The epidemiology of teaching and training general practices in England

There is no national picture of teaching and training practices or the communities they serve. We aimed to describe the association between general practices’ engagement with education and their characteristics, locality and patients’ health-status and satisfaction. This data linkage study of all English practices calculated odds ratios for teaching and training status and practice, locality and patient variables. Teaching and training practices are larger than practices which do neither (mean list size (SD) 7074 (3736), 10112 (4934), and 5327 (3368) respectively, p < 0.001 and have fewer patients per GP (1932 (951), 1838 (544), and 2117 (1585) respectively, p < 0.001). Their localities have a higher proportion of White British residents (77.99% (24.17), 81.66% (20.81), 73.07% (26.91), p < 0.001). Practices with more GPs (OR 1.21 (95%CI 1.18–1.20)), fewer male GPs (0.45 (0.36–0.55)) and a higher proportion of White British people in their locality (1.30 (1.06–1.60)) were more likely to teach. Practices in rural areas (1.68 (1.43–1.98)), with more GPs (1.22 (1.27–1.39)), more full time equivalent GPs (2.68 (1.64–4.40)), fewer male GPs (0.17 (0.13–0.22)) and a higher proportion of White British people in their locality (1.34 (1.02–1.75)) were more likely to train. Teaching and training practices had higher patient satisfaction (0.293 (0.190, 0.397) and (0.563 (0.442, 0.685)) respectively and quality and outcomes framework scores (0.507 (0.211, 0.804)) and (0.996 (0.650, 1.342)) respectively than those which did not. Educationally engaged practices are unrepresentative in serving less ethnically diverse and (for training practices) less urban environments. Investment is needed to increase the proportion of educational practices in diverse urban localities

HeII Recombination Lines From the First Luminous Objects

The hardness of the ionizing continuum from the first sources of UV radiation plays a crucial role in the reionization of the intergalactic medium (IGM). While usual stellar populations have soft spectra, mini-quasars or metal-free stars with high effective temperatures may emit hard photons, capable of doubly ionizing helium and increasing the IGM temperature. Absorption within the source and in the intervening IGM will render the ionizing continuum of high-redshift sources inaccessible to direct observation. Here we show that HeII recombination lines from the first luminous objects are potentially detectable by the Next Generation Space Telescope. Together with measurements of the hydrogen Balmer alpha emission line, this detection can be used to infer the ratio of HeII to HI ionizing photons. A measurement of this ratio would shed light on the nature and emission mechanism of the first luminous sources, with important astrophysical consequences for the reheating and reionization of the IGM.Comment: ApJ published version. Due to an error in one of the references, the strength of the 1640 A line was underestimated in a previous version; this line is now brighter by a factor of 1

Stochastic Self-Similar and Fractal Universe

The structures formation of the Universe appears as if it were a classically self-similar random process at all astrophysical scales. An agreement is demonstrated for the present hypotheses of segregation with a size of astrophysical structures by using a comparison between quantum quantities and astrophysical ones. We present the observed segregated Universe as the result of a fundamental self-similar law, which generalizes the Compton wavelength relation. It appears that the Universe has a memory of its quantum origin as suggested by R.Penrose with respect to quasi-crystal. A more accurate analysis shows that the present theory can be extended from the astrophysical to the nuclear scale by using generalized (stochastically) self-similar random process. This transition is connected to the relevant presence of the electromagnetic and nuclear interactions inside the matter. In this sense, the presented rule is correct from a subatomic scale to an astrophysical one. We discuss the near full agreement at organic cell scale and human scale too. Consequently the Universe, with its structures at all scales (atomic nucleus, organic cell, human, planet, solar system, galaxy, clusters of galaxy, super clusters of galaxy), could have a fundamental quantum reason. In conclusion, we analyze the spatial dimensions of the objects in the Universe as well as spacetime dimensions. The result is that it seems we live in an El Naschie's E infinity Cantorian spacetime; so we must seriously start considering fractal geometry as the geometry of nature, a type of arena where the laws of physics appear at each scale in a self--similar way as advocated long ago by the Swedish school of astrophysics.Comment: 17 pages, 3 figures, accepted by Chaos, Solitons & Fractla

Development and psychometric evaluation of a new team effectiveness scale for all types of community adult mental health teams:a mixed-methods approach

Defining 'effectiveness' in the context of community mental health teams (CMHTs) has become increasingly difficult under the current pattern of provision required in National Health Service mental health services in England. The aim of this study was to establish the characteristics of multi-professional team working effectiveness in adult CMHTs to develop a new measure of CMHT effectiveness. The study was conducted between May and November 2010 and comprised two stages. Stage 1 used a formative evaluative approach based on the Productivity Measurement and Enhancement System to develop the scale with multiple stakeholder groups over a series of qualitative workshops held in various locations across England. Stage 2 analysed responses from a cross-sectional survey of 1500 members in 135 CMHTs from 11 Mental Health Trusts in England to determine the scale's psychometric properties. Based on an analysis of its structural validity and reliability, the resultant 20-item scale demonstrated good psychometric properties and captured one overall latent factor of CMHT effectiveness comprising seven dimensions: improved service user well-being, creative problem-solving, continuous care, inter-team working, respect between professionals, engagement with carers and therapeutic relationships with service users. The scale will be of significant value to CMHTs and healthcare commissioners both nationally and internationally for monitoring, evaluating and improving team functioning in practice

Seizure outcomes and survival in adult low-grade glioma over 11 years: living longer and better

Background: There has been a trend toward earlier and more aggressive resection for low-grade gliomas (LGGs). This study set out to compare seizure control and survival of adults with LGG seen in the same neuro-oncology clinic over 11 years and to determine whether a change in surgical philosophy has led to a corresponding improvement in outcomes. / Methods: We conducted a retrospective analysis using case-note review of 153 adults with histologically verified or radiologically suspected LGG, collecting data on patient, tumor, and seizure characteristics between 2006 and 2017. / Results: We studied 79 patients in 2006 and 74 patients in 2017. There was no significant difference between the 2 groups in age at presentation, tumor location, or integrated pathological diagnosis. The numbers of complete or partial resections increased from 21.5% in 2006 to 60.8% in 2017 (P < .05). Five- and 10-year overall survival increased from 81.8% and 51.7% in 2006 to 100% and 95.8% in 2017 (P < .001); similarly, 5- and 10-year progression-free survival increased from 47.0% and 30.7% in 2006 to 93.1% and 68.7% in 2017. The proportion of patients with intractable epilepsy declined from 72.2% in 2006 to 43.2% in 2017 (P < .05). The neurosurgical morbidity rate was identical in both groups (11.8% in 2006 vs 11.1% in 2017). / Conclusion: Management of LGG over the last 11 years has led to substantial improvements in survival and seizure control. This is most likely thanks to a change in surgical philosophy, with early resection now favored over watchful waiting where possible

Students’ Experiences of Peer Observed Teaching: A Qualitative Interview Study

Purpose: To summarise and appraise evidence on the prognosis and long-term clinical and socio-economic outcomes following wrist fracture among adults aged 50 years and over. Methods: Five databases (MEDLINE, EMBASE, AMED, CINAHL-P and PsycINFO) were comprehensively searched (supplemented by a grey-literature search) from inception till June 2021 for prospective/retrospective cohort studies of patients (≥50 years) with a history of wrist fracture and reporting long-term (≥6 months) outcomes. Peer study selection, data extraction and risk of bias assessment were conducted. A random effects meta-analysis was used to summarise estimates of pain and function outcomes. Results: 78 studies (n=688,041 patients) were included. Patients report persistent moderate to severe pain (range: 7.5%-62%) and functional limitations (range: 5.5-78%) up to 12-months or later after wrist fracture. Mean PatientRated Wrist Evaluation (PRWE) score for pain and function (9 studies, n=1759 patients) was 15.23 (95%CI 12.77, 17.69) at 6-months to 13-years follow-up. Mean disabilities of the arm, shoulder and hand (DASH) score (9 studies, n=1346 patients) was 13.82 (95%CI 12.71, 14.93)( at 6- to 17-months follow-up. A 10-20% increase in healthcare encounters in the first 12-months after fracture was observed. Twelve prognostic factors were associated with poor long-term outcomes. Conclusion: Evidence shows that a high proportion of people aged over 50 years with wrist fracture experience pain and functional limitation >6months after fracture. This is associated with increased healthcare costs, and reduced quality of life. Exploratory evidence was found for several candidate prognostic factors. Their predictive performance needs to be investigated further

First stars, very massive black holes and metals

Recent studies suggest that the initial mass function (IMF) of the first stars was likely to be extremely top-heavy, unlike what is observed at present. We propose a scenario to generate fragmentation to lower masses once the first massive stars have formed and derive constraints on the primordial IMF. We estimate the mass fraction of pair-unstable supernovae, shown to be the dominant sources of the first heavy elements. These metals enrich the gas up to about $10^{-5}$ solar metallicity, when a transition to efficient cooling-driven fragmentation occurs producing 1 solar mass clumps. We argue that the remaining fraction of the first stars ends up in 100 solar mass VMBHs (Very Massive Black Holes). We obtain constraints on the fraction of first stars that contribute to the initial metal enrichment and the transition redshift for primordial IMF away from a top-heavy one, by making various assumptions about the fate of these VMBHs at late times. We conclude with a discussion of several hitherto unexplored implications of a high-mass dominated star formation mode in the early Universe.Comment: revised version, Fig. 4 modified, abbreviated abstract, matches accepted version in ApJ, ApJ in pres

Social media in undergraduate medical education: A systematic review

Introduction There are over 3.81 billion worldwide active social media (SoMe) users. SoMe are ubiquitous in medical education, with roles across undergraduate programmes, including professionalism, blended learning, well being and mentoring. Previous systematic reviews took place before recent explosions in SoMe popularity and revealed a paucity of high-quality empirical studies assessing its effectiveness in medical education. This review aimed to synthesise evidence regarding SoMe interventions in undergraduate medical education, to identify features associated with positive and negative outcomes. Methods Authors searched 31 key terms through seven databases, in addition to references, citation and hand searching, between 16 June and 16 July 2020. Studies describing SoMe interventions and research on exposure to existing SoMe were included. Title, abstract and full paper screening were undertaken independently by two reviewers. Included papers were assessed for methodological quality using the Medical Education Research Study Quality Instrument (MERSQI) and/or the Standards for Reporting Qualitative Research (SRQR) instrument. Extracted data were synthesised using narrative synthesis. Results 112 studies from 26 countries met inclusion criteria. Methodological quality of included studies had not significantly improved since 2013. Engagement and satisfaction with SoMe platforms in medical education are described. Students felt SoMe flattened hierarchies and improved communication with educators. SoMe use was associated with improvement in objective knowledge assessment scores and self-reported clinical and professional performance, however evidence for long term knowledge retention was limited. SoMe use was occasionally linked to adverse impacts upon mental and physical health. Professionalism was heavily investigated and considered important, though generally negative correlations between SoMe use and medical professionalism may exist. Conclusions Social media is enjoyable for students who may improve short term knowledge retention and can aid communication between learners and educators. However, higher-quality study is required to identify longer-term impact upon knowledge and skills, provide clarification on professionalism standards and protect against harms

Salivary cortisol response to ACTH stimulation is a reliable alternative to serum cortisol in evaluating hypoadrenalism

Context The serum total cortisol response to the ACTH stimulation test is widely used to assess adrenocortical function but is affected by changes in cortisol-binding globulin (CBG) concentration. Salivary cortisol reflects free cortisol concentrations and may offer a reliable alternative. Objectives 1: To establish the salivary cortisol response to ACTH stimulation in healthy volunteers and patients with altered CBG concentrations. 2. To evaluate the performance of a lower reference limit (LRL) determined in healthy volunteers in patients with suspected hypoadrenalism (SH-patients). Design A 250 µg-ACTH stimulation test was undertaken in 139 healthy volunteers, 24 women taking an estradiol-containing oral contraceptive pill (OCP-females), 10 patients with low serum protein concentration (LP-patients) and 30 SH-patients. Salivary cortisol was measured by liquid chromatography-tandem mass spectrometry. Mean and LRL of the 30-minute salivary cortisol response (mean - 1.96 standard deviation) were derived from log-transformed concentrations. The LRL was applied as a diagnostic cut-off in SH-patients, with comparison to the serum response. Results Mean CBG concentrations [range] were 58 [42-81] mg/L, 64 [43-95] mg/L, 41 [28-60] mg/L and 116 [84-159] mg/L in males, females, LP-patients and OCP-females, respectively. The mean 30-minute salivary cortisol concentration was 19.3 [2.5th-97.5th percentile 10.3-36.2] nmol/l in healthy volunteers. Corresponding values were not different in OCP-females (19.7 [9.5-41.2] nmol/l; p = 0.59) or LP-patients (19.0 [7.7-46.9] nmol/l; p = 0.97). Overall diagnostic agreement between salivary and serum responses in SH-patients was 79%. Conclusions Salivary cortisol response to ACTH stimulation offers a reliable alternative to serum and may be especially useful in conditions of altered CBG concentration