The medical licensing examination debate

National licensing examinations are typically large-scale examinations taken early in a career or near the point of graduation, and, importantly, success is required to subsequently be able to practice. They are becoming increasingly popular as a method of quality assurance in the medical workforce, but debate about their contribution to patient safety and the improvement of healthcare outcomes continues. A systematic review of the national licensing examination literature demonstrates that there is disagreement between assessment experts about the strengths and challenges of licensing examinations. This is characterized by a trans-Atlantic divide between the dominance of psychometric reliability assurance in North America and the wider interpretations of validity, to include consequences, in Europe. We conclude that the debate might benefit from refocusing to what a national licensing examination should assess: to achieve a balance between assessing a breadth of skills and the capacity for such skills in practice, and focusing less on reproducibility

The International Landscape of Medical Licensing Examinations: A Typology Derived From a Systematic Review

Background National licensing examinations (NLEs) are large-scale examinations usually taken by medical doctors close to the point of graduation from medical school. Where NLEs are used, success is usually required to obtain a license for full practice. Approaches to national licensing, and the evidence that supports their use, varies significantly across the globe. This paper aims to develop a typology of NLEs, based on candidacy, to explore the implications of different examination types for workforce planning. Methods A systematic review of the published literature and medical licensing body websites, an electronic survey of all medical licensing bodies in highly developed nations, and a survey of medical regulators. Results The evidence gleaned through this systematic review highlights four approaches to NLEs: where graduating medical students wishing to practice in their national jurisdiction must pass a national licensing exam before they are granted a license to practice; where all prospective doctors, whether from the national jurisdiction or international medical graduates, are required to pass a national licensing exam in order to practice within that jurisdiction; where international medical graduates are required to pass a licensing exam if their qualifications are not acknowledged to be comparable with those students from the national jurisdiction; and where there are no NLEs in operation. This typology facilitates comparison across systems and highlights the implications of different licensing systems for workforce planning. Conclusion The issue of national licensing cannot be viewed in isolation from workforce planning; future research on the efficacy of national licensing systems to drive up standards should be integrated with research on the implications of such systems for the mobility of doctors to cross borders

The effects of meson mixing on dilepton spectra

The effect of scalar and vector meson mixing on the dilepton radiation from hot and dense hadronic matter is estimated in different isospin channels. In particular, we study the effect of $\sigma$-$\omega$ and $\rho-a_0$ mixing and calculate the corresponding rates. Effects are found to be significant compared to standard $\pi$-$\pi$ and $K$-${\bar K}$ annihilations. While the mixing in the isoscalar channel mostly gives a contribution in the invariant mass range between the two-pion threshold and the $\omega$ peak, the isovector channel mixing induces an additional peak just below that of the $\phi$. Experimentally, the dilepton signals from $\rho$-$a_0$ mixing seem to be more tractable than those from $\sigma$-$\omega$ mixing.Comment: 10 pages, 9 figure

Evolving spiking networks with variable resistive memories

Neuromorphic computing is a brainlike information processing paradigm that requires adaptive learning mechanisms. A spiking neuro-evolutionary system is used for this purpose; plastic resistive memories are implemented as synapses in spiking neural networks. The evolutionary design process exploits parameter self-adaptation and allows the topology and synaptic weights to be evolved for each network in an autonomous manner. Variable resistive memories are the focus of this research; each synapse has its own conductance profile which modifies the plastic behaviour of the device and may be altered during evolution. These variable resistive networks are evaluated on a noisy robotic dynamic-reward scenario against two static resistive memories and a system containing standard connections only. The results indicate that the extra behavioural degrees of freedom available to the networks incorporating variable resistive memories enable them to outperform the comparative synapse types. © 2014 by the Massachusetts Institute of Technology

Algorithms for Stable Matching and Clustering in a Grid

We study a discrete version of a geometric stable marriage problem originally proposed in a continuous setting by Hoffman, Holroyd, and Peres, in which points in the plane are stably matched to cluster centers, as prioritized by their distances, so that each cluster center is apportioned a set of points of equal area. We show that, for a discretization of the problem to an $n\times n$ grid of pixels with $k$ centers, the problem can be solved in time $O(n^2 \log^5 n)$, and we experiment with two slower but more practical algorithms and a hybrid method that switches from one of these algorithms to the other to gain greater efficiency than either algorithm alone. We also show how to combine geometric stable matchings with a $k$-means clustering algorithm, so as to provide a geometric political-districting algorithm that views distance in economic terms, and we experiment with weighted versions of stable $k$-means in order to improve the connectivity of the resulting clusters.Comment: 23 pages, 12 figures. To appear (without the appendices) at the 18th International Workshop on Combinatorial Image Analysis, June 19-21, 2017, Plovdiv, Bulgari

Microscopic evidence for liquid-liquid separation in supersaturated CaCO3 solutions

Recent experimental observations of the onset of calcium carbonate (CaCO3) mineralization suggest the emergence of a population of clusters that are stable rather than unstable as predicted by classical nucleation theory. This study uses molecular dynamics simulations to probe the structure, dynamics, and energetics of hydrated CaCO3 clusters and lattice gas simulations to explore the behavior of cluster populations before nucleation. Our results predict formation of a dense liquid phase through liquid-liquid separation within the concentration range in which clusters are observed. Coalescence and solidification of nanoscale droplets results in formation of a solid phase, the structure of which is consistent with amorphous CaCO3. The presence of a liquid-liquid binodal enables a diverse set of experimental observations to be reconciled within the context of established phase-separation mechanisms

Estudio taxonómico de Albizia (Leguminosae: Mimosoideae: Ingeae) en México y América Central

The genus Albizia is economically and environmentally important because many elements are multipurpose trees. A taxonomic study of 12 Central American and Mexican Albizia species is presented. Identification keys, illustrations and ecological information are provided together with some taxonomic comments. Distribution maps and conservation status are given for each native species in the area. Three epithets are lectotypyfied and three new name combinations are made. An interactive identification electronic key is available from the authors if requested. Full specimen records are available at www.kew.org/herbcat .El género Albizia tiene importancia económica y ecológica porque en su mayoría está integrado por árboles con usos múltiples. Se presenta un estudio taxonómico para 12 especies con distribución en México y Centro América, se incluyen claves para la identificación de las especies, ilustraciones, mapas de distribución, estados de conservación de las especies nativas del área y comentarios ecológicos y taxonómicos. Se formaliza la lectipificacion de tres epítetos y se proponen tres nuevas combinaciones. Una clave electrónica interactiva para la identificación de las especies se puede solicitar a los autores. Finalmente el conjunto completo de los ejemplares de herbario puede ser consultado en el sitio Web de los Jardines Reales de Kew: www.kew.org/herbcat

Exploring variations in childhood stunting in Nigeria using league table, control chart and spatial analysis

Background: Stunting, linear growth retardation is the best measure of child health inequalities as it captures multiple dimensions of children’s health, development and environment where they live. The developmental priorities and socially acceptable health norms and practices in various regions and states within Nigeria remains disaggregated and with this, comes the challenge of being able to ascertain which of the regions and states identifies with either high or low childhood stunting to further investigate the risk factors and make recommendations for action oriented policy decisions. Methods: We used data from the birth histories included in the 2008 Nigeria Demographic and Health Survey (DHS) to estimate childhood stunting. Stunting was defined as height for age below minus two standard deviations from the median height for age of the standard World Health Organization reference population. We plotted control charts of the proportion of childhood stunting for the 37 states (including federal capital, Abuja) in Nigeria. The Local Indicators of Spatial Association (LISA) were used as a measure of the overall clustering and is assessed by a test of a null hypothesis. Results: Childhood stunting is high in Nigeria with an average of about 39%. The percentage of children with stunting ranged from 11.5% in Anambra state to as high as 60% in Kebbi State. Ranking of states with respect to childhood stunting is as follows: Anambra and Lagos states had the least numbers with 11.5% and 16.8% respectively while Yobe, Zamfara, Katsina, Plateau and Kebbi had the highest (with more than 50% of their underfives having stunted growth). Conclusions: Childhood stunting is high in Nigeria and varied significantly across the states. The northern states have a higher proportion than the southern states. There is an urgent need for studies to explore factors that may be responsible for these special cause variations in childhood stunting in Nigeria

Impact of COVID-19 on cardiac procedure activity in England and associated 30-day mortality

BACKGROUND: Limited data exists on the impact of COVID-19 on national changes in cardiac procedure activity, including patient characteristics and clinical outcomes before and during the COVID-19 pandemic. METHODS AND RESULTS: All major cardiac procedures (n = 374,899) performed between 1st January and 31st May for the years 2018, 2019 and 2020 were analysed, stratified by procedure type and time-period (pre-COVID: January-May 2018 and 2019 and January-February 2020 and COVID: March-May 2020). Multivariable logistic regression was performed to examine the odds ratio (OR) of 30-day mortality for procedures performed in the COVID period.Overall, there was a deficit of 45,501 procedures during the COVID period compared to the monthly averages (March-May) in 2018-2019. Cardiac catheterisation and device implantations were the most affected in terms of numbers (n = 19,637 and n = 10,453) whereas surgical procedures such as MVR, other valve replacement/repair, ASD/VSD repair and CABG were the most affected as a relative percentage difference (Δ) to previous years' averages. TAVR was the least affected (Δ-10.6%). No difference in 30-day mortality was observed between pre-COVID and COVID time-periods for all cardiac procedures except cardiac catheterisation (OR 1.25 95% confidence interval (CI) 1.07-1.47, p = 0.006) and cardiac device implantation (OR 1.35 95% CI 1.15-1.58, p < 0.001). CONCLUSION: Cardiac procedural activity has significantly declined across England during the COVID-19 pandemic, with a deficit in excess of 45000 procedures, without an increase in risk of mortality for most cardiac procedures performed during the pandemic. Major restructuring of cardiac services is necessary to deal with this deficit, which would inevitably impact long-term morbidity and mortality

Determinants of excess mortality following unprotected left main stem percutaneous coronary intervention.

For percutaneous coronary intervention (PCI) to the unprotected left main stem (UPLMS), there are limited long-term outcome data. We evaluated 5-year survival for UPLMS PCI cases taking into account background population mortality.A population-based registry of 10 682 cases of chronic stable angina (CSA), non-ST-segment elevation acute coronary syndrome (NSTEACS), ST-segment elevation myocardial infarction with (STEMI+CS) and without cardiogenic shock (STEMI-CS) who received UPLMS PCI from 2005 to 2014 were matched by age, sex, year of procedure and country to death data for the UK populace of 56.6 million people. Relative survival and excess mortality were estimated.Over 26 105 person-years follow-up, crude 5-year relative survival was 93.8% for CSA, 73.1% for NSTEACS, 77.5% for STEMI-CS and 28.5% for STEMI+CS. The strongest predictor of excess mortality among CSA was renal failure (EMRR 6.73, 95% CI 4.06 to 11.15), and for NSTEACS and STEMI-CS was preprocedural ventilation (6.25, 5.05 to 7.75 and 6.92, 4.25 to 11.26, respectively). For STEMI+CS, the strongest predictor of excess mortality was preprocedural thrombolysis in myocardial infarction (TIMI) 0 flow (2.78, 1.87 to 4.13), whereas multivessel PCI was associated with improved survival (0.74, 0.61 to 0.90).Long-term survival following UPLMS PCI for CSA was high, approached that of the background populace and was significantly predicted by co-morbidity. For NSTEACS and STEMI-CS, the requirement for preprocedural ventilation was the strongest determinant of excess mortality. By contrast, among STEMI+CS, in whom survival was poor, the strongest determinant was preprocedural TIMI flow. Future cardiovascular cohort studies of long-term mortality should consider the impact of non-cardiovascular deaths