Taking time out of training to shed light on “the dark side”

The importance of effective management and leadership is increasingly accepted in medicine, moving from “the dark side to centre stage.” However, few trainees are exposed to formal leadership opportunities. On many courses theory predominates over hands-on experience and reflective practice, and trainees are often observers rather than active participants in management decisions. Some appropriate leadership programmes do exist, however, and increasing numbers of trainees are pursuing these formal learning avenues. One such scheme is the Darzi fellowship, which we completed between 2014 and 2015

Multi-professional clinical leadership training in healthcare: A peer-led evaluation of the experience and benefits of the 'Darzi Fellowship'

Purpose: This paper examines the impact of a structured clinical leadership programme on healthcare professionals working within the British National Health Service (NHS). Clinical leadership is now regarded as essential in addressing the complex challenges in the NHS, yet few trainees of any healthcare discipline receive formal training. The study describes a peer-led evaluation of a year-long, multidisciplinary, experiential programme, the ‘Darzi Fellowship’, based in London. Design: An anonymous survey was analysed using a mixed-methods approach. Individual and collective experiences of fellows were evaluated, in particular the perceived impact the fellowship had on: 1) the fellows themselves, 2) their ‘host’ organisation, and 3) the NHS as a whole Findings A 90% return rate was achieved. 94% reported that the experience had been valuable to them, 85% feeling more empowered to effect change in healthcare systems. Crucial mechanisms to achieve this included increased self-awareness, personal reflection and the freedom to gain a greater understanding of organisations. Particular emphasis was placed on the value of developing clinical networks which promote collaboration across boundaries. Fellows emerged as more reflexive, critical and strategic thinkers. Practical implications: This paper demonstrates the positive impact that clinical leadership training can have on participants, and the mechanisms by which future leaders can be created. Value: Our novel, non-commissioned, peer-initiated and peer-led evaluation describes the personal experiences of Fellows in a unique, multidisciplinary clinical leadership programme. We hope this will inform the development of future schemes in the NHS and provide learning for an international healthcare audience

An atypical adenomatoid odontogenic tumour in the mandible: a report of a paediatric case

An adenomatoid odontogenic tumour (AOT) is a rare odontogenic tumour that is often misdiagnosed as an odontogenic cyst. To acquire additional information about AOT, all reports regarding AOT that had been cited in ‘Pub Med’ since 1990 onwards were reviewed. AOT accounts for about 1–9% of all odontogenic tumours. It is predominantly found in young and female patients, is located more often in the maxilla, and in most cases is associated with an unerupted permanent tooth. The differential diagnosis between AOT and other odontogenic tumours such as ameloblastoma should be well made to avoid extensive ablative surgery. However, AOT frequently resembles other odontogenic lesions such as dentigerous cysts or ameloblastoma. Immunohistochemically, AOT is characterized by positive reactions with certain cytokeratins. For illustration a rare case of an AOT in the mandible is presented that had atypical findings such as buccolingual cortical perforation and resorption with displacement of adjoining teeth.Keywords: adenomatoid odontogenic tumor, dentigerous cyst, odontogenic tumor, paediatric cas

Vortices on the worldsheet of the QCD string

We investigate the properties of the QCD string in the Euclidean SU(N) pure gauge theory when the space-time dimensions transverse to it are periodic. From the point of view of an effective string theory, the string tension $\sigma$ and the low-energy constants $c_k$ of the theory are arbitrary functions of the sizes of the transverse dimensions L_p. Since the gauge theory is linearly confining in D=2, 3 and 4 dimensions, we propose an effective string action for the flux-tube energy levels at any choice of $L_p$, given $\sigma(L_p)$ and $c_k(L_p)$. The Luscher term only depends on the number of massless bosonic degrees of freedom and the effective theory can account for its evolution as a function of $L_p$. As the size of one transverse dimension is varied, we predict a Kosterlitz-Thouless transition of the worldsheet field theory at $\sigma(L_p)L_p^2 \simeq 1/8\pi$ driven by vortices, after which the periodic component of the worldsheet displacement vector develops a mass gap and the effective central charge drops by one unit. The universal properties of the transition are emphasised.Comment: 18 pages, 1figur

The equation of state for two flavor QCD at N_t=6

We calculate the two flavor equation of state for QCD on lattices with lattice spacing a=(6T)^{-1} and find that cutoff effects are substantially reduced compared to an earlier study using a=(4T)^{-1}. However, it is likely that significant cutoff effects remain. We fit the lattice data to expected forms of the free energy density for a second order phase transition at zero-quark-mass, which allows us to extrapolate the equation of state to m_q=0 and to extract the speed of sound. We find that the equation of state depends weakly on the quark mass for small quark mass.Comment: 24 pages, latex, 11 postscipt figure

Mapping geographical inequalities in childhood diarrhoeal morbidity and mortality in low-income and middle-income countries, 2000–17: analysis for the Global Burden of Disease Study 2017

© 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Background: Across low-income and middle-income countries (LMICs), one in ten deaths in children younger than 5 years is attributable to diarrhoea. The substantial between-country variation in both diarrhoea incidence and mortality is attributable to interventions that protect children, prevent infection, and treat disease. Identifying subnational regions with the highest burden and mapping associated risk factors can aid in reducing preventable childhood diarrhoea. Methods: We used Bayesian model-based geostatistics and a geolocated dataset comprising 15 072 746 children younger than 5 years from 466 surveys in 94 LMICs, in combination with findings of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, to estimate posterior distributions of diarrhoea prevalence, incidence, and mortality from 2000 to 2017. From these data, we estimated the burden of diarrhoea at varying subnational levels (termed units) by spatially aggregating draws, and we investigated the drivers of subnational patterns by creating aggregated risk factor estimates. Findings: The greatest declines in diarrhoeal mortality were seen in south and southeast Asia and South America, where 54·0% (95% uncertainty interval [UI] 38·1–65·8), 17·4% (7·7–28·4), and 59·5% (34·2–86·9) of units, respectively, recorded decreases in deaths from diarrhoea greater than 10%. Although children in much of Africa remain at high risk of death due to diarrhoea, regions with the most deaths were outside Africa, with the highest mortality units located in Pakistan. Indonesia showed the greatest within-country geographical inequality; some regions had mortality rates nearly four times the average country rate. Reductions in mortality were correlated to improvements in water, sanitation, and hygiene (WASH) or reductions in child growth failure (CGF). Similarly, most high-risk areas had poor WASH, high CGF, or low oral rehydration therapy coverage. Interpretation: By co-analysing geospatial trends in diarrhoeal burden and its key risk factors, we could assess candidate drivers of subnational death reduction. Further, by doing a counterfactual analysis of the remaining disease burden using key risk factors, we identified potential intervention strategies for vulnerable populations. In view of the demands for limited resources in LMICs, accurately quantifying the burden of diarrhoea and its drivers is important for precision public health. Funding: Bill & Melinda Gates Foundation

The global distribution of lymphatic filariasis, 2000–18: a geospatial analysis

Background Lymphatic filariasis is a neglected tropical disease that can cause permanent disability through disruption of the lymphatic system. This disease is caused by parasitic filarial worms that are transmitted by mosquitos. Mass drug administration (MDA) of antihelmintics is recommended by WHO to eliminate lymphatic filariasis as a public health problem. This study aims to produce the first geospatial estimates of the global prevalence of lymphatic filariasis infection over time, to quantify progress towards elimination, and to identify geographical variation in distribution of infection. Methods A global dataset of georeferenced surveyed locations was used to model annual 2000–18 lymphatic filariasis prevalence for 73 current or previously endemic countries. We applied Bayesian model-based geostatistics and time series methods to generate spatially continuous estimates of global all-age 2000–18 prevalence of lymphatic filariasis infection mapped at a resolution of 5 km2 and aggregated to estimate total number of individuals infected. Findings We used 14 927 datapoints to fit the geospatial models. An estimated 199 million total individuals (95% uncertainty interval 174–234 million) worldwide were infected with lymphatic filariasis in 2000, with totals for WHO regions ranging from 3·1 million (1·6–5·7 million) in the region of the Americas to 107 million (91–134 million) in the South-East Asia region. By 2018, an estimated 51 million individuals (43–63 million) were infected. Broad declines in prevalence are observed globally, but focal areas in Africa and southeast Asia remain less likely to have attained infection prevalence thresholds proposed to achieve local elimination. Interpretation Although the prevalence of lymphatic filariasis infection has declined since 2000, MDA is still necessary across large populations in Africa and Asia. Our mapped estimates can be used to identify areas where the probability of meeting infection thresholds is low, and when coupled with large uncertainty in the predictions, indicate additional data collection or intervention might be warranted before MDA programmes cease

Mapping geographical inequalities in childhood diarrhoeal morbidity and mortality in low-income and middle-income countries, 2000–17 : analysis for the Global Burden of Disease Study 2017

Background Across low-income and middle-income countries (LMICs), one in ten deaths in children younger than 5 years is attributable to diarrhoea. The substantial between-country variation in both diarrhoea incidence and mortality is attributable to interventions that protect children, prevent infection, and treat disease. Identifying subnational regions with the highest burden and mapping associated risk factors can aid in reducing preventable childhood diarrhoea. Methods We used Bayesian model-based geostatistics and a geolocated dataset comprising 15 072 746 children younger than 5 years from 466 surveys in 94 LMICs, in combination with findings of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, to estimate posterior distributions of diarrhoea prevalence, incidence, and mortality from 2000 to 2017. From these data, we estimated the burden of diarrhoea at varying subnational levels (termed units) by spatially aggregating draws, and we investigated the drivers of subnational patterns by creating aggregated risk factor estimates. Findings The greatest declines in diarrhoeal mortality were seen in south and southeast Asia and South America, where 54·0% (95% uncertainty interval [UI] 38·1–65·8), 17·4% (7·7–28·4), and 59·5% (34·2–86·9) of units, respectively, recorded decreases in deaths from diarrhoea greater than 10%. Although children in much of Africa remain at high risk of death due to diarrhoea, regions with the most deaths were outside Africa, with the highest mortality units located in Pakistan. Indonesia showed the greatest within-country geographical inequality; some regions had mortality rates nearly four times the average country rate. Reductions in mortality were correlated to improvements in water, sanitation, and hygiene (WASH) or reductions in child growth failure (CGF). Similarly, most high-risk areas had poor WASH, high CGF, or low oral rehydration therapy coverage. Interpretation By co-analysing geospatial trends in diarrhoeal burden and its key risk factors, we could assess candidate drivers of subnational death reduction. Further, by doing a counterfactual analysis of the remaining disease burden using key risk factors, we identified potential intervention strategies for vulnerable populations. In view of the demands for limited resources in LMICs, accurately quantifying the burden of diarrhoea and its drivers is important for precision public health

The impact of immediate breast reconstruction on the time to delivery of adjuvant therapy: the iBRA-2 study

Background: Immediate breast reconstruction (IBR) is routinely offered to improve quality-of-life for women requiring mastectomy, but there are concerns that more complex surgery may delay adjuvant oncological treatments and compromise long-term outcomes. High-quality evidence is lacking. The iBRA-2 study aimed to investigate the impact of IBR on time to adjuvant therapy. Methods: Consecutive women undergoing mastectomy ± IBR for breast cancer July–December, 2016 were included. Patient demographics, operative, oncological and complication data were collected. Time from last definitive cancer surgery to first adjuvant treatment for patients undergoing mastectomy ± IBR were compared and risk factors associated with delays explored. Results: A total of 2540 patients were recruited from 76 centres; 1008 (39.7%) underwent IBR (implant-only [n = 675, 26.6%]; pedicled flaps [n = 105,4.1%] and free-flaps [n = 228, 8.9%]). Complications requiring re-admission or re-operation were significantly more common in patients undergoing IBR than those receiving mastectomy. Adjuvant chemotherapy or radiotherapy was required by 1235 (48.6%) patients. No clinically significant differences were seen in time to adjuvant therapy between patient groups but major complications irrespective of surgery received were significantly associated with treatment delays. Conclusions: IBR does not result in clinically significant delays to adjuvant therapy, but post-operative complications are associated with treatment delays. Strategies to minimise complications, including careful patient selection, are required to improve outcomes for patients