What drives the 'August effect'?: an observational study of the effect of junior doctor changeover on out of hours work

Objective: To investigate whether measurements of junior doctor on-call workload and performance can clarify the mechanisms underlying the increase in morbidity and mortality seen after junior doctor changeover: the ‘August effect’. Design: Quantitative retrospective observational study of routinely collected data on junior doctor workload. Setting: Two large teaching hospitals in England. Participants: Task level data from a wireless out of hours system (n = 29,885 requests) used by medical staff, nurses, and allied health professionals. Main outcome measures: Number and type of tasks requested by nurses, time to completion of tasks by junior doctors. Results: There was no overall change in the number of tasks requested by nurses out of hours around the August changeover (median requests per hour 15 before and 14 after, p = 0.46). However, the number of tasks classified as urgent was greater (p = 0.016) equating to five more urgent tasks per day. After changeover, doctors took less time to complete tasks overall due to a reduction in time taken for routine tasks (median 74 vs. 66 min; p = 3.9 × 10−9). Conclusion: This study suggests that the ‘August effect’ is not due to new junior doctors completing tasks more slowly or having a greater workload. Further studies are required to investigate the causes of the increased number of urgent tasks seen, but likely factors are errors, omissions, and poor prioritization. Thus, improved training and quality control has the potential to address this increased duration of unresolved patient risk. The study also highlights the potential of newer technologies to facilitate quantitative study of clinical activity

Tear fluid biomarkers in ocular and systemic disease: potential use for predictive, preventive and personalised medicine

In the field of predictive, preventive and personalised medicine, researchers are keen to identify novel and reliable ways to predict and diagnose disease, as well as to monitor patient response to therapeutic agents. In the last decade alone, the sensitivity of profiling technologies has undergone huge improvements in detection sensitivity, thus allowing quantification of minute samples, for example body fluids that were previously difficult to assay. As a consequence, there has been a huge increase in tear fluid investigation, predominantly in the field of ocular surface disease. As tears are a more accessible and less complex body fluid (than serum or plasma) and sampling is much less invasive, research is starting to focus on how disease processes affect the proteomic, lipidomic and metabolomic composition of the tear film. By determining compositional changes to tear profiles, crucial pathways in disease progression may be identified, allowing for more predictive and personalised therapy of the individual. This article will provide an overview of the various putative tear fluid biomarkers that have been identified to date, ranging from ocular surface disease and retinopathies to cancer and multiple sclerosis. Putative tear fluid biomarkers of ocular disorders, as well as the more recent field of systemic disease biomarkers, will be shown

Comprehensive and Integrated Genomic Characterization of Adult Soft Tissue Sarcomas

Summary Sarcomas are a broad family of mesenchymal malignancies exhibiting remarkable histologic diversity. We describe the multi-platform molecular landscape of 206 adult soft tissue sarcomas representing 6 major types. Along with novel insights into the biology of individual sarcoma types, we report three overarching findings: (1) unlike most epithelial malignancies, these sarcomas (excepting synovial sarcoma) are characterized predominantly by copy-number changes, with low mutational loads and only a few genes (TP53, ATRX, RB1) highly recurrently mutated across sarcoma types; (2) within sarcoma types, genomic and regulomic diversity of driver pathways defines molecular subtypes associated with patient outcome; and (3) the immune microenvironment, inferred from DNA methylation and mRNA profiles, associates with outcome and may inform clinical trials of immune checkpoint inhibitors. Overall, this large-scale analysis reveals previously unappreciated sarcoma-type-specific changes in copy number, methylation, RNA, and protein, providing insights into refining sarcoma therapy and relationships to other cancer types

What do evidence-based secondary journals tell us about the publication of clinically important articles in primary healthcare journals?

BACKGROUND: We conducted this analysis to determine i) which journals publish high-quality, clinically relevant studies in internal medicine, general/family practice, general practice nursing, and mental health; and ii) the proportion of clinically relevant articles in each journal. METHODS: We performed an analytic survey of a hand search of 170 general medicine, general healthcare, and specialty journals for 2000. Research staff assessed individual articles by using explicit criteria for scientific merit for healthcare application. Practitioners assessed the clinical importance of these articles. Outcome measures were the number of high-quality, clinically relevant studies published in the 170 journal titles and how many of these were published in each of four discipline-specific, secondary "evidence-based" journals (ACP Journal Club for internal medicine and its subspecialties; Evidence-Based Medicine for general/family practice; Evidence-Based Nursing for general practice nursing; and Evidence-Based Mental Health for all aspects of mental health). Original studies and review articles were classified for purpose: therapy and prevention, screening and diagnosis, prognosis, etiology and harm, economics and cost, clinical prediction guides, and qualitative studies. RESULTS: We evaluated 60,352 articles from 170 journal titles. The pass criteria of high-quality methods and clinically relevant material were met by 3059 original articles and 1073 review articles. For ACP Journal Club (internal medicine), four titles supplied 56.5% of the articles and 27 titles supplied the other 43.5%. For Evidence-Based Medicine (general/family practice), five titles supplied 50.7% of the articles and 40 titles supplied the remaining 49.3%. For Evidence-Based Nursing (general practice nursing), seven titles supplied 51.0% of the articles and 34 additional titles supplied 49.0%. For Evidence-Based Mental Health (mental health), nine titles supplied 53.2% of the articles and 34 additional titles supplied 46.8%. For the disciplines of internal medicine, general/family practice, and mental health (but not general practice nursing), the number of clinically important articles was correlated withScience Citation Index (SCI) Impact Factors. CONCLUSIONS: Although many clinical journals publish high-quality, clinically relevant and important original studies and systematic reviews, the articles for each discipline studied were concentrated in a small subset of journals. This subset varied according to healthcare discipline; however, many of the important articles for all disciplines in this study were published in broad-based healthcare journals rather than subspecialty or discipline-specific journals

The effect of sets and repetitions of the spirometer by flow in cardiorespiratory parameters

IntroductionThe incentive spirometer helps pulmonary ventilation and the cardiorespiratory changes of its use are controversial. ObjectiveTo evaluate the effect of sets and repetitions on cardiorespiratory parameters using a spirometer alinear flow (SAF). The sample group consisted of 50 young people, healthy and sedentary. The evaluated parameters were: systolic blood pressure (SBP), diastolic (DBP), heart rate (HR), respiratory rate (RR), oxygen saturation (SaO2), minute volume (VE), tidal volume (VT), vital capacity (VC), maximal inspiratory pressure (Pimax), maximal expiratory pressure (Pemax), and peak expiratory flow (PEF). The moments of study were: initial evaluations (M1); 3 sets of 10 repetitions using SAF (M2); 3 sets of 15 repetitions using SAF (M3); and final evaluation (M4). Statistical analysis was made by t test, ANOVA and Tukey test (p < 0.05). ResultSBP and HR decreased in M2 after the 2nd set. In the 3rd set, SBP and RR decreased. Comparing the initial and final variables in M2, SBP and RR decreased, and Pemax increased. After 1st set in M3, SBP and SaO2 decreased. The 2nd set: SBP, HR, RR, and SaO2 decreased. After the 3rd set: SBP, HR, SaO2, and RR decreased. Comparing the initial and final variables in M3, SBP, HR, RR decreased, and Pimax and Pemax increased. Comparing M4 to M1, Pimax, Pemax, and VC increased, and RR decreased. ConclusionThere are changes in cardiorespiratory parameters after the use of a spirometer alinear flow, especially in the sets with more repetitions.Introdução Os incentivadores respiratórios auxiliam na ventilação pulmonar e as modificações cardiorrespiratórias mediante seu uso ainda são discutidas. Objetivo Avaliar efeito das séries e repetições com uso do inspirômetro alinear a fluxo (IAF) nos parâmetros cardiorrespiratórios. Materiais e métodos A amostra foi composta de 50 jovens, saudáveis e sedentários. Os parâmetros avaliados foram: pressão arterial (PA), frequência de pulso (FP), frequência respiratória (FR), saturação (SatO2), volume minuto (VM), volume corrente (VC), capacidade vital (CV), pressão inspiratória (Pimáx), pressão expiratória (Pemáx) e fluxometria. Os momentos foram: avaliações inicial (M1); uso do IAF em 3 séries de 10 repetições (M2); 3 séries de 15 repetições (M3); avaliação final (M4). A análise estatística se deu pelo teste “t” de Student, ANOVA e Teste de Tukey (p < 0,05). Resultados No M2, após a 2ª série houve diminuição da PAS e FP; na 3ª série: diminuição da PAS e FR. Comparando as variáveis iniciais e finais do M2, houve diminuição da PAS e FR, e aumento da Pemáx. No M3, 1ª série, houve diminuição da PAS e SatO2. Na 2ª série: diminuição da PAS, FP, FR e SatO2. Após a 3ª série: diminuição da PAS, FP, SatO2 e FR. Comparando as variáveis iniciais e finais do M3, houve diminuição da PAS, FP, FR; aumento da Pimáx e Pemáx. Comparando M4 com M1, houve aumento da Pimáx e Pemáx, diminuição da FR e aumento da CV. Conclusão Há alterações nos parâmetros cardiorrespiratórios após utilização do IAF, principalmente nas séries com maiores repetições.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Unesp Faculdade de Medicina de BotucatuUniversidade do Sagrado CoraçãoUniversidade Estadual PaulistaUnesp Faculdade de Medicina de BotucatuUniversidade Estadual Paulist

Randomized Clinical Trial of Laparoscopic Versus Open Repair of the Perforated Peptic Ulcer: The LAMA Trial

Background: Laparoscopic surgery has become popular during the last decade, mainly because it is associated with fewer postoperative complications than the conventional open appr

Quantifying culture gaps between physicians and managers in Dutch hospitals: a survey

Background: The demands in hospitals for safety and quality, combined with limitations in financing health care require effective cooperation between physicians and managers. The complex relationship between both groups has been described in literature. We aim to add a perspective to literature, by developing a questionnaire which provides an opportunity to quantitatively report and elaborate on the size and content of differences between physicians and managers. Insight gained from use of the questionnaire might enable us to reflect on these differences and could provide practical tools to improve cooperation between physicians and managers, with an aim to enhance hospital performance.\ud \ud Methods: The CG-Questionnaire was developed by adjusting, pre-testing, and shortening Kralewski's questionnaire, and appeared suitable to measure culture gaps. It was shortened by exploratory factor analysis, using principal-axis factoring extraction with Varimax rotation. The CG-Questionnaire was sent to all physicians and managers within 37 Dutch general hospitals. ANOVA and paired sample T-tests were used to determine significant differences between perceptions of daily work practices based in both professional cultures; culture gaps. The size and content of culture gaps were determined with descriptive statistics.\ud \ud Results: The total response (27%) consisted of 929 physicians and 310 managers. The Cronbachs alpha's were 0.70 - 0.79. Statistical analyses showed many differences; culture gaps were found in the present situation; they were even larger in the preferred situation. Differences between both groups can be classified into three categories: (1) culture gaps in the present situation and not in the preferred, (2) culture gaps in the preferred situation and not in the present, and (3) culture gaps in both situations.\ud \ud Conclusions: With data from the CG-Questionnaire it is now possible to measure the size and content of culture gaps between physicians and managers in hospitals. Results gained with the CG-Questionnaire enables hospitals to reflect on these differences. Combining the results, we distinguished three categories of increasing complexity. We linked these three categories to three methods from intergroup literature (enhanced information, contact and ultimately meta cognition) which could help to improve the cooperation between physicians and managers

Cultural Contestation in China: Ethnicity, Identity and the State

This chapter explores how the political-administrative design of the Chinese state, characterized as “multi-level governance”, might be the cause of more subtle forms of resistance. By looking at the formulation of heritage policies of Lancang County, Christina Maags illustrates how the administrative fragmentation resulted in both administrative contestation and cultural contestation, with a threatened local identity at its core