Does orthopaedic resident efficiency improve with respect to decreased fluoroscopic times in tibial intramedullary nailing? A measure of an ACGME milestone

Background: Intramedullary nailing of tibial fractures is a surgical milestone from the Accreditation Council for Graduate Medical Education (ACGME). Our purpose was to evaluate if fluoroscopic time decreased with increasing resident experience and could be used as a measure of this milestone. Methods: Current Procedural Terminology (CPT) codes were used to identify patients who underwent intramedullary nailing of tibial shaft fractures under the direction of fellowship-trained trauma attending staff. The data collected included patient demographics, fracture classification, fluoroscopic imaging total time, and the post-graduate years (PGY) of orthopaedic residency of the operating resident. Exclusions of patients included concomitant fluoroscopic procedures, inadequate records, or surgeries involving primary assisting residents with less than PGY-2 experience. We compared overall groups between half years and looked at individual resident years for each of the continuous variables. Results: When residents were grouped as senior (PGY-4 and PGY-5) or junior (PGY-2 and PGY-3), seniors used significantly less fluoroscopy than juniors (207.39 sec vs. 258.30 sec, P=0.018). In the first half of the academic year, PGY-2 residents completed tibial nailing slowest in terms of fluoroscopic usage (P=0.003). PGY-4 residents completed tibial nailing faster in terms of fluoroscopic usage than other years (P=0.031). In the second half of the academic year, PGY-5 residents used significantly less fluoroscopy than PGY-2 residents (P=0.035). Conclusions: As the ACGME currently has no measurement for resident progress and efficiency regarding tibial shaft intramedullary nailing, our data indicate that fluoroscopic measurements may be useful in assessing resident proficiency

Preventing and lessening exacerbations of asthma in school-age children associated with a new term (PLEASANT) : Study protocol for a cluster randomised control trial

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly citedBackground: Within the UK, during September, there is a pronounced increase in the number of unscheduled medical contacts by school-aged children (4-16 years) with asthma. It is thought that that this might be caused by the return back to school after the summer holidays, suddenly mixing with other children again and picking up viruses which could affect their asthma. There is also a drop in the number of prescriptions administered in August. It is possible therefore that children might not be taking their medication as they should during the summer contributing to them becoming ill when they return to school. It is hoped that a simple intervention from the GP to parents of children with asthma at the start of the summer holiday period, highlighting the importance of maintaining asthma medication can help prevent increased asthma exacerbation, and unscheduled NHS appointments, following return to school in September.Methods/design: PLEASANT is a cluster randomised trial. A total of 140 General Practices (GPs) will be recruited into the trial; 70 GPs randomised to the intervention and 70 control practices of "usual care" An average practice is expected to have approximately 100 children (aged 4-16 with a diagnosis of asthma) hence observational data will be collected on around 14000 children over a 24-month period. The Clinical Practice Research Datalink will collect all data required for the study which includes diagnostic, prescription and referral data.Discussion: The trial will assess whether the intervention can reduce exacerbation of asthma and unscheduled medical contacts in school-aged children associated with the return to school after the summer holidays. It has the potential to benefit the health and quality of life of children with asthma while also improving the effectiveness of NHS services by reducing NHS use in one of the busiest months of the year. An exploratory health economic analysis will gauge any cost saving associated with the intervention and subsequent impacts on quality of life. If results for the intervention are positive it is hoped that this could be adopted as part of routine care management of childhood asthma in general practice. Trial registration: Current controlled trials: ISRCTN03000938 (assigned 19/10/12) http://www.controlled-trials.com/ISRCTN03000938/.UKCRN ID: 13572.Peer reviewe

Nutritional factors and gender influence age-related DNA methylation in the human rectal mucosa

Aberrant methylation of CpG islands (CGI) occurs in many genes expressed in colonic epithelial cells, and may contribute to the dysregulation of signalling pathways associated with carcinogenesis. This cross-sectional study assessed the relative importance of age, nutritional exposures and other environmental factors in the development of CGI methylation. Rectal biopsies were obtained from 185 individuals (84 male, 101 female) shown to be free of colorectal disease, and for whom measurements of age, body size, nutritional status and blood cell counts were available. We used quantitative DNA methylation analysis combined with multivariate modelling to investigate the relationships between nutritional, anthropometric and metabolic factors and the CGI methylation of 11 genes, together with LINE-1 as an index of global DNA methylation. Age was a consistent predictor of CGI methylation for 9/11 genes but significant positive associations with folate status and negative associations with vitamin D and selenium status were also identified for several genes. There was evidence for positive associations with blood monocyte levels and anthropometric factors for some genes. In general, CGI methylation was higher in males than in females and differential effects of age and other factors on methylation in males and females were identified. In conclusion, levels of age-related CGI methylation in the healthy human rectal mucosa are influenced by gender, the availability of folate, vitamin D and selenium, and perhaps by factors related to systemic inflammatio

Prediction of malignant transformation and recurrence of oral epithelial dysplasia using architectural and cytological feature specific prognostic models

Oral epithelial dysplasia (OED) is a precursor state usually preceding oral squamous cell carcinoma (OSCC). Histological grading is the current gold standard for OED prognostication but is subjective and variable with unreliable outcome prediction. We explore if individual OED histological features can be used to develop and evaluate prognostic models for malignant transformation and recurrence prediction. Digitised tissue slides for a cohort of 109 OED cases were reviewed by three expert pathologists, where the prevalence and agreement of architectural and cytological histological features was assessed and association with clinical outcomes analysed using Cox proportional hazards regression and Kaplan–Meier curves. Within the cohort, the most prevalent features were basal cell hyperplasia (72%) and irregular surface keratin (60%), and least common were verrucous surface (26%), loss of epithelial cohesion (30%), lymphocytic band and dyskeratosis (34%). Several features were significant for transformation (p < 0.036) and recurrence (p < 0.015) including bulbous rete pegs, hyperchromatism, loss of epithelial cohesion, loss of stratification, suprabasal mitoses and nuclear pleomorphism. This led us to propose two prognostic scoring systems including a ‘6-point model’ using the six features showing a greater statistical association with transformation and recurrence (bulbous rete pegs, hyperchromatism, loss of epithelial cohesion, loss of stratification, suprabasal mitoses, nuclear pleomorphism) and a ‘two-point model’ using the two features with highest inter-pathologist agreement (loss of epithelial cohesion and bulbous rete pegs). Both the ‘six point’ and ‘two point’ models showed good predictive ability (AUROC ≥ 0.774 for transformation and 0.726 for recurrence) with further improvement when age, gender and histological grade were added. These results demonstrate a correlation between individual OED histological features and prognosis for the first time. The proposed models have the potential to simplify OED grading and aid patient management. Validation on larger multicentre cohorts with prospective analysis is needed to establish their usefulness in clinical practice

Does wage rank affect employees' well-being?

How do workers make wage comparisons? Both an experimental study and an analysis of 16,000 British employees are reported. Satisfaction and well-being levels are shown to depend on more than simple relative pay. They depend upon the ordinal rank of an individual's wage within a comparison group. “Rank” itself thus seems to matter to human beings. Moreover, consistent with psychological theory, quits in a workplace are correlated with pay distribution skewness

Linked Markov sources: Modeling outcome-dependent social processes

Many social processes are adaptive in the sense that the process changes as a result of previous outcomes. Data on such processes may come in the form of categorical time series. First, the authors propose a class of Markov Source models that embody such adaptation. Second, the authors discuss new methods to evaluate the fit of such models. Third, the authors apply these models and methods to data on a social process that is a preeminent example of an adaptive process: (encoded) conversation as arises in structured interviews. © 2007 Sage Publications

Pollinating insects: what do they mean to people and why does it matter?

1. People value pollinating insects, and especially bees, in a wide range of different ways: as beautiful or fascinating creatures; as providers of goods; as objects of stewardship; as participants in a greater, interconnected whole – in which humans also participate; and as creatures with lives and characters. 2. An understanding of pollinators as creative connectors, sustaining and creating life by moving from plant to plant, is particularly powerful. Pollinators prompt people to think about nature as an interconnected whole, in which they too participate; and can unlock feelings of wonder, awe, groundedness, concern, responsibility, and nostalgia. 3. Social and cultural values provide a powerful resource for effective communications, a store of pre-existing meanings and associations that can be used to frame messages. Communications about pollinators would resonate more powerfully if they framed pollinators as creative connecters, emblematic of the interconnected and interdependent nature of ecosystems. By contrast, communications which focus on what pollinators do for us (e.g. pollination framed as an ‘ecosystem service’) are rational but unemotional. 4. Communications drawing on these insights should: • Highlight first and foremost the critical role played by pollinators as creative connectors in a greater, interconnected whole • Acknowledge our dependency on that greater interconnected whole, but also our responsibilities as participants in it • Be willing to embrace and use non-scientific language, ideas and tonalities in talking about both pollinators and the interconnected whole of which they are part, for example: o spiritual/religious language in evoking feelings of awe and wonder at the greater interconnected whole o evocations of an idealised, traditional way of life, and the possibilities of reconnecting in some small way o metaphorical characterisations of pollinators as spreading life and love • Recognise that we face choices about the environment not just as individuals, but as a society; that people see evidence of our society as a whole making the wrong choices; and that the actions of any body seeking to campaign about pollinators will speak as loudly, if not louder, than the messages it promotes • Emphasise – in messages, but also in developing the case for a campaign – the link between the holistic perspective, subjective wellbeing, and reconnection: o reconnection with nature: the consolation of knowing that one has a place in an enduring, greater whole, and a responsibility to play a positive role in that whole o reconnection with self: the experience of a moment of self-aware contemplation in contrast to the day-to-day stresses of life o reconnection with history: a sense of contact with an idealised traditional way of life 5. If developed effectively, such campaigns will contribute to many of the key actions in the National Pollinator Strategy, and in particular actions relating to “supporting pollinators across towns, cities and the countryside” (including encouraging the public to take action) and to “raising awareness of what pollinators need to survive and thrive”. 6. Because they prompt people to think about and respond emotionally to the interconnectedness of nature, pollinators framed as creative connectors could play an important role in communications seeking to increase awareness and change behaviour in relation to a much wider range of policies and approaches which relate to the connectedness of nature: for example, maintaining wider natural connectivity, protecting biodiversity, and ensuring environmental resilience through approaches such as those relating to the concept of landscape level conservation. As such, pollinators could play an important role in delivery of the 25-year plan for the environment, and in particular in efforts to increase public engagement. 7. Compared to other pollinating insects, bees occupy a central position in our culture. The ‘popular bee’ is not a real insect, but a product of a blurring of species, idealisation of the past, ignorance of the diversity of pollinators and, often, a shaky grasp on what pollination actually means. It is, however, a very meaningful and valued insect, and as such can serve as a flagship for communications in all of the above areas. 8. In terms of wider policy and decision-making, this research offers a potential model of how to create an evidence-based catalogue of social and cultural values. The development of such an evidence-based catalogue, using a mix of interpretative and participatory methods to explore how, and in what capacities, people can and do value objects of interest, should be an essential pre-requisite for robust valuation across a wide range of natural environment policy areas, but in practice is rarely undertaken. 9. Some types of social and cultural value can be captured through economic valuation: either through monetisation or through the inclusion of non-monetised criteria in multi-criteria analysis approaches. To do this, however, it is essential that data-gathering tools assess the right things: e.g. that willingness-to-pay questions frame the object of value in the right capacity and from the right perspective. 10. It may be more practical and/or appropriate to take account of some types of social and cultural value in policy and decision-making through other mechanisms, such as public consultation, political representation, or open policy-making. It may not be possible to monetise some kinds of value. In other cases, the effort involved in economic valuation may be disproportionate. If alternative mechanisms are not used, there is a risk that certain kinds of social and cultural value, or certain objects of value, are systematically overlooked. 11. Key levers to ensure that these alternative mechanisms are used effectively include: • Align policy frameworks – for example, set priorities and requirements in overarching national policies which ensure key social and cultural values or objects of value are taken into account. • Provide contexts – for example, create public consultation contexts in which certain kinds of value will be surfaced, or objects of value considered. • Improve processes – e.g. ensure consultation questions frame objects of value in ways that invite the articulate of key values. 12. An evidence-based catalogue of social and cultural values also provides a basis on which to anticipate risks and opportunities arising from changes in public opinion. Social and cultural values may be widely available within a society or culture but not, at any given moment, widely used. It is not always possible to predict how patterns of use will change in response to policies (e.g. forest privatisation, neonicotinoid pesticide policy); but an evidence-based understanding of underlying social and cultural values makes it possible to develop and explore scenarios of how they could change and develop responses accordingly