Challenges in evaluating surgical innovation

Research on surgical interventions is associated with several methodological and practical challenges of which few, if any, apply only to surgery. However, surgical evaluation is especially demanding because many of these challenges coincide. In this report, the second of three on surgical innovation and evaluation, we discuss obstacles related to the study design of randomised controlled trials and non-randomised studies assessing surgical interventions. We also describe the issues related to the nature of surgical procedures—for example, their complexity, surgeon-related factors, and the range of outcomes. Although difficult, surgical evaluation is achievable and necessary. Solutions tailored to surgical research and a framework for generating evidence on which to base surgical practice are essential.The Balliol Colloquium has been supported by Ethicon UK with unrestricted educational grants and by the National Institute of Health Research Health Technology Assessment Programme. The Balliol Colloquium was administratively and financially supported by the Nuffield Department of Surgery at the University of Oxford and the Department of Surgery at McGill University. JAC holds a Medical Research Council UK special training fellowship. The University of Aberdeen’s Health Services Research Unit is core funded by the Chief Scientist Offi ce of the Scottish Government Health Directorates. IB is supported by a grant from the Société Française de Rhumatologie and Lavoisier Program (Ministère des Aff aires Etrangères et Européennes). PLE is a DPhil Candidate in Evidence-Based Health Care at Oxford University

Mercury in the snow and firn at Summit Station, Central Greenland, and implications for the study of past atmospheric mercury levels

Gaseous Elemental Mercury (Hg° or GEM) was investigated at Summit Station, Greenland, in the interstitial air extracted from the perennial snowpack (firn) at depths ranging from the surface to 30 m, during summer 2005 and spring 2006. Photolytic production and destruction of Hg° were observed close to the snow surface during summer 2005 and spring 2006, and we observed dark oxidation of GEM up to 270 cm depth in June 2006. Photochemical transformation of gaseous elemental mercury resulted in diel variations in the concentrations of this gas in the near-surface interstitial air, but destruction of Hg° was predominant in June, and production was the main process in July. This seasonal evolution of the chemical mechanisms involving gaseous elemental mercury produces a signal that propagates downward through the firn air, but is unobservably small below 15 m in depth. As a consequence, multi-annual averaged records of GEM concentration should be well preserved in deep firn air at depths below 15 m, and available for the reconstruction of the past atmospheric history of GEM over the last decades

The Effect of Disease Site (Knee, Hip, Hand, Foot, Lower Back or Neck) on Employment Reduction Due to Osteoarthritis

Osteoarthritis (OA) has a significant impact on individuals' ability to work. Our goal was to investigate the effects of the site of OA (knee, hip, hand, foot, lower back or neck) on employment reduction due to OA (EROA).This study involved a random sample of 6,000 patients with OA selected from the Medical Service Plan database in British Columbia, Canada. A total of 5,491 were alive and had valid addresses, and of these, 2,259 responded (response rate = 41%), from which 2,134 provided usable data. Eligible participants were 19 or older with physician diagnosed OA based on administrative data between 1992 and 2006. Data of 688 residents were used (mean age 62.1 years (27 to 86); 60% women). EROA had three levels: no reduction; reduced hours; and total cessation due to OA. The (log) odds of EROA was regressed on OA sites, adjusting for age, sex, education and comorbidity. Odds ratios (ORs) represented the effect predicting total cessation and reduced hours/total cessation. The strongest effect was found in lower back OA, with OR = 2.08 (95% CI: 1.47, 2.94), followed by neck (OR = 1.59; 95% CI: 1.11, 2.27) and knee (OR = 1.43; 95% CI: 1.02, 2.01). We found an interaction between sex and foot OA (men: OR = 1.94; 95% CI: 1.05, 3.59; women: OR = 0.89; 95% CI = 0.57, 1.39). No significant effect was found for hip OA (OR = 1.33) or hand OA (OR = 1.11). Limitations of this study included a modest response rate, the lack of an OA negative group, the use of administrative databases to identify eligible participants, and the use of patient self-reported data.After adjusting for socio-demographic variables, comorbidity, and other OA disease sites, we find that OA of the lower back, neck and knee are significant predictors for EROA. Foot OA is only significantly associated with EROA in males. For multi-site combinations, ORs are multiplicative. These findings may be used to guide resource allocation for future development/improvement of vocational rehabilitation programs for site-specific OA

Halogen species record Antarctic sea ice extent over glacial–interglacial periods

Abstract. Sea ice is an integral part of the earth's climate system because it affects planetary albedo, sea-surface salinity, and the atmosphere–ocean exchange of reactive gases and aerosols. Bromine and iodine chemistry is active at polar sea ice margins with the occurrence of bromine explosions and the biological production of organoiodine from sea ice algae. Satellite measurements demonstrate that concentrations of bromine oxide (BrO) and iodine oxide (IO) decrease over sea ice toward the Antarctic interior. Here we present speciation measurements of bromine and iodine in the TALDICE (TALos Dome Ice CorE) ice core (159°11' E, 72°49' S; 2315 m a.s.l.) spanning the last 215 ky. The Talos Dome ice core is located 250 km inland and is sensitive to marine air masses intruding onto the Antarctic Plateau. Talos Dome bromide (Br−) is positively correlated with temperature and negatively correlated with sodium (Na). Based on the Br−/Na seawater ratio, bromide is depleted in the ice during glacial periods and enriched during interglacial periods. Total iodine, consisting of iodide (I−) and iodate (IO3−), peaks during glacials with lower values during interglacial periods. Although IO3− is considered the most stable iodine species in the atmosphere it was only observed in the TALDICE record during glacial maxima. Sea ice dynamics are arguably the primary driver of halogen fluxes over glacial–interglacial timescales, by altering the distance between the sea ice edge and the Antarctic plateau and by altering the surface area of sea ice available to algal colonization. Based on our results we propose the use of both halogens for examining Antarctic variability of past sea ice extent

Centre selection for clinical trials and the generalisability of results: a mixed methods study.

BACKGROUND: The rationale for centre selection in randomised controlled trials (RCTs) is often unclear but may have important implications for the generalisability of trial results. The aims of this study were to evaluate the factors which currently influence centre selection in RCTs and consider how generalisability considerations inform current and optimal practice. METHODS AND FINDINGS: Mixed methods approach consisting of a systematic review and meta-summary of centre selection criteria reported in RCT protocols funded by the UK National Institute of Health Research (NIHR) initiated between January 2005-January 2012; and an online survey on the topic of current and optimal centre selection, distributed to professionals in the 48 UK Clinical Trials Units and 10 NIHR Research Design Services. The survey design was informed by the systematic review and by two focus groups conducted with trialists at the Birmingham Centre for Clinical Trials. 129 trial protocols were included in the systematic review, with a total target sample size in excess of 317,000 participants. The meta-summary identified 53 unique centre selection criteria. 78 protocols (60%) provided at least one criterion for centre selection, but only 31 (24%) protocols explicitly acknowledged generalisability. This is consistent with the survey findings (n = 70), where less than a third of participants reported generalisability as a key driver of centre selection in current practice. This contrasts with trialists' views on optimal practice, where generalisability in terms of clinical practice, population characteristics and economic results were prime considerations for 60% (n = 42), 57% (n = 40) and 46% (n = 32) of respondents, respectively. CONCLUSIONS: Centres are rarely enrolled in RCTs with an explicit view to external validity, although trialists acknowledge that incorporating generalisability in centre selection should ideally be more prominent. There is a need to operationalize 'generalisability' and incorporate it at the design stage of RCTs so that results are readily transferable to 'real world' practice

Magnetic field and pressure effects on charge density wave, superconducting, and magnetic states in Lu5_5Ir4_4Si10_{10} and Er5_5Ir4_4Si10_{10}

We have studied the charge-density-wave (CDW) state for the superconducting Lu$_5$Ir$_4$Si$_{10}$ and the antiferromagnetic Er$_5$Ir$_4$Si$_{10}$ as variables of temperature, magnetic field, and hydrostatic pressure. For Lu$_5$Ir$_4$Si$_{10}$, the application of pressure strongly suppresses the CDW phase but weakly enhances the superconducting phase. For Er$_5$Ir$_4$Si$_{10}$, the incommensurate CDW state is pressure independent and the commensurate CDW state strongly depends on the pressure, whereas the antiferromagnetic ordering is slightly depressed by applying pressure. In addition, Er$_5$Ir$_4$Si$_{10}$ shows negative magnetoresistance at low temperatures, compared with the positive magnetoresistance of Lu$_5$Ir$_4$Si$_{10}$.Comment: 12 pages, including 6 figure