Educational effectiveness of gynaecological teaching associates: a multi-centre randomised controlled trial

This trial was funded by The Medical College St Bartholo-mew’s Hospital Trust (reference number: 8368137)

Paleontology of leaf beetles

`The rate of evolution in any large group is not uniform; there are periods of relatise stability, and periods of comparatively rapid change.' Cockerell and LeVeque, 1931 To Yenli Ych, my beloved wife, a most wonderful person! The fossil record of the Chrysomelidae can be tentatively traced back to the late Paleozoic to early Mesozoic Triassic. Mesozoic records at least 9 subfamilies, 19 genera, and 35 species, are represented by the Sagrinae, the exclusively Mesozoic Proto scelinae, Clytrinae, Cryptocephalinae, Eumolpinae, Chrysomelinae. Galerucinac, Alticinae, and Cassidinae. Cenozoic records at least 12 subfamilies- 63 % of the extant- 12! genera, and 325 species, include the same extant subfamilies as well as the Donaciinae, Zeugophorinae, Criocerinae, and Hispinae and can be frequently identified to genus, especially if preserved in amber. Quaternary records are often identified to extant species. tn total, at least t3! genera about 4 % of total extant, and 357 species < 1 % have been reported. At least, 24 genera <1 % of the extant seem to be extinct. Although reliable biological information associated with the fossil chrysomelids is very scarce, it seems that most of the modern host-plant associations were established, at least, in the late Mesozoic to early Cenozoic. As a whole, stasis seems to be the general rule of the chrysomelid fossil record. Together with other faunal elements, chrysomelids, especially donaciines, have been used as biogeographic and paleoclimatological indicators in the Holocene. I

Improving the management of musculoskeletal conditions: Can an alternative approach to referral management underpinned by quality improvement and behavioural change theories offer a solution and a better patient experience? A mixed-methods study

Copyright © Author(s) (or their employer(s)) 2019. Objectives To assess whether a quality improvement-based approach to referral management can result in better musculoskeletal care within general practice. Design Prospective cohort study using mixed methodology including random-effects meta-analysis and interrupted time series. Setting and participants 36 general practices in East London. Intervention Informed by the results of a Cochrane review on educational interventions to improve general practitioners’ (GPs) musculoskeletal care, we developed a multifaceted intervention, underpinned by quality improvement and behavioural change theories. It combined locally agreed clinical pathways, feedback on referral rates, clinical audit and peer review. Main outcome measures Referral letter content, pathway adherence, referral rates, inter-practice variability and patient experience were evaluated before and after the intervention. Results Referral letter content on suspected diagnosis and prior management improved from a pooled preintervention proportion of 59% (95% CI 53% to 65%) and 67% (95% CI 61% to 73%), respectively, to 77% (95% CI 70% to 84%) and 81% (95% CI 74% to 88%). Pathway adherence improved from a pooled preintervention percentage of 42% (95% CI 35% to 48%) to 66% (95% CI 57% to 76%). The effect was greater across all quality outcomes for practices with baseline performance below or equal to the pooled baseline performance. There were reductions in the variability and rates of orthopaedic referrals at 6, 12 and 18 months (referral rate relative effect 32% (95% CI 14% to 48%), 30% (95% CI 7% to 53%) and 30% (95% CI 0% to 59%), respectively). Patient rating of how well GPs explained the musculoskeletal condition improved by 29% (95% CI 14% to 43%) and patient perception on the usefulness of the GP appointment improved by 24% (95% CI 9% to 38%). Conclusions A quality improvement-based approach to referral management which values GPs’ professionalism can result in improvements across a range of outcomes including referral quality, patient experience, referral rates and variability.Arthritis Research UK (grant number 18678); National Institute for Health Research (NIHR) (grant numbers GPPH1C6R and CATSCL-2013-04-003)

Management of Acutely Symptomatic Hernia (MASH) study

Background Acutely symptomatic abdominal wall and groin hernias are a common reason for acute surgical hospital admissions. There are limited data to guide the treatment of these patients. This study aimed to assess outcomes of emergency hernia surgery and identify common management strategies, to improve care for these high-risk patients. Methods A 20-week, national multicentre, collaborative, prospective cohort study (NCT04197271) recruited adults with acutely symptomatic abdominal wall and groin hernias across the UK. Data on patient characteristics, inpatient management, quality of life, complications, and wound healing were collected. Follow-up telephone calls at 30 and 90 days were used to assessed complications and quality of life. Descriptive analyses were undertaken to describe the population and outcomes. Results Twenty-three hospitals recruited 272 eligible patients. Inguinal (37.8 per cent) and umbilical (37.1 per cent) hernias were the most common. Some 13.9 per cent were awaiting elective surgery and 12.8 per cent had previously declined intervention. CT was performed in 47.1 per cent and 81.3 per cent underwent surgical management. Open repairs were carried out in 93.5 per cent, and 92.5 per cent of these were performed under general anaesthesia. Four of 13 laparoscopic procedures were converted to open surgery. Mesh was used in 55.1 per cent of repairs, typically synthetic non-absorbable (87.4 per cent). Complications were infrequent; surgical-site infection (9.4 per cent), delirium (3.2 per cent), and pneumonia (2.3 per cent) were the most common. The 90-day mortality rate was 4.9 per cent. Immediate surgical management was associated with a significant improvement in quality of life at 30 days (median score 0.73–0.82). Conclusion There is variation in the investigation, management, and surgical technique used to treat acutely symptomatic abdominal wall and groin hernias in the UK. The optimal management strategy for specific acute presentations remains to be established. Presented to the Association of Surgeons in Training Conference, Birmingham, UK, March 2021, the Association of Surgeons of Great Britain and Ireland Congress, May 2021, the World Society of Emergency Surgery, Edinburgh, UK, September 2021, and the European Hernia Society Congress, Copenhagen, Denmark, October 2021