OPTIma: simplifying calorimetry for proton computed tomography in high proton flux environments

Objective.Proton computed tomography (pCT) offers a potential route to reducing range uncertainties for proton therapy treatment planning, however the current trend towards high current spot scanning treatment systems leads to high proton fluxes which are challenging for existing systems. Here we demonstrate a novel approach to energy reconstruction, referred to as 'de-averaging', which allows individual proton energies to be recovered using only a measurement of their integrated energy without the need for spatial information from the calorimeter.Approach.The method is evaluated in the context of the Optimising Proton Therapy through Imaging (OPTIma) system which uses a simple, relatively inexpensive, scintillator-based calorimeter that reports only the integrated energy deposited by all protons within a cyclotron period, alongside a silicon strip based tracking system capable of reconstructing individual protons in a high flux environment. GEANT4 simulations have been performed to examine the performance of such a system at a modern commercial cyclotron facility using aσ≈ 10 mm beam for currents in the range 10-50 pA at the nozzle.Main results.Apart from low-density lung tissue, a discrepancy of less than 1% on the Relative Stopping Power is found for all other considered tissues when embedded within a 150 mm spherical Perspex phantom in the 10-30 pA current range, and for some tissues even up to 50 pA.Significance.By removing the need for the calorimeter system to provide spatial information, it is hoped that the de-averaging approach can facilitate clinically relevant, cost effective and less complex calorimeter systems for performing high current pCTs.

Training, experience, and perceptions of chest tube insertion by higher speciality trainees: implications for training, patient safety, and service delivery

BACKGROUND

Seldinger Chest Tube Insertion (CTI) is a high acuity low occurrence procedure and remains a core capability for UK physician higher speciality trainee's (HST). A multitude of factors have emerged which may affect the opportunity of generalists to perform CTI. In view of which, this paper sought to establish the current experiences, attitudes, training, and knowledge of medical HST performing Seldinger CTI in acute care hospitals in the Peninsula deanery.

METHODS

A Scoping review was performed to establish the UK medical HST experience of adult seldinger CTI. Synonymous terms for CTI training were searched across Cochrane, ERIC, Pubmed and British education index databases. Following which, a regional survey was constructed and completed by HST and pleural consultants from five hospitals within the Peninsula deanery between April-July 2022. Data collected included participants demographics, attitudes, training, experience, and clinical knowledge. Outcomes were collated and comparisons made across groups using SPSS. A p-value of < 0.05 was defined as significant.

RESULTS

The scoping review returned six papers. Salient findings included low self-reported procedural confidence levels, poor interventional selection for patient cases, inadequate site selection for CTI and 1 paper reported only 25% of respondents able to achieve 5-10 CTI annually. However, all papers were limited by including grades other than HST in their responses. The regional survey was completed by 87 HST (12 respiratory, 63 non-respiratory medical HST and 12 intensivists/anaesthetists HST). An additional seven questionnaires were completed by pleural consultants. Respiratory HSTs performed significantly more Seldinger CTI than general and ICM/anaesthetic registrars (p < 0.05). The percentage of HST able to achieve a self-imposed annual CTI number were 81.8, 12.9 and 41.7% respectively. Self-reported transthoracic ultrasound competence was 100, 8 and 58% respectively (p < 0.001). The approach to clinical management significantly differed with national guidance with pleural consultants showing an agreement of 89%, respiratory HST 75%, general HST 52% and ICM/anaesthetic HST 54% (p = 0.002).

CONCLUSION

Compared to respiratory trainees, non-respiratory trainees perform lower numbers of Seldinger CTI, with lower confidence levels, limited knowledge, and a reduced perceived relevance of the skill set. This represents a significant training and service challenge, with notable patient safety implications.

Review of the validity of DOPS as an assessment tool for the procedural skills of surgical trainees

INTRODUCTION

Surgical trainees at all stages are mandated to use workplace-based assessments (WBAs) to gain feedback from their trainers. Direct observation of procedural skills (DOPS) is a tool to assess hands-on surgical skills. This review of the literature seeks to ascertain how valid DOPS are as an assessment tool for the procedural skills of surgical trainees according to the American Psychology Association (APA) validity framework.

METHODS

Relevant literature was identified through a structured search of Medline, CINAHL and Web of Science databases, with further papers included on citation review. Following this, papers meeting the inclusion and exclusion criteria were included in the final review specifying those investigating WBAs including DOPS, assessments in practice rather than simulation and specifically for postgraduate surgical trainees.

FINDINGS

Sixteen papers were included in the final analysis. Extracted data from the returned papers were assessed for evidence of validity in each of the five domains on the APA framework: validity based on consequence, response process, reliability, content and relationship to other variables. There are studies that show good parameters for reliability and validity for specific DOPS used in endoscopy and otolaryngology. However, there is confusion over the purpose of DOPS among trainers and trainees as to whether they should be used formatively or summatively. Recent changes to the surgical curriculum have sought to address this, and further work into the impact of this needs to be done.

545 Review of the Validity of DOPS as an Assessment Tool for the Procedural Skills of Surgical Trainees

Introduction

Surgical trainees at all stages are mandated to use workplace-based assessments (WBAs) to gain feedback from their trainers. Direct observation of procedural skills (DOPS) is a tool to assess hands-on surgical skills. This review of the literature seeks to ascertain how valid DOPS are as an assessment tool for the procedural skills of surgical trainees according to the APA (American Psychology Association) validity framework.

Method

Relevant literature was identified through a structured search of Medline, CINAHL and web of science databases, with further papers included on citation review. Following this, papers meeting the inclusion and exclusion criteria were included in the final review specifying those investigating WBAs including DOPS, assessments in practice rather than simulation and specifically for post-graduate surgical trainees.

Results

16 papers were included in the final analysis. Extracted data from the returned papers was assessed for evidence of validity within each of the five domains on the APA framework: validity based on consequence, response process, reliability, content, and relationship to other variables.

Conclusions

There are studies that show good parameters for reliability and validity for specific DOPS used in endoscopy and otolaryngology. However, there is confusion over the purpose of DOPS amongst trainers and trainees as to whether they should be used formatively or summatively. There is a wealth of evidence examining the perspectives of trainees and trainers into the summative nature of DOPS, however future research should be conducted into to validity of DOPS as a summative tool for career progression and selection processes.

A novel range telescope concept for proton CT

Proton beam therapy can potentially offer improved treatment for cancers of the head and neck and in paediatric patients. There has been a sharp uptake of proton beam therapy in recent years as improved delivery techniques and patient benefits are observed. However, treatments are currently planned using conventional x-ray CT images due to the absence of devices able to perform high quality proton computed tomography (pCT) under realistic clinical conditions. A new plastic-scintillator-based range telescope concept, named ASTRA, is proposed here to measure the proton’s energy loss in a pCT system. Simulations conducted using GEANT4 yield an expected energy resolution of 0.7%. If calorimetric information is used the energy resolution could be further improved to about 0.5%. In addition, the ability of ASTRA to track multiple protons simultaneously is presented. Due to its fast components, ASTRA is expected to reach unprecedented data collection rates, similar to 108 protons/s. The performance of ASTRA has also been tested by simulating the imaging of phantoms. The results show excellent image contrast and relative stopping power reconstruction.

Optimising the delivery of remediation programmes for doctors: A realist review

CONTEXT

Medical underperformance puts patient safety at risk. Remediation, the process that seeks to 'remedy' underperformance and return a doctor to safe practice, is therefore a crucially important area of medical education. However, although remediation is used in health care systems globally, there is limited evidence for the particular models or strategies employed. The purpose of this study was to conduct a realist review to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety.

METHOD

We conducted a realist literature review consistent with RAMESES standards. We developed a programme theory of remediation by carrying out a systematic search of the literature and through regular engagement with a stakeholder group. We searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, HMIC, CINAHL, ERIC, ASSIA and DARE) and conducted purposive supplementary searches. Relevant sections of text relating to the programme theory were extracted and synthesised using a realist logic of analysis to identify context-mechanism-outcome configurations (CMOcs).

RESULTS

A 141 records were included. The majority of the studies were from North America (64%). 29 CMOcs were identified. Remediation programmes are effective when a doctor's insight and motivation are developed and behaviour change reinforced. Insight can be developed by providing safe spaces, using advocacy to promote trust and framing feedback sensitively. Motivation can be enhanced by involving the doctor in remediation planning, correcting causal attribution, goal setting and destigmatising remediation. Sustained change can be achieved by practising new behaviours and skills, and through guided reflection.

CONCLUSION

Remediation can work when it creates environments that trigger behaviour change mechanisms. Our evidence synthesis provides detailed recommendations on tailoring implementation and design strategies to improve remediation interventions for doctors.

Remediation programmes for practising doctors to restore patient safety: the RESTORE realist review

Background

An underperforming doctor puts patient safety at risk. Remediation is an intervention intended to address underperformance and return a doctor to safe practice. Used in health-care systems all over the world, it has clear implications for both patient safety and doctor retention in the workforce. However, there is limited evidence underpinning remediation programmes, particularly a lack of knowledge as to why and how a remedial intervention may work to change a doctor’s practice.

Objectives

To (1) conduct a realist review of the literature to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety; and (2) provide recommendations on tailoring, implementation and design strategies to improve remediation interventions for doctors.

Design

A realist review of the literature underpinned by the Realist And MEta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards.

Data sources

Searches of bibliographic databases were conducted in June 2018 using the following databases: EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Education Resources Information Center, Database of Abstracts of Reviews of Effects, Applied Social Sciences Index and Abstracts, and Health Management Information Consortium. Grey literature searches were conducted in June 2019 using the following: Google Scholar (Google Inc., Mountain View, CA, USA), OpenGrey, NHS England, North Grey Literature Collection, National Institute for Health and Care Excellence Evidence, Electronic Theses Online Service, Health Systems Evidence and Turning Research into Practice. Further relevant studies were identified via backward citation searching, searching the libraries of the core research team and through a stakeholder group.

Review methods

Realist review is a theory-orientated and explanatory approach to the synthesis of evidence that seeks to develop programme theories about how an intervention produces its effects. We developed a programme theory of remediation by convening a stakeholder group and undertaking a systematic search of the literature. We included all studies in the English language on the remediation of practising doctors, all study designs, all health-care settings and all outcome measures. We extracted relevant sections of text relating to the programme theory. Extracted data were then synthesised using a realist logic of analysis to identify context–mechanism–outcome configurations.

Results

A total of 141 records were included. Of the 141 studies included in the review, 64% related to North America and 14% were from the UK. The majority of studies (72%) were published between 2008 and 2018. A total of 33% of articles were commentaries, 30% were research papers, 25% were case studies and 12% were other types of articles. Among the research papers, 64% were quantitative, 19% were literature reviews, 14% were qualitative and 3% were mixed methods. A total of 40% of the articles were about junior doctors/residents, 31% were about practicing physicians, 17% were about a mixture of both (with some including medical students) and 12% were not applicable. A total of 40% of studies focused on remediating all areas of clinical practice, including medical knowledge, clinical skills and professionalism. A total of 27% of studies focused on professionalism only, 19% focused on knowledge and/or clinical skills and 14% did not specify. A total of 32% of studies described a remediation intervention, 16% outlined strategies for designing remediation programmes, 11% outlined remediation models and 41% were not applicable. Twenty-nine context–mechanism–outcome configurations were identified. Remediation programmes work when they develop doctors’ insight and motivation, and reinforce behaviour change. Strategies such as providing safe spaces, using advocacy to develop trust in the remediation process and carefully framing feedback create contexts in which psychological safety and professional dissonance lead to the development of insight. Involving the remediating doctor in remediation planning can provide a perceived sense of control in the process and this, alongside correcting causal attribution, goal-setting, destigmatising remediation and clarity of consequences, helps motivate doctors to change. Sustained change may be facilitated by practising new behaviours and skills and through guided reflection.

Limitations

Limitations were the low quality of included literature and limited number of UK-based studies.

Future work

Future work should use the recommendations to optimise the delivery of existing remediation programmes for doctors in the NHS.

Study registration

This study is registered as PROSPERO CRD42018088779.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.

'You're just a locum': professional identity and temporary workers in the medical profession

Internationally, there has been substantial growth in temporary working, including in the medical profession where temporary doctors are known as locums. There is little research into the implications of temporary work in health care. In this paper, we draw upon theories concerning the sociology of the medical profession to examine the implications of locum working for the medical profession, healthcare organisations and patient safety. We focus particularly on the role of organisations in professional governance and the positioning of locums as peripheral to or outside the organisation, and the influence of intergroup relationships (in this case between permanent and locum doctors) on professional identity. Qualitative semi-structured interviews were conducted between 2015 and 2017 in England with 79 participants including locum doctors, locum agency staff, and representatives of healthcare organisations who use locums. An abductive approach to analysis combined inductive coding with deductive, theory-driven interpretation. Our findings suggest that locums were perceived to be inferior to permanently employed doctors in terms of quality, competency and safety and were often stigmatised, marginalised and excluded. The treatment of locums may have negative implications for collegiality, professional identity, group relations, team functioning and the way organisations deploy and treat locums may have important consequences for patient safety.

Remediating professionalism lapses in medical students and doctors: A systematic review

CONTEXT

A remediation intervention aims to facilitate the improvement of an individual whose competence in a particular skill has dropped below the level expected. Little is known regarding the effectiveness of remediation, especially in the area of professionalism. This review sought to identify and assess the effectiveness of interventions to remediate professionalism lapses in medical students and doctors.

METHODS

Databases Embase, MEDLINE, Education Resources Information Center and the British Education Index were searched in September 2017 and October 2018. Studies reporting interventions to remediate professionalism lapses in medical students and doctors were included. A standardised data extraction form incorporating a previously described behaviour change technique taxonomy was utilised. A narrative synthesis approach was adopted. Quality was assessed using the Critical Appraisal Skills Programme checklist.

RESULTS

A total of 19 studies on remediation interventions reported in 23 articles were identified. Of these, 13 were case studies, five were cohort studies and one was a qualitative study; 37% targeted doctors, 26% medical students, 16% residents and 21% involved mixed populations. Most interventions were multifaceted and addressed professionalism issues concomitantly with clinical skills, but some focused on specific areas (eg sexual boundaries and disruptive behaviours). Most used three or more behaviour change techniques. The included studies were predominantly of low quality as 13 of the 19 were case studies. It was difficult to assess the effectiveness of the interventions as the majority of studies did not carry out any evaluation.

CONCLUSIONS

The review identifies a paucity of evidence to guide best practice in the remediation of professionalism lapses in medical students and doctors. The literature tentatively suggests that remediating lapses in professionalism, as part of a wider programme of remediation, can facilitate participants to graduate from a programme of study, and pass medical licensing and mock oral board examinations. However, it is not clear from this literature whether these interventions are successful in remediating lapses in professionalism specifically. Further research is required to improve the design and evaluation of interventions to remediate professionalism lapses.

Reviving clinical governance? A qualitative study of the impact of professional regulatory reform on clinical governance in healthcare organisations in England

BACKGROUND

Until recently, processes of professional regulation and organisational clinical governance in the UK have been largely separate. However, the introduction of medical revalidation in 2012 means that all doctors have to demonstrate periodically to the regulator that they are up to date and fit to practise, and as part of this process doctors must engage with clinical governance activities in the organisations in which they work.

OBJECTIVE

To explore how the recent implementation of medical revalidation has affected the arrangements for clinical governance in healthcare organisations in England.

DESIGN

Thematic analysis of interviews with 62 senior clinicians and non-clinicians in management or senior administrative roles, from a range of healthcare organisations in England.

RESULTS

Revalidation has engendered changes to clinical governance systems, resulting in: increased doctor engagement with clinical governance activities; new or improved systems for access to clinical governance data for doctors and leaders within healthcare organisations; and more leverage - through the Responsible Officer role - to enforce engagement with clinical governance. Organisational context has been an important mediator of the impact of revalidation on clinical governance.

CONCLUSION

Revalidation has increased alignment between systems for organisational and professional oversight and accountability, resulting in increased scrutiny of clinical practice. However, it is still a matter of conjecture whether this will in turn lead to improvements in medical performance.

Reforming medical regulation: a qualitative study of the implementation of medical revalidation in England, using Normalization Process Theory

Objectives

The introduction of medical revalidation in 2012 has been a controversial and radical change to medical regulation in the UK. It involved changes to the way organizations manage medical performance, and to the relationships between doctors, their employers and the professional regulatory body. In this paper, we explore the implementation of medical revalidation, analysing the change process and its consequences for doctors and organizations.

Methods

We conducted a qualitative investigation of the implementation of revalidation in 15 case study organizations in 2016–2017, collecting documents and undertaking a total of 80 interviews with medical and non-medical staff. We used Normalization Process Theory to frame and structure the analysis.

Results

Revalidation reforms were largely implemented successfully within and across our case study organizations, with evidence of growing acceptance of the purpose and processes of revalidation. There was an emergent shift from securing doctors’ compliance towards the use of revalidation to strengthen clinical governance, and towards evaluating revalidation processes and seeking to make them more effective. However, there was substantial variation in the implementation and impact of revalidation; it was still not fully understood by many doctors, and revalidation processes were highly reliant on a few key individuals in each organization. The changes brought about by revalidation have had consequences for the way in which doctors construct their identity and the way they relate to the organizations in which they work.

Conclusion

Despite considerable early scepticism and overt opposition in the medical profession, revalidation has become gradually accepted, embedded and even valued over time. Its impact and effectiveness are still questioned by many stakeholders, and the focus of attention has now shifted towards revising and improving the way revalidation works in practice.

Comparison of Oxidizing Solutions in the Evaluation of Metmyoglobin Reducing Activity in Dark-Cutting Beef

ObjectivesMetmyoglobin reducing activity (MRA) is an inherent muscle biochemical property that can influence color stability. Hence, MRA is used in color research to better understand meat color changes. A greater postmortem muscle pH can affect inherent biochemical properties, including the conventional methodologies to determine MRA. The MRA methodology described in the American Meat Science Association Color Guide utilize changes in nitric oxide induced-metmyoglobin level pre- and post-incubation. However, a greater muscle pH can limit initial metmyoglobin formation. Hence, the methodology discussed in the AMSA color guide may not provide accurate results. Therefore, the objectives of this research were to compare different conditions to induce initial metmyoglobin formation.Materials and MethodsIn the first objective, normal-pH and dark-cutting steaks were dipped in 0.3%s (level recommended in the AMSA color guide) and 1% nitrite solution to induce metmyoglobin formation. Metmyoglobin formed steaks were blotted dry, vacuum packaged, and incubated at 30°C to induce metmyoglobin reduction. In the second experiment, 1% ferricyanide solution was used as an oxidizing agent. The methodology used in objective 1 was used to measure MRA. The experiments were replicated three times and the data were analyzed using the Mixed Procedure of SAS.ResultsThere was no effect (P > 0.05) of nitrite concentration on MRA of dark-cutting beef. However, when 1% ferricyanide was used as an oxidizing agent, initial metmyoglobin was more (P < 0.05) in dark-cutting beef compared with 0.3% sodium nitrite solution.ConclusionThe results suggest that the use of a strong oxidizing agent can impart more metmyoglobin formation in high-pH/dark-cutting beef.

Reforming regulatory relationships: The impact of medical revalidation on doctors, employers, and the General Medical Council in the United Kingdom

In 2012, medical regulation in the United Kingdom was fundamentally changed by the introduction of revalidation - a process by which all licensed doctors are required to regularly demonstrate that they are up to date and fit to practice in their chosen field and are able to provide a good level of care. This paper examines the implications of revalidation on the structure, governance, and performance management of the medical profession, as well as how it has changed the relationships between the regulator, employer organizations, and the profession. We conducted semi-structured interviews with clinical and non-clinical staff from a range of healthcare organizations. Our research suggests that organizations have become intermediaries in the relationship between the General Medical Council and doctors, enacting regulatory processes on its behalf and extending regulatory surveillance and oversight at local level. Doctors' autonomy has been reduced as they have become more accountable to and reliant on the organizations that employ them.

Sociodemographic and educational characteristics of doctors applying for psychiatry training in the UK: secondary analysis of data from the UK Medical Education Database project

Aims and methodWorkforce shortages in psychiatry are common worldwide. The international literature provides insights into factors influencing decisions to train in psychiatry but is predominately survey based. This national cohort study aimed to identify the characteristics of doctors who were most likely to apply to psychiatry training programmes. The sample comprised doctors who entered UK medical schools in 2007/8 and who made first-time specialty training applications in 2015. The association between application to psychiatry and doctors' sociodemographic and educational characteristics was examined using multivariable logistic regression. RESULTS: Those most likely to apply were White, privately educated older doctors with below average performance at medical school.Clinical implicationsTo reduce workforce shortages, psychiatry must make itself more attractive to all doctors, especially those from underrepresented groups such as state-educated Black and minority ethnic individuals. Otherwise, national policies to widen participation in the study of medicine by such groups may exacerbate the current recruitment crisis.Declaration of interestNone.

Hypertension as a predictor of advanced colorectal cancer outcome and cetuximab treatment response

Background

Adrenergic receptor stimulation is involved in the development of hypertension (htn) and has been implicated in cancer progression and dissemination of metastases in various tumours, including colon cancer. Adrenergic antagonists such as beta-blockers (bbs) demonstrate inhibition of invasion and migration in colon cancer cell lines and have been associated with decreased mortality in colorectal cancer (crc). We examined the association of baseline htn and bb use with overall (os) and progression-free survival (pfs) in patients with pretreated, chemotherapy refractory, metastatic crc (mcrc). We also examined baseline htn as a predictor of cetuximab efficacy.

Methods

Using data from the Canadian Cancer Trials Group co.17 study [cetuximab vs. best supportive care (bsc)], we coded baseline htn and use of anti-htn medications, including bbs, for 572 patients. The chi-square test was used to assess the associations between those variables and baseline characteristics. Cox regression models were used for univariate and multivariate analyses of os and pfs by htn diagnosis and bb use.

Results

Baseline htn, bb use, and anti-htn medication use were not found to be prognostic for improved os. Baseline htn and bb use were not significant predictors of cetuximab benefit.

Conclusions

In chemorefractory mcrc, neither baseline htn nor bb use is a significant prognostic factor. Baseline htn and bb use are not predictive of cetuximab benefit. Further investigation to determine whether baseline htn or bb use have a similarly insignificant impact on prognosis in patients receiving earlier lines of treatment remains warranted.

Remediating doctors' performance to restore patient safety: a realist review protocol

INTRODUCTION

Underperformance by doctors poses a risk to patient safety. Remediation is an intervention designed to remedy underperformance and return a doctor to safe practice. Remediation is widely used across healthcare systems globally, and has clear implications for both patient safety and doctor retention. Yet, there is a poor evidence base to inform remediation programmes. In particular, there is a lack of understanding as to why and how a remedial intervention may work to change a doctor's practice. The aim of this research is to identify why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to support patient safety.

METHODS AND ANALYSIS

Realist review is an approach to evidence synthesis that seeks to develop programme theories about how an intervention works to produce its effects. The initial search strategy will involve: database and grey literature searching, citation searching and contacting authors. The evidence search will be extended as the review progresses and becomes more focused on the development of specific aspects of the programme theory. The development of the programme theory will involve input from a stakeholder group consisting of professional experts in the remediation process and patient representatives. Evidence synthesis will use a realist logic of analysis to interrogate data in order to develop and refine the initial programme theory into a more definitive realist programme theory of how remediation works. The study will follow and be reported according to Realist And Meta-narrative Evidence Syntheses-Evolving Standards (RAMESES).

ETHICS AND DISSEMINATION

Ethical approval is not required. Our dissemination strategy will include input from our stakeholder group. Customised outputs will be developed using the knowledge-to-action cycle framework, and will be targeted to: policy-makers; education providers and regulators, the National Health Service, doctors and academics.

PROSPERO REGISTRATION NUMBER

CRD42018088779.

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.

Multiple breath washout in pediatric patients after lung transplantation

Forced expiratory volume in 1 second (FEV₁ ) from spirometry is the most commonly used parameter to detect early allograft dysfunction after lung transplantation (LTx). There are concerns regarding its sensitivity. Nitrogen-multiple breath washout (N₂ -MBW) is sensitive at detecting early global (lung clearance index [LCI]) and acinar (S_acin ) airway inhomogeneity. We investigated whether N₂ -MBW indices indicate small airways pathology after LTx in children with stable spirometry. Thirty-seven children without bronchiolitis obliterans syndrome [BOS] at a median of 1.6 (0.6-3.0) years after LTx underwent N₂ -MBW and spirometry, 28 of those on 2 occasions (≤6 months apart) during clinically stable periods. Additional longitudinal data (11 and 8 measurements, respectively) are provided from 2 patients with BOS. In patients without BOS, LCI and S_acin were significantly elevated compared with healthy controls. LCI was abnormal at the 2 test occasions in 81% and 71% of patients, respectively, compared with 30% and 39% of patients with abnormal FEV₁ /forced vital capacity (FVC). Correlations of LCI with FEV₁ /FVC (r = 0.1, P = .4) and FEV₁ (r = -0.1, P = .6) were poor. N₂ -MBW represents a sensitive and reproducible tool for the early detection of airways pathology in stable transplant recipients. Moreover, indices were highly elevated in both patients with BOS. Spirometry and LCI showed poor correlation, indicating distinct and complementary physiologic measures.

Prospective randomized trial of neoadjuvant chemotherapy during the 'wait period' following preoperative chemoradiotherapy for rectal cancer: results of the WAIT trial

AIM

The aim was to determine whether the addition of additional cycles of chemotherapy during the 'wait period' following neoadjuvant chemoradiotherapy for rectal cancer improves the pathological complete response (pCR) rate.

METHOD

Rectal cancer patients were randomly allocated either to a standard 10 week wait period before surgery (standard chemoradiotherapy, SCRT) or to receive three cycles of fluorouracil based chemotherapy following chemoradiotherapy during a similar 10 week wait (extended chemoradiotherapy, XCRT). The primary end-point was pCR as determined by blinded pathological assessment.

RESULTS

Forty-nine patients were randomized (SCRTn = 24, XCRTn = 25). pCR occurred in 10 patients overall but there was no significant difference in pCR between the groups (SCRTn = 6, XCRTn = 4, P = 0.49).

CONCLUSION

The addition of three cycles of 5-fluorouracil/leucovorin in a 10 week wait period after conventional chemoradiotherapy seems to result in similar pCR rates in patients with locally advanced rectal cancer based on this small randomized trial.

An experimental demonstration of a new type of proton computed tomography using a novel silicon tracking detector

PURPOSE

Radiography and tomography using proton beams promise benefit to image guidance and treatment planning for proton therapy. A novel proton tracking detector is described and experimental demonstrations at a therapy facility are reported. A new type of proton CT reconstructing relative "scattering power" rather than "stopping power" is also demonstrated. Notably, this new type of imaging does not require the measurement of the residual energies of the protons.

METHODS

A large area, silicon microstrip tracker with high spatial and temporal resolution has been developed by the Proton Radiotherapy Verification and Dosimetry Applications consortium and commissioned using beams of protons at iThemba LABS, Medical Radiation Department, South Africa. The tracker comprises twelve planes of silicon developed using technology from high energy physics with each plane having an active area of ∼10 × 10 cm segmented into 2048 microstrips. The tracker is organized into four separate units each containing three detectors at 60° to one another creating an x-u-v coordinate system. Pairs of tracking units are used to reconstruct vertices for protons entering and exiting a phantom containing tissue equivalent inserts. By measuring the position and direction of each proton before and after the phantom, the nonlinear path for each proton through an object can be reconstructed.

RESULTS

Experimental results are reported for tracking the path of protons with initial energies of 125 and 191 MeV. A spherical phantom of 75 mm diameter was imaged by positioning it between the entrance and exit detectors of the tracker. Positions and directions of individual protons were used to create angular distributions and 2D fluence maps of the beam. These results were acquired for 36 equally spaced projections spanning 180°, allowing, for the first time, an experimental CT image based upon the relative scattering power of protons to be reconstructed.

CONCLUSIONS

Successful tracking of protons through a thick target (phantom) has demonstrated that the tracker discussed in this paper can provide the precise directional information needed to perform proton radiography and tomography. When synchronized with a range telescope, this could enable the reconstruction of proton CT images of stopping power. Furthermore, by measuring the deflection of many protons through a phantom, it was demonstrated that it is possible to reconstruct a new kind of CT image (scattering power) based upon this tracking information alone.

Venous thromboembolism in patients with esophageal or gastric cancer undergoing neoadjuvant chemotherapy

There is a well-established link between cancer and venous thromboembolism (VTE), and patients receiving chemotherapy for esophageal or gastric cancer appear at high risk of developing VTE. The incidence of VTE in the neoadjuvant setting in these patients is poorly understood, as is the role for thromboprophylaxis during neoadjuvant chemotherapy. A PubMed search was conducted using a combination of terms including; esophageal & gastric cancer, deep venous thrombosis (DVT), VTE, neoadjuvant, chemotherapy and chemoradiotherapy. One hundred and fifty-four articles were retrieved and a narrative review was conducted. For patients with esophageal and gastric cancer the incidence of VTE ranged from 4 to 19%. Gastric cancer (Odds Ratio [OR] 6.38, [95% CI: 1.96-20.80]) and Stage III/IV disease, (OR 5.16 [95% CI: 1.29-20.73]) were identified as risk factors for developing VTE. Neoadjuvant chemotherapy was identified as an independent risk factor for developing VTE. Symptomatic and asymptomatic VTE have a similar effect on mortality. Median overall survival for asymptomatic VTE was 13.9 months (95% CI: 5.0-∞) versus 12.8 months (95% CI: 4.7-30.3) if the VTE was symptomatic. Neoadjuvant chemotherapy is a significant risk factor for VTE in patients with esophageal and gastric cancer. Intervention to minimize the risk using pharmacological and mechanical thromboprophylaxis should be considered, and this should start in the neoadjuvant period.

UK Policy on Doctor Remediation: Trajectories and Challenges

Around the world, policy-makers, academics, and health service professionals have become increasingly aware of the importance of remediation, the process by which poor performance is "remedied," as part of the changing landscape of medical regulation. It is, therefore, an opportune time to critique the UK experience with remediation policy. This article frames, for the first time, the UK remediation policy as developing from a central policy aim that was articulated in the 1990s: to accelerate the identification of underperformance and, subsequently, remedy any problems identified as soon as possible. In pursuit of this aim, three policy trajectories have emerged: professionalizing and standardizing remediation provision; linking remediation with other forms of regulation, namely relicensure (known in the UK as medical revalidation); and fostering obligations for doctors to report themselves and others for remediation needs. The operationalization of policy along these trajectories, and the challenges that have arisen, has relevance for anyone seeking to understand or indeed improve remediation practices within any health care system. It is argued here that the UK serves as an example of the more general challenges posed by seeking to integrate remediation policy within broader frameworks of medical governance, in particular systems of relicensure, and the need to develop a solid evidence base for remediation practices.

A new silicon tracker for proton imaging and dosimetry

For many years, silicon micro-strip detectors have been successfully used as tracking detectors for particle and nuclear physics experiments. A new application of this technology is to the field of particle therapy where radiotherapy is carried out by use of charged particles such as protons or carbon ions. Such a treatment has been shown to have advantages over standard x-ray radiotherapy and as a result of this, many new centres offering particle therapy are currently under construction around the world today. The Proton Radiotherapy, Verification and Dosimetry Applications (PRaVDA) consortium are developing instrumentation for particle therapy based upon technology from high-energy physics. The characteristics of a new silicon micro-strip tracker for particle therapy will be presented. The array uses specifically designed, large area sensors with technology choices that follow closely those taken for the ATLAS experiment at the HL-LHC. These detectors will be arranged into four units each with three layers in an x-u-v configuration to be suitable for fast proton tracking with minimal ambiguities. The sensors will form a tracker capable of tracing the path of ~200 MeV protons entering and exiting a patient allowing a new mode of imaging known as proton computed tomography (pCT). This will aid the accurate delivery of treatment doses and in addition, the tracker will also be used to monitor the beam profile and total dose delivered during the high fluences used for treatment. We present here details of the design, construction and assembly of one of the four units that will make up the complete tracker along with its characterisation using radiation tests carried out using a 90Sr source in the laboratory and a 60 MeV proton beam at the Clatterbridge Cancer Centre.

The impact of large scale licensing examinations in highly developed countries: a systematic review

BACKGROUND

To investigate the existing evidence base for the validity of large-scale licensing examinations including their impact.

METHODS

Systematic review against a validity framework exploring: Embase (Ovid Medline); Medline (EBSCO); PubMed; Wiley Online; ScienceDirect; and PsychINFO from 2005 to April 2015. All papers were included when they discussed national or large regional (State level) examinations for clinical professionals, linked to examinations in early careers or near the point of graduation, and where success was required to subsequently be able to practice. Using a standardized data extraction form, two independent reviewers extracted study characteristics, with the rest of the team resolving any disagreement. A validity framework was used as developed by the American Educational Research Association, American Psychological Association, and National Council on Measurement in Education to evaluate each paper's evidence to support or refute the validity of national licensing examinations.

RESULTS

24 published articles provided evidence of validity across the five domains of the validity framework. Most papers (n = 22) provided evidence of national licensing examinations relationships to other variables and their consequential validity. Overall there was evidence that those who do well on earlier or on subsequent examinations also do well on national testing. There is a correlation between NLE performance and some patient outcomes and rates of complaints, but no causal evidence has been established.

CONCLUSIONS

The debate around licensure examinations is strong on opinion but weak on validity evidence. This is especially true of the wider claims that licensure examinations improve patient safety and practitioner competence.

'Shrink' losses in commercially sized corn silage piles: Quantifying total losses and where they occur

Silage 'shrink' (i.e., loss of fresh chopped crop between ensiling and feedout) represents a nutrient loss which can degrade air quality as volatile carbon compounds, degrade surface waterways due to seepage, or degrade aquifers due to seepage. Virtually no research has documented shrink in large silage piles. The term 'shrink' is often ill defined, but can be expressed as losses of wet weight (WW), oven dry matter (oDM), and oDM corrected for volatiles lost in the drying oven (vcoDM). Corn silage piles (4 wedge, 2 rollover/wedge, 1 bunker) from 950 to 12,204 tonnes as built, on concrete (4), soil (2) and a combination (1) in California's San Joaquin Valley, using a bacterial inoculant, covered within 24 h with an oxygen barrier inner film and black/white outer plastic, fed out using large front end loaders through an electronic feed tracking system, and from the 2013 crop year, were used. Shrink as WW, oDM and vcoDM were 90±17, 68±18 and 28±21 g/kg, suggesting that much WW shrink is water and much oDM shrink is volatiles lost during analytical oven drying. Most shrink occurred in the silage mass with losses from exposed silage faces, as well as between exposed face silage removal and the total mixed ration mixer, being low. Silage bulk density, exposed silage face management and face use rate did not have obvious impacts on any shrink measure, but age of the silage pile during silage feedout impacted shrink losses ('older' silage piles being higher), but most strongly for WW shrink. Real shrink losses (i.e., vcoDM) of large well managed corn silage piles are low, the exposed silage face is a small portion of losses, and many proposed shrink mitigations appeared ineffective, possibly because shrink was low overall and they are largely directed at the exposed silage face.