A Multicentric, Retrospective, Real-world Study on Immune-related Adverse Events in Patients with Advanced Non-small Cell Lung Cancers Treated with Pembrolizumab Monotherapy.

AIMS: We present 7 years of clinical experience with single-agent pembrolizumab immune checkpoint inhibitor immunotherapy in non-small cell lung cancers (NSCLC) from four UK cancer centres. MATERIALS AND METHODS: This multi-institutional retrospective cohort study included 226 metastatic NSCLC patients. Outcomes were number and severity of immune-related adverse events (irAEs), median progression-free survival (mPFS) and median overall survival (mOS). RESULTS: Within our cohort, 119/226 (53%) patients developed irAEs. Of these, 54/119 (45%) experienced irAEs affecting two or more organ systems. The most common irAEs were diarrhoea and rash. The development of an irAE was associated with better mOS (20.7 versus 8.0 months; P < 0.001) and mPFS (12.0 versus 3.9 months; P < 0.001). The development of grade 3/4 toxicities was associated with worse outcomes compared with the development of grade 1/2 toxicities (mOS 6.1 months versus 25.2 months, P < 0.01; mPFS 5.6 months versus 19.3 months, P = 0.01, respectively). Females had a higher proportion of reported grade 3/4 toxicities (13/44 [29.5%] versus 10/74 [13.5%], P = 0.03). Using a multiple Cox regression model, the presence of irAEs was associated with a better overall survival (hazard ratio = 0.42, 95% confidence interval 0.29-0.61; P < 0.01) and better PFS (hazard ratio 0.38, 95% confidence interval 0.27-0.53; P < 0.001). CONCLUSION: In this multicentre retrospective cohort study, the development of at least one irAE was associated with significantly longer mPFS and mOS; however, more severe grade 3 and 4 irAEs were associated with worse outcomes. Delayed-onset irAEs, after the 3-month timepoint, were associated with better clinical outcomes.

A cross-sectional study examining the association between MRCS performance and surgeons receiving sanctions against their medical registration.

BACKGROUND: Fitness to practice (FtP) investigations by the General Medical Council (GMC) safeguard patients and maintain the integrity of the medical profession. The likelihood of FtP sanctions is influenced by specialty and socio-demographic factors and can be predicted by performance at postgraduate examinations. This is the first study to characterise the prevalence of FtP sanctions in early-career surgeons and to examine the association with performance at the Membership of the Royal College of Surgeons (MRCS) examination. METHODS: All UK graduates who attempted MRCS between September 2007-January 2020 were matched to the GMC list of registered medical practitioners. Clinicians who had active FtP sanctions between 28th August 2018 and 28th August 2020 were identified. Data were anonymised by RCS England prior to analysis. RESULTS: Of 11,660 candidates who attempted MRCS within the study period, only 31 (0.3%) had FtP sanctions between 2018 and 2020. Of these, 12 had active conditions on registration, seven had undertakings and 14 had warnings. There was no statistically significant difference in MRCS performance in either Parts A or B of the examination for those with and those free from FtP sanctions (P > 0.05). CONCLUSIONS: In this, the largest study of MRCS candidates to date, the prevalence of active FtP sanctions in early-career surgeons was 0.3%, significantly lower than the prevalence of sanctions across more experienced UK surgeons (0.9%). These data highlight early-career surgeons as a low-risk group for disciplinary action and should reassure patients and medical professionals of the rarity of FtP sanctions.

The impact of disability on performance in a high-stakes postgraduate surgical examination: a retrospective cohort study.

OBJECTIVE: Despite rising numbers of doctors in the workforce with disabilities, little is known about the impact of disabilities on postgraduate performance. To ensure all groups are treated fairly in surgical training, it is essential to know whether any attainment differences exist in markers of surgical performance. To address this gap, we assessed the impact of disabilities on performance on the Intercollegiate Membership of the Royal College of Surgeons examination (MRCS). DESIGN: Retrospective cohort study. SETTING: Secondary care. PARTICIPANTS: All UK MRCS candidates attempting Part A (n = 9600) and Part B (n = 4560) between 2007 and 2017 with linked disability data in the UK Medical Education Database (https://www.ukmed.ac.uk) were included. MAIN OUTCOME MEASURES: Chi-square tests and correlation coefficients established univariate associations with MRCS performance, while multiple logistic regressions identified independent predictors of success. RESULTS: Though MRCS Part B pass rates were similar (p = 0.339), candidates with registered disabilities had significantly lower first-attempt Part A pass rates (46.3% vs. 59.8%, p < 0.001). Candidates with disabilities also performed less well in examinations taken throughout school and medical school, and after adjusting for prior academic performance and sociodemographic predictors of success, logistic regression found that candidates with disabilities were no less likely to pass MRCS than their peers (odds ratio 1.04, 95% confidence interval 0.66 to 1.62). No significant variation was found in MRCS performance between type of disability or degree of limitations caused by disability (p > 0.05). CONCLUSION: Although candidates with registered disabilities performed less well in formal, written examinations, our data indicate that they are as likely to pass MRCS at first attempt as their peers who achieved similar grades at high school and medical school. In order to enable equity in career progression, further work is needed to investigate the causes of attainment differences in early career assessments.

Ultrasonic Propagation in Highly Attenuating Insulation Materials.

Experiments have been performed to demonstrate that ultrasound in the 100-400 kHz frequency range can be used to propagate signals through various types of industrial insulation. This is despite the fact that they are highly attenuating to ultrasonic signals due to scattering and viscoelastic effects. The experiments used a combination of piezocomposite transducers and pulse compression processing. This combination allowed signal-to-noise levels to be enhanced so that signals reflected from the surface of an insulated and cladded steel pipe could be obtained.

Prediction of success at UK Specialty Board Examinations using the mandatory postgraduate UK surgical examination.

Background: While performance in other mandatory examinations taken at the beginning of a doctor's career are predictive of final training outcomes, the influence early postgraduate surgical examinations might have on success at Specialty Board Exams in the UK is currently unknown. The aim was to investigate whether performance at the mandatory Membership of the Royal College of Surgeons (MRCS) examination, and other variables, are predictive of success at the Fellowship of the Royal College of Surgeons (FRCS) examination, thus potentially identifying those who may benefit from early academic intervention. Methods: Pearson correlation coefficients examined the linear relationship between both examinations and logistic regression analysis identified potential independent predictors of FRCS success. All UK medical graduates who attempted either section of FRCS (Sections 1 and 2) between 2012 and 2018 were included. Results: First attempt pass rates for Sections 1 and 2 FRCS were 87.4 per cent (n = 854) and 91.8 per cent (n = 797) respectively. In logistic regression analysis, sex (male: odds ratio (OR) 2.32, 95 per cent c.i 1.43 to 3.76), age (less than 29 years at graduation: OR 3.22, 1.88 to 5.51), Part B MRCS attempts (1 attempt: OR 1.77, 1.08 to 3.00), Part A score (OR 1.14, 1.09 to 1.89) and Part B score (OR 1.06, 1.03 to 1.09) were independent predictors of Section 1 FRCS success. Predictors of Section 2 FRCS success were age (less than 29 years at graduation: OR 3.55, 2.00 to 6.39), Part A score (OR 1.06, 1.02 to 1.11) and Section 1 FRCS score (OR 1.13, 1.07 to 1.18). Conclusion: Part A and B MRCS performance were independent predictors of FRCS success, providing further evidence to support the predictive validity of this mandatory postgraduate exam. However, future research must explore the reasons between the attainment gaps observed for different groups of doctors.

Antecedentes: Si bien el resultado obtenido en otros exámenes obligatorios efectuados al inicio de la formación médica son predictores de los resultados finales obtenidos al terminar la etapa de formación, se desconoce la influencia que podrían tener los resultados de primeros exámenes quirúrgicos de postgrado en el éxito de los exámenes de la Comisión de Especialidad del Reino Unido. El objetivo fue investigar si los resultados obtenidos en el examen obligatorio para ser miembro del Real Colegio de Cirujanos (membership of the Royal College of Surgeons, MRCS) y de otras variables son predictores de éxito en el examen de ingreso de licenciados universitarios del Real Colegio de Cirujanos (Fellowship of the Royal College of Surgeons, FRCS), de modo, que fuera posible identificar a aquellos colectivos de cirujanos que podrían beneficiarse de una acción formativa temprana. Métodos: Se utilizaron los coeficientes de correlación de Pearson para evaluar la relación lineal entre ambos exámenes, y un análisis de regresión logística para identificar posibles variables predictivas de éxito del examen del FRCS. Se incluyeron todos los graduados médicos del Reino Unido que intentaron cualquier sección del FRCS (secciones 1 y 2) entre los años 2012 y 2018. Resultados: Al primer intento, las tasas de superación de las secciones 1 y 2 del FRCS fueron del 87,4% (n = 854) y del 91,8% (n = 797), respectivamente. En el análisis de regresión logística, el sexo (masculino, razón de oportunidades, odds ratio, OR 2,32, i.c. del 95% 1,43­3,76), la edad (menos de 29 años en el momento de la graduación, OR 3,22, 1,88­5,51), el número de intentos para superar la Parte B del MRCS (un intento, OR 1,77, 1,08­3,00) y la puntuación obtenida en las Partes A (OR 1,14, 1,09­1,89) y B del MRCS (OR 1,06, 1,03­1,09), fueron predictores independientes de éxito en la Sección 1 del FRCS. Los factores predictivos del éxito en la Sección 2 del FRCS fueron la edad (menos de 29 años a la graduación, 3,55, 1,88­5,51), la puntuación de la Parte A del MRCS (1,06, 1,02­1,11) y la puntuación de la Sección 1 del FRCS (1,13, 1,07­1,18). Conclusión: Los resultados de las partes A y B del MRCS fueron factores predictivos independientes del éxito del FRCS, lo que supone una evidencia adicional en favor de la validez predictiva de este examen obligatorio de postgrado. Sin embargo, la investigación futura debe explorar las razones entre las diferencias de logros observadas para diferentes grupos de médicos.

Achieving Self-Directed Integrated Cancer Aftercare (ASICA) in melanoma: protocol for a randomised patient-focused pilot trial of delivering the ASICA intervention as a means to earlier detection of recurrent and second primary melanoma.

BACKGROUND: Melanoma is common; 15,906 people in the UK were diagnosed with melanoma in 2015 and incidence has increased fivefold in 30 years. Melanoma affects old and young people, with poor prognosis once metastatic. UK guidelines recommend people treated for cutaneous melanoma receive extended outpatient, hospital follow up to detect recurrence or new primaries. Such follow up of the growing population of melanoma survivors is burdensome for both individuals and health services. Follow up is important since approximately 20% of patients with early-stage melanoma experience a recurrence and 4-8% develop a new primary; the risk of either is highest in the first 5 years. Achieving Self-directed Integrated Cancer Aftercare (ASICA) is a digital intervention to increase total-skin-self-examination (TSSE) by people treated for melanoma, with usual follow up. METHODS: We aim to recruit 240 adults with a previous first-stage 0-2C primary cutaneous melanoma, from secondary care in North-East Scotland and the East of England. Participants will be randomised to receive the ASICA intervention (a tablet-based digital intervention to prompt and support TSSE) or control group (treatment as usual). Patient-reported and clinical data will be collected at baseline, including the modified Melanoma Worry Scale (MWS), the Hospital Anxiety and Depression Scale (HADs), the EuroQoL 5-dimension 5-level questionnaire (EQ-5D-5 L), and questions about TSSE practice, intentions, self-efficacy and planning. Participants will be followed up by postal questionnaire at 3, 6 and 12 months following randomization, along with a 12-month review of clinical data. The primary timepoint for outcome analyses will be12 months after randomisation. DISCUSSION: If the ASICA intervention improves the practice of TSSE in those affected by melanoma, this may lead to improved psychological well-being and earlier detection of recurrent and new primary melanoma. This could impact both patients and National Health Service (NHS) resources. This study will determine if a full-scale randomised controlled trial can be undertaken in the UK NHS to provide the high-quality evidence needed to determine the effectiveness of the intervention. ASICA is a pilot study evaluating the effectiveness of the practice of digitally supported TSSE in those affected by melanoma. TRIAL REGISTRATION: Clinical Trials.gov, NCT03328247 . Registered on 1 November 2017.

Predicting the chances of having a baby with or without treatment at different time points in couples with unexplained subfertility.

STUDY QUESTION: Can we develop a prediction model that can estimate the chances of conception leading to live birth with and without treatment at different points in time in couples with unexplained subfertility? SUMMARY ANSWER: Yes, a dynamic model was developed that predicted the probability of conceiving under expectant management and following active treatments (in vitro fertilisation (IVF), intrauterine insemination with ovarian stimulation (IUI + SO), clomiphene) at different points in time since diagnosis. WHAT IS KNOWN ALREADY: Couples with no identified cause for their subfertility continue to have a realistic chance of conceiving naturally, which makes it difficult for clinicians to decide when to intervene. Previous fertility prediction models have attempted to address this by separately estimating either the chances of natural conception or the chances of conception following certain treatments. These models only make predictions at a single point in time and are therefore inadequate for informing continued decision-making at subsequent consultations. STUDY DESIGN, SIZE, DURATION: A population-based study of 1316 couples with unexplained subfertility attending a regional clinic between 1998 and 2011. PARTICIPANTS/MATERIALS, SETTING, METHODS: A dynamic prediction model was developed that estimates the chances of conception within 6 months from the point when a diagnosis of unexplained subfertility was made. These predictions were recomputed each month to provide a dynamic assessment of the individualised chances of conception while taking account of treatment status in each month. Conception must have led to live birth and treatments included clomiphene, IUI + SO, and IVF. Predictions for natural conception were externally validated using a prospective cohort from The Netherlands. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 554 (42%) couples started fertility treatment within 2 years of their first fertility consultation. The natural conception leading to live birth rate was 0.24 natural conceptions per couple per year. Active treatment had a higher chance of conception compared to those who remained under expectant management. This association ranged from weak with clomiphene to strong with IVF [clomiphene, hazard ratio (HR) = 1.42 (95% confidence interval, 1.05 to 1.91); IUI + SO, HR = 2.90 (2.06 to 4.08); IVF, HR = 5.09 (4.04 to 6.40)]. Female age and duration of subfertility were significant predictors, without clear interaction with the relative effect of treatment. LIMITATIONS, REASONS FOR CAUTION: We were unable to adjust for other potentially important predictors, e.g. measures of ovarian reserve, which were not available in the linked Grampian dataset that may have made predictions more specific. This study was conducted using single centre data meaning that it may not be generalizable to other centres. However, the model performed as well as previous models in reproductive medicine when externally validated using the Dutch cohort. WIDER IMPLICATIONS OF THE FINDINGS: For the first time, it is possible to estimate the chances of conception following expectant management and different fertility treatments over time in couples with unexplained subfertility. This information will help inform couples and their clinicians of their likely chances of success, which may help manage expectations, not only at diagnostic workup completion but also throughout their fertility journey. STUDY FUNDING/COMPETING INTEREST(S): This work was supported by a Chief Scientist Office postdoctoral training fellowship in health services research and health of the public research (ref PDF/12/06). B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck, and Guerbet. None of the other authors declare any conflicts of interest.

The effects of human factor related issues on assessors during the recruitment process for general and vascular surgery in the UK.

INTRODUCTION: Healthcare professionals increasingly recognise how human factors (HF) can contribute to medical error. An understanding of HF is also important during other high stakes activities such as summative assessments or examinations. National organisations hosting such events need to be aware of potential fatigue, boredom and stress that can occur in interviewers during these often repetitive activities. METHODS: A previously validated questionnaire based around the well known HF analysis and classification system (HFACS) was used to evaluate four factors (care and support, asking questions about the role as an interviewer, working within the rules and boundaries, and stress and pressure) at the 2018 UK general and vascular surgery trainee national selection process. RESULTS: A total of 92 questionnaires were completed and analysed (48% response rate). After recoding for negative phrased questions, no significant differences were found between years of experience in the selection process and mean scores obtained for all four factor items. Interviewers had a positive experience during national selection with mean factor scores ranging from 3.84 to 3.98 (out of a maximum satisfaction score of 5). CONCLUSIONS: Organisations need to plan carefully and recognise the human element to ensure that their interviewers are cared for during any high stakes assessment such as national selection. Our work suggests that a positive assessor experience will further help contribute to a reliable and fair recruitment process.

Does the Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination predict 'on-the-job' performance during UK higher specialty surgical training?

INTRODUCTION: The Intercollegiate Membership of the Royal College of Surgeons (MRCS) is a mandatory examination to enter higher surgical specialty training in the UK. It is designed to help to ensure that successful candidates are competent to practice as higher surgical trainees. The annual review of competence progression (ARCP) assesses trainees' competence to progress to the next level of training and can be interpreted as a measure of 'on-the-job' performance. We investigated the relationship between MRCS performance and ARCP outcomes. MATERIALS AND METHODS: All UK medical graduates who passed MRCS (Parts A and B) from 2007 to 2016 were included. MRCS scores, attempts and sociodemographics for each candidate were crosslinked with ARCP outcomes (satisfactory, unsatisfactory and insufficient evidence). Multinomial logistic regression was used to identify potential independent predictors of ARCP outcomes. RESULTS: A total of 2570 trainees underwent 11,064 ARCPs; 1589 (61.8%) had only satisfactory outcomes recorded throughout training; 510 (19.9%) had at least one unsatisfactory outcome; and 471 (18.3%) supplied insufficient evidence. After adjusting for age, gender, first language and Part A performance, ethnicity (non-white vs white, OR 1.36, 95% CI 1.08 to 1.71), Part B passing score (OR 0.98, 95% CI 0.98 to 1.00) and number of attempts at Part B (two or more attempts vs one attempt, OR 1.50, 95% CI 1.16 to 1.94) were found to be independent predictors of an unsatisfactory ARCP outcome. CONCLUSIONS: This is the first study to identify predictors of ARCP outcomes during higher surgical specialty training in the UK and provides further evidence of the predictive validity of the MRCS examination.

Proton pump inhibitor and histamine-2 receptor antagonist use and risk of liver cancer in two population-based studies.

BACKGROUND: Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) are commonly used. PPIs have been shown to promote liver cancer in rats; however, only one study has examined the association in humans. AIMS: To investigate PPIs and H2RAs and risk of primary liver cancer in two large independent study populations. METHODS: We conducted a nested case-control study within the Primary Care Clinical Informatics Unit (PCCIU) database in which up to five controls were matched to cases with primary liver cancer, recorded by General Practitioners. Odds ratios (ORs) and 95% confidence intervals (95% CIs) for associations with prescribed PPIs and H2RAs were calculated using conditional logistic regression. We also conducted a prospective cohort study within the UK Biobank using self-reported medication use and cancer-registry recorded primary liver cancer. Hazard ratios (HRs) and 95% CIs were calculated using Cox regression. RESULTS: In the PCCIU case-control analysis, 434 liver cancer cases were matched to 2103 controls. In the UK Biobank cohort, 182 of 475 768 participants developed liver cancer. In both, ever use of PPIs was associated with increased liver cancer risk (adjusted OR 1.80, 95% CI 1.34, 2.41 and adjusted HR 1.99, 95% CI 1.34, 2.94 respectively). There was little evidence of association with H2RA use (adjusted OR 1.21, 95% CI 0.84, 1.76 and adjusted HR 1.70, 95% CI 0.82, 3.53 respectively). CONCLUSIONS: We found some evidence that PPI use was associated with liver cancer. Whether this association is causal or reflects residual confounding or reverse causation requires additional research.

Factors predicting success in the Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination: a summary for OMFS.

The Intercollegiate Membership of the Royal College of Surgeons (MRCS, parts A and B) is a mandatory examination for entry into higher surgical training in the UK. We investigated which factors predict success in both the written (Part A) and clinical (Part B) parts of the examination, and provide a summary for oral and maxillofacial surgeons (OMFS). All UK graduates who attempted both parts between 2007 and 2016 were included. There was a positive correlation between the scores in parts A and B (r=0.41, p<0.01). For Part A, men (odds ratio (OR) 2.78; 95% CI 1.83 to 4.19), white candidates (OR 1.70; 95% CI 1.52 to 1.89), and younger graduates (under 29years of age), were more likely to pass (OR 2.60; 95% CI 1.81 to 3.63). Foundation year one (FY1) doctors had higher pass rates than all other grades (e.g. core surgical trainee 2 compared with FY1 OR 0.50; 95% CI 0.32 to 0.77). The number of attempts at Part A and the final score, as well as ethnicity and stage of training, were independent predictors of success in Part B. Candidates who did well in Part A were more likely to do well in Part B. Several independent predictors of success were identified, but only the stage of training and ethnicity were common predictors in both parts. Higher scores obtained by younger candidates might be relevant to OMFS trainees who take Part A after studying medicine as a second degree.

Predictors of success in the Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination.

Introduction The Intercollegiate Membership of the Royal College of Surgeons (MRCS, Parts A and B) is designed to safeguard patients and ensure high standards for trainees wishing to pursue a surgical career. We investigated which factors predict Part A and B success. Methods UK graduates who had attempted both parts of MRCS from September 2007 to February 2016 were included. Pearson correlation coefficients were used to examine the linear relationship between each part of MRCS and logistic regression analysis to identify potential independent predictors of MRCS pass/fail outcome. Results A positive correlation between Part A and B score was identified (r = 0.41, P < 0.01). In Part A, males had higher pass rates than females (odds ratio, OR, 2.78, 95% confidence interval, CI, 1.83-4.19), white candidates were more likely to pass than black minority and ethnic doctors (OR 1.70, 95% CI 1.52-1.89), foundation year 1 doctors had higher pass rates than all other grades (e.g. core surgical year 2 trainees vs. foundation year 1 doctors, OR 0.50, 95% CI 0.32-0.77) and younger graduates were more likely to pass than older graduates (OR 2.60, 95% CI 1.81-3.63). In addition to ethnicity and stage of training, Part A performance (number of attempts and score) was an independent predictor for Part B. Conclusions Part A performance is related to Part B score. Many independent predictors of MRCS success were identified, but only stage of training and ethnicity were found to be common predictors of both parts. This article summarises the findings of our most recent MRCS study which was published in The Surgeon (online) in October 2017. 1.

Do surgeon interviewers have human factor-related issues during the long day UK National Trauma and Orthopaedic specialty recruitment process?

PURPOSE: The role that human factors (HF) play in contributing to medical error is increasingly being recognised by healthcare professionals. Surprisingly, much less is known about the possible effects of HF including boredom, fatigue and organisational influences, on performance outside of the clinical environment such as examining or assessing candidates in other high stakes situations. METHODS: The authors used a validated 38 response questionnaire based around the HF analysis and classification system (HFACS) to assess factors including stress and pressure, care and support and working within the rules for surgeon interviewers at the UK national trainee selection process in Trauma and Orthopaedic surgery. RESULTS: 121 completed questionnaires were analysed (86% response rate). No statistically significant differences were found between interviewer experience, grade or role at the interview and the mean scores obtained for all four factor items. Overall interviewers had a positive experience during national selection with mean factor scores ranging from 3.80 to 3.98 (out of a maximum satisfaction score of 5). CONCLUSIONS: Careful planning by organisations and recognising the importance of the human element are essential to ensure assessors are looked after properly during high stakes assessment processes. Our data suggests that a positive experience for examiners is likely to benefit candidate performance and contribute to a fair and reliable recruitment process. The relationship between examiner experience and candidate performance merits further investigation.

Which factors predict success in the mandatory UK postgraduate surgical exam: The Intercollegiate Membership of the Royal College of Surgeons (MRCS)?

BACKGROUND: The Membership of the Royal College of Surgeons examination (MRCS, Parts A and B) is one of the largest postgraduate surgical exams in the world, but little is known about the factors that affect candidate performance. We describe the relationship between both parts of MRCS and several independent predictors of MRCS success. METHODS: Pearson correlation coefficients were used to examine the linear relationship between MRCS Part A and B and logistic regression analysis to identify potential independent predictors of MRCS success. We included all UK medical graduates who attempted either part of MRCS between 2007 and 2016. RESULTS: 7896 candidates made 11,867 attempts at Part A and 4310 made 5738 attempts at Part B. A positive correlation was found between Part A and B first attempt score (r = 0.41, P < 0.001). Gender (male vs. female, odds ratio (OR) 2.78, 95% confidence interval (CI) 1.83-4.19), ethnicity (white vs. Black Minority and Ethnic, OR 1.70, 95% CI 1.52-1.89), stage of training (e.g. Core Surgical Year 2 trainees vs. Foundation Year 1 doctors, OR 0.50, 95% CI 0.32-0.77) and maturity (young vs. mature graduates, OR 2.60, 95% CI 1.81-3.63) were all found to be independent predictors of Part A success. In addition to ethnicity and stage of training, Part A performance (number of attempts and score) was also identified as an independent predictor for Part B. The odds of passing each part of the MRCS decreased by 14% (OR 0.86, 95% CI 0.80-0.92) for Part A and 30% for Part B (OR 0.70, 95% CI 0.61-0.81) with each additional attempt that was made. CONCLUSIONS: Several independent predictors of MRCS success were identified, but only ethnicity and stage of training were found to be common predictors of both Part A and B.

Impact of performance in a mandatory postgraduate surgical examination on selection into specialty training.

BACKGROUND: The Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination is undertaken by large numbers of trainees in the UK and internationally as a mandatory step within surgical training. Unlike some high-stakes medical examinations, the MRCS is yet to be validated. A quantitative study was undertaken to assess its predictive validity by investigating the relationship between MRCS (Parts A and B) and national selection interview scores for general and vascular surgery in the UK. METHODS: Pearson correlation coefficients were used to examine the linear relationship between each assessment, and linear regression analyses were employed to identify potential independent predictors of the national selection score. All UK medical graduates who attempted the interview in 2011-2015 were included. RESULTS: Some 84·4 per cent of the candidates (1231 of 1458) were matched with MRCS data. There was a significant positive correlation between the first attempt score at Part B of the MRCS examination and the national selection score (r = 0·38, P < 0·001). In multivariable analysis, 17 per cent of variance in the national selection first attempt score was explained by the Part B MRCS score and number of attempts (change in R 2 value of 0·10 and 0·07 respectively; P < 0·001). Candidates who required more than two attempts at Part B were predicted to score 8·1 per cent less than equally matched candidates who passed at their first attempt. CONCLUSION: This study supports validity of the MRCS examination, and indicates its predictive value regarding entry into specialist training.

The Effect of Boundary Conditions on Resonant Ultrasonic Spherical Chains.

The response of a resonant chain of spheres to changes in holder material and precompression is studied at ultrasonic frequencies. The system is found to be very sensitive to these parameters, with the creation of impulsive waveforms from a narrow bandwidth input seen only for certain chain lengths and holder materials. In addition, careful experiments were performed using known amounts of precompression force, using a calibrated stylus arrangement. At negligible precompression levels, impulses were generated within the chain, which were then suppressed by increased precompression. This was accompanied by large changes in the propagation velocity as the system gradually changes from being strongly nonlinear to being more linear. Simulations using a discrete model for the motion of each sphere agree well with the experimental data.

Single-Center Experience of ABO-Incompatible Living-Donor Liver Transplantation With a New Simplified Intravenous Immunoglobulin Protocol: A Propensity Score-Matching Analysis.

The outcomes of patients who undergo ABO-incompatible (ABO-I) living-donor liver transplantation (LDLT) have markedly improved as strategies have become more innovative and advanced. Here, we describe 25 cases of ABO-I LDLT with a simplified protocol and compare the outcomes to those of ABO-compatible LDLT. We analyzed outcomes via a retrospective review of 182 adult LDLT cases including 25 ABO-I LDLTs from January 2011 to December 2014. Propensity scoring was used to compare the groups. The desensitization protocol included plasma exchange, rituximab, and intravenous immunoglobulin without local infusion therapy. The triple immunosuppression protocol consisted of tacrolimus and steroids with mycophenolate mofetil; a splenectomy was not routinely performed. The median age of recipients was 51 years (range, 35-66 years), and the median mean Model for End-Stage Liver Disease (MELD) score was 15 (range, 7-37). The initial ranges of isoagglutinin IgM and IgG titers were 1:1 to 1:256 and 1:4 to 1:2048, respectively. There were no significant differences in patient demographics or perioperative variables between the groups. Although significant rebound elevation in anti-ABO antibody during the postoperative period was observed in 3 cases, neither C4d staining nor clinical signs of antibody-mediated rejection was apparent in these cases. No diffuse intrahepatic biliary stricture was encountered in any ABO-I LDLT patient within a mean follow-up of 22.6 ± 17.2 months. Moreover, no significant difference in overall or graft survival was observed between the groups. ABO-I LDLT can be performed safely under this new simplified protocol and may be proposed when ABO-compatible donors are unavailable.

Patient and family/friend satisfaction in a sample of Jordanian Critical Care Units.

AIM: The aim of the study was to assess the validity of family members/friends as proxies by comparing perceptions of satisfaction with care and decision making between critically ill patients and their family/friends. DESIGN: A comparative, descriptive cross-sectional study. SETTING: Seven Critical Care Units across four public and military hospitals in the centre and southern regions of Jordan. METHODS: A modified version of the Family Satisfaction-ICU (FS-ICU) questionnaire was distributed to Critical Care Unit (CCU) patients before hospital discharge. In addition, up to two family members/close friends were also asked to complete the questionnaire. RESULTS: A total of 213 patients (response rate 72%) and 246 family members/friends (response rate 79%) completed and returned the questionnaire. Although the majority of family members/friends and patients were satisfied with overall care, patients were generally significantly less satisfied (mean (SD) care subscale 75.6 (17.8) and 70.9 (17.3), respectively, (p=0.005). When individual items were examined, significant differences in nursing care (family/friends 80.1 (20.7) versus patient 75.9 (22.2), p=0.038) and inclusion in decision making (family/friends 53.9 (33.2) versus patient 62.0 (34.2), p=0.010) were found. CONCLUSION: The study showed a degree of congruence between patients and their family members/friends in relation to their satisfaction with the CCU experience. Thus, views of family/friends may serve as a proxy in assessing care and decision making processes of critically ill patients. RELEVANCE TO CLINICAL PRACTICE: Appropriate training of the critical care team and provision of strategies to address the concerns of patients' families are needed to improve overall patient satisfaction.