Learning from significant medical events: a systematic review

Rationale, aims and objectives: Learning from significant medical events is a core component of quality and safety practice in healthcare worldwide and is a key component of efforts to increase the person-centeredness of clinical service. However, the evidence that analysis of, or reflection on, significant events has a positive impact on subsequent doctor performance is relatively sparse. This review aims to explore the impact of undertaking significant event analysis on medical performance.Method: A systematic review using the following databases: PubMed, EMBASE, Medline, PsycINFO and the Cochrane Collaboration Library. Citation searches were carried out on included studies. Impact was defined according to a modified adaptation of the Kirkpatrick evaluation model. The selection and quality appraisal of studies was conducted by 2 reviewers, independently and blinded. Data were extracted from included studies related to: study type and location, population, methodology and intervention type.Results: Six papers met the inclusion criteria for this review. Of these: one reported learners’ reaction (Kirkpatrick 1); 2 reported modified attitudes (modified Kirkpatrick 2a); 5 reported the acquisition of knowledge (modified Kirkpatrick level 2b) and all 6 identified reported changes in behaviour (modified Kirkpatrick level 3a). Significant event analysis is reported to identify gaps in knowledge, improve teamwork and communication and encourage reflection leading to improvements in practice. Time, resources and team dynamics were identified as factors that impacted on the effectiveness of significant event analysis. Significant event analysis may benefit from suspending existing hierarchies during the process itself and external facilitation.Conclusion: There is a lack of high quality evidence within the existing literature to ascertain the effectiveness of significant event analysis in the medical context. Existing studies are largely based on self-reported measures, which may reinforce the importance of the discursive process for practitioners. Future research could be directed at identifying the pedagogical processes that effect changes in performance as a result of engaging in significant event analysis, leading to substantial increase in the person-centeredness of clinical care

An Overview of the Performance of the Chandra X-Ray Observatory

The Chandra X-ray Observatory is the X-ray component of NASA's Great Observatory Program which includes the recently launched Spitzer Infrared Telescope, the Hubble Space Telescope (HST) for observations in the visible, and the Compton Gamma-Ray Observatory (CGRO) which, after providing years of useful data has reentered the atmosphere. All these facilities provide, or provided, scientific data to the international astronomical community in response to peer-reviewed proposals for their use. The Chandra X-ray Observatory was the result of the efforts of many academic, commercial, and government organizations primarily in the United States but also in Europe. NASA's Marshall Space Flight Center (MSFC) manages the Project and provides Project Science; Northrop Grumman Space Technology (NGST -- formerly TRW) served as prime contractor responsible for providing the spacecraft, the telescope, and assembling and testing the Observatory; and the Smithsonian Astrophysical Observatory (SAO) provides technical support and is responsible for ground operations including the Chandra X-ray Center (CXC). Telescope and instrument teams at SAO, the Massachusetts Institute of Technology (MIT), the Pennsylvania State University (PSU), the Space Research Institute of the Netherlands (SRON), the Max-Planck Institut fur extraterrestrische Physik (MPE), and the University of Kiel also provide technical support to the Chandra Project. We present here a detailed description of the hardware, its on-orbit performance, and a brief overview of some of the remarkable discoveries that illustrate that performance.Comment: 71 pages, 66 Figures, accepted for Experimental Astronom

Survey for Transiting Extrasolar Planets in Stellar Systems. II. Spectrophotometry and Metallicities of Open Clusters

We present metallicity estimates for seven open clusters based on spectrophotometric indices from moderate-resolution spectroscopy. Observations of field giants of known metallicity provide a correlation between the spectroscopic indices and the metallicity of open cluster giants. We use \chi^2 analysis to fit the relation of spectrophotometric indices to metallicity in field giants. The resulting function allows an estimate of the target-cluster giants' metallicities with an error in the method of \pm0.08 dex. We derive the following metallicities for the seven open clusters: NGC 1245, [m/H]=-0.14\pm0.04; NGC 2099, [m/H]=+0.05\pm0.05; NGC 2324, [m/H]=-0.06\pm0.04; NGC 2539, [m/H]=-0.04\pm0.03; NGC 2682 (M67), [m/H]=-0.05\pm0.02; NGC 6705, [m/H]=+0.14\pm0.08; NGC 6819, [m/H]=-0.07\pm0.12. These metallicity estimates will be useful in planning future extra-solar planet transit searches since planets may form more readily in metal-rich environments.Comment: 38 pages, including 12 figures. Accepted for publication in A

Current socio-economic measures, and not those measured during infancy, affect bone mass in poor urban South african children.

Understanding the impact of socio-economic status (SES) on physical development in children is important, especially in developing countries where considerable inequalities persist. This is the first study to examine the association between SES on bone development at the whole body, femoral neck, and lumbar spine in black children living in Soweto and Johannesburg, South Africa. Linear regression models were used to study associations between SES during infancy and current SES, anthropometric, and DXA-derived bone mass in 9/10-yr-old children (n = 309). Findings suggest that current SES measures, rather than SES during infancy, are stronger predictors of current whole body bone area (BA) and whole body BMC after adjusting for body size, pubertal development, physical activity, habitual dietary calcium intake, and body composition. SES had no significant effect on either hip or spine bone mass. Caregiver's marital/cohabiting status (indicator of social support) and whether there was a television in the home (indicator of greater income) at age 9/10 yr were the most important socio-economic determinants of whole body BA and BMC. SES has a significant independent effect on whole body BMC through its impact on BA. This suggests that poverty alleviation policies in South Africa could have a positive effect on bone health

The Chandra Multi-Wavelength Project: Optical Spectroscopy and the Broadband Spectral Energy Distributions of X-ray Selected AGN

From optical spectroscopy of X-ray sources observed as part of ChaMP, we present redshifts and classifications for a total of 1569 Chandra sources from our targeted spectroscopic follow up using the FLWO, SAAO, WIYN, CTIO, KPNO, Magellan, MMT and Gemini telescopes, and from archival SDSS spectroscopy. We classify the optical counterparts as 50% BLAGN, 16% NELG, 14% ALG, and 20% stars. We detect QSOs out to z~5.5 and galaxies out to z~3. We have compiled extensive photometry from X-ray to radio bands. Together with our spectroscopic information, this enables us to derive detailed SEDs for our extragalactic sources. We fit a variety of templates to determine bolometric luminosities, and to constrain AGN and starburst components where both are present. While ~58% of X-ray Seyferts require a starburst event to fit observed photometry only 26% of the X-ray QSO population appear to have some kind of star formation contribution. This is significantly lower than for the Seyferts, especially if we take into account torus contamination at z>1 where the majority of our X-ray QSOs lie. In addition, we observe a rapid drop of the percentage of starburst contribution as X-ray luminosity increases. This is consistent with the quenching of star formation by powerful QSOs, as predicted by the merger model, or with a time lag between the peak of star formation and QSO activity. We have tested the hypothesis that there should be a strong connection between X-ray obscuration and star-formation but we do not find any association between X-ray column density and star formation rate both in the general population or the star-forming X-ray Seyferts. Our large compilation also allows us to report here the identification of 81 XBONG, 78 z>3 X-ray sources and 8 Type-2 QSO candidates. Also we have identified the highest redshift (z=5.4135) X-ray selected QSO with optical spectroscopy.Comment: 17 pages, 16 figures, accepted for publication in ApJS. Full data table and README file can be found online at http://hea-www.harvard.edu/~pgreen/Papers.htm

Risk of Lower Extremity Injury in a Military Cadet Population After a Supervised Injury-Prevention Program

Specific movement patterns have been identified as possible risk factors for noncontact lower extremity injuries. The Dynamic Integrated Movement Enhancement (DIME) was developed to modify these movement patterns to decrease injury risk

Biomarkers associated with early stages of kidney disease in adolescents with type 1 diabetes

Objectives: To identify biomarkers of renal disease in adolescents with type 1 diabetes (T1D) and to compare findings in adults with T1D. Methods: Twenty‐five serum biomarkers were measured, using a Luminex platform, in 553 adolescents (median [interquartile range] age: 13.9 [12.6, 15.2] years), recruited to the Adolescent Type 1 Diabetes Cardio‐Renal Intervention Trial. Associations with baseline and final estimated glomerular filtration rate (eGFR), rapid decliner and rapid increaser phenotypes (eGFR slopes  3 mL/min/1.73m2/year, respectively), and albumin‐creatinine ratio (ACR) were assessed. Results were also compared with those obtained in 859 adults (age: 55.5 [46.1, 64.4) years) from the Scottish Diabetes Research Network Type 1 Bioresource. Results: In the adolescent cohort, baseline eGFR was negatively associated with trefoil factor‐3, cystatin C, and beta‐2 microglobulin (B2M) (B coefficient[95%CI]: −0.19 [−0.27, −0.12], P = 7.0 × 10−7; −0.18 [−0.26, −0.11], P = 5.1 × 10−6; −0.12 [−0.20, −0.05], P = 1.6 × 10−3), in addition to clinical covariates. Final eGFR was negatively associated with osteopontin (−0.21 [−0.28, −0.14], P = 2.3 × 10−8) and cystatin C (−0.16 [−0.22, −0.09], P = 1.6 × 10−6). Rapid decliner phenotype was associated with osteopontin (OR: 1.83 [1.42, 2.41], P = 7.3 × 10−6), whereas rapid increaser phenotype was associated with fibroblast growth factor‐23 (FGF‐23) (1.59 [1.23, 2.04], P = 2.6 × 10−4). ACR was not associated with any of the biomarkers. In the adult cohort similar associations with eGFR were found; however, several additional biomarkers were associated with eGFR and ACR. Conclusions: In this young population with T1D and high rates of hyperfiltration, osteopontin was the most consistent biomarker associated with prospective changes in eGFR. FGF‐23 was associated with eGFR increases, whereas trefoil factor‐3, cystatin C, and B2M were associated with baseline eGFR