The influence of candidates' physical attributes on patient ratings in simulated assessments of clinical practice.

BACKGROUND: We have previously shown that clinical examiners' scoring is not negatively impacted when a candidate has a tattoo, unnatural hair colour, or a regional accent. We investigated whether these physical attributes in exam candidates impact patient scoring. METHODS: Simulated/real patients were randomly assigned to watch five videos of simulated candidate performances of a cranial nerve examination: clear fail, borderline, good, 'clear pass' without an attribute, and 'clear pass' with one of the attributes (tattoo, purple hair, accent). Participants scored domains of communication and professionalism. We compared scores for the clear pass candidates with and without attributes. RESULTS: One hundred and eighty three patients participated. The total scores for the candidates with tattoos and purple hair were higher than the candidate with no physical attribute (p < 0.001). For the candidate with a Liverpool English accent no difference was identified (p = 0.120). CONCLUSIONS: The presence of certain physical attributes (tattoos or purple hair) was associated with higher scores given by patients to candidates in a simulated physical examination station.

The influence of candidates' physical attributes on assessors' ratings in clinical practice.

BACKGROUND: Assessments of physician competence in the work-place are common and often contribute to high-stakes assessments. Previous research suggests that assessors' judgements can be influenced by candidates' physical attributes. We investigated whether simulated candidates' scores were influenced by assessor bias based on tattoos, hair colour, and a regional accent. METHODS: We used an experimental, video-based, single-blinded, randomised, internet-based design. We created videos of simulated medical intern performances of a clinical examination at four different standards of competence. Four videos were also created of simulated candidates performing at a 'clear pass' standard, with either no stereotypical attribute (CPX), purple hair (CPH), tattoos (CPT) or a Liverpool English accent (CPA). Assessors were randomly assigned to watch five videos including the "clear pass" candidate without an attribute and one of the "clear pass" candidates with an attribute and asked to give an overall global grade for each candidate. We compared the global grades for the clear pass candidates with and without attributes. RESULTS: Ninety-eight assessors were included in the analysis. The total scores for the candidates with stereotyped attributes were not significantly lower than the candidate with no attribute. Assessors showed moderate levels of agreement between the global grades awarded for all the candidates. The global grades awarded to candidate with a stereotypical attribute were not significantly lower than for those without. CONCLUSIONS: The presence of tattoos, purple hair, or a regional accent did not systematically negatively influence the grade or score awarded by assessors to candidates in observed clinical examination scenarios.

Varus thrust during walking and the risk of incident and worsening medial tibiofemoral MRI lesions: the Multicenter Osteoarthritis Study.

OBJECTIVE: To determine the association of varus thrust during walking to incident and worsening medial tibiofemoral cartilage damage and bone marrow lesions (BMLs) over 2 years in older adults with or at risk for osteoarthritis (OA). METHOD: Subjects from the Multicenter Osteoarthritis Study (MOST) were studied. Varus thrust was visually assessed from high-speed videos of forward walking trials. Baseline and two-year MRIs were acquired from one knee per subject and read for cartilage loss and BMLs. Logistic regression with generalized estimating equations was used to estimate the odds of incident and worsening cartilage loss and BMLs, adjusting for age, sex, race, body mass index (BMI), and clinic site. The analysis was repeated stratified by varus, neutral, and valgus alignment. RESULTS: 1007 participants contributed one knee each. Varus thrust was observed in 29.9% of knees. Knees with thrust had 2.17 [95% CI: 1.51, 3.11] times the odds of incident medial BML, 2.51 [1.85, 3.40] times the odds of worsening medial BML, and 1.85 [1.35, 2.55] times the odds of worsening medial cartilage loss. When stratified by alignment, varus knees also had significantly increased odds of these outcomes. CONCLUSION: Varus thrust observed during walking is associated with increased odds of incident and worsening medial BMLs and worsening medial cartilage loss. Increased odds of these outcomes persist in varus-aligned knees.

Glomerular Lesions in Proteinuric Miniature Schnauzer Dogs.

Miniature Schnauzer dogs are predisposed to idiopathic hypertriglyerceridemia, which increases risk for diseases such as pancreatitis and gallbladder mucocele. Recently, elevated triglyceride concentrations have been associated with proteinuria in this breed, although it is difficult to determine which abnormality is primary. Retrospective review of renal tissue from 27 proteinuric Miniature Schnauzers revealed that 20 dogs had ultrastructural evidence of osmophilic globules consistent with lipid in glomerular tufts. Seven of these dogs had lipid thromboemboli in glomerular capillary loops that distorted their shape and compressed circulating erythrocytes. Triglyceride concentrations were reported in 6 of these 7 dogs, and all were hypertriglyceridemic. In addition, glomerular lipidosis (defined as accumulation of foam cells within peripheral capillary loops) was identified in a single dog. The remaining 12 dogs had smaller amounts of lipid that could only be identified ultrastructurally. Neither signalment data nor clinicopathologic parameters (serum albumin, serum creatinine, urine protein-to-creatinine ratio, and blood pressure) differed among the various types of lipid lesions. During the time course of this study, all dogs diagnosed with glomerular lipid thromboemboli were Miniature Schnauzers, underscoring the importance of recognizing these clear spaces within capillary loops as lipid.

Chronic Kidney Disease in Aged Cats: Clinical Features, Morphology, and Proposed Pathogeneses.

Chronic kidney disease (CKD) is the most common metabolic disease of domesticated cats, with most affected cats being geriatric (>12 years of age). The prevalence of CKD in cats exceeds that observed in dogs, and the frequency of the diagnosis of CKD in cats has increased in recent decades. Typical histologic features include interstitial inflammation, tubular atrophy, and fibrosis with secondary glomerulosclerosis. In contrast to people and dogs, primary glomerulopathies with marked proteinuria are remarkably rare findings in cats. Although a variety of primary renal diseases have been implicated, the disease is idiopathic in most cats. Tubulointerstitial changes, including fibrosis, are present in the early stages of feline CKD and become more severe in advanced disease. A variety of factors-including aging, ischemia, comorbid conditions, phosphorus overload, and routine vaccinations-have been implicated as factors that could contribute to the initiation of this disease in affected cats. Factors that are related to progression of established CKD, which occurs in some but not all cats, include dietary phosphorus intake, magnitude of proteinuria, and anemia. Renal fibrosis, a common histologic feature of aged feline kidneys, interferes with the normal relationship between peritubular capillaries and renal tubules. Experimentally, renal ischemia results in morphologic changes similar to those observed in spontaneous CKD. Renal hypoxia, perhaps episodic, may play a role in the initiation and progression of this disease.

Unilateral Renal Ischemia as a Model of Acute Kidney Injury and Renal Fibrosis in Cats.

The objectives of this study were to define the acute and chronic effects of 1-hour unilateral in vivo renal ischemia on renal function and histology in cats. Twenty-one adult purpose-bred research cats were anesthetized, and 1 kidney underwent renal artery and vein occlusion for 1 hour. Serum creatinine and urea concentrations, urine protein:creatinine ratio, urine-specific gravity, glomerular filtration rate, hematocrit, platelet concentration and function, and white blood cell count were measured at baseline and variable time points after ischemia. Renal histopathology was evaluated on days 3, 6, 12, 21, 42, and 70 postischemia; changes in smooth muscle actin and interstitial collagen were examined. Following ischemia, whole animal glomerular filtration rate was significantly reduced (57% of baseline on day 6; P < .05). At the early time points, the ischemic kidneys exhibited severe acute epithelial necrosis accompanied by evidence of regeneration of tubules predominantly within the corticomedullary junction. At later periods, postischemic kidneys had evidence of tubular atrophy and interstitial inflammation with significantly more smooth muscle actin and interstitial collagen staining and interstitial fibrosis when compared with the contralateral control kidneys. This study characterizes the course of ischemic acute kidney injury in cats and demonstrates that ischemic acute kidney injury triggers chronic fibrosis, interstitial inflammation, and tubular atrophy in feline kidneys. These late changes are typical of those observed in cats with naturally occurring chronic kidney disease.

World Small Animal Veterinary Association Renal Pathology Initiative: Classification of Glomerular Diseases in Dogs.

Evaluation of canine renal biopsy tissue has generally relied on light microscopic (LM) evaluation of hematoxylin and eosin-stained sections ranging in thickness from 3 to 5 µm. Advanced modalities, such as transmission electron microscopy (TEM) and immunofluorescence (IF), have been used sporadically or retrospectively. Diagnostic algorithms of glomerular diseases have been extrapolated from the World Health Organization classification scheme for human glomerular disease. With the recent establishment of 2 veterinary nephropathology services that evaluate 3-µm sections with a panel of histochemical stains and routinely perform TEM and IF, a standardized objective species-specific approach for the diagnosis of canine glomerular disease was needed. Eight veterinary pathologists evaluated 114 parameters (lesions) in renal biopsy specimens from 89 dogs. Hierarchical cluster analysis of the data revealed 2 large categories of glomerular disease based on the presence or absence of immune complex deposition: The immune complex-mediated glomerulonephritis (ICGN) category included cases with histologic lesions of membranoproliferative or membranous patterns. The second category included control dogs and dogs with non-ICGN (glomerular amyloidosis or focal segmental glomerulosclerosis). Cluster analysis performed on only the LM parameters led to misdiagnosis of 22 of the 89 cases-that is, ICGN cases moved to the non-ICGN branch of the dendrogram or vice versa, thereby emphasizing the importance of advanced diagnostic modalities in the evaluation of canine glomerular disease. Salient LM, TEM, and IF features for each pattern of disease were identified, and a preliminary investigation of related clinicopathologic data was performed.

Feline chronic kidney disease is associated with upregulation of transglutaminase 2: a collagen cross-linking enzyme.

Chronic kidney disease is a major cause of morbidity and mortality in cats. Transglutaminase 2 (TG2) is a calcium-dependent enzyme proposed to mediate tubulointerstitial fibrosis in the kidney by cross-linking collagen fibrils. Postmortem kidney tissue was obtained from primary renal azotemic (n = 10) and nonazotemic (n = 5) cats (14 domestic short hair, 1 Burmese; aged 9-23.7 years). Extracellular matrix protein deposition was determined by Masson's trichrome staining and collagen immunofluorescence. Total kidney transglutaminase (TG) enzyme activity and TG2 protein were measured in tissue homogenates by putrescine incorporation and Western blotting. Extracellular TG enzyme activity and TG2 protein were determined in situ by immunofluorescence, quantified by multiphase image analysis. Results were compared using the unpaired Student's t-test with Welch's correction. Elevated plasma creatinine, urea, and phosphate concentrations were associated with tubulointerstitial fibrosis but not glomerular fibrosis. Kidney homogenates from azotemic cats showed a 3-fold higher total TG enzyme activity and TG2 protein compared with kidneys from nonazotemic cats. Immunofluorescent studies performed in situ confirmed a 3-fold higher extracellular TG enzyme activity and TG2 protein in cats with azotemia. Tubulointerstitial TG2 showed a positive linear correlation with both renal function and tubulointerstitial fibrosis. In conclusion, for cats with azotemia, both filtration failure and tubulointerstitial fibrosis were associated with the upregulation of TG2, a collagen cross-linking enzyme and the major isoform of transglutaminase in the kidney. TG2 may provide a new therapeutic target for drugs designed to slow the progression of feline chronic kidney disease.

Level of male infertility in the Ghanaian city of Tema.

Infertility among couples is a sensitive issue in Ghana; females are mostly blamed. Most male infertility cases are generally due to low sperm counts (oligozoospermia), poor sperm quality - characterised by poor sperm motility (asthenozoospermia) - or a combination of both (oligoasthenozoospermia). This is a retrospective study from January 1995 to December 2005 which determined the level and type of male infertility in and around the city of Tema. Seminal fluid analysis reports of male clients who visited the Adom Medical Laboratory in Tema were extracted from laboratory data and analysed. Our study involved 2795 males in the age range of 24-36 years. In 1995, 75% of the total samples analysed had sperm concentrations ranging from 21 to 350 million sperms/ml and showed a decreasing trend to 41% in 2005. Samples with sperm concentrations below 20 million sperms/ml in 1995 increased from 20.5% to 57.6% in 2005; those with active motility > 45% decreased from 27 (30.7%) in 1995 to zero (0%) in 2005, whilst samples with > 50% non-motile sperms increased from 47 (53.4%) in 1995 to 449 (87.7%) in 2005. Male infertility in the samples analysed was due to a combination of oligozoospermia and asthenozoospermia.

Metabolic and embryonic responses to terrestrial incubation of Fundulus grandis embryos across a temperature gradient.

This study simulated terrestrial incubation and measured rates of embryogenesis, nitrogen elimination, heart rate, lactate production, maximum length of time a hatch could be delayed and developmental responses of terrestrially incubated Gulf killifish Fundulus grandis embryos at temperatures ranging from 20 to 30° C. Temperature had a positive relationship with rate of embryogenesis, but a negative relationship with extent of extended incubation. The 30° C treatment reached embryonic maturity 6 days before the 20° C treatment. Embryos hatched between intervals of 240 and 336, 144 and 288, 96 and 240 and 96 and 192 h after reaching developmental maturity for the 20, 23, 26 and 30° C treatments. Significantly higher concentrations of total nitrogen, in the form of ammonia and urea, were recorded in the 20 and 30° C treatments. While temperature significantly influenced lactate and ATP concentrations, no significant influence of time of incubation was detected. Terrestrial embryos displayed an ability to develop quickly during embryogenesis and prolong incubation for an extended period of time after reaching embryonic maturity. This adaptation may be a life-history trait used to minimize asynchronous hatching, cannibalism and cohort size heterogeneity.

Human papillomavirus genotypes in a subset of head and neck squamous cell carcinoma.

BACKGROUND: Squamous cell carcinoma originating from the oral cavity, lip, larynx and pharynx are grouped under head and neck squamous cell carcinomas (HNSCC). OBJECTIVE: To report on human papillomavirus (HPV) genotypes involved in HNSCC. STUDY DESIGN: A retrospective review of archival HNSCC specimens and patient demographic and clinical data accessioned between January, 2007 and December, 2009 in the Department of Pathology, Korle-Bu Teaching Hospital, Accra, Ghana. RESULTS: Cases from 58 males and 20 females included 29 from the oral cavity, 33 from the larynx, 11 from the pharynx and 5 from the parotid gland. HPV DNA was found in 15 (19.23%) of the tumors with 12 being HPV-16, 2 HPV-18 and 1 dual infection with HPV-16 and HPV-18, giving HPV-16 prevalence of 86.7%. Higher prevalence of HPV DNA was found in males than females. There was a trend towards subjects younger than 58 years being more likely to have HPV-positive tumors.The 15 HPV-positive cases were distributed in location as 8 of 33 (24.2%) from the larynx, 4 of 29 (13.8%) from the oral cavity, and 2 of 11 (18.2%) from the pharynx and 1 of 5 (20%) from the parotid gland. CONCLUSION: Oncogenic HPV infection was found in 19.23% of HNSCCs, with genotype 16 predominating. HPV-related HNSCC tended to occur at younger age compared to non-HPV-related HNSCC. The commonest site for HPV-associated HNSSC in Ghana is the larynx, rather than the oropharynx as reported in other studies. Host factors may be responsible for the site difference and more work is required to further elucidate this.

Prevalence of hepatitis d infection in patients with hepatitis B virus-related liver diseases in Accra, Ghana.

BACKGROUND: Hepatitis D virus (HDV), a defective RNA virus which depends on hepatitis B virus (HBV) for its replication and expression, appears to be highly pathogenic and modifies the natural history of HBV infection. Two types of infection, co-infection and super-infection are recognised. During infection, anti-delta antibodies appear in serum and can be detected by Enzyme linked Immunosorbent Assay (ELISA). OBJECTIVE: We determined the prevalence of hepatitis D infection amongst HBsAg-positive patients with HBV-related liver diseases in Accra, Ghana using an Enzyme linked Immunosorbent assay (ELISA) method. METHODS: We collected blood samples from 53 patients with hepatitis B-related liver diseases. The sera were analysed using a commercially available kit, the EIA-ANTI-HDV, a third generation ELISA kit (Globe Diagnostics, Italy). RESULTS: There were 39 males (73.6%) and 14 females (26.4%) giving a male:female ratio of about 3:1.The mean age of patients was 38.6 years (range, 15-75). Six patients were reactive for anti-delta antibodies, yielding a HDV sero-prevalence of 11.3%. A higher proportion of males were anti-HDV positive (9.4%) compared to females (1.9%) but the difference was not statistically significant (p=0.350). Anti-HDV was detected in 4(22.2%) patients with chronic hepatitis B, 1(7.6%) with cirrhosis of the liver and 1(5.3%) with hepatocellular carcinoma. CONCLUSION: The prevalence of HDV infection amongst patients with liver disease in Accra with HBV-related liver diseases appears to be high compared to developed countries but similar to several developing countries. No significant difference exists in gender prevalences. A concerted public health effort is required to reduce this high prevalence rate.

Forensic anthropologists and estimates of skeletal completeness: The impacts of training and experience.

Forensic anthropologists engage with numerous and diverse stakeholders in their casework. Regarding the recovery of human remains, these stakeholders may be interested in quantifying or qualifying the amount of remains recovered. How forensic anthropologists respond to such questions, whether verbally or in written reporting, has the potential to impact the trajectory of a case. However, communications about skeletal completeness are rarely discussed within the field. Current data-collection procedures recommend the use of inventories. This approach may be less feasible for complicated assemblages involving commingling or high degrees of fragmentation. Numerous methods exist to quantify the amount of skeletal remains present in complex or larger assemblages, but it remains unclear to what extent forensic anthropologists utilize these methods and whether factors like degree of expertise influence analysts' ability to report skeletal completeness consistently and precisely. A study was designed to examine differences between public and professional perceptions of skeletal completeness, presenting images of incomplete bones and skeletal remains. Survey participants were asked to assess the completeness of the remains in each image. Few patterns were observed regarding photographs of skeletal assemblages, but distinct differences were observed among individual bones between respondents with different degrees of expertise. These responses reflect potentially unexamined assumptions underlying assessments of incomplete bones and skeletal assemblages. This highlights the necessity of standardizing how we report estimates of completeness within the forensic anthropology community and how we discuss these results with external stakeholders. Completeness estimates must be either removed from reports and bench notes or annotated and cited clearly, as is standard with other aspects of forensic anthropological analysis. Several methods are summarized, with recommendations for integrating them into casework.

Histomorphometry of feline chronic kidney disease and correlation with markers of renal dysfunction.

Chronic kidney disease is common in geriatric cats, but most cases have nonspecific renal lesions, and few studies have correlated these lesions with clinicopathological markers of renal dysfunction. The aim of this study was to identify the lesions best correlated with renal function and likely mediators of disease progression in cats with chronic kidney disease. Cats were recruited through 2 first-opinion practices between 1992 and 2010. When postmortem examinations were authorized, renal tissues were preserved in formalin. Sections were evaluated by a pathologist masked to all clinicopathological data. They were scored semiquantitatively for the severity of glomerulosclerosis, interstitial inflammation, and fibrosis. Glomerular volume was measured using image analysis; the percentage of glomeruli that were obsolescent was recorded. Sections were assessed for hyperplastic arteriolosclerosis and tubular mineralization. Kidneys from 80 cats with plasma biochemical data from the last 2 months of life were included in the study. Multivariable linear regression (P < .05) was used to assess the association of lesions with clinicopathological data obtained close to death. Interstitial fibrosis was the lesion best correlated with the severity of azotemia, hyperphosphatemia, and anemia. Proteinuria was associated with interstitial fibrosis and glomerular hypertrophy, whereas higher time-averaged systolic blood pressure was associated with glomerulosclerosis and hyperplastic arteriolosclerosis.

Utilization of Screening Mammography in Women Before 50: Cross-Sectional Survey Results from the National Health Interview Survey.

OBJECTIVE: While the American College of Radiology recommends annual screening mammography starting at age 40 years, the US Preventive Services Task Force (USPSTF) recommends that screening mammography in women younger than age 50 years should involve shared- decision making (SDM) between clinicians and patients, considering benefits and potential harms in younger women. Using a nationally representative cross-sectional survey, we aimed to evaluate patient-reported reasons and predictors of screening mammography utilization in this age group. METHODS: Respondents aged 40-49 years from the 2018 National Health Interview Survey (NHIS) without a history of breast cancer were included (response rate 64%). Participants reported sociodemographic variables and reasons they did not engage in mammography screening within the last two years. Multiple variable logistic regression analyses were performed to evaluate the association between sociodemographic characteristics and patient-reported screening mammography use, accounting for complex survey sampling design elements. RESULTS: 1,948 women between the ages of 40-49 years were included. Of this group, (758/1948) 46.6% reported receiving a screening mammogram within the last year, and 1196/1948 (61.4%) reported receiving a screening mammogram within the last two years. The most common reasons for not undergoing screening included: "No reason/never thought about it" 744/1948 (38.2%), "Put it off" 343/1948 (17.6%), "Didn't need it" 331/1948 (16.9%), "Doctor didn't order it" 162/1948 (8.3%), and "I'm too young" 63/1948 (5.3%). Multiple variable analyses demonstrated that lack of health insurance was the strongest predictor of mammography non-engagement (p< 0.001). CONCLUSION: Deficits in shared- decision-making in women younger than 50 years related to mammography utilization exist. Radiologists may be key in addressing this issue among ambulatory care providers and patients, educating about the benefits and harms of screening younger women, particularly in racial/ethnic minorities and uninsured patients, who experience additional barriers to care and SDM discussions.

Food and pharmaceuticals. Lessons learned from global contaminations with melamine/cyanuric acid and diethylene glycol.

Recently, contamination of pharmaceuticals with diethylene glycol (DEG) and food with melamine and cyanuric acid has demonstrated the impact of globalization on drug and food safety. By examining the details of these outbreaks, some important lessons can be learned. Toxicoses from contaminated food and drugs are often identified only when large numbers of people or animals are affected and numerous deaths result. Populations most at risk are those repeatedly exposed to a single product. Toxicoses may be complex, involving synergism among relatively nontoxic co-contaminants. Although some contamination may occur inadvertently, practices of deliberate contamination of food and drug ingredients may be widespread but escape detection in poorly regulated markets. If this deliberate contamination is motivated by personal financial gain, it is likely to recur and be concealed. The contaminated raw material produced in a poorly regulated market may cross national boundaries and be used in manufacturing processes for numerous products, sometimes in more well-regulated markets. Once in the production chain, contaminated raw materials may be widely disseminated. It is not clear that regulatory organizations have the capacity to identify significant contaminations despite their best efforts. The veterinary and medical communities, in cooperation with regulatory agencies, should develop cooperative programs designed to detect and limit these global outbreaks. Although addressing regional or national outbreaks remains an important role for regulatory agencies, the veterinary and medical communities must develop proactive global approaches to this global problem.

Diagnostic exercise: chronic vomiting in a dog.

An approximately one-and-a-half-year-old, neutered male, mixed-breed dog was presented for a chronic history of vomiting. Profuse diarrhea was also noted during examination. An exploratory laparotomy was performed, bone chips were removed from the stomach, and a raised, circular area of gastric mucosa was biopsied. Histologically, there was severe gastric cryptosporidiosis as well as numerous spiral bacteria, consistent with Helicobacter spp. Polymerase chain reaction revealed visible bands for the 18S ribosomal RNA gene for Cryptosporidium spp. The polymerase chain reaction product was sequenced and was found to be most similar to Cryptosporidium muris. Both the gastric location and the species of Cryptosporidium are unusual in a dog.

Bond lengths in free molecules of buckminsterfullerene, c60, from gas-phase electron diffraction.

Electron diffraction patterns of the fullerene C(60) in the gaseous state have been obtained by volatilizing it from a newly designed oven-nozzle at 730 degrees C. The many peaks of the experimental radial distribution curve calculated from the scattered intensity are completely consistent with icosahedral symmetry for the free molecule. On the basis of this symmetry assumption, least-squares refinement of a model incorporating all possible interatomic distances led to the values r(g)(C(1)-C(2)) = 1.458(6) angstroms (A) for the thermal average bond length within the five-member ring (that is, for the bond fusing five- and six-member rings) and r(g)(C(1)-C(6)) = 1.401(10) A for that connecting five-member rings (the bond fusing six-member rings). The weighted average of the two bond lengths and the difference between them are the values 1.439(2) A and 0.057(6) A, respectively. The diameter of the icosahedral sphere is 7.113(10) A. The uncertainties in parentheses are estimated 2sigma values.

The impact of the Cartwright Report upon the regulation, discipline and accountability of medical practitioners in New Zealand.

The Cartwright Report instigated a profound change in thinking about patient-doctor relationships and the need for public involvement in the processes by which doctors are censored. It was also the key catalyst to legislative reforms designed to ensure the accountability of practitioners to their patients. This article considers the effect of the Cartwright Report on the incidence of disciplinary hearings against medical practitioners in New Zealand. Perhaps contrary to expectations, the statistics show a pronounced decline in disciplinary hearings. The authors argue that this should not necessarily be considered an adverse development, and that these statistics in fact reflect the working of multi-layered, more constructive and open processes for regulating doctors and holding them accountable.