Improving the quality of written feedback using written feedback

Background: Educational feedback is amongst the most powerful of all learning interventions. Research questions: (1) Can we measure the quality of written educational feedback with acceptable metrics? (2) Based on such a measure, does a quality improvement (QI) intervention improve the quality of feedback? Study design: We developed a QI instrument to measure the quality of written feedback and applied it to written feedback provided to medical students following workplace assessments. We evaluated the measurement characteristics of the QI score using generalisability theory. In an uncontrolled intervention, QI profiles were fed back to GP tutors and pre and post intervention scores compared. Study results: A single assessor scoring 6 feedback summaries can discriminate between practices with a reliability of 0.82.The quality of feedback rose for two years after the introduction of the QI instrument and stabilised in the third year. The estimated annual cost to provide this feedback is £12 per practice. Interpretation and recommendations: It is relatively straightforward and inexpensive to measure the quality of written feedback with good reliability. The QI process appears to improve the quality of written feedback. We recommend routine use of a QI process to improve the quality of educational feedback

Quantification of uncertainty in sub-sea acoustic measurement, and validation of wave-current kinematics, at a tidal energy site

As developers seek to convert the energy of the tides into electricity, sub-sea turbines must be designed to perform well in increasingly harsh conditions. Such energetic seas have historically been avoided, hence measurements taken below the surface in strong tidal currents and large waves are relatively few, and the theory behind these interactions is underdeveloped. This thesis compares measurements of subsurface velocity taken in the field, at a UK site proposed for development, to the velocity outputs of a model capable of combining waves and currents in a number of ways. In particular the interaction between waves and currents is investigated. The methodology incorporates a novel virtual velocity measurement instrument to measure the model flow, replicating the physical instruments used at sea, such that direct comparisons can be made between the two data-sets. Model and field velocities show good agreement across a range of current speeds and wave heights, with a range of metrics used to demonstrate the suitability of the model, based on linear wave-current theory, for this site. The wave-current interaction module is calibrated, with linear superposition of wave and current velocities proving a suitable representation of field velocities. Calculation of a dispersion relationship affected by mean current velocity marginally improves calibration with field data. Analysis of other sites using the tools developed will further validate this type of model, which in combination with blade element momentum theory, is able to predict pre-construction site specific loads on tidal turbines. Doppler Current Profilers (DCPs) are able to measure subsurface water particle kinematics and sea surface elevation simultaneously, however assumptions made by these instruments jeopardise detail when recording in highly energetic seas, particularly where waves and turbulent tidal currents combine. Models developed to optimise the design of tidal turbines require correct site specific inputs to accurately reflect the conditions that a turbine may encounter through its lifetime, moreover, the kinematics of these models must be accurately validated. To overcome the limitations in DCP measurements a 'Virtual' Doppler Current Profiler (VDCP) is developed (Crossley et al. 2017), enabling quantification of error in site characteristics, and 'like for like' comparisons of field and model kinematics that has never previously been documented. The numerical model developed incorporates tidal currents, waves and turbulence combined linearly to output subsurface velocity based on conditions from the field which have been averaged over ten minute intervals. The inputs are simple, time averaged characteristics (current magnitude, direction, and profile; wave height, period and direction, turbulence intensity and turbulence length-scale) and the model outputs velocities over a two dimensional grid that develops with time. The VDCP samples this flow as if it were the very instrument in the field that recorded the data used for validation. Taking into account the heading, pitch and roll of the instrument a data set directly comparable to that measured in the field is generated. The VDCP is initially used in quantifying error in wave and turbulence statistics, demonstrating a phase dependency of velocity measurements averaged between beams and providing a theoretical error for wave and turbulence characteristics sampled under a range of conditions, in order to improve tidal site characterisation. Spectral moments of the subsurface longitudinal wave orbital velocities recorded by the VDCP can be between 0.1 and 9 times those measured at a point for certain turbulent current conditions, turbulence intensity measurements may vary between 0.2 and 1.5 times the input value in low wave conditions and turbulence length scale calculations can vary by over ten times the input value, dependent on both current and wave conditions. The methodology can be used to determine a theoretical error in any site characterisation parameter for any set of wave, current and turbulence conditions. Results of the model validation using the VDCP show that the tidal flow model, and in particular the newly developed wave-current interaction module, is effective in simulating field subsurface velocities over a range of depths, for waves of up to 3m significant wave height and currents of up to 3.5ms-1. The model is effective in reproducing the wave climate using both measured and modelled surface elevation spectra, and tests, with marginal improvements, the effect of modifying the dispersion equation to account for currents. Field and model velocities compare well over the frequency range dominated by waves, showing only small underestimations in model standard deviations with respect to those from field data, at depths close to the sea surface. At the low frequency end of the modelled spectra, where large turbulent eddies dominate, there is some deviation in model accuracy, particularly during the ebb tide where recorded turbulence parameters are extremely variable, creating uncertainty due to a relatively small sample size. Between field and model velocity maxima, some scatter is observed, potentially providing uncertainty in the estimation of ultimate loads. Model and field damage equivalent velocities, used in the determination of fatigue loads, agree well. Results suggest that a linear wave-current representation of subsurface velocities at this particular tidal site is applicable. Care should be taken when interpreting this result due to the relatively small sample size, and the possibility of site specific nuances, and as such further studies are proposed. The Virtual DCP model is a novel development which has proven its usefulness in the work contained in this thesis and in the analysis of commercial field data. It is extremely versatile, adapting to a range of configurations and set up criteria such that it can be used in the quantification of DCP measurement error for a range of flow characteristics. This information is useful in the design of tidal turbines (and other sub-sea structures) as well as for oceanographic and biological processes. The tidal flow model developed extends beyond the capability of similar numerical models with the capability to model the interaction between waves and currents according to a number of different options. Combined with the VDCP, which samples from the model flow field, a system is created that can be effectively calibrated to find the best model solution to replicate flows at a tidal site measured by a 'real' DCP over a broad range of sea conditions and water depths. The purpose is to ensure that models used to predict the sub surface velocities in the field are suitable and a key question was to understand whether the linear super-position of linear wave models and a turbulent current flow provides a realistic model of the particle kinematics with a view to undertaking loads analysis of a tidal stream turbine. Comparisons of this kind have not previously been documented, and this thesis lays out the path to improved site characterisatio

Inference with Difference-in-Differences Revisited

A growing literature on inference in difference-in-differences (DiD) designs with grouped errors has been pessimistic about obtaining hypothesis tests of the correctsize, particularly with few groups. We provide Monte Carlo evidence for three points: (i) it is possible to obtain tests of the correct size even with few groups, and in many settings very straightforward methods will achieve this; (ii) the main problem in DiD designs with grouped errors is instead low power to detect real effects; and (iii) feasible GLS estimation combined with robust inference can increase power considerably whilst maintaining correct test size – again, even with few group

Coupling angle variability in healthy and patellofemoral pain runners

Background Patellofemoral pain is hypothesized to result in less joint coordination variability. The ability to relate coordination variability to patellofemoral pain pathology could have many clinical uses; however, evidence to support its clinical application is lacking. The aim was to determine if vector coding's coupling angle variability, as a measure of joint coordination variability, was less for runners with patellofemoral pain than healthy controls as is commonly postulated. Methods Nineteen female recreational runners with patellofemoral pain and eleven healthy controls performed a treadmill acclimation protocol then ran at a self-selected pace for 15 min. 3-D kinematics, force plate kinetics, knee pain and rating of perceived exertion were recorded each minute. Data were selected for the: pain group at the highest pain reached (pain � 3/10) in a non-exerted state (exertion < 14/20), and; non-exerted healthy group from the eleventh minute. Coupling angle variability was calculated over several portions of the stride for six knee-ankle combinations during five non-consecutive strides. Findings 46 of 48 coupling angle variability measures were greater for the pain group, with 7 significantly greater (P <.05). Interpretation These findings oppose the theory that less coupling angle variability is indicative of a pathological coordinate state during running. Greater coupling angle variability may be characteristic of patellofemoral pain in female treadmill running when a larger threshold of pain is reached than previously observed. A predictable and directional response of coupling angle variability measures in relation to knee pathology is not yet clear and requires further investigation prior to considerations for clinical utility. © 2013 Elsevier Ltd

The Foot Orthoses versus Hip eXercises (FOHX) trial for patellofemoral pain:a protocol for a randomized clinical trial to determine if foot mobility is associated with better outcomes from foot orthoses

Background: Patellofemoral pain (PFP) is a prevalent, often recalcitrant and multifactorial knee pain condition. One method to optimize treatment outcome is to tailor treatments to the patient's presenting characteristics. Foot orthoses and hip exercises are two such treatments for PFP with proven efficacy yet target different ends of the lower limb with different proposed mechanisms of effect. These treatments have not been compared head-to-head, so there is a dearth of evidence for which to use clinically. Only foot orthoses have been explored for identifying patient characteristics that might predict a beneficial effect with either of these two treatments. Preliminary evidence suggests patients will do well with foot orthoses if they have a midfoot width in weight bearing that is≥11mm more than in non-weight bearing, but this has yet to be verified in a study that includes a comparator treatment and an adequate sample size. This trial will determine if: (i) hip exercises are more efficacious than foot orthoses, and (ii) greater midfoot width mobility will be associated with success with foot orthoses, when compared to hip exercises. Methods: Two hundred and twenty participants, aged 18-40 years, with a clinical diagnosis of PFP will be randomly allocated with a 1:1 ratio to receive foot orthoses or progressive resisted hip exercises, and stratified into two subgroups based on their presenting midfoot width mobility (high mobility defined as ≥11mm). The primary outcome will be a 7-point Likert scale for global rating of change. All analyses will be conducted on an intention-to-treat basis using regression models. Discussion: This trial is designed to compare the efficacy of foot orthoses versus hip exercise, as well as to determine if high midfoot width mobility is associated with better outcomes with foot orthoses when compared to hip exercises. Results of this trial will assist clinicians in optimising the management of those with PFP by testing whether a simple measure of midfoot width mobility can help to determine which patients are most likely to benefit from foot orthoses. Trial registration: This trial is registered on the Australian New Zealand Clinical Trials Register (ACTRN12614000260628

The 25th Anniversary of the Baby Doe Rules: Perspectives from the Fields of Law, Health Care, Ethics, and Disability Policy

A highly publicized and controversial case involving the withholding of medical treatment from a “Baby Doe” with Down syndrome gave rise in 1984 to the federal law known as the Baby Doe Rules, which went into effect the following year. The law conditions the grant of federal funds for any state’s child protective services program on the state’s assurance that it can respond to reports of medical neglect, which may include the withholding of medical treatment from disabled infants with life-threatening conditions. Leading scholars and practitioners from the fields of health care, law, ethics, and disability policy who are experts in the field of neonatal medicine and decision-making involving very premature and other medically at-risk infants gathered to provide thoughtful commentary and debate on the occasion of the 25th Anniversary of the Baby Doe Rules. The Georgia State University Law Review will publish a symposium volume on the topic in Fall 2009