo G. Transient pseudohypoaldosteronism secondary to obstructive uropathy in infancy. J Pediatr. 1983; 103 :375–80. 10.1016/s0022–3476(83)80406–5. • Delforge X, Kongolo G, Cauliez A, Braun K, Haraux E, Buisson P. Transient pseudohypoaldosteronism: a potentially severe condition affecting infants with urinary tract malformation. J Pediatr Urol. 2019; 15 :265.e1–7. 10.1016/j.jpurol.2019.03.002.

Background India is a large and populous country where reliable data on headache disorders are relatively scarce. This study in northern India (Delhi and National Capital Territory Region [NCR], including surrounding districts in the States of Haryana, Uttar Pradesh and Rajasthan) continues the series of population-based studies within the Global Campaign against Headache and follows an earlier study, using the same protocol and questionnaire, in the southern State of Karnataka. Methods This cross-sectional study used the Global Campaign’s established methodology. Biologically unrelated Indian nationals aged 18–65 years were included through multistage random sampling in both urban and rural areas of NCR. Interviews at unannounced household visits followed the structured Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire in its original English version or in the validated Hindi version. Demographic enquiry was followed by a neutral headache screening question and diagnostic questions based on the International Classification of Headache Disorders edition 3 (ICHD-3), which focused on each respondent’s most bothersome headache. Questions about headache yesterday (HY) enabled estimation of 1-day prevalence. A diagnostic algorithm first identified participants reporting headache on ≥ 15 days/month (H15+), diagnosing probable medication-overuse headache (pMOH) in those also reporting acute medication use on ≥ 15 days/month, and “other H15+” in those not. To all others, the algorithm applied ICHD-3 criteria in the order definite migraine, definite tension-type headache (TTH), probable migraine, probable TTH. Definite and probable diagnoses were combined. Results Adjusted for age, gender and habitation, 1-year prevalences were 26.3% for migraine, 34.1% for TTH, 3.0% for pMOH and 4.5% for other H15+. Female preponderance was seen in all headache types except TTH: migraine 35.7% vs. 15.1% (aOR = 3.3; p < 0.001); pMOH 4.3% vs. 0.7% (aOR = 5.1; p < 0.001); other H15 + 5.9% vs. 2.3% (aOR = 2.5; p = 0.08). One-day prevalence of (any) headache was 12.0%, based on reported HY. One-day prevalence predicted from 1-year prevalence and mean recalled headache frequency over 3 months was slightly lower (10.5%). Conclusions The prevalences of migraine and TTH in Delhi and NCR substantially exceed global means. They closely match those in the Karnataka study: migraine 25.2%, TTH 35.1%. We argue that these estimates can reasonably be extrapolated to all India.

The Dental Practicality Index (DPI) has been designed to describe, on a clinical level, the 'practicality' of restoring a tooth versus referring to secondary care or extraction.The systematic approach of DPI has been shown to improve decision-making and confidence in treatment planning when used by young dentists. In addition, there is good evidence demonstrating that it provides an accurate estimation of the outcome of treatment. The DPI enhances clinician-patient communication and ultimately the consent process.

Cirrhosis is an advanced-stage liver disease that occurs due to persistent physiological insults such as excessive alcohol consumption, infections, or toxicity. It is characterised by scar tissue formation, portal hypertension, and ascites (accumulation of fluid in the abdominal cavity) in decompensated cirrhosis. This review evaluates how albumin infusion ameliorates cirrhosis-associated complications. Since albumin is an oncotic plasma protein, albumin infusion allows movement of water into the intravascular space, aids with fluid resuscitation, and thereby contributes to resolving cirrhosis-induced hypovolemia (loss of extracellular fluid) seen in ascites. Thus, albumin infusion helps prevent paracentesis-induced circulatory dysfunction, a complication that occurs when treating ascites. When cirrhosis advances, other complications such as spontaneous bacterial peritonitis and hepatorenal syndrome can manifest. Infused albumin helps mitigate these by exhibiting plasma expansion, antioxidant, and anti-inflammatory functions. In hepatic encephalopathy, albumin infusion is thought to improve cognitive function by reducing ammonia concentration in blood and thereby tackle cirrhosis-induced hepatocyte malfunction in ammonia clearance. Infused albumin can also exhibit protective effects by binding to the cirrhosis-induced proinflammatory cytokines TNFα and IL6. While albumin administration has shown to prolong overall survival of cirrhotic patients with ascites in the ANSWER trial, the ATTIRE and MACHT trials have shown either no effect or limitations such as development of pulmonary oedema and multiorgan failure. Thus, albumin infusion is not a generic treatment option for all cirrhosis patients. Interestingly, cirrhosis-induced structural alterations in native albumin (which lead to formation of different albumin isoforms) can be used as prognostic biomarkers because specific albumin isoforms indicate certain complications of decompensated cirrhosis.

Background Knowledge of the prevalence and attributable burden of headache disorders in India is sparse, with only two recent population-based studies from South and East India. These produced conflicting results. A study in North India is needed. We report the methodology of such a study using, and validating, a Hindi translation of the Headache-Attributed Restriction, Disability, Social Handicap, and Impaired Participation (HARDSHIP) questionnaire developed by Lifting The Burden (LTB). Almost half of the Indian population speak Hindi or one of its dialects. Methods The study adopted LTB’s standardized protocol for population-based studies in a cross-sectional survey using multistage random sampling conducted in urban Delhi and a surrounding rural area. Trained interviewers visited households unannounced, randomly selected one adult member from each and applied the Hindi version of HARDSHIP in face-to-face interviews. The most bothersome headache reported by participants was classified algorithmically into headache on ≥ 15 days/month (H15 +), migraine (including definite and probable) or tension-type headache (including definite and probable). These diagnoses were mutually exclusive. All participants diagnosed with H15 + and a 10% subsample of all others were additionally assessed by headache specialists and classified as above. We estimated the sensitivity and specificity of HARDSHIP diagnoses by comparison with the specialists’ diagnoses. Results From 3,040 eligible households, 2,066 participants were interviewed. The participating proportions were 98.3% in rural areas but 52.9% in urban Delhi. In the validation subsample of 291 participants (149 rural, 142 urban), 61 did not report any headache (seven of those assessed by HARDSHIP, eight by headache specialists and 46 by both) [kappa = 0.83; 95% CI: 0.74-0.91]. In the remaining 230 participants who reported headache in the preceding year, sensitivity, specificity and kappa with (95% CI) were 0.73 (0.65-0.79), 0.80 (0.67-0.90) and 0.43 (0.34-0.58) for migraine; 0.71 (0.56-0.83), 0.80 (0.730.85) and 0.43 (0.37-0.62) for TTH and 0.75 (0.47-0.94), 0.93 (0.89-0.96) and 0.46 (0.34-0.58) for H15 + respectively. Conclusion This study validates the Hindi version of HARDSHIP, finding its performance similar to those of other versions. It can be used to conduct population surveys in other Hindi-speaking regions of India.

Background Rheumatoid arthritis (RA) is a common acute inflammatory autoimmune connective tissue arthropathy. The genetic studies, tissue analyses, experimental animal models, and clinical investigations have confirmed that stromal tissue damage and pathology driven by RA mounts the chronic inflammation and dysregulated immune events. Methods We developed methotrexate (MTX)-loaded lipid-polymer hybrid nanoparticles (MTX-LPHNPs) and aceclofenac (ACE)-loaded nanostructured lipid carriers (ACE-NLCs) for the efficient co-delivery of MTX and ACE via intravenous and transdermal routes, respectively. Bio-assays were performed using ex-vivo skin permeation and transport, macrophage model of inflammation (MMI) (LPS-stimulated THP-1 macrophages), Wistar rats with experimental RA (induction of arthritis with Complete Freund’s adjuvant; CFA and BCG), and programmed death of RA affected cells. In addition, gene transcription profiling and serum estimation of inflammatory, signaling, and cell death markers were performed on the blood samples collected from patients with RA. Results Higher permeation of ACE-NLCs/CE across skin layers confirming the greater “therapeutic index” of ACE. The systemic delivery of MTX-loaded LPHNPs via the parenteral (intravenous) route is shown to modulate the RA-induced inflammation and other immune events. The regulated immunological and signaling pathway(s) influence the immunological axis to program the death of inflamed cells in the MMI and the animals with the experimental RA. Our data suggested the CD40-mediated and Akt1 controlled cell death along with the inhibited autophagy in vitro. Moreover, the ex vivo gene transcription profiling in drug-treated PBMCs and serum analysis of immune/signalling markers confirmed the therapeutic role co-delivery of drug nanoparticles to treat RA. The animals with experimental RA receiving drug treatment were shown to regain the structure of paw bones and joints similar to the control and were comparable with the market formulations. Conclusion Our findings confirmed the use of co-delivery of drug nanoformulations as the “combination drug regimen” to treat RA.

This review provides a concise overview of the cellular and clinical aspects of the role of zinc, an essential micronutrient, in human physiology and discusses zinc-related pathological states. Zinc cannot be stored in significant amounts, so regular dietary intake is essential. ZIP4 and/or ZnT5B transport dietary zinc ions from the duodenum into the enterocyte, ZnT1 transports zinc ions from the enterocyte into the circulation, and ZnT5B (bidirectional zinc transporter) facilitates endogenous zinc secretion into the intestinal lumen. Putative promoters of zinc absorption that increase its bioavailability include amino acids released from protein digestion and citrate, whereas dietary phytates, casein and calcium can reduce zinc bioavailability. In circulation, 70% of zinc is bound to albumin, and the majority in the body is found in skeletal muscle and bone. Zinc excretion is via faeces (predominantly), urine, sweat, menstrual flow and semen. Excessive zinc intake can inhibit the absorption of copper and iron, leading to copper deficiency and anaemia, respectively. Zinc toxicity can adversely affect the lipid profile and immune system, and its treatment depends on the mode of zinc acquisition. Acquired zinc deficiency usually presents later in life alongside risk factors like malabsorption syndromes, but medications like diuretics and angiotensin-receptor blockers can also cause zinc deficiency. Inherited zinc deficiency condition acrodermatitis enteropathica, which occurs due to mutation in the SLC39A4 gene (encoding ZIP4), presents from birth. Treatment involves zinc supplementation via zinc gluconate, zinc sulphate or zinc chloride. Notably, oral zinc supplementation may decrease the absorption of drugs like ciprofloxacin, doxycycline and risedronate.

Introduction The COVID-19 pandemic has led to significantly more healthcare workers (HCWs) experiencing burnout than previously. This burnout is strongly associated with low resilience. Addressing organisational stresses and the introduction of resilience training will help to reduce the proportion of HCWs experiencing this phenomenon. Aims The aim of this study was to assess the impact of the biopsychosocial changes and challenges associated with the COVID-19 pandemic on the healthcare workforce, exploring, specifically, the impact on and relationship between HCWs' resilience and burnout. Methods An electronic opt-in survey was distributed to HCWs through hospital and professional association communications emails and websites, as well as social media. The survey consisted of demographic questions, the Oldenburg Burnout Inventory to assess burnout, Brief Resilience Scale to assess general resilience, and 10-item Connor-Davidson Resilience Scale to assess resilience during the pandemic. Univariate and multivariate analysis was undertaken to examine the relationship between these factors. Results A total of 1370 HCWs completed the questionnaire, with 802 (58.5%) having burnout, 348 (25.4%) having low general resilience and 390 (28.5%) having low COVID resilience. Burnout was significantly associated with being public sector workers, low general resilience and low COVID resilience. Resilience training was found to be protective for burnout. Conclusion The introduction of resilience training in the workplace is a fundamental tool that will significantly benefit HCWs when working under challenging conditions.

Specialist, associate specialist and specialty (SAS) doctors constitute a marginalised professional group who can struggle to achieve the professional development they desire. Our primary objective was to understand, from a theoretically informed perspective, the ways in which the professional identity of SAS doctors influences their professional development opportunities, including through appraisal. Ten UK SAS doctors participated in in-depth, narrative interviews. Participants were drawn from six medical specialities, and ranged in experience (2.5–15 years) and country of primary medical qualification. Interview transcripts were analysed via critical discourse analysis using Figured Worlds theory. The position of SAS doctors within the Figured World was at times unstable, ambiguous and context dependent. They were often relative outsiders, not immediately trusted by colleagues. Some found their development needs eclipsed by the priorities of colleagues, typically consultants and postgraduate trainees. Appraisal was often not perceived to have successfully addressed these issues. This study enhances our understanding of the lived experience of SAS doctors, which is often in stark contrast to formal policy on the range of roles that they can fulfil. The struggles and successes of SAS doctors described here suggest that there is scope to improve the professional status and professional development opportunities for SAS doctors, including through appraisal.

Introduction Interprofessional leadership is essential to sustain the National Health Service (NHS) in pressured times, which should include the NHS’s third largest clinical workforce in England: allied health professionals (AHPs) (AHPs as defined by NHS England: Art therapists; Dramatherapists; Music therapists; Dietitians; Occupational therapists; Operating department practitioners; Orthoptists; Osteopaths; Paramedics; Physiotherapists; Podiatrists, Prosthetists and Orthotists; Radiographers; Speech and language therapists). Therefore, a feasibility study was undertaken, to explore the views of AHPs working in early to mid-career positions, regarding the barriers and opportunities they encounter, in both leadership and career development. Methods Twenty-seven participants, representing 8 of the 14 AHP professions across England, were interviewed across 10 focus groups. Results Thematic analysis (TA) generated four themes, including the barriers and opportunities for AHP leadership development and career progression. Further TA identified three overarching themes: equitable and interprofessional leadership development; an equitable and structured AHP career pathway; and having AHP leaders at a strategical and/or very senior level. These overarching themes were subsumed under the umbrella category: equity of opportunity and voice. The AHPs, who were interviewed, reported inequitable access to both career and leadership development, compared with other professions, such as nurses, doctors and pharmacists. Discussion Further work is needed to ensure that interprofessional representation, within senior leadership levels, includes AHPs; which the data suggests would directly benefit all AHPs’ leadership and career development. Recommendations for organisations to facilitate leadership and career development were developed from the TA and at a system-wide level. Further research would be beneficial to gather the views of the six AHP professions not interviewed in this study and from other organisations, such as independent practice. However, this feasibility study does attempt to represent the voices of AHPs, which can be lacking in both organisations and research.