Not in the file: How competency committees work with undocumented contributions.

INTRODUCTION: Competence committees (CCs) centre their work around documentation of trainees' performance; undocumented contributions (i.e. informal, unrecorded material like personal judgements, experiential anecdotes and contextual information) evoke suspicion even though they may play a role in decision making. This qualitative multiple case study incorporates insights from a social practice perspective on writing to examine the use of undocumented contributions by the CCs of two large post-graduate training programmes, one in a more procedural (MP) speciality and the other in a less procedural (LP) one. METHODS: Data were collected via observations of meetings and semi-structured interviews with CC members. In the analysis, conversations were organised into triptychs of lead-up, undocumented contribution(s), and follow-up. We then created thick descriptions around the undocumented contributions, drawing on conversational context and interview data to assign possible motivations and significance. RESULTS: We found no instances in which undocumented contributions superseded the contents of a trainee's file or stood in for missing documentation. The number of undocumented contributions varied between the MP CC (six instances over two meetings) and the LP CC (22 instances over three meetings). MP CC discussions emphasised Entrustable Professional Activity (EPA) observations, whereas LP CC members paid more attention to narrative data. The divergent orientations of the CCs-adding an 'advis[ing]/guid[ing]' role versus focusing simply on evaluation-offers the most compelling explanation. In lead-ups, undocumented contributions were prompted by missing and flawed documentation, conflicting evidence and documentation at odds with members' perceptions. Recognising other 'red flags' in documentation often required professional experience. In follow-ups, purposes served by undocumented contributions varied with context and were difficult to generalise; we, therefore, provide deeper analysis of two vignettes to illustrate. CONCLUSIONS: Our data suggest undocumented contributions often serve best efforts to ground decisions in documentation. We would encourage CC practices and policies be rooted in more nuanced approaches to documentation.

Identifying leverage points for sustainable nutrient policy integration in Canada.

Addressing the 'wicked problem' of nutrient pollution requires coordinated policies spanning across diverse sectors and environmental systems. Using a case study of Canadian legislation, we apply semantic network analysis to identify thematic links across an inventory of 245 nutrient-related policies. Our analysis identifies twelve topics with unique types of connections across multiple facets of Canadian society. 'Hub' policies include broad environmental protection, land use planning, and climate-related legislation with close ties to multiple other topics. 'Bridge' policies create connections among otherwise disconnected topics in the network, representing opportunities to inform new policy proposals. Some legislation, such as food processing regulations, indirectly relates to nutrient use but could inform policy integration towards more coordinated and holistic nutrient management across the food system. A computational text network approach can be useful for addressing challenges in complex policy analysis, including by identifying unique entry points to guide more cross-cutting nutrient policy development.

A patienthood that transcends the patient: An analysis of patient research partners' narratives of involvement in a Canadian arthritis patient advisory board.

OBJECTIVES: Incorporating the perspectives of patients and public into the conduct of research has the potential to make scientific research more democratic. This paper explores how being a patient partner on an arthritis patient advisory board shapes the patienthood of a person living with arthritis. METHODS: An analysis was undertaken of the narratives of 22 patient research partners interviewed about their experiences on the Arthritis Patient Advisory Board (APAB), based in Vancouver, Canada. RESULTS: Participants' motivations to become involved in APAB stemmed largely from their desire to change their relationship with their condition. APAB was a living collective project in which participants invested their hope, both for their own lives as patients and for others with the disease. CONCLUSIONS: Our findings highlight how the journeys of patient partners connect and integrate seemingly disparate conceptions of what it means to be a patient. One's experience as a clinical 'patient' transforms into the broader notion of civic patienthood.

Exploring Mistreatment of Medical Students by Patients: A Qualitative Study.

PURPOSE: Mistreatment of medical students by patients has not been qualitatively explored in the literature. The authors sought to develop a rich understanding of the impact and consequences of medical students' experiences of mistreatment by patients. METHOD: This exploratory descriptive qualitative study was conducted at a large Canadian medical school from April-November 2020. Fourteen medical students were recruited for semistructured interviews. Students were asked about their experiences of mistreatment by patients and how they responded to these experiences. Transcripts were thematically analyzed using an inductive approach, and the authors interwove critical theory into their conceptual interpretation of the data. RESULTS: Fourteen medical students (median age = 25.5; 10, 71.4% self-reported male; 12, 85.7% self-identified visible minority) participated in this study. Twelve (85.7%) participants had personally experienced patient mistreatment and 2 (14.3%) had witnessed mistreatment of another learner. Medical students described being mistreated by patients based on their gender and race/ethnicity. Although all participants were aware of the institution's official mechanism for reporting mistreatment, none filed an official report. Some participants described turning to their formal (faculty members and residents) and informal (family and friends) social supports to cope with mistreatment by patients. Participants described resenting and avoiding patients who mistreated them and struggling to maintain empathy for, openness to, and overall ethical engagement with discriminatory patients. Students often described a need to be stoic toward their experiences of mistreatment by patients, often seeing it as their "professional duty" to overcome and thus suppress the negative emotions associated with mistreatment. CONCLUSIONS: Medical schools must proactively develop multifaceted mechanisms to support medical students who experience mistreatment by patients. Future research can further uncover this neglected dimension of the hidden curriculum to better develop responses to incidents of mistreatment that commit to antiracism, antisexism, patient care, and learner care.

What do you mean, 'negotiating?': Patient, physician, and healthcare professional experiences of navigating hierarchy in networks of interprofessional care.

Interprofessional collaborative practice is a phenomenon that can be fraught with power dynamics between professions, within professions, and between professionals and patients. In the literature, the dominant notion is that conflicting viewpoints and interests arising from unequal power dynamics can be resolved through negotiation. This study examined COPD patients, health professionals, and physician experiences of negotiation within 10 interprofessional collaborative COPD care teams. Physicians, patients, and healthcare professionals each had strikingly different conceptions and experiences of negotiating their perspective with other team members. Our study suggests that negotiation is an idealized notion rather than a relational process embedded in interprofessional collaborative practice. Importantly, we found that the ability and opportunity to negotiate one's perspective is heavily influenced by one's position in the workplace division of labor and professional hierarchy. We conclude that "negotiation" is only one approach among many in navigating interprofessional relations. Further, the rhetorical and ideological appeal of "negotiation" may overstate its role in interactions in interprofessional care settings, and lead to a misunderstanding of the power dynamics at play. It may be naïve to assume team members can control their situation through the competitive assertion of their individual perspective in a rational debate. Unfortunately, adopting the language of negotiation uncritically may not offer relevant solutions to structural and collective problems within a healthcare workplace.

Untangling the role of social relationships for overcoming challenges in local food systems: a case study of farmers in Québec, Canada.

Advocates for re-localizing food systems often encourage consumers to support local farmers and strengthen local food economies. Yet, local food systems hinge not only on consumers' willingness to buy local food but also on whether farmers have the social support networks to address diverse challenges during food production and distribution. This study characterizes the challenges and support systems of farmers selling to local markets in Québec, Canada, across multiple growing seasons using a mixed-methods research design. We sent an online questionnaire to 1046 farmers and conducted follow-up interviews with 15 of the 133 respondents. Our findings show that farmers relied on an average of four support actor groups, particularly employees, customers, and other farmers. Actors played distinct roles in terms of the importance, frequency, and formality of interactions, providing immediate and long-term support through formal and informal relationships across multiple spatial scales (farm, local community, and regional/international). Our thematic analysis showed that support actors helped farmers in four key domains: (1) Knowledge sharing and emotional support; (2) Labour and workforce; (3) Material and financial aid; and (4) Consumer education and business promotion. Farmer associations provided resources to tackle various challenges, acting as bridges across multiple support actor groups. Yet, our results suggest that political desires to encourage local food systems are in some cases poorly matched with resources to address specific types of challenges farmers face. Specifically, overlooking the role of diverse social support actors in helping farmers build food production and distribution capacity could undermine efforts to foster localization. Supplementary Information: The online version contains supplementary material available at 10.1007/s10460-022-10343-0.

A new dietary guideline balancing sustainability and nutrition for China's rural and urban residents.

Diets have important but often complex implications for both environmental quality and nutrition. We establish a production-oriented life cycle model to quantify and compare the farm-to-gate environmental impacts and food nutritional qualities underlying rural and urban diets in China from 1980 to 2019, a period of rapid urbanization and socioeconomic changes. The environmental impacts of rural diets were generally higher than those of urban diets, but this gap reduced after 2000. Environmental and nutritional values varied considerably across the 31 Chinese provinces due to their different food intakes and dietary structures. Dietary changes coinciding with urbanization increased greenhouse gas emissions, eutrophication potential, and nutritional quality, but decreased energy consumption and acidification potential. Based on our results, we propose a new dietary guideline to mitigate environmental impacts and improve nutritional quality.

A qualitative study of medical students' perceptions of resident feedback.

CONTEXT: Residents play a pivotal role in medical students' clinical education. From a feedback lens, the near-peer relationship between student and resident holds the potential to foster an educational alliance that could influence learning. We undertook the current qualitative study to explore medical students' perceptions of feedback experiences with residents, addressing when, how and why (and conversely when not and why not) resident feedback plays a role in their clinical education. METHODS: Our methodology was qualitative interpretive description, informed by phenomenology. We conducted 24 semi-structured interviews with third and fourth year medical students at one institution. The interviews aimed to foster rich discussion about students' feedback experiences with residents during clinical rotations. Data collection and analysis proceeded iteratively. Initial interviews were independently open-coded by three investigators and then collaboratively refined. Codes were applied to subsequent interviews, and new codes were developed. During the final stages of analysis, we organised our themes by drawing on a sociocultural perspective to examine students' perceptions of relationship-building with residents and when and how this influenced feedback and learning. RESULTS: From the students' perspectives, when residents contributed to building interpersonal relationships with students, this in turn influenced students' receptivity to both encouraging and constructive feedback conversations. In the context of resident-student relationships that were perceived as supportive, resident feedback influenced how students approached learning and working in the clinical environment, as well as students' visions of their future selves. In unsupportive relationships, students were less inclined to engage in feedback with residents and students noted resident behaviours that they wanted to avoid in themselves. CONCLUSION: Residents are uniquely positioned to create a strong educational alliance with students in which feedback conversations can flourish. Focusing educational efforts on resident feedback conversations has the potential to significantly impact the feedback culture of our clinical environments.

Imaging Modality and Frequency in Surveillance of Stage I Seminoma Testicular Cancer: Results From a Randomized, Phase III, Noninferiority Trial (TRISST).

PURPOSE: Survival in stage I seminoma is almost 100%. Computed tomography (CT) surveillance is an international standard of care, avoiding adjuvant therapy. In this young population, minimizing irradiation is vital. The Trial of Imaging and Surveillance in Seminoma Testis (TRISST) assessed whether magnetic resonance images (MRIs) or a reduced scan schedule could be used without an unacceptable increase in advanced relapses. METHODS: A phase III, noninferiority, factorial trial. Eligible participants had undergone orchiectomy for stage I seminoma with no adjuvant therapy planned. Random assignment was to seven CTs (6, 12, 18, 24, 36, 48, and 60 months); seven MRIs (same schedule); three CTs (6, 18, and 36 months); or three MRIs. The primary outcome was 6-year incidence of Royal Marsden Hospital stage ≥ IIC relapse (> 5 cm), aiming to exclude increases ≥ 5.7% (from 5.7% to 11.4%) with MRI (v CT) or three scans (v 7); target N = 660, all contributing to both comparisons. Secondary outcomes include relapse ≥ 3 cm, disease-free survival, and overall survival. Intention-to-treat and per-protocol analyses were performed. RESULTS: Six hundred sixty-nine patients enrolled (35 UK centers, 2008-2014); mean tumor size was 2.9 cm, and 358 (54%) were low risk (< 4 cm, no rete testis invasion). With a median follow-up of 72 months, 82 (12%) relapsed. Stage ≥ IIC relapse was rare (10 events). Although statistically noninferior, more events occurred with three scans (nine, 2.8%) versus seven scans (one, 0.3%): 2.5% absolute increase, 90% CI (1.0 to 4.1). Only 4/9 could have potentially been detected earlier with seven scans. Noninferiority of MRI versus CT was also shown; fewer events occurred with MRI (two [0.6%] v eight [2.6%]), 1.9% decrease (-3.5 to -0.3). Per-protocol analyses confirmed noninferiority. Five-year survival was 99%, with no tumor-related deaths. CONCLUSION: Surveillance is a safe management approach-advanced relapse is rare, salvage treatment successful, and outcomes excellent, regardless of imaging frequency or modality. MRI can be recommended to reduce irradiation; and no adverse impact on long-term outcomes was seen with a reduced schedule.

Diverse adaptation strategies helped local food producers cope with initial challenges of the Covid-19 pandemic: Lessons from Québec, Canada.

The Covid-19 pandemic has demonstrated the vulnerability of food systems to disturbances. Advocates have promoted short food supply chains as more resilient and adaptable thanks to their embeddedness in local economic and ecological networks. As part of a broader case study on challenges facing farmers in local food supply chains in Québec, Canada, we asked farmers about the pandemic's impacts on food production and marketing in the province, including how food producers coped with these challenges. We sent an online questionnaire to 1,046 farmers who distribute food through direct marketing in Québec, identified through consumer-facing online platforms. We conducted follow-up interviews with 15 of the 133 farmers that completed the questionnaire to gain a better understanding of their pandemic-related challenges and opportunities, as well as their adaptation needs and strategies. We identified four main types of challenges among farmers: workforce shortages, balancing food demand and supply, changes in sales outlets and marketing channels, and other operational and development issues. In turn, six key adaptation strategies helped farmers reorganize their marketing and sales, which we categorize as: redistribution, streamlining, replacement, collaboration, farm adjustment, and outlet adjustment. Most surveyed local farmers felt well-prepared to adapt to the four major challenges that the Covid-19 pandemic forged or escalated, and our findings suggest that they demonstrated remarkable resilience to additional challenges posed by the pandemic. Our study therefore contributes important insights about how flexibility and redundancy among local farmers stabilized the local food system during the onset of a global pandemic.

Perspectives of Persons With Arthritis on the Use of Wearable Technology to Self Monitor Physical Activity: A Qualitative Evidence Synthesis.

OBJECTIVE: We aimed to broaden understanding of the perspectives of persons with arthritis on their use of wearables to self-monitor physical activity, through a synthesis of evidence from qualitative studies. METHODS: We conducted a systematic search of 5 databases (including Medline, CINAHL, and Embase) from inception to 2018. Eligible studies qualitatively examined the use of wearables from the perspectives of persons with arthritis. All relevant data were extracted and coded inductively in a thematic synthesis. RESULTS: Of 4,358 records retrieved, 7 articles were included. Participants used a wearable during research participation in 3 studies and as part of usual self-management in 2 studies. In remaining studies, participants were shown a prototype they did not use. Themes identified were: 1) the potential to change dynamics in patient-health professional communication: articles reported a common opinion that sharing wearable data could possibly enable patients to improve communication with health professionals; 2) wearable-enabled self-awareness, whether a benefit or downside: there was agreement that wearables could increase self-awareness of physical activity levels, but perspectives were mixed on whether this increased self-awareness motivated more physical activity; 3) designing a wearable for everyday life: participants generally felt that the technology was not obtrusive in their everyday lives, but certain prototypes may possibly embarrass or stigmatize persons with arthritis. CONCLUSION: Themes hint toward an ethical dimension, as participants perceive that their use of wearables may positively or negatively influence their capacity to shape their everyday self-management. We suggest ethical questions pertinent to the use of wearables in arthritis self-management for further exploration.

Experiences of Wearable Technology by Persons with Knee Osteoarthritis Participating in a Physical Activity Counseling Intervention: Qualitative Study Using a Relational Ethics Lens.

BACKGROUND: Current evidence indicates physical activity wearables could support persons with knee osteoarthritis (OA) to be more physically active. However, recent evidence also identifies some persons with arthritis experience guilt or worry while using a wearable if they are not as active as they feel they should be. Questions remain around how persons with knee OA experience benefits or downsides using a wearable in their everyday lives. Better understanding is needed if wearables are to be incorporated in arthritis self-management in ethically aware ways. OBJECTIVE: Using an ethics lens, we aimed to describe a range of experiences from persons with knee OA who used a wearable during a physical activity counseling intervention study. METHODS: This is a secondary analysis of qualitative interviews nested within a randomized controlled trial. Guided by phenomenography, we explored the experiences of persons with knee OA following participation in a physical activity counseling intervention that involved using a Fitbit Flex and biweekly phone calls with a study physiotherapist (PT) in an 8-week period. Benefits or downsides experienced in participants' relationships with themselves or the study PT when using the wearable were identified using a relational ethics lens. RESULTS: Interviews with 21 participants (12 females and 9 males) aged 40 to 82 years were analyzed. Education levels ranged from high school graduates (4/21, 19%) to bachelor's degrees or above (11/21, 52%). We identified 3 categories of description: (1) participants experienced their wearable as a motivating or nagging influence to be more active, depending on how freely they were able to make autonomous choices about physical activity in their everyday lives; (2) some participants felt a sense of accomplishment from seeing progress in their wearable data, which fueled their motivation; (3) for some participants, sharing wearable data helped to build mutual trust in their relationship with the study PT. However, they also expressed there was potential for sharing wearable data to undermine this trust, particularly if this data was inaccurate. CONCLUSIONS: Findings provide an early glimpse into positive and negative emotional impacts of using a wearable that can be experienced by participants with knee OA when participating in a randomized controlled trial to support physical activity. To our knowledge, this is the first qualitative study that uses a relational ethics lens to explore how persons with arthritis experienced changes in their relationship with a health professional when using a wearable during research participation.

Contractility of permeabilized rat vastus intermedius muscle fibres following high-fat, high-sucrose diet consumption.

Obesity is a worldwide health concern associated with impaired physical function. It is not clear if contractile protein dysfunction contributes to the impairment of muscle function observed with obesity. The purpose of this study was to examine if diet-induced obesity affects contractile function of chemically permeabilized vastus intermedius fibres of male Sprague-Dawley rats expressing fast myosin heavy chain (MHC) IIa or slow MHC I. Rats consumed either a high-fat, high sucrose (HFHS) diet or a standard (CHOW) diet beginning as either weanlings (7-week duration: WEAN7 cohort, or 14-week duration: WEAN14 cohort) or young adults (12-week duration: ADULT12 cohort, 24-week duration: ADULT24 cohort). HFHS-fed rats had higher (P < 0.05) whole-body adiposity (derived from dual-energy X-ray absorptiometry) than CHOW-fed rats in all cohorts. Relative to CHOW diet groups, the HFHS diet was associated with impaired force production in (a) MHC I fibres in the ADULT24 cohort; and (b) MHC IIa fibres in the ADULT12 and ADULT24 cohorts combined. However, the HFHS diet did not significantly affect the Ca2+-sensitivity of force production, unloaded shortening velocity, or ratio of active force to active stiffness in any cohort. We conclude that diet-induced obesity can impair force output of permeabilized muscle fibres of adult rats. Novelty: We assessed contractile function of permeabilized skeletal muscle fibres in a rat model of diet-induced obesity. The high-fat, high-sucrose diet was associated with impaired force output of fibres expressing MHC I or MHC IIa in some cohorts of rats. Other measures of contractile function were not significantly affected by diet.

Macro and meso level influences on distributed integrated COPD care delivery: a social network perspective.

BACKGROUND: Care guidelines for people with chronic obstructive pulmonary disease (COPD) recommend an integrated approach for holistic, flexible, and tailored interventions. Continuity of care is also emphasised. However, many patients with COPD experience fragmented care. Discontinuities in healthcare and related social services are likely to result in disjointed rather than integrated care which can negatively affect patient health outcomes. The purpose of this qualitative study was to improve our understanding of, and how, contextual features pertaining to structures and processes of COPD integrated care influence delivery of care within patients' healthcare networks. METHODS: We conducted individual interviews with 28 participants (9 patients, 16 healthcare professionals, and 3 spousal caregivers). Participants were recruited through the lung clinic at a city hospital in western Canada. We employed a social network paradigm to analyse and interpret the data. RESULTS: The analysis revealed an overarching theme of fragmented COPD care with two sub-themes: (1) Funding shortfalls and availability of resources, and (2) Dis(mis)connected communication pathways. The overarching theme depicts variations, delays, and discontinuities in patient care. The sub-themes describe how macro level influences and meso level shortfalls were perceived to influence the availability of respiratory care resources that contributed to fragmented COPD care. CONCLUSIONS: Employing a social network lens drew particular attention to family physicians' pivotal role in delivering community-based COPD care. While an integrated approach to care is recommended by care guidelines, institutional and organizational structures and processes, such as financial and communication structures, may inhibit delivery of integrated care. Thus, macro and meso level structures and processes have the potential to shape patient care by constraining family physicians' purposive and communication actions necessary for facilitating an integrated distributed approach to care. We propose a context of care which fosters a context for family physicians' delivery of patient-centered care. Integrated care delivery may improve patients' wellbeing and alleviate financial constraints on the healthcare system.

The persistent threat of emerging plant disease pandemics to global food security.

Plant disease outbreaks are increasing and threaten food security for the vulnerable in many areas of the world. Now a global human pandemic is threatening the health of millions on our planet. A stable, nutritious food supply will be needed to lift people out of poverty and improve health outcomes. Plant diseases, both endemic and recently emerging, are spreading and exacerbated by climate change, transmission with global food trade networks, pathogen spillover, and evolution of new pathogen lineages. In order to tackle these grand challenges, a new set of tools that include disease surveillance and improved detection technologies including pathogen sensors and predictive modeling and data analytics are needed to prevent future outbreaks. Herein, we describe an integrated research agenda that could help mitigate future plant disease pandemics.

Challenging presentations of germ cell tumours in routine clinical practice.

Testicular cancer is the most common malignancy in young men. We discuss four cases of germ cell tumours (GCTs) presenting to general practitioners and physicians where there were notable preventable delays in the diagnosis and management. This diagnostic delay is associated with a more advanced stage of disease, and subsequent increased treatment-related morbidity and decreased survival. Our series highlights the variety of ways in which GCTs may present and we discuss the importance of prompt diagnosis through a thorough history and examination, early measurement of serum tumour markers and appropriate multidisciplinary team discussion. GCTs are highly curable cancers in the majority of patients and delays in management can, therefore, have devastating consequences.

Cardiac ventricular muscle mechanical properties through the first year of life in Sprague-Dawley rats.

Advanced age has been shown to result in decreased compliance, shortening velocity, and calcium sensitivity of the heart muscle. Even though cardiac health has been studied extensively in elderly populations, relatively little is known about cardiac health and age for the first part of adulthood. The purpose of this study was to compare cardiac contractile properties across the first year of life in rats (between 17-53 weeks), corresponding to early to mid-adulthood. Hearts were harvested from rats aged 17-, 24-, 36-, and 53-weeks. Skinned cardiac trabecular fibre bundle testing was used to evaluate active and passive force properties, maximum shortening velocity, calcium sensitivity, and myosin heavy chain isoforms. Maximum active stress production was not different between age groups. Calcium sensitivity increased progressively, while shortening velocity remained unchanged after an increase from 17-and 24-weeks. Passive stiffness decreased between 17- and 24-weeks, but then increased progressively through to 53-weeks. Thus, many of the observed detrimental changes in systolic function (reduced shortening velocity and calcium sensitivity) associated with aging, do not seem to occur in early to mid-adulthood, while early signs of increased diastolic stiffness manifest within 53 weeks of age and may represent a first sign of decreasing heart function and health.

Mechanical adaptations of skinned cardiac muscle in response to dietary-induced obesity during adolescence in rats.

Childhood obesity is a major risk factor for heart disease during adulthood, independent of adulthood behaviours. Therefore, it seems that childhood obesity leads to partly irreversible decrements in cardiac function. Little is known about how obesity during maturation affects the mechanical properties of the heart. The purpose of this study was to evaluate contractile properties in developing hearts from animals with dietary-induced obesity (high-fat high-sucrose diet). We hypothesized that obesity induced during adolescence results in decrements in cardiac contractile function. Three-week-old rats (n = 16) were randomized into control (chow) or dietary-induced obesity (high-fat high-sucrose diet) groups. Following 14 weeks on the diet, skinned cardiac trabeculae fibre bundle testing was performed to evaluate active and passive force, maximum shortening velocity, and calcium sensitivity. Rats in the high-fat high-sucrose diet group had significantly larger body mass and total body fat percentage. There were no differences in maximal active or passive properties of hearts between groups. Hearts from the high-fat high-sucrose diet rats had significantly slower maximum shortening velocities and lower calcium sensitivity than controls. Decreased shortening velocity and calcium sensitivity in hearts of obese animals may constitute increased risk of cardiac disease in adulthood. Novelty Cardiac muscle from animals exposed to an obesogenic diet during development had lower shortening velocity and calcium sensitivity than those from animals fed a chow diet. These alterations in mechanical function may be a mechanism for the increased risk of cardiac disease observed in adulthood.

Testicular cancer: improving outcomes with national quality performance indicators.

Testicular cancer is the most common malignancy in young adult men. The prognosis is excellent in limited disease and cure is possible even in advanced disease. Quality performance indicators (QPI) are used in many developed countries as a measure of healthcare performance. We report and discuss the development of a national set of QPIs in Scotland for testicular cancer as a method of gathering demographic data and driving improvement in nationwide testicular cancer outcomes.